The case for a population standardized infection ratio (SIR): A metric that marries the device SIR to the standardized utilization ratio (SUR)

AbstractBackground:The device standardized infection ratio (SIR) is used to compare unit and hospital performance for different publicly reported infections. Interventions to reduce unnecessary device use may select a higher-risk population, leading to a paradoxical increase in SIR for some high-performing facilities. The standardized utilization ratio (SUR) adjusts for device use for different units and facilities.Methods:We calculated the device SIR (calculated based on actual device days) and population SIR (defined as Σ observed events divided by Σ predicted events based on predicted device days), adjusting for the facility SUR for both central-line–associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) in 84 hospitals from a single system for calendar years 2016 and 2017.Results:The central-line SUR was 1.02 for 801,172 central-line days, with a device SIR of 0.76 and a population SIR of 0.78, a 1.6% relative increase. On the other hand, the urinary catheter SUR was 0.90 for 757,504 urinary catheter days, with a device SIR of 0.84 and a population SIR of 0.76, a 10.0% relative decrease. The cumulative attributable difference for CAUTI to a target SIR of 1 was −135.4 for the device SIR compared to −203.66 for the population SIR, a 50.8% increase in prevented events.Conclusion:Population SIR accounts for predicted device utilization; thus, it is an attractive metric with which to address overall risk of infection or harm to a patient population. It also reduces the risk of selection bias that may impact the device SIR with interventions to reduce device use.

Download Full-text

Population Standardized Infection Ratio (pSIR): A More Meaningful Reflection of Performance With Reduction in Device Use

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.564 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s75-s75

Author(s):

Mamta Sharma ◽

Angelo Bufalino ◽

Ren-huai Huang ◽

Lisa Sturm ◽

Network Service ◽

...

Keyword(s):

Infection Prevention ◽

Risk Of Infection ◽

Infection Rates ◽

High Performing ◽

Prevention Interventions ◽

Utilization Ratio ◽

Device Use ◽

Tract Infections ◽

Relative Change ◽

Substantial Change

Background: Interventions to reduce unnecessary device use may select a higher-risk population, leading to a paradoxical increase in SIR for some high-performing facilities. The standardized utilization ratio (SUR) adjusts for device use for different units and facilities. We evaluated the performance of a population SIR (pSIR) metric compared to device SIR (dSIR) in the situations of increased, decreased, and no change in SUR for a large system. Methods: We evaluated hospitals that had a reduction, increase, and no substantial change (±5% relative change) in their SUR in FY2019 (July 2018–June 2019) compared to baseline FY2017 (July 2016–June 2017). The dSIR (defined as Σ observed events divided by Σ predicted events based on actual device days) and pSIR (defined as Σ observed events divided by Σ predicted events based on predicted device days). We calculated the cumulative attributable difference (CAD) for catheter-associated urinary tract infections (CAUTIs) for the same facilities based on dSIR and pSIR. Results: Overall, the system SUR dropped from 0.92 in 2017 to 0.85 in 2019 (7.3% decrease). Of the 48 hospitals included, 25 (52%) exhibited a drop, 13 (27%) exhibited an increase, and 10 (21%) had no change in SUR during 2019. For hospitals in which SUR decreased, the dSIR decreased by 15.9% from 0.88 to 0.74, and the pSIR decreased by 32.3% from 0.85 to 0.58 (Table 1). In 2019, the CAD for CAUTI to a target SIR of 1 was 133 for the dSIR compared to 181 for the pSIR, and 36% more events were avoided. Conclusions: The traditional SIR (dSIR) underestimated improvements in infection rates compared to the pSIR because it failed to account for reduced device utilization associated with infection prevention interventions. The pSIR accounts for overall risk of infection associated with device exposure in a population and better reflects the efficacy of prevention efforts compared to dSIR. The pSIR should be considered in situations in which interventions have led to substantial reductions in device use.Funding: NoneDisclosures: None

Download Full-text

Comparison of Metrics Used to Track CLABSIs and CAUTIs Across a Regional Network

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.710 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s178-s179

Author(s):

Sonali Advani ◽

Becky Smith ◽

Jessica Seidelman ◽

Nicholas Turner ◽

Christopher Hostler ◽

...

Keyword(s):

Negative Correlation ◽

Urine Culture ◽

Bloodstream Infections ◽

Central Line ◽

Regional Network ◽

Community Hospitals ◽

Scatter Plots ◽

Preventable Harm ◽

Device Use ◽

Tract Infections

Background: The standardized infection ratio (SIR) is the nationally adopted metric used to track and compare catheter-associated urinary tract infections (CAUTIs) and central-line– associated bloodstream infections (CLABSIs). Despite its widespread use, the SIR may not be suitable for all settings and may not capture all catheter harm. Our objective was to look at the correlation between SIR and device use for CAUTIs and CLABSIs across community hospitals in a regional network. Methods: We compared SIR and SUR (standardized utilization ratio) for CAUTIs and CLABSIs across 43 hospitals in the Duke Infection Control Outreach Network (DICON) using a scatter plot and calculated an R2 value. Hospitals were stratified into large (>70,000 patient days), medium (30,000–70,000 patient days), and small hospitals (<30,000 patient days) based on DICON’s benchmarking for community hospitals. Results: We reviewed 24 small, 11 medium, and 8 large hospitals within DICON. Scatter plots for comparison of SIRs and SURs for CLABSIs and CAUTIs across our network hospitals are shown in Figs. 1 and 2. We detected a weak positive overall correlation between SIR and SUR for CLABSIs (0.33; R2 = 0.11), but no correlation between SIR and SUR for CAUTIs (−0.07; R2 = 0.00). Of 15 hospitals with SUR >1, 7 reported SIR <1 for CLABSIs, whereas 10 of 13 hospitals with SUR >1 reported SIR <1 for CAUTIs. Smaller hospitals showed a better correlation for CLABSI SIR and SUR (0.37) compared to medium and large hospitals (0.19 and 0.22, respectively). Conversely, smaller hospitals showed no correlation between CAUTI SIR and SUR, whereas medium and larger hospitals showed a negative correlation (−0.31 and −0.39, respectively). Conclusions: Our data reveal a weak positive correlation between SIR and SUR for CLABSIs, suggesting that central line use impacts CLABSI SIR to some extent. However, we detected no correlation between SIR and SUR for CAUTIs in smaller hospitals and a negative correlation for medium and large hospitals. Some hospitals with low CAUTI SIRs might actually have higher device use, and vice versa. Therefore, the SIR alone does not adequately reflect preventable harm related to urinary catheters. Public reporting of SIR may incentivize hospitals to focus more on urine culture stewardship rather than reducing device utilization.Funding: NoneDisclosures: None

Download Full-text

COVID-19 Pandemic, CLABSI, and CAUTI: The Urgent Need to Refocus on Hardwiring Prevention Efforts

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2021.70 ◽

2021 ◽

pp. 1-22

Author(s):

Mohamad G. Fakih ◽

Angelo Bufalino ◽

Lisa Sturm ◽

Ren-Huai Huang ◽

Allison Ottenbacher ◽

...

Keyword(s):

Urinary Catheter ◽

Bloodstream Infections ◽

Central Line ◽

Coagulase Negative Staphylococcus ◽

Safe Environment ◽

Candida Sp ◽

Optimal Line ◽

Considerable Impact ◽

Tract Infections ◽

The Impact

Abstract Background: The coronavirus disease 2019 (COVID-19) pandemic has had a considerable impact on US hospitalizations, affecting processes and patient population. Methods: We evaluated the impact of COVID-19 pandemic in 78 US hospitals on central line associated bloodstream infections (CLABSI) and catheter associated urinary tract infections (CAUTI) events 12 months pre-COVID-19 and 6 months during COVID-19 pandemic. Results: There were 795,022 central line-days and 817,267 urinary catheter-days over the two study periods. Compared to pre-COVID-19 period, CLABSI rates increased during the pandemic period from 0.56 to 0.85 (51.0%) per 1,000 line-days (p<0.001) and from 1.00 to 1.64 (62.9%) per 10,000 patient-days (p<0.001). Hospitals with monthly COVID-19 patients representing >10% of admissions had a NHSN device standardized infection ratio for CLABSI that was 2.38 times higher compared to those with <5% prevalence during the pandemic period (p=0.004). Coagulase-negative staphylococcus CLABSI increased by 130% from 0.07 to 0.17 events per 1,000 line-days (p<0.001), and Candida sp. by 56.9% from 0.14 to 0.21 per 1,000 line-days (p=0.01). In contrast, no significant changes were identified for CAUTI (0.86 vs. 0.77 per 1,000 catheter-days; p=0.19). Conclusions: The COVID-19 pandemic was associated with substantial increases in CLABSI but not CAUTI events. Our findings underscore the importance of hardwiring processes for optimal line care, and regular feedback on performance to maintain a safe environment.

Download Full-text

Surveillance of Healthcare-Associated Bloodstream and Urinary Tract Infections in a National Level Network of Indian Hospitals

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.1043 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s398-s399

Author(s):

Purva Mathur ◽

Paul Malpiedi ◽

Kamini Walia ◽

Rajesh Malhotra ◽

Padmini Srikantiah ◽

...

Keyword(s):

Urinary Tract ◽

Data Quality ◽

Urinary Tract Infections ◽

Urinary Catheter ◽

National Level ◽

Central Line ◽

Infection Prevention And Control ◽

Utilization Ratio ◽

Tract Infections ◽

Healthcare Associated

Background: Healthcare-associated infections (HAIs) are a major global threat to patient safety. Systematic surveillance is crucial for understanding HAI rates and antimicrobial resistance trends and to guide infection prevention and control (IPC) activities based on local epidemiology. In India, no standardized national HAI surveillance system was in place before 2017. Methods: Public and private hospitals from across 21 states in India were recruited to participate in an HAI surveillance network. Baseline assessments followed by trainings ensured that basic microbiology and IPC implementation capacity existed at all sites. Standardized surveillance protocols for central-line–associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) were modified from the NHSN for the Indian context. IPC nurses were trained to implement surveillance protocols. Data were reported through a locally developed web portal. Standardized external data quality checks were performed to assure data quality. Results: Between May 2017 and April 2019, 109 ICUs from 37 hospitals (29 public and 8 private) enrolled in the network, of which 33 were teaching hospitals with >500 beds. The network recorded 679,109 patient days, 212,081 central-line days, and 387,092 urinary catheter days. Overall, 4,301 bloodstream infection (BSI) events and 1,402 urinary tract infection (UTI) events were reported. The network CLABSI rate was 9.4 per 1,000 central-line days and the CAUTI rate was 3.4 per 1,000 catheter days. The central-line utilization ratio was 0.31 and the urinary catheter utilization ratio was 0.57. Moreover, 3,542 (73%) of 4,742 pathogens reported from BSIs and 868 (53%) of 1,644 pathogens reported from UTIs were gram negative. Also, 1,680 (26.3%) of all 6,386 pathogens reported were Enterobacteriaceae. Of 1,486 Enterobacteriaceae with complete antibiotic susceptibility testing data reported, 832 (57%) were carbapenem resistant. Of 951 Enterobacteriaceae subjected to colistin broth microdilution testing, 62 (7%) were colistin resistant. The surveillance platform identified 2 separate hospital-level HAI outbreaks; one caused by colistin-resistant K. pneumoniae and another due to Burkholderia cepacia. Phased expansion of surveillance to additional hospitals continues. Conclusions: HAI surveillance was successfully implemented across a national network of diverse hospitals using modified NHSN protocols. Surveillance data are being used to understand HAI burden and trends at the facility and national levels, to inform public policy, and to direct efforts to implement effective hospital IPC activities. This network approach to HAI surveillance may provide lessons to other countries or contexts with limited surveillance capacity.Funding: NoneDisclosures: None

Download Full-text

Comparison of metrics used to track central-line–associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) across a regional network

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2021.297 ◽

2021 ◽

pp. 1-3

Author(s):

Sonali D. Advani ◽

Becky A. Smith ◽

Jessica Seidelman ◽

Nicholas Turner ◽

Deverick J. Anderson ◽

...

Keyword(s):

Urinary Tract ◽

Urinary Tract Infections ◽

Urine Culture ◽

Bloodstream Infections ◽

Central Line ◽

Regional Network ◽

Utilization Ratio ◽

Tract Infections

Abstract The paradoxical relationship between standardized infection ratio and standardized utilization ratio for catheter-associated urinary tract infections (CAUTIs) in contrast to central-line–associated bloodstream infections (CLABSIs), in addition to CAUTI definition challenges, incentivizes hospitals to focus their prevention efforts on urine culture stewardship rather than catheter avoidance and care.

Download Full-text

Device-Associated Infection Rates for Non–Intensive Care Unit Patients

Infection Control and Hospital Epidemiology ◽

10.1086/503339 ◽

2006 ◽

Vol 27 (4) ◽

pp. 357-361 ◽

Cited By ~ 56

Author(s):

Ralf-Peter Vonberg ◽

M. Behnke ◽

C. Geffers ◽

D. Sohr ◽

H. Rüden ◽

...

Keyword(s):

Intensive Care ◽

Urinary Tract ◽

Urinary Tract Infections ◽

Reference Data ◽

Urinary Catheter ◽

Bloodstream Infections ◽

Icu Patients ◽

Device Use ◽

Device Associated Infection ◽

Tract Infections

Background.Reference data from intensive care units (ICUs) are not applicable to non-ICU patients because of the differences in device use rates, length of stay, and severity of underlying diseases among the patient populations. In contrast to the huge amount of data available for ICU patients, appropriate surveillance data for non-ICU patients have been missing in Germany.Objective.To establish a new module (“DEVICE-KISS”) of the German Nosocomial Infection Surveillance System for generating stratified reference data for non-ICU wards.Setting.Non-ICU patients from 42 German hospitals.Methods.Monthly patient-days, device-days and nosocomial infections (NIs) (using Centers for Disease Control and Prevention definitions) were counted. Device use rates were calculated, and NI rates were stratified by different medical specialities.Results.From July 2002 through June 2004, among the 77 wards, there were a total of 536,955 patient-days and 74,188 device-days (for CVC-associated primary bloodstream infections, there were 181,401 patient-days and 8,317 central vascular catheter [CVC]-days in 29 wards; for urinary catheter–associated urinary tract infections, there were 445,536 patient-days and 65,871 urinary catheter–days in 65 wards) and 483 NIs (36 bloodstream infections and 447 urinary tract infections). The mean device use rates were 4.6 device-days per 100 patient-days for CVCs (29 wards) and 14.8 device-days per 100 patient-days for urinary catheters (65 wards), respectively. Mean device-associated NI rates were 4.3 infections per 1,000 CVC-days for CVC-associated bloodstream infections and 6.8 infections per 1,000 urinary catheter–days for catheter-associated urinary tract infections.ConclusionsDEVICE-KISS allows non-ICUs to recognize an outlier position with regard to NIs by providing well-founded reference data for non-ICU patients.

Download Full-text

A Decade in Trying to Increase Hand Hygiene—Finally Success

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.592 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s93-s94

Author(s):

Linda Huddleston ◽

Sheila Bennett ◽

Christopher Hermann

Keyword(s):

Hand Hygiene ◽

Hand Hygiene Compliance ◽

Compliance Rate ◽

Bloodstream Infections ◽

Central Line ◽

Second Phase ◽

Two Phase ◽

Hygiene Compliance ◽

Tract Infections ◽

The Voice

Background: Over the past 10 years, a rural health system has tried 10 different interventions to reduce hospital-associated infections (HAIs), and only 1 intervention has led to a reduction in HAIs. Reducing HAIs is a goal of nearly all hospitals, and improper hand hygiene is widely accepted as the main cause of HAIs. Even so, improving hand hygiene compliance is a challenge. Methods: Our facility implemented a two-phase longitudinal study to utilize an electronic hand hygiene reminder system to reduce HAIs. In the first phase, we implemented an intervention in 2 high-risk clinical units. The second phase of the study consisted of expanding the system to 3 additional clinical areas that had a lower incidence of HAIs. The hand hygiene baseline was established at 45% for these units prior to the voice reminder being turned on. Results: The system gathered baseline data prior to being turned on, and our average hand hygiene compliance rate was 49%. Once the voice reminder was turned on, hand hygiene improved nearly 35% within 6 months. During the first phase, there was a statistically significant 62% reduction in the average number of HAIs (catheter associated urinary tract infections (CAUTI), central-line–acquired bloodstream infections (CLABSIs), methicillin-resistant Staphylococcus aureus (MRSA), multidrug-resistant organisms (MDROs), and Clostridiodes difficile experienced in the preliminary units, comparing 12 months prior to 12 months after turning on the voice reminder. In the second phase, hand hygiene compliance increased to >65% in the following 6 months. During the second phase, all HAIs fell by a statistically significant 60%. This was determined by comparing the HAI rates 6 months prior to the voice reminder being turned on to 6 months after the voice reminder was turned on. Conclusions: The HAI data from both phases were aggregated, and there was a statistically significant reduction in MDROs by 90%, CAUTIs by 60%, and C. difficile by 64%. This resulted in annual savings >$1 million in direct costs of nonreimbursed HAIs.Funding: NoneDisclosures: None

Download Full-text

Effect of Removing Contact Precautions for Multidrug-Resistant Organisms on Hospital Infections in a Pediatric Health System

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.742 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s199-s200

Author(s):

Matthew Linam ◽

Dorian Hoskins ◽

Preeti Jaggi ◽

Mark Gonzalez ◽

Renee Watson ◽

...

Keyword(s):

Hand Hygiene ◽

Antibiotic Stewardship ◽

Infection Prevention ◽

Tertiary Care ◽

Bloodstream Infections ◽

Central Line ◽

Contact Precautions ◽

Stewardship Program ◽

Tract Infections ◽

The Impact

Background: Discontinuation of contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE) have failed to show an increase in associated transmission or infections in adult healthcare settings. Pediatric experience is limited. Objective: We evaluated the impact of discontinuing contact precautions for MRSA, VRE, and extended-spectrum β-lactamase–producing gram-negative bacilli (ESBLs) on device-associated healthcare-associated infections (HAIs). Methods: In October 2018, contact precautions were discontinued for children with MRSA, VRE, and ESBLs in a large, tertiary-care pediatric healthcare system comprising 2 hospitals and 620 beds. Coincident interventions that potentially reduced HAIs included blood culture diagnostic stewardship (June 2018), a hand hygiene education initiative (July 2018), a handshake antibiotic stewardship program (December 2018) and multidisciplinary infection prevention rounding in the intensive care units (November 2018). Compliance with hand hygiene and HAI prevention bundles were monitored. Device-associated HAIs were identified using standard definitions. Annotated run charts were used to track the impact of interventions on changes in device-associated HAIs over time. Results: Average hand hygiene compliance was 91%. Compliance with HAI prevention bundles was 81% for ventilator-associated pneumonias, 90% for catheter-associated urinary tract infections, and 97% for central-line–associated bloodstream infections. Overall, device-associated HAIs decreased from 6.04 per 10,000 patient days to 3.25 per 10,000 patient days after October 2018 (Fig. 1). Prior to October 2018, MRSA, VRE and ESBLs accounted for 10% of device-associated HAIs. This rate decreased to 5% after October 2018. The decrease in HAIs was likely related to interventions such as infection prevention rounds and handshake stewardship. Conclusions: Discontinuation of contact precautions for children with MRSA, VRE, and ESBLs were not associated with increased device-associated HAIs, and such discontinuation is likely safe in the setting of robust infection prevention and antibiotic stewardship programs.Funding: NoneDisclosures: None

Download Full-text

Costs of ambulatory pediatric healthcare-associated infections: Central-line–associated bloodstream infection (CLABSIs), catheter-associated urinary tract infection (CAUTIs), and surgical site infections (SSIs)

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.305 ◽

2020 ◽

Vol 41 (11) ◽

pp. 1292-1297

Author(s):

Michael L. Rinke ◽

Suzette O. Oyeku ◽

William J. H. Ford ◽

Moonseong Heo ◽

Lisa Saiman ◽

...

Keyword(s):

Urinary Tract ◽

Ambulatory Surgery ◽

Bloodstream Infections ◽

Surgical Site Infections ◽

Central Line ◽

Healthcare Associated Infections ◽

Retrospective Case ◽

Additional Costs ◽

Tract Infections ◽

Healthcare Associated

AbstractObjective:Ambulatory healthcare-associated infections (HAIs) occur frequently in children and are associated with morbidity. Less is known about ambulatory HAI costs. This study estimated additional costs associated with pediatric ambulatory central-line–associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTI), and surgical site infections (SSIs) following ambulatory surgery.Design:Retrospective case-control study.Setting:Four academic medical centers.Patients:Children aged 0–22 years seen between 2010 and 2015 and at risk for HAI as identified by electronic queries.Methods:Chart review adjudicated HAIs. Charges were obtained for patients with HAIs and matched controls 30 days before HAI, on the day of, and 30 days after HAI. Charges were converted to costs and 2015 USD. Mixed-effects linear regression was used to estimate the difference-in-differences of HAI case versus control costs in 2 models: unrecorded charge values considered missing and a sensitivity analysis with unrecorded charge considered $0.Results:Our search identified 177 patients with ambulatory CLABSIs, 53 with ambulatory CAUTIs, and 26 with SSIs following ambulatory surgery who were matched with 382, 110, and 75 controls, respectively. Additional cost associated with an ambulatory CLABSI was $5,684 (95% confidence interval [CI], $1,005–$10,362) and $6,502 (95% CI, $2,261–$10,744) in the 2 models; cost associated with a CAUTI was $6,660 (95% CI, $1,055, $12,145) and $2,661 (95% CI, −$431 to $5,753); cost associated with an SSI following ambulatory surgery at 1 institution only was $6,370 (95% CI, $4,022–$8,719).Conclusions:Ambulatory HAI in pediatric patients are associated with significant additional costs. Further work is needed to reduce ambulatory HAIs.

Download Full-text