2020 Healthcare-Associated Infection Report (2024)

Pennsylvania Department of Health

2024-05-08

Pennsylvania was one of the first states to recognize the harmful impact that healthcare-associated infections (HAIs) had on patient outcomes and quality of life related to additional medical treatment, loss of time, and financial burden. As a result, in 2007, the Pennsylvania General Assembly amended the Medical Care Availability and Reduction of Error (MCARE) Act by adding a new chapter (Pennsylvania Act 52) to address the reduction and prevention of HAIs in Pennsylvania. This law includes requirements for hospitals to report all HAI events into the National Healthcare Safety Network (NHSN), a secure internet-based data collection/reporting system managed by the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention (CDC). The use of NHSN provides standardized HAI case definitions and allows for analysis and comparison to hospitals located throughout the nation. As required by Act 52, the Pennsylvania Department of Health (Department) analyzes HAI data reported to NHSN, summarizes the findings and releases an annual report that documents progress that hospitals have made in implementing HAI prevention strategies to encourage statewide reduction of HAIs.

This 2020 report is the 13th report to be released by the Department and the fifth to use an interactive online format. The reader must be aware that this report does not include data from nursing homes, long-term care facilities, ambulatory surgical centers, or other outpatient care centers and only includes information from Pennsylvania acute care, critical access, inpatient rehabilitation, long-term acute care, inpatient psychiatric, and children’s hospitals for the calendar year 2020. Results are presented for a subset of NHSN HAI types, two device utilization rates, surgical site infections (SSI) following seven types of surgical procedures, and two proxy infection events [Laboratory-Identified Events (LabID)]. Included are:

1. Central line-associated bloodstream infections (CLABSI)
2. Catheter-associated urinary tract infections (CAUTI)
3. SSIs for seven procedure types
   • Abdominal hysterectomies (HYST)
   • Colon surgeries (COLO)
   • Cardiac surgeries (CARD)
   • Coronary bypass with chest incision and donor incisions (CBGB)
   • Coronary bypass with chest incision only (CBGC)
   • Hip prosthesis (HPRO)
   • Knee prosthesis (KPRO)
4. Urinary catheter utilization
5. Central line utilization
6. Clostridioides difficile lab events (CDI LabID)
7. Methicillin-resistant Staphylococcus aureus blood specimen events (MRSA LabID)

Other HAIs occur but are not included in this report. These may include respiratory illnesses and SSIs that follow other types of surgeries. This report presents HAI results using two NHSN metrics to gauge the progress in reducing HAIs.

1. The standardized infection ratio (SIR) compares the number of reported infections with the number of predicted infections based on 2015 baseline data. It adjusts for several risk factors that have been found to be significantly associated with differences in infection incidence. Factors may be either facility-related or, for SSIs, patient characteristics.

\[SIR = \frac{Number \: of \: Reported \: HAIs}{Number \: of \: Predicted \: HAIs}\]

2. The standardized utilization ratio (SUR) compares the number of device days reported to the number of predicted device days based on 2015 national baseline data. It adjusts for facility characteristics.

\[SUR = \frac{Number \: of \: Reported \: device \: days}{Number \: of \: Predicted \: device \: days}\]

The SIR and SUR are useful metrics to compare one facility to similar facilities in the rest of the country. Below are rules to interpret the value of a SIR:

• If the SIR is greater than 1.0, then more HAIs were reported than predicted, based on the 2015 national baseline data.
• If the SIR equals 1.0, then the same number of HAIs were reported as predicted, based on the 2015 national baseline data.
• If the SIR is less than 1.0, then fewer HAIs were reported than predicted, based on the 2015 national baseline data.

Comparisons of SIR and SUR values from different years can only be made when the baseline data are from the same timeframe. Readers are cautioned not to compare SIR values in this report to Pennsylvanian HAI reports prior to 2016. The SIR values in this report can be compared to data from Pennsylvania annual reports generated after 2015 and CDC HAI progress reports that use the 2015 national baseline.

To fully interpret SIR and SUR values, it’s best to examine not only how large or small the SIR or SUR value is when compared to 1.0, but also examine the 95% confidence interval (CI). The 95% CI is a range of values in which a high degree of confidence exists that the true SIR or SUR lies within that range. If the number 1.0 does not fall within the range, the SIR or SUR is considered statistically significant. The combination of both approaches is considered the best way to evaluate a SIR or SUR value. Below are rules for interpreting the 95% CI.

95% Confidence Interval:

• The 95% CI is a range of values in which a high degree of confidence exists that the true SIR or SUR lies within that range.
• If the CI does not include 1.0, then the SIR is significantly different from 1.0 (i.e., the number of reported infections is significantly different from the number predicted).
  • Example: 95% CI = (0.85, 0.92). One can be 95% certain that the true SIR value is between 0.85 and 0.92 and statistically significantly less than 1.0.
  • Example: 95% CI = (1.04, 1.22). One can be 95% certain that the true SIR value is between 1.04 and 1.22 and statistically significantly more than 1.0.
• If the CI includes the value of 1.0, then the SIR is not significantly different from 1.0 (i.e., the number of reported infections is not significantly different from the number predicted).
  • Example: 95% CI = (0.85, 1.24). One can be 95% certain that the true SIR value is between 0.85 and 1.24 and is not statistically significantly different from 1.0.
• If the SIR is 0.000 (i.e., the infection count is 0 and the number of predicted infections is 1.0 or more), the lower bound of the 95% CI will be set at zero.
  • Example: 95% CI = (0, 1.49). One can be 95% certain that the true SIR value is between 0 and 1.49 and is not statistically significantly different from 1.0.
  • Example: 95% CI = (0, 0.85). One can be 95% certain that the true SIR value is between 0 and 0.85 and is statistically significantly less than 1.0.

The metrics are calculated using aggregate data reported by Pennsylvania hospitals that were open for all 12 months in 2020 and are presented for the entire commonwealth, by hospital type and by individual hospitals.

Healthcare-Associated Infections in Hospital Settings by Type: Number of Infections (Cases), Standardized Infection Ratio (SIR), and Number of Infections Needed to Prevent to Reach National SIR Goal (Goal) | Pennsylvania, 2020

2020 Catheter-associated urinary tract infections (CAUTIs): Among the 1,255,340 patient urinary catheter days, 1,304 CAUTIs were reported to NHSN from 278 Pennsylvania hospitals. The state SIR was 0.82 (95% CI: (0.78, 0.87)), which was statistically significantly lower than the 2015 NHSN national baseline. The SIR in inpatient rehabilitation facilities was highest (SIR: 1.2; 95% CI: (0.97, 1.46)), and it was lowest in inpatient psychiatric hospitals (SIR: 0.43; 95% CI: (0.02, 2.14)). Ten hospitals had a SIR that was statistically significantly greater than 1.0. The urinary catheter SUR was 0.85 (95% CI: (0.85, 0.85)) among 157 acute care hospitals. The SUR was highest among inpatient rehabilitation facilities (SUR: 0.91; 95% CI: (0.90, 0.92)).

2020 Central line-associated blood stream infections (CLABSIs): Among 1,393,324 patient central line days, 1,213 CLABSIs were reported to NHSN from 274 hospitals. The state SIR was 0.84 (95% CI: (0.79, 0.88)), statistically significantly less than the 2015 national baseline. The SIR from acute care (0.82; 95% CI: (0.77, 0.88)) and long-term acute care hospitals 0.75; 95% CI: (0.61, 0.91)) reached statistical significance. Critical access hospitals in Pennsylvania use central lines 11% more often than similar hospitals from the 2015 national baseline (SUR: 1.11; 95% CI: (1.07, 1.14)) whereas acute care hospitals use central lines 16% less often than similar hospitals from the 2015 national baseline (SUR: 0.84; 95% CI: (0.84, 0.84))

2020 Surgical site infections (SSI): In 2020, 164 Pennsylvania hospitals performed at least one of the seven surgical benchmarked procedures tracked for SSI surveillance. Hospitals reported 99,908 of these surgical procedures and 743 (deep tissue or organ space) SSIs. Knee replacement surgery (KPRO) was the most common (N= 34,285) and represented 34.3% of all the surgical procedures. The state SSI SIR values for each surgery type were 0.86 (95% CI:(0.58, 1.23)) for cardiac surgeries, 1.01 (95% CI:(0.77, 1.31)) for cardiac bypass surgeries with two incisions (CBGB), 1.43 (95% CI:(0.70, 2.63)) for CBG with one incision (CBGC), 0.8 (95% CI:(0.72, 0.90)) for colon surgeries (COLO), 0.98 (95% CI:(0.84, 1.14)) for hip replacement surgeries (HPRO), 0.7 (95% CI:(0.53, 0.91)) for abdominal hysterectomy surgeries (HYST), and 0.91 (95% CI:(0.75, 1.09)) for KPRO. Seven hospitals had a statistically significant KPRO SSI SIR value greater than 1.0. Three hospitals had a statistically significant HPRO SSI SIR value greater than 1.0. Two hospitals had a statistically significant COLO SSI SIR value greater than 1.0. Three hospitals had a statistically significant KPRO SSI SIR value greater than 1.0. Two hospitals had a statistically significant CBGB SSI SIR value greater than 1.0. Seven hospitals had a statistically significant COLO SSI SIR value less than 1.0. One hospital had a statistically significant HPRO SSI SIR value that was less than 1.0. One hospital had a statistically significant HYST SSI SIR value that was less than 1.0. The commonwealth met the 2020 HYST SSI goal.

2020 Clostridioides difficile infections (CDI LabID): Among the 7,046,240 patient days, 2,492 CDI LabID events were reported from 241 hospitals. Clostridioides difficile infection LabID events from children’s, critical access, and inpatient psychiatric hospitals were not required to be reported into NHSN. The state SIR was 0.61 (95% CI: (0.59, 0.64)), statistically lower than predicted from the 2015 national baseline. The SIR values from acute care hospitals, inpatient rehabilitation facilities and long-term acute care hospitals were statistically significantly lower than predicted from the 2015 national baseline. The SIR from acute care hospitals was 0.62 (95% CI: (0.59, 0.64)). The SIR value from long-term acute care hospitals was 0.48 (95% CI: (0.38, 0.61)). The SIR value from inpatient rehabilitation facilities was 0.62 (95% CI: (0.53, 0.72)). One facility had a statistically significant SIR value greater than 1.0. The state met the 2020 HHS HAI CDI goal of a 30% reduction in cases compared with the number predicted by the 2015 national baseline data.

2020 Methicillin-resistant Staphylococcus aureus Blood Infections (MRSA LabID): Among the 7,478,095 patient days, 426 MRSA LabID events were reported from 241 facilities. The MRSA LabID events from children’s, critical access, and inpatient psychiatric hospitals are not required to be reported to NHSN. The state SIR was 0.87 (95% CI: (0.79, 0.96)), statistically significantly lower than predicted from the 2015 national baseline. The lowest SIR was among long term acute care hospitals (SIR 0.68; 95% CI: (0.40, 1.08)). Two facilities had a statistically significant SIR value greater than 1.0.

Although a thorough investigation has not been completed, it is noteworthy that the total number of CAUTI, CLABSI, and MRSA blood infections increased by 131 (11.2%), 217 (21.8%), and 83 (24.2%), respectively, since 2019. The change in number of device and patient days ranged between -0.1% and 4.5%. The total number of CDIs decreased by 361 (12.7%) and there were 0.1% more CDI patient days.

The total number of SSIs from COLO, HYST, HPRO and KPRO decreased since 2019 and the number of procedures had similar percentage drops. There were 3% fewer COLO SSIs and 7.3% fewer procedures performed in 2019. There were 32.5% fewer HYST SSIs and 22.6% fewer procedures performed in 2019. There were 17.6% fewer HPRO SSIs and 14.3% fewer procedures performed in 2019. There were 19.7% fewer KPRO SSIs and 19% fewer procedures performed in 2019. There were the same number of CARD SSIs reported in 2019 as in 2020 and 7.2% more procedures were completed. There were 14.4% fewer CBGB procedures performed in 2019 than 2020, but there were 9 more SSIs. A similar situation occurred among CBGC procedures. There were 25.5% fewer procedures performed in 2019 than 2020, but there were 7 more SSIs.

According to CDC, each day, approximately one in 31 U.S. patients has at least one infection in association with his or her hospital care.¹ In Pennsylvania, this would equate to 55,496 people in 2020. The Pennsylvania Health Care Cost Containment Council (PHC4) reported that during 2020 there were 1,720,383 discharges from inpatient facilities.² While progress has been made since tracking HAIs began, significant opportunities still exist for hospitals to prevent HAIs. A review article that evaluated the effectiveness of multifaceted interventions across different HAIs from 2005 - 2016 found that 54.3% of CAUTIs, 45.9% of CLABSIs and 46.1% of SSIs can be prevented.³ The Department recommends that hospitals train staff and audit processes to ensure adherence to national guidelines, implement multifaceted interventions to prevent HAIs and perform surveillance to identify HAI clusters and outbreaks.