results
Combined use of Clinical, Administrative & surveillance Data to CharacterizeIncidence and Outcomes of Healthcare Associated Infections (HAI) in aHighly Computerized Integrated Healthcare system
David J. Pombo, MD1, Bert K. lopansri, MD2, Michelle Keane, Bs, MBA3, Caroline taylor, rN, MsN, CIC1, ruth Kleckner, rN1, sharon sumner, rN, BsN1, rajesh r. Mehta, rPh, Ms and John P. Burke, MD1, (1)lDs Hospital, salt lake City, ut, (2)Infectious Diseases, Intermountain Healthcare, Murray, ut, (3)enterprise Analysis Corporation, stamford, Ct
1096
Background: HAIs increase morbidity, hospitalization, and cost. Increased scrutiny has been placed on HAIs associated with use of invasive medical devices. We describe the incidence, cost, and outcomes for device and non-device related HAIs.
Methods: HAIs were detected using an electronic surveillance tool & verified using standard NHSN definitions by 3 experienced infection preventionists for all inpatient encounters, >=18 years old, between July 1, 2008 and September 30, 2010. Cases were verified by review of electronic medical records and entered into a database at two urban hospitals comprising 640 beds. Clinical, cost, and demographic data were abstracted from the Enterprisewide Data Warehouse.
results: There were 79,839 admissions from 62,647 patients representing 319,149 patient days. We identified 2707 HAIs among 2240 admissions in 2080 patients. HAIs developed in 3.3% of all patients with a rate of 8.5 HAIs/1000 patient days. A total of 1876 (90.2%) & 364 (9.8%) admissions resulted in a single or multiple HAIs, respectively. Eighty percent of all HAIs in patients who experienced a single infection were attributed to five infections: catheter associated UTIs (29.6%), surgical site infections (26%), Clostridium difficile infection (10.6%), non-ventilator healthcare associated pneumonia (8%), non-catheter associated UTIs (7.7%). The length of stay and total costs associated with these infections were (median length of stay [25th & 75th percentile], median daily total cost [25th, 75th percentile]): catheter-associated UTIs 11 days [7,18], $2,775 [$2,050, $3,835]; surgical site infections 16 days [4,11], $1,849 [$1,904, $3,224]; Clostridium difficile infection 13 days [7,19], $2,972 [$2,163, $4,011]; non-ventilator healthcare associated pneumonia 13 days [8,20], $3,606 [$2,673, $4,577]; non-catheter associated UTIs 16 days [8,25], $1,849 [$1,618, $2,436]. The median duration of hospitalization for encounters with HAI was 12 days [6,21], with a median total cost of $33,626/ patient [$15,060, $68,716].
Conclusion: Catheter associated UTIs and surgical site infections remain as the most common cause of HAIs. Clostridium difficile has become the most common microbial cause of HAIs. Nearly half of all HAIs were non-device related.
Current surveillance for HAIs in US hospitals focuses on high risk conditions, medical devices, and procedures and on the prevalence of MDROs. There are scant data on the overall incidence of HAIs that occur hospital wide although an estimated 5% of patients have HAIs(1). The CDC/Emerging Infections Program has recently reported aggregated point prevalence results for HAIs from a large number of sites(2).
The overall goal of our study is to assess the potential for enhanced targeted infection prevention based on improved understanding of underlying conditions and risk factors predisposing to HAIs. The current study provides HAI incidence rates and an analysis of both device- and non-device associated infections as well as infections due to MDROs across the entire healthcare system.
ABstrACt MetHODs
INtrODuCtION
1. Ansell Healthcare, Iselin, NJ, Jamie Ashworth and Dr. Michael Zedalis for sponsoring the study. The sponsor had no role in design, conduct or analysis or interpretation of the data. The sponsor did aid in poster preparation.
2. Susan Farber and Emery Stephans at Enterprise Analysis Corp, Stamford, CT for contribution to study design, data analysis and interpretation.
3. The Enterprise Data Warehouse team at Intermountain Healthcare.
1. Burke, J.P., Infection control - a problem for patient safety. N Engl J Med, 2003. 348(7): p. 651-6.
2. Magill S, Reassessing the burden of HAIs in U.S. hospitals. Presented in session 108: New insights in evaluating Healthcare-associated infections in the U.S. ID Week 2012, San Diego.
For this study we excluded patients with multiple HAI acquired during a hospital stay. Such patients represent a substantial segment of all HAI, but we chose to analyze single HAI occurrences initially in order to more easily define comorbidities and outcomes data for individual HAI categories. Therefore this study very clearly underestimates the actual extent of the HAI problem and costs.
We present estimates of HAI incidence in a modern, tertiary care referral center based on hospital wide surveillance for all types of infections.
Our analysis provides estimates for device and non-device associated infections, as well as for MDRO and routinely susceptible organisms across the spectrum of HAI.
One half of all HAI were non-device related. Among device related infections the highest incidence were CAUTI and CLABSI respectively, with VAP accounting for a minimal number of cases.
Catheter associated UTIs and surgical site infections were the most common cause of HAIs in our our populations. We used active surveil-lance for detection of CAUTI, and NHSN definitions current at the time of data collection.
Clostridium difficile has become the most common microbial cause of HAI.
Further analysis of underlying conditions and procedures associated with HAI, with comparison to the underlying population, can permit the development of more sophisticated prediction models for HAI.
ACKNOwleDgeMeNts
refereNCe
lIMItAtIONs
CONClusION
Contact InformationDavid J. Pombo, M.D, D(ABMM)
The HELP (Health Evaluation and Logical Processing) hospital information system (HIS) serves as the clinical computing system to all of the Intermountain hospitals. We collected the data from the Enterprise Data Warehouse systems that stores clinical/surveillance data from the HELP system in addition to the administrative & finance data related to each patient encounter.
All patients >= 18 years age, admitted to LDS Hospital or Intermountain Medical Center, inpatient service between July1, 2008 and September 30, 2010 were included in the study.
Infection preventionists at Intermountain Healthcare use a locally developed database program to detect, record and confirm nosocomial infections using standard Centers for Disease Control and Prevention (CDC) definitions.
Underlying conditions and procedures were determined using ICD9 codes (International Statistical Classification of Diseases and Related Health Problems) assigned upon discharge. Most assignments such as Diabetic (Type II) include several ICD9 codes which were reviewed, grouped and confirmed by the study team.
CAUTI SSI GIT UTI VAP SSTI BSI PNEU CLABSI
N 556 487 198 145 40 122 32 150 131
Daily cost, median
[25th, 75th percentile]
$2,775[$2,050, $3,799]
$2,436 [$1,904, $3,224]
$2,972 [$2,163, $4,011]
$1,849 [$1,618, $2,436]
$4,626 [$3,777, $5,581]
$2,129 [$1,644, $3,132]
$2,530 [$2,014, $2,957]
$3,606 [$2,673, $4,577]
$3,241 [$2,690, $4,112]
Length of Stay, daysmedian
[25th, 75th percentile]
11[7, 18]
5 [4, 11]
13 [7, 19]
16 [8, 25]
21 [15, 28] 5 [2, 12] 10
[6, 15]13
[8, 20]20
[14, 35]
Mortality 3.4% 0.6% 7.1% 0.0% 22.5% 0.0% 9.4% 18.0% 9.9%
MeDIAN [INterquArtIle rANge] DAIly COst, leNgtH Of stAy AND MOrtAlIty fOr tHe HAIs.HAI retrOsPeCtIve OutCOMe stuDy
BACTERIA
Gram Negative Bacteria
Gra
m N
egat
ive
Bac
teria
Gram Positive Cocci
Gra
m P
osit
ive
Coc
ci
Anaerobes
Ana
erob
e
Can
dida
alb
ican
s an
d ye
ast
Not
Cul
ture
d/O
ther
Pro
teus
mirab
ilis
Pse
udom
onas
aer
ugin
osa
Ser
rati
a m
arce
scen
s
Ente
roba
cter
clo
acae
All
Oth
er G
ram
Neg
ativ
e
Ente
roco
ccus
fae
calis
Ente
roco
ccus
fae
cium
Ente
roco
ccus
(A
ll O
ther
)
MR
SA
/Sta
ph A
Sta
phyl
ococ
cus
coag
neg
ativ
e
Sta
phyl
ococ
cus
epid
erm
is
Str
epto
cocc
us (
All)
VR
E
All
Oth
er G
ram
Pos
itiv
e
C. D
iffici
le
Bac
teriod
es fra
gilis
Ana
erob
es (
All
Oth
er)
Esch
eric
hia
coli
Kle
bsie
lla *
CAUTI 165 63 12 53 2 21 68 384 85 4 24 11 2 17 0 17 16 176 0 0 0 0 52 6
SSI 28 9 3 15 0 15 22 92 38 9 6 97 30 16 37 5 8 246 1 25 21 52 14 231
GIT 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 197 0 0 197 0 0
UTI 58 19 7 10 0 5 13 112 17 0 2 3 0 7 2 4 1 36 0 0 0 0 4 6
VAP 3 7 0 2 0 1 18 31 0 0 0 10 0 1 6 0 0 17 0 0 0 0 2 3SSTI 1 1 1 5 0 0 2 10 2 0 0 14 4 5 9 0 0 34 0 0 1 2 3 85
BSI 0 4 0 1 1 0 1 7 3 2 0 12 0 2 3 0 2 24 0 2 0 3 2 0
PNEU 5 3 0 6 7 3 25 49 1 0 1 19 10 2 14 0 1 48 0 0 0 0 0 83
CLABSI 8 3 0 6 0 3 2 22 5 5 0 6 21 40 4 10 18 109 0 0 3 3 6 4
URI 0 0 0 0 0 0 0 0 2 0 0 4 1 0 0 0 0 7 0 0 1 1 0 4
OTHER 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 3
269 109 23 98 10 48 152 709 153 20 33 176 68 90 75 37 46 698 198 27 26 258 83 418
Fungi
DIstrIButION Of MICrOOrgANIsMs IDeNtIfIeD By tyPe Of HAI
PR
OC
EDU
RA
L A
CTI
VIT
IES
AN
D I
NTE
RV
ENTI
ON
S
SSI GIT UTI VAP SSTI BSI PNEU CLABSI URI Other
321 88 32 32 37 8 80 31 7 1
242 68 24 17 29 6 71 19 4 0
68 16 8 11 7 1 7 8 2 0
11 4 0 4 1 1 2 4 1 1
160 99 51 26 39 20 80 32 6 3
55 71 17 40 19 9 95 47 9 0
15 53 7 38 4 7 63 37 7 0
40 18 10 2 15 2 32 10 2 0
7 34 7 26 3 4 70 27 5 0
73 27 9 8 5 2 20 19 0 1
21 19 4 7 5 3 19 10 3 0
11 25 10 6 4 2 16 13 0 2
62 15 4 4 1 3 9 4 0 0
64 10 3 4 9 1 4 5 0 1
63 10 4 2 2 1 9 7 1 0
6 18 0 10 2 1 29 17 1 0
7 7 2 6 5 2 11 8 4 0
3 7 3 6 10 2 14 4 3 0
0 7 4 14 2 2 14 11 2 0
60 0 1 0 5 0 2 0 0 0
2 4 2 0 1 0 5 26 1 0
0 1 2 0 3 1 8 3 0 0
4 7 6 4 1 2 9 3 1 0
123 86 28 29 20 12 74 99 6 2
17 21 15 16 21 4 29 11 3 0
CAUTI
211
159
43
9
317
173
87
86
68
42
48
36
22
18
14
12
41
41
17
2
9
13
34
181
106
65 85 23 11 9 4 2 27 8 0 1
Surgery
Surgery: 1 Surgery
Surgery: 2 or 3 Surgeries
Surgery 4 or more Surgeries
ER Entry
On Ventilator
On Ventilator >96 Hours
On Ventilator <96 Hours
Endotrachial Tube Insertion
Intestinal Surgery
Pleural Incision
Hemodialysis
Laparoscopy
Wound Debridement
Abdominal Paracentesis
Endoscopic Bronchial Biopsy
Cardiac Catheterization
Coronary Arteriography
Tracheostomy
C-Section
Bone Marrow Biopsy
Stent Placement
Head CT
Transfusion
Cardiothoracic Surgery
Orthopedic Surgery
PAtIeNt HAI rIsK AssessMeNt usINg ADMINIstrAtIve ICD9 PrOCeDure CODes
754
607
293 247
217 209 160
118 75
28%
50%
61%
70%
78%
86%
92% 96%
99%
0%
20%
40%
60%
80%
100%
0
100
200
300
400
500
600
700
800
CAUTI SSI GIT PNEU UTI CLABSI SSTI BSI VAP
80% of HAIs at IMC and LDS fall within these categories
Catheter Associated
Urinary Tract Infection
Surgical Site Infection
Gastro-Intestinal Infection
Ventilator Associated Pneumonia
Blood Stream Infection
Urinary Tract Infection
Skin and Soft Tissue
Infection
Central Line Associated
Blood Stream Infection
Pneumonia
Note: Upper Respiratory Infections (n=22) and Other Infections (n=4) were excluded from in-depth analysis
BreAKOut Of HAIs: All PAtIeNts, N=2,707
2,240 encounters
ITU2178%
ITUAC754 28%
ISB118 4%
GIT 293 11%
ISS607 22%
VAP 75 3%
ITSS160 6%
ISBALC209 8%
PNEU 247 9%
Bone Marrow
Transplant 87
Floors 49
Medical Surgery ICU
15
Floors 165
Neurology 107
Shock Trauma ICU
100 13%
OR 391
Labor & Delivery
86
Bariatric Surgery
64
Floors 105
Shock Trauma ICU
42
Bone Marrow
Transplant 31
Floors 59
Shock Trauma ICU
27
Bone Marrow
Transplant 26
Bone Marrow
Transplant 85
Shock Trauma ICU
27
Floors 26
Labor & Delivery
57
Cath Lab 22
Physical Therapy
12
Operating Room
26
General Floors
23
Shock Trauma ICU
12
Shock Trauma ICU
32 22% 40% 64% 36% 24% 41% 36% 22% 43%
Thoracic ICU 14
14% 23% 14% 14% 11% 13% 14% 19% 19%
Neurology/Post Stroke
14 7% 11% 11% 11% 12% 8% 10% 19%
20% or Higher
HAIs At IMC AND lDs HOsPItAl By DePArtMeNtOverAll stAtIstICs
Starting date for retrospective study July 2008
Ending date for retrospective study September 2010
Calendar time covered by study 26 months
Patients admitted during this period 62,647(IMC and LDS)
Total admissions during period 79,839(Multiple encounters for some patients at IMC and LDS)
Total patient days accumulated by patients 319,149(IMC and LDS)
Overall average length of stay 4.0 days(All patients and encounters at IMC and LDS)
Number of patients who developed HAI 2,080 3.3%
Number of HAIs acquired 2,707
Number of admissions resulting in HAIs 2,240 2.8%
LOS for HAI patients 16.42 days
Number of HAIs per 1,000 patient days 8.48