healthcare associated infections report 2014 hospital

STATEOFNEWHAMPSHIREHEALTHCAREASSOCIATEDINFECTIONS

2014HOSPITALREPORT

August3,2015

NewHampshireDepartmentofHealthandHumanServicesDivisionofPublicHealthServices

State of New Hampshire Healthcare-Associated Infections 2014 Hospital Report

NHDepartmentofHealthandHumanServices August3,2015DivisionofPublicHealthServices

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TABLEOFCONTENTSLISTOFDATATABLES.....................................................................................................................4LISTOFFIGURES.............................................................................................................................5INDIVIDUALHOSPITALREPORTS...................................................................................................6ABBREVIATIONSUSEDINTHISDOCUMENT.................................................................................7CONTRIBUTORSANDACKNOWLEDGMENTS................................................................................8EXECUTIVESUMMARY...................................................................................................................9I.INTRODUCTION.........................................................................................................................12Purpose......................................................................................................................................12Audience....................................................................................................................................12HowtoUsethisDocument.......................................................................................................12BackgroundonHealthcareAssociatedInfections....................................................................13NewHampshireHealthcareAssociatedInfectionsProgram....................................................13StateofNewHampshireHealthcareAssociatedInfectionsPlan.............................................14OverviewofHealthcareAssociatedInfectionsPreventionEfforts..........................................14HealthcareAssociatedInfectionsTechnicalAdvisoryWorkgroup...........................................15

II.SURVEILLANCEMETHODS........................................................................................................182014HealthcareAssociatedInfectionsReportingRequirementsforHospitals......................18SelectionofReportingRequirements.......................................................................................18AccuracyofReportedHealthcareAssociatedInfectionsSurveillanceData.............................20NationalHealthcareSafetyNetwork........................................................................................20ComparisonswithNationalData..............................................................................................21CentralLineAssociatedBloodstreamInfectionsSurveillance..................................................21CentralLineInsertionPracticesMonitoring.............................................................................22CatheterAssociatedUrinaryTractInfectionsSurveillance......................................................22SurgicalSiteInfectionsSurveillance..........................................................................................23SurgicalAntimicrobialProphylaxisAdministrationMonitoring................................................25InfluenzaVaccinationPercentageMonitoring..........................................................................26

III.STATEWIDEDATA....................................................................................................................28StatewideStandardizedInfectionRatios..................................................................................28OverallStandardizedInfectionRatiosbyHospital....................................................................31CentralLineAssociatedBloodstreamInfections......................................................................37



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CentralLineInsertionPractices.................................................................................................45CatheterAssociatedUrinaryTractInfections...........................................................................51SurgicalSiteInfections..............................................................................................................57SurgicalAntimicrobialProphylaxisAdministration...................................................................72InfluenzaVaccinationPercentages...........................................................................................72

IV.CONCLUSIONS.........................................................................................................................81V.ACUTECAREHOSPITALREPORTS............................................................................................82APPENDIX1:TechnicalNotes....................................................................................................143APPENDIX2:InfluenzaVaccinationSurveyQuestions,20142015Season.............................147APPENDIX3:UnderstandingtheRelationshipbetweenHealthcareAssociatedInfectionRatesandStandardizedInfectionRatioComparisonMetrics............................................................149APPENDIX4:PreventingHealthcareAssociatedInfections.....................................................151APPENDIX5:MapofNewHampshireHospitals,2014.............................................................156REFERENCES................................................................................................................................157



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LISTOFDATATABLESTable1.Statewidestandardizedinfectionratios.......................................................................................30Table2.Overallhealthcareassociatedinfectionsstandardizedinfectionratios.......................................32Table3.Overallhealthcareassociatedinfectionsstandardizedinfectionratios,comparisonbetween2013and2014.....................................................................................................................................................34Table4.Overallhealthcareassociatedinfectionsstandardizedinfectionratiosbyhospital,comparisonbetween2013and2014.............................................................................................................................36Table5.Statewideratesforcentrallineassociatedbloodstreaminfections............................................37Table6.Statewideratesforcentrallineassociatedbloodstreaminfectionsinneonatalintensivecareunitsbybirthweightcategory..............................................................................................................................38Table7.Centrallineassociatedbloodstreaminfectionsrates..................................................................40Table8.Centrallineassociatedbloodstreaminfectionsratesinneonatalintensivecareunitsbybirthweightcategory...................................................................................................................................41Table9.Centrallineassociatedbloodstreaminfectionsstandardizedinfectionratios............................42Table10.Centrallineassociatedbloodstreaminfectionsstandardizedinfectionratios,comparisonbetween2013and2014.............................................................................................................................44Table11.Centrallineinsertionpracticesadherencepercentagesbyoccupationofinserter...................46Table12.Centrallineinsertionpracticesadherencepercentagesbyhospital..........................................47Table13.Centrallineinsertionpracticesadherencepercentagesbyoccupationofinserter,comparisonbetween2013and2014.............................................................................................................................49Table14.Centrallineinsertionpracticesadherencepercentagesbyhospital,comparisonbetween2013and2014.....................................................................................................................................................50Table15.Statewideratesforcatheterassociatedurinarytractinfections...............................................51Table16.Catheterassociatedurinarytractinfectionrates.......................................................................53Table17.Catheterassociatedurinarytractinfectionsstandardizedinfectionratios...............................54Table18.Catheterassociatedurinarytractinfectionsstandardizedinfectionratios,comparisonbetween2013and2014............................................................................................................................................56Table19.Surgicalsiteinfectionsstandardizedinfectionratios.................................................................59Table20.Surgicalsiteinfectionsstandardizedinfectionratios,comparisonbetween2013and2014....61Table21.Coronaryarterybypassgraftprocedureassociatedsurgicalsiteinfectionsstandardizedinfectionratios...........................................................................................................................................................62Table22.Colonprocedureassociatedsurgicalsiteinfectionsstandardizedinfectionratios...................63Table23.Abdominalhysterectomyprocedureassociatedsurgicalsiteinfectionsstandardizedinfectionratios...........................................................................................................................................................65Table24.Kneearthroplastyprocedureassociatedsurgicalsiteinfectionsstandardizedinfectionratios67Table25.PostdischargesurveillancemethodsandpercentageofSSIdetectedpostdischargeinNewHampshirehospitals,20132014................................................................................................................71Table26.InfluenzavaccinationpercentagesforhospitalHCPbyhospital,201415influenzaseason...73Table27.Influenzavaccinationpercentagesforhospitalhealthcarepersonnelbyhospital,comparisonbetween201314and201415influenzaseasons.....................................................................................77Table28.Influenzavaccinationpoliciesandconsequencesforhealthcarepersonnelbyhospital,201415influenzaseason..........................................................................................................................................79



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LISTOFFIGURESFigure1.TypesofhealthcareassociatedinfectionsreportedtoNHDepartmentofHealthandHumanServices.............................................................................................................................17Figure2.Statewidestandardizedinfectionratios........................................................................31Figure3.Overallhealthcareassociatedinfectionsstandardizedinfectionratios.......................33Figure4.Statewidestandardizedinfectionratios,comparisonbetween20102014.................35Figure5.Statewideratesforcentrallineassociatedbloodstreaminfectionsinneonatalintensivecareunitsbybirthweightcategory...............................................................................38Figure6.Statewideratesforcentrallineassociatedbloodstreaminfections.............................39Figure7.Centrallineassociatedbloodstreaminfectionsstandardizedinfectionratios.............43Figure8.Overallcentrallineassociatedbloodstreaminfectionsstandardizedinfectionratiosbyyear,20102014............................................................................................................................45Figure9.Centrallineinsertionpracticesadherencepercentagesbyhospital............................48Figure10.Statewideratesforcatheterassociatedurinarytractinfections................................52Figure11.Catheterassociatedurinarytractinfectionsstandardizedinfectionratios................55Figure12.Overallcatheterassociatedurinarytractinfectionsstandardizedinfectionratiosbyyear,20122014............................................................................................................................57Figure13.Surgicalsiteinfectionsstandardizedinfectionratios.................................................60Figure14.Coronaryarterybypassgraftprocedureassociatedsurgicalsiteinfectionsstandardizedinfectionratios........................................................................................................62Figure15.Colonprocedureassociatedsurgicalsiteinfectionsstandardizedinfectionratios....64Figure16.Abdominalhysterectomyprocedureassociatedsurgicalsiteinfectionsstandardizedinfectionratios..............................................................................................................................66Figure17.Kneearthroplastyprocedureassociatedsurgicalsiteinfectionsstandardizedinfectionratios..............................................................................................................................68Figure18.Overallsurgicalsiteinfectionstandardizedinfectionratiosbyyear,20102014......69Figure19.Overallcoronaryarterybypassgraftprocedurestandardizedinfectionratiosbyyear,20102014.....................................................................................................................................69Figure20.Overallcolonprocedurestandardizedinfectionratiosbyyear,20102014...............70Figure21.Overallabdominalhysterectomystandardizedinfectionratiosbyyear,20122014.70Figure22.Overallkneearthroplastystandardizedinfectionratiosbyyear,20102014............70Figure23.StatewideinfluenzavaccinationpercentagesforhospitalHCPbyinfluenzaseason.72Figure24.Influenzavaccinationpercentagesforhealthcarepersonnelbyhospital,201415influenzaseason............................................................................................................................74Figure25.Influenzavaccinationpercentagesforhealthcarepersonnelbyhospital,201314and201415influenzaseasons............................................................................................................76Figure26.Influenzavaccinationpercentagesforhospitalswithandwithoutvaccinationpolicies,201415influenzaseason.............................................................................................................78



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INDIVIDUALHOSPITALREPORTSAlicePeckDayMemorialHospital 83AndroscogginValleyHospital.. 85CatholicMedicalCenter.. 87CheshireMedicalCenter. 89ConcordHospital.. 91CottageHospital 93DartmouthHitchcockMedicalCenter.. 95ElliotHospital.. 97ExeterHospital.. 99FranklinRegionalHospital. 101FrisbieMemorialHospital.. 103HugginsHospital.. 105LakesRegionGeneralHospital 107LittletonRegionalHospital. 109MonadnockCommunityHospital. 111NewLondonHospital... 113ParklandMedicalCenter 115PortsmouthRegionalHospital 117SouthernNewHampshireMedicalCenter 119SpeareMemorialHospital. 121St.JosephHospital.. 123TheMemorialHospital. 125UpperConnecticutValleyHospital. 127ValleyRegionalHospital.. 129WeeksMedicalCenter. 131WentworthDouglassHospital.. 133CrotchedMountainRehabilitationCenter 135HampsteadHospital.. 136HealthSouthRehabilitationHospital.. 137NewHampshireHospital.. 138NortheastRehabilitationHospitalatTheElliot.. 139NortheastRehabilitationHospitalatPease. 140NortheastRehabilitationHospital,Salem 141NortheastRehabilitationHospital,SouthernNewHampshireMedicalCenter.. 142Note:DHMCreferstoDartmouthHitchcockMedicalCenter(MaryHitchcockMemorialHospital).NERehabreferstoNortheastRehabilitationHospitalandispresentedasfourfacilitieswithspecifiedlocations.CrotchedMountainreferstoCrotchedMountainRehabilitationCenter.



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ABBREVIATIONSUSEDINTHISDOCUMENTASAScore AmericanSocietyofAnesthesiologists(ASA)ClassificationofPhysicalStatusASC Ambulatorysurgicalcenter(s)BSI Bloodstreaminfection(s)CABG Coronaryarterybypassgraftprocedure(s)CAUTI Catheterassociatedurinarytractinfection(s)CBGB NHSNoperativecodeforcoronaryarterybypassgraftprocedure(s)withbothachestanddonorsiteincisionCBGC NHSNoperativecodeforcoronaryarterybypassgraftprocedure(s)withchestincisionsiteonlyCCN CMSCertificationNumberCDC U.S.CentersforDiseaseControlandPreventionCLABSI Centrallineassociatedbloodstreaminfection(s)CLIP CentrallineinsertionpracticesCMS CentersforMedicareandMedicaidServicesCOLO NHSNoperativecodeforcolonprocedure(s)CrotchedMountain CrotchedMountainRehabilitationCenterDHMC DartmouthHitchcockMedicalCenter(MaryHitchcockMemorialHospital)DHHS NewHampshireDepartmentofHealthandHumanServicesHAI Healthcareassociatedinfection(s)HCP HealthcarepersonnelHICPAC HealthcareInfectionControlPracticesAdvisoryCommitteeHHS U.S.DepartmentofHealthandHumanServicesHYST NHSNoperativecodeforabdominalhysterectomyprocedure(s)ICU Intensivecareunit(s)KPRO NHSNoperativecodeforkneearthroplastyprocedure(s)NERehab NortheastRehabilitationHospitalNH NewHampshireNHHCQAC NewHampshireHealthcareQualityAssuranceCommissionNHSN NationalHealthcareSafetyNetworkRSA RevisedStatutesAnnotatedSCIP SurgicalCareImprovementProjectSIR Standardizedinfectionratio(s)SSI Surgicalsiteinfection(s)TAW HealthcareAssociatedInfectionsTechnicalAdvisoryWorkgroupVAP Ventilatorassociatedpneumonia(s)



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CONTRIBUTORSANDACKNOWLEDGMENTSThe following individuals contributed to the review and analysis of data and other contentprovidedinthisreport:ChristineAdamski,MS,Chief,BureauofInfectiousDiseaseControlElizabethR.Daly,MPH,Chief,InfectiousDiseaseSurveillanceSectionJohnDreisig,MPH,VaccinePreventableDiseaseSurveillanceCoordinatorRenelleGagnon,MPH(inprogress),HealthcareAssociatedInfectionsProgramInternKatrinaE.Hansen,MPH,HealthcareAssociatedInfectionsProgramManagerErinMetcalf,MPH,HIV/AIDSSurveillanceCoordinatorElizabethA.Talbot,MD,DeputyStateEpidemiologistRozaTammer,MPH,HealthcareAssociatedInfectionsSurveillanceCoordinatorTylorYoung,GISAnalyst,InfectiousDiseaseSurveillanceSectionTheHAIProgramwouldalso like to thank the InfectionPrevention,Quality,and InformationTechnologystaffatNewHampshirehospitalsforcollaboratingtoprovidethedatapresentedinthis report. Finally, theHAI Program acknowledges the review, comments, input, and otherprogram contributions provided by the members of the HealthcareAssociated InfectionsTechnicalAdvisoryWorkgroupaslistedonpage16.Forquestionsaboutthisreport,pleasecontact:NewHampshireHealthcareAssociatedInfectionsProgramInfectiousDiseaseSurveillanceSectionDivisionofPublicHealthServicesNHDepartmentofHealthandHumanServices29HazenDrive,Concord,NH033016504Phone:(603)2714496Email:[email protected]:http://www.dhhs.nh.gov/dphs/cdcs/hai/index.htm



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EXECUTIVESUMMARYAhealthcareassociatedinfection(HAI)isaninfectionthatapatientacquiresduringthecourseofreceivingtreatmentforanotherconditionwithinahealthcaresetting.Anestimated722,000HAIand75,000associateddeathsoccurredinUnitedStates(U.S.)acutecarehospitalsin2011.iDuringthe2006 legislativeseason,theNewHampshire(NH)LegislaturepassedabillcreatingNHRevisedStatutesAnnotated(RSA)151:3235,whichrequireshospitalstoidentify,track,andreportselectedHAItotheNHDepartmentofHealthandHumanServices(DHHS).All26ofNH'sacute care hospitals began reporting data to DHHS on two infections and three processmeasuresinJanuary2009,andfivespecialtyhospitalsreportedinfluenzavaccinationcoverage.ThisreportrepresentsthesixthsummaryofHAIrelateddatareportedbyhospitalsinNH.HealthcareAssociatedInfectionsinNewHampshireHospitalsTherewere fewer infections thanpredicted inNHbasedonnationaldata.A totalof219HAIwere reported, representing 124 surgical site infections (SSI), 27 central lineassociatedbloodstream infections (CLABSI), and 68 catheterassociated urinary tract infections (CAUTI).TheobservednumberofHAIinNHhospitalswas15%fewerthanpredictedbasedonnationaldata. Therewere 39% fewer CLABSI, 26%more CAUTI, and 22% fewer SSI than predicted.Twentytwohospitalshadsufficientlyrobustdata1topresenthospitalspecificdataforoverallHAI.Ofthese,fourhospitalshadanoverallnumberofinfectionsthatwaslowerthanpredictedbasedonnationaldataandtwohospitalshadanoverallnumberof infectionsthatwashigherthan predicted based on national data. The remaining 16 all observed a similar number ofinfections as predicted based on national data. The total number of infections occurringincreased in 2014 in comparison to 2013; however, this difference was not statisticallysignificant.CentralLineAssociatedBloodstreamInfectionsTwentyfourhospitals2withintensivecareunits(ICU)reportedCLABSIdatafromtheirICU.Datawererobustenoughforhospitalstopresentdatafor20individualICUinthisreport.NineteenICUexperiencedsimilarratesofCLABSIincomparisontonationalrates,whileonehospitalICUexperiencedahigherrateofCLABSIcomparedwithnationaldata.ThetotalnumberofCLABSIreported increased in2014 compared to2013;however, thisdifferencewasnot statisticallysignificant.CentralLineInsertionPracticesThe hospitals2 with ICU reported information on central line insertion practices (CLIP) forcentral lines inserted in their ICU. Statewide adherence to the four infection preventionpractices during central line insertions was 98.3%. Compared with attending physicians,registerednursesmore frequently adhered to the four infectionpreventionpracticesduringcentral line insertions (99.9%versus95.8%).Datawere sufficiently robust for12hospitals to 1Dataarenotshownforfacilitieswithlessthanonepredictedinfection,fewerthan50centrallinesorcatheterdays,andfewerthan20centrallineinsertionsperformed.2Ofthe34hospitalslicensedin2014,only24hospitalshadICUinwhichtomonitorCAUTI,CLABSI,andCLIP.



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present hospitalspecific data in this report. Eleven hospitals reported CLIP adherencepercentagesthatweresimilartotheStatepercentage,andonehospitalreportedanadherencepercentage that was lower than the State percentage. In 2014, the statewide adherencepercentageforCLIPdecreasedfrom2013(98.4%);however,thisdecreasewasnotstatisticallysignificant.Ofthe12hospitalsforwhichavailabilityofdataallowedacomparisonbetweenthetwo years, 11 hospitals CLIP adherence was similar in 2014 compared to 2013, and onehospitalsCLIPadherencewaslowerthanin2013.CatheterAssociatedUrinaryTractInfectionsDataweresufficientlyrobustenoughforhospitalstopresentCAUTIdatafor27individualICUinthis report. Twentyfive ICU experienced similar rates of CAUTI in comparisonwith nationalrates,whiletwohospitalICUexperiencedahigherrateofCAUTIcomparedwithnationaldata.The total number of CAUTI reported increased in 2014 compared to 2013; however, thisdifferencewasnotstatisticallysignificant.SurgicalSiteInfectionsTwentysix3acutecarehospitalsreportedSSIdataforfoursurgicalprocedures.

CoronaryArteryBypassGraft (CABG)Procedures:FouracutecarehospitalsperformedCABG,anddataweresufficientlyrobustforallfourhospitalstopresenthospitalspecificdata in this report. Three hospitals reported a similar number of CABG procedureassociatedSSIcomparedwithnationaldata,andonehospitalreported fewerSSIthanpredictedbasedonnationaldata.Overall, therewere fewerCABGSSI thanpredictedbasedonnationaldata.

Colon (COLO)Procedures:Twentyfiveacute carehospitalsperformed theprocedure,anddataweresufficientlyrobustfor14hospitalstopresenthospitalspecificdatainthisreport. Ten hospitals reported a similar number of colon procedureassociated SSIcomparedwithnationaldata,twohospitalsreportedfewerSSIthanpredictedbasedonnationaldata,and twohospitals reportedmoreSSI thanpredictedbasedonnationaldata. Overall, there were a similar number of colon procedureassociated SSI aspredictedbasedonnationaldata.

Abdominal Hysterectomy (HYST) Procedures: Twentyfour acute care hospitalsperformed the procedure, and data were sufficiently robust for eight hospitals topresent hospitalspecific data in this report. All eight hospitals reported a similarnumberofabdominalhysterectomyprocedureassociatedSSIcomparedwithnationaldata. Overall, there were a similar number of abdominal hysterectomy procedureassociatedSSIaspredictedbasedonnationaldata.

KneeArthroplasty(KPRO)Procedures:Twentyfouracutecarehospitalsperformedtheprocedure,anddataweresufficientlyrobustfor10hospitalstopresenthospitalspecificdata in this report. Eight hospitals reported a similar number of knee arthroplastyprocedureassociated SSI compared with national data, and two hospitals reportedfewerSSIthanpredictedbasedonnationaldata.Overall,therewasasimilarnumberofkneearthroplastyrelatedSSIaspredictedbasedonnationaldata.

3 Ofthe34hospitalslicensedin2014,only26hospitalsperformedproceduresinwhichtomonitorSSI.



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SurgicalAntimicrobialProphylaxisAdministrationSurgicalantimicrobialprophylaxisdata is reported to theCenters forMedicareandMedicaidServices(CMS)throughtheSurgicalCareImprovementProject(SCIP).Inpreviousyears,DHHSaccessed thesedataandpresented it in this report. At the timeof this reportspublication,2014datawasunavailableandconsequentlyisnotincludedinthisreport.InfluenzaVaccinationCoverageinHospitalHealthcarePersonnelAll34acutecare,psychiatric,andrehabilitationhospitalsreportedhealthcarepersonnel(HCP)influenza vaccination percentages. Vaccination coverage by hospital ranged from 69.6% to100%, and the hospital State percentage was 93.5%. Nine hospitals had vaccinationpercentages similar to the overall State vaccination percentage, 11 hospitals reportedvaccination percentages that were significantly higher than the overall State vaccinationpercentage, and 14 hospitals reported vaccination percentages thatwere significantly lowerthan the overall State vaccination percentage. The statewide hospital HCP vaccinationpercentage increased significantly from the201314 influenza season (93.0%) to the201415influenza season (93.5%). Specifically, seven hospitals increased HCP influenza vaccinationcoverage in 201415 compared to the 201314 influenza season, 19 hospitals had similarvaccinationcoverage,andsevenhospitalsdecreasedvaccinationcoverage.ConclusionThis sixth report of hospital HAI data displays continuous progress toward the goal ofeliminatingHAIinNH.ThisreportprovidesapictureofselectedHAIdata,whichcanbeusedbyhealthcare facilities in the state to identifyareas for improvementandpreventionaswellashealthcareconsumerstomakeinformedhealthcaredecisions.



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I.INTRODUCTIONA.PurposeThisreportrepresentsthesixthsummaryofhealthcareassociatedinfection(HAI)relateddatareportedbyhospitals inNewHampshire (NH)duringcalendaryear2014. This reportcanbeusedbyhealthcarefacilitiesinthestatetoidentifyareasforimprovementaswellbyhealthcareconsumerstomakeinformedhealthcaredecisions.B.AudienceTheintendedaudiencemayinclude,butisnotlimitedto:healthcarepersonnel(HCP),infectioncontrol and prevention staff, facility leadership andmanagement, clinicians, and healthcareconsumers.C.HowtoUsethisDocumentThis document includes aggregate data reported by all 34 acute care, critical access, andspecialtyhospitalsinNH.Thisreportalsoincludesindividualhospitalreportsonpage83.Thedocumentconsistsofsixsections:

I) IntroductionII) SurveillancemethodsIII) Statewidedata

a. OverallNHdatab. Centrallineassociatedbloodstreaminfections(CLABSI)c. Centrallineinsertionpractices(CLIP)d. Catheterassociatedurinarytractinfections(CAUTI)e. Surgicalsiteinfections(SSI)followingcoronaryarterybypassgraft(CABG),colon

(COLO), abdominal hysterectomy (HYST), and knee arthroplasty (KPRO)procedures

f. Postdischargesurveillancemethodsg. Surgicalantimicrobialprophylaxisadministrationh. PercentageofHCPreceivinginfluenzavaccination

IV) ConclusionsV) IndividualhospitalreportsVI) Appendices

a. Technicalnotesb. Influenzavaccinationsurveyquestions,201415seasonc. Understanding the relationship betweenHAI rates and standardized infection

ratio(SIR)comparisonmetricsd. PreventingHAIe. MapofNHhospitals



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Please contact the NH Department of Health and Human Services (DHHS) HealthcareAssociatedInfectionsProgram(6032714496)withanyquestionsaboutthecontentorhowtousethisdocument.D.BackgroundonHealthcareAssociatedInfectionsAnHAI is an infection that a patient acquires during the course of receiving treatment foranotherconditionwithinahealthcaresetting.Anestimated722,000HAIand75,000associateddeaths occurred inUnited States (U.S.) acute care hospitals in 2011.ii Thismay represent adecreasingtendbecausepreviousstudiesdepicthighernumbersofHAI;1.7million infectionsand99,000deathseachyear.iiiBytheseestimates,HAIareamongthetop10leadingcausesofdeathintheU.S.,and510%ofallhospitaladmissionsarecomplicatedbyHAI.ivTheeconomicburdenofHAI is substantialand increasing.The totalcostofHAIhasbeenestimatedat$33billion per year in U.S. hospitals.v The most common HAI are pneumonia, gastrointestinalillness,primarybloodstreaminfections(BSI),andSSI.iiE.NewHampshireHealthcareAssociatedInfectionsProgramThe NH DHHS has been developing and improving a HAI surveillance program since 2007.Duringthe2006legislativeseason,theNHLegislaturepassedabillcreatingNHRevisedStatutesAnnotated(RSA)151:3235,whichrequireshospitalstoidentify,track,andreportHAItoDHHS.RSA 151:33 specifically requires reporting of CLABSI, SSI, ventilatorassociated pneumonia(VAP),CLIP,surgicalantimicrobialprophylaxis,andinfluenzavaccinationcoverage.TheintentofthebillistoprovideHAIdatabyhospitalinapubliclyaccessibleforum.Becausethebilldidnotinclude funding tocarryout theseactivities,mandatory reportingwasnot fully implementeduntilJanuary2009.DHHS, with consideration of the law, required that eligible hospitals initially report thefollowingmeasures:

CLABSI in adult intensive care units (ICU) (via NHSN).Only those hospitalswith ICUenrollandreportdatatoNHSN.

CLIPinallICU(viaNHSN).OnlythosehospitalswithICUenrollandreportdatatoNHSN. SSI following CABG, colon, and knee arthroplasty procedures (viaNHSN).Only those

hospitalsthatperformtheselectedproceduresenrollandreportdatatoNHSN. Surgical antimicrobial prophylaxis (via Centers for Medicare and Medicaid Services

[CMS]). Only those hospitals that administer antimicrobial prophylaxis report thesedata.

Influenza vaccination in patients andHCP (viaDHHSwebbased survey).All hospitals(includingrehabilitationandpsychiatric)reportinfluenzavaccinationinHCP.

All26acutecarehospitalssuccessfullyenrolledinNHSNandbeganreportingtherequireddatainJanuary2009.



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Duringthe2010legislativeseason,theNHLegislaturepassedHouseBill1548(2010)amendingRSA151:3235torequirealllicensedambulatorysurgerycenters(ASCs)toreportHAItoDHHS.HAIdata reportedbyASC ispublished in a separate report andposted to theHAIProgrampublicationswebsite:http://www.dhhs.nh.gov/dphs/cdcs/hai/publications.htm.The administrative rules related toHAI reportingwere revised in 2011 to include additionalreportingmeasuresforeligiblehospitals.StartingJanuary2012,hospitalswerealsorequiredtoreport:

CLABSIinallICU(viaNHSN) CLIPinallICU(viaNHSN) Catheterassociatedurinary tract infections (CAUTI) in allpediatric and adult ICU (via

NHSN) SSIfollowingabdominalhysterectomy(HYST)procedures(viaNHSN)

F.StateofNewHampshireHealthcareAssociatedInfectionsPlanInresponsetoincreasingconcernsaboutthepublichealthimpactofHAI,theU.S.Departmentof Health and Human Services (HHS) developed its Action Plan to Prevent HealthcareAssociated Infections (HHS Action Plan) in 2009. The HHS Action Plan includesrecommendations for surveillance, research, communication, and metrics for measuringprogress toward national goals. In a concurrent development, the 2009 OmnibusAppropriationsActrequiredstatesreceivingPreventiveHealthandHealthServicesBlockGrantfundstocertifythattheywouldsubmitaplantoreduceHAItotheSecretaryofHHSnotlaterthanJanuary1,2010.InordertoassiststatesinrespondingwithintheshorttimelinerequiredbythatlanguageandtofacilitatecoordinationwithnationalHAIpreventionefforts,theCentersforDiseaseControlandPrevention(CDC)providedatemplatetoassiststateplanningeffortsinthepreventionofHAI.Thetemplatetargeted fourareas:1)DevelopmentorEnhancementofHAIProgramInfrastructure;2)Surveillance,Detection,Reporting,andResponse;3)Prevention;and4)Evaluation,Oversight,andCommunication.In2009,DHHSdrafteditsStateHAIPlanandsubmittedittoHHS.UpdatestotheplanareinprogressandwillbepostedtotheHAIProgramwebsite:http://www.dhhs.nh.gov/dphs/cdcs/hai/index.htm.G.OverviewofHealthcareAssociatedInfectionsPreventionEffortsDHHSparticipatesinstatewidepreventionactivitiesthroughtheNHHealthCareQualityAssurance Commission (NHHCQAC), onwhich theDivision of PublicHealth Services directorserves.DHHS isactive invariousprojectscoordinatedby theNHHCQACand theCMSQualityInnovationNetworkQuality ImprovementOrganization (QINQIO).Majorstatewide initiativesthroughtheseorganizationshave includedhandhygienecampaigns,patientsafetychecklists,andprogramstopreventBSI,antimicrobialresistance,andClostridiumdifficile.Additionally,theFoundation for Healthy Communities received a large grant through the Partnership forPatientsprogram to conductadditional large, statewideprevention initiatives.Foradditionalinformationonthesevariousefforts,thefollowingwebsitesmaybehelpful:



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NewHampshireHealthCareQualityAssuranceCommission:http://www.healthynh.com/fhcinitiatives/nhhealthcarequalityassurancecommission.htmlCMSQINQIOforConnecticut,Maine,Massachusetts,NH,RhodeIsland,andVermont:www.HealthCareForNewEngland.orgFoundationforHealthyCommunitiesPartnershipforPatients:http://www.healthynh.com/partnershipforpatients.htmlInadditiontosupportingandengaging inpreventionactivitieswithpatientsafetygroups,theHAIProgramprovideseducationalopportunitiestohealthcarefacilitiesacrossthestateinordertosharebestpracticesforinfectionpreventionandultimatelyreduceHAI.H.HealthcareAssociatedInfectionsTechnicalAdvisoryWorkgroupInthespringof2009,DHHSformedanHAITechnicalAdvisoryWorkgroup(TAW).ThepurposeoftheTAWistoprovidescientificand infectionpreventionexpertisetotheHAIProgram.TheTAWmeetsquarterly,andasaforumforstakeholderparticipation indecisionmakingaroundtheHAIProgram.TheTAW iscurrentlya21membergroupthat includesrepresentationfromstakeholdersacrossNHand includesrepresentativesfromvarioussizesandtypesofhospitalsandASC,infectioncontrolassociations,aconsumeradvocate,theNHHospitalAssociation,theNewHampshireHealthcareQualityAssurance Commission, theNewHampshireAmbulatorySurgeryAssociation,andtheNortheastHealthCareQualityFoundation(seepage17foralistofTAWmembersduringthe2014reportingyear).



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HEALTHCAREASSOCIATEDINFECTIONSTECHNICALADVISORYWORKGROUP

Members OrganizationRepresentationBenjaminChan,MD,MPH DHHS,StateEpidemiologistBethDaly,MPH DHHS,InfectiousDiseaseSurveillanceSectionChiefMichaelFleming DHHS,HealthFacilitiesAdministrationKatrinaHansen,MPH DHHS,HAIProgramManagerElizabethTalbot,MD DHHS,DeputyStateEpidemiologistRozaTammer,MPH DHHS,HAIProgramSurveillanceCoordinatorJoeConley,COO ConcordHospital(NewHampshireHospitalAssociation)AnneNolan,RN,BSN,CIC CheshireHospital(NewHampshireHospitalAssociation)AnneDiefendorf,MS,RD,LD NewHampshireHealthCareQualityAssuranceCommissionLyndaCaine,RN,MPH,CIC ConcordHospital(NewHampshireInfectionControland

EpidemiologyProfessionals)JanLarmouth,MS,CIC SouthernNewHampshireMedicalCenter(AcuteCare)ElissaMalcolm,MS DartmouthHitchcockMedicalCenter(AcuteCare)DarleneBurrows,RN,BSN,CIC FranklinRegionalHospital(CriticalAccess)CharlieWhite,COO* UpperConnecticutValleyHospital(CriticalAccess)CathyMartin,CPRN* NortheastRehabilitation(Rehabilitation)TerriKangasFeller,BS,RN,CIC* NewHampshireHospital(Psychiatric)TanyaLord,MPH,PhD ConsumerRepresentativeDonnaQuinn,RN,BSN,MBA OrthopaedicSurgeryCenter(AmbulatorySurgicalCenter)RobinSheppard,RN BedfordAmbulatorySurgicalCenter(AmbulatorySurgicalCenter)BeverlyPrimeau,RN,MBA ConcordASC(NewHampshireAmbulatorySurgeryAssociation)MargaretCrowley,RN,PhD NortheastHealthCareQualityFoundation(QIO)*ServedonTAWforpartof2014DHHS:NewHampshireDepartmentofHealthandHumanServices



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Figure1.TypesofhealthcareassociatedinfectionsreportedtoNHDepartmentofHealthandHumanServices



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II.SURVEILLANCEMETHODS A.2014HealthcareAssociatedInfectionsReportingRequirementsforNewHampshireHospitalsReportingrequirementsaregovernedbyRSA151:33withauthoritygiventoDHHStodevelopadministrativerulestoprovidespecificreportinginstructionsandmethodology.Administrativerules,HeP309HealthcareAssociatedInfections,weredraftedin2010withstakeholderinputand approved January 14, 2011 by the Joint Legislative Committee onAdministrative Rules.Reportingrequirementsfor20092014includedthefollowingrequiredmeasuresforhospitals:

CLABSIinadultICU CLIPinadultICU SSIfollowingCABG,colon,andkneearthroplastyprocedures Surgicalantimicrobialprophylaxis InfluenzavaccinationinpatientsandHCP

Theruleswereupdatedin2012toincludethefollowingrequiredmeasuresforhospitals:

CLABSIinallICU CLIPinallICU CAUTIinalladultandICU SSIfollowingCABG,colon,abdominalhysterectomy,andkneearthroplastyprocedures Surgicalantimicrobialprophylaxis InfluenzavaccinationinpatientsandHCP

Whileall licensedhospitals includingacutecareandspecialtyhospitalsarerequiredtoreportthe selectedmeasures under RSA 151:33, specialty hospitals (rehabilitation and psychiatrichospitals)arenotrequiredtoreportCAUTI,CLABSIandCLIP,becausetheydonothaveICU,norSSI and surgical antimicrobial prophylaxis administration data, because they do not performsurgeries.ThefiverehabilitationandtwopsychiatrichospitalsinNHareonlyrequiredtoreportinfluenzavaccinationcoverageforpatientsandHCP. B.SelectionofReportingRequirementsRSA 151:33 broadly requires reporting of all SSI and CLABSI; however, it is not feasible toperform surveillance for all of these infections using NHSN. In order to generate infectionmeasuresforhospitalsandcomparethemwithnationaldata,infectionreportingwaslimitedtothe capabilities of NHSN and measures were selected in accordance with nationalrecommendationsforHAIsurveillanceinthecontextofpublicreporting.In 2005, the CDC released a report titled Guidance on Public Reporting of HealthcareAssociatedInfections:RecommendationsoftheHealthcareInfectionControlPracticesAdvisoryCommittee (HICPAC).vi The group recommended selecting outcomemeasures for reporting



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basedon the frequency,severity,andpreventabilityof theoutcomesand the likelihood thattheycanbedetectedandreportedaccurately.Specifically,thegrouprecommendedmonitoringthefollowingoutcomemeasures:

CLABSIinICU SSIfollowingselectedoperations CAUTI and VAP were not recommended because of lower morbidity and mortality

resulting in lesspreventioneffectiveness relative to theburdenofdatacollectionandreporting (in the case of CAUTI), and difficulty in detecting infections accuratelyresultingininvalidandmisleadingcomparisonsofinfectionratesforconsumers(inthecaseofVAP)

Additionally,thegrouprecommendedmonitoringthefollowingprocessmeasures:

CLIP Surgicalantimicrobialprophylaxis InfluenzavaccinationofpatientsandHCP

In 2008, the HealthcareAssociated Infections Working Group4 of the Joint Public PolicyCommitteereleasedEssentialsofPublicReportingofHealthcareAssociatedInfections:AToolKit.vii The working group agreed with the CDC/HICPAC document, Guidance on PublicReporting of HealthcareAssociated Infections (referenced above) and recommendedexclusion of outcomemeasures related toVAP and CAUTI because the existing surveillancecriteria are difficult to apply consistently, making case counts unreliable. The toolkitrecommendsmonitoringthefollowingoutcomemeasures:

CLABSIinICU Surgicalproceduresthatareperformedwithadequatefrequencytopermitmeaningful

comparisons among institutions. Specific reasonable options listedwere: 1)CABG; 2)colon resection; 3) totalhip arthroplasty; 4) total knee arthroplasty; 5) laminectomy;and6)totalabdominalhysterectomy

TheonlyprocessmeasurethegrouprecommendedmonitoringwasHCP influenzavaccinationcoverage.Within thecontextofRSA151:33,DHHS reviewed thenationalguidelinesandcapabilitiesofNHSN in selecting infection and process measures. It is expected that these reportingrequirementsmaychangeinthefutureaswelearnfrompublicreporting,asHAIepidemiologyevolves,andasnewsurveillancemethodsandreportingtechnologiesbecomeavailable.

4 TheHealthcareAssociatedInfectionWorkingGroupoftheJointPublicPolicyCommitteeisamultiorganizationalgrouprepresentedbytheAssociationforProfessionalsinInfectionControlandEpidemiology,CDC,CouncilofStateandTerritorialEpidemiologists,andSocietyforHealthcareEpidemiologyofAmerica.



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C.AccuracyofReportedHealthcareAssociatedInfectionsSurveillanceData DHHSconductedavalidationstudyof20092010datatoassessthedegreeofunderandoverreporting and toprovide additional training to address any commonor systematic errors inreportingprocesses.DHHS contractedwith an independent, external agency toperform thevalidation studyandHAIProgram staffparticipated inactivities includingNHSNdata review,medical record review, data analysis, corrections, and followup for deficiencies. Overall,validation of 20092010 data showed that therewas approximately 33% underreporting ofCLABSI and SSI combined across all NH hospitals. This underreporting wasmostly due tomisunderstandings of the NHSN definitions for HAI. In addition to underreporting, thevalidation studies also found 12% of CLABSI and SSIwere over reported and not classifiedaccurately (i.e., reporting an infection that was not truly a CLABSI or SSI). The 2014 datapresented in this report have not been validated and must be interpreted with theunderstandingthat ingeneraltherearebothunderandoverreportingofHAI.However,theHAIProgramisplanningtovalidatedataonarollingbasisstartinginthefallof2015.Severalprocessesareusedtoensurethatthese201415dataareasaccurateaspossible.First,DHHSselectedNHSNformandatoryreporting,whichrequirestheuseofstandardizedinfectiondefinitionsandreportingmethods.Second,DHHSanalyzedandreviewedalldatareportedfor2014 from each hospital. This review identified any obvious reporting errors or internalinconsistencies that suggestederrors.Third,DHHSprovidedpreliminarydata reports toeachhospitalwiththerequesttoconfirmaccuracy.Thisreconciliationprocesswasiterativeuntilallhospitalsmadecorrectionsandagreedtothereporteddata.Lastly,20092010datavalidationwas performed, reducing systematic errors that may have occurred during the reportingprocess; thishas likelyresulted ina lasting improvement todataquality,even inyearswhenvalidationdoesnottakeplace.Despitetheabovemeasures,thereareseveral limitationstothereportingmethodsthatmaylimitcomparisonofdataacrosshospitals.Definitionsforclassifyinganinfectionashealthcareassociated are standardized through the use of NHSN; however, methods to identify theinfectionineachhospitalarenot.Forexample,hospitalsmayusedifferentmethodstoidentifyCLABSI (e.g., reviewing laboratory records, reviewing ICU records) or may have differentapproachestodiagnosingandmanagingsuspectCLABSIintheICU.ForSSI,identifyingpatientswhodevelopinfectionsafterdischargefromthehospitalcanbedifficult,andeachhospitalmayuse a differentmethod of postdischarge surveillance (e.g., letters to surgeons, conductingchartreviewsforsurgicalpatients,callingsurgeonoffices).Thesedifferentapproachesvary insensitivity.Seepage57formoredetailsabouthowhospitalsidentifySSI. D.NationalHealthcareSafetyNetworkNHSN is a voluntary, secure, internetbased surveillance system for healthcare facilities tomonitorpatient safetyand infectionpreventionmeasures.Enrollment isopen toall typesofhealthcarefacilitiesintheU.S.DHHSselectedNHSNbecauseitiswidelyusedacrosstheentireU.S.,itoffersalreadydevelopedandacceptedsurveillancedefinitionsandmethods,itprovidesnationalcomparisondata,andthereisnocosttouseorjointhesystem.



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MoreinformationaboutNHSNisavailableat:http://www.cdc.gov/nhsn/index.html. E.ComparisonswithNationalDataAllSSIcomparisonswithnationaldatause20062008NHSNdatapublished in theNationalHealthcare Safety Network (NHSN) report: Data summary for 2006 through 2008, issuedDecember2009.viiiAlldeviceassociated infection (CLABSI andCAUTI) comparisonswithnationaldatause 2013datapublished in theNationalHealthcareSafetyNetwork (NHSN) report:Datasummary for2013,DeviceAssociatedModuleissuedMarch2015.ixThesereportsareavailableat:http://www.cdc.gov/nhsn/dataStat.html.F.CentralLineAssociatedBloodstreamInfectionsSurveillanceACLABSIisalaboratoryconfirmedBSIthatdevelopsafterinsertionofacentrallineandisnotsecondarytoan infectionatanotherbodysite.Acentral line isan intravascularcatheterthatterminates at or close to the heart or in one of the great vessels and is used for infusion,withdrawalofblood,orhemodynamicmonitoring.HospitalsarerequiredtomonitorandreportCLABSI inadult ICU.Thismonitoring includesreportingthenumberof infections identifiedaswellasthetotalnumberofcentrallinedaysintheunit.ThesemetricsaremonitoredfollowingNHSNprotocolsanddefinitions,andreportedinNHSN.Centrallinedaysarethenumberofpatientswithoneormorecentrallinesofanytype,whicharecountedatthesametimeeachdayandaggregatedoverthereportingperiod.Forexample,apatientwithacentrallineinplaceforfivedayswouldbecountedasfivecentrallinedays.DetaileddescriptionsoftheNHSNCLABSIsurveillanceprotocolsareavailableat:http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf.LimitationsforCLABSIsurveillance:

NHSNonlyallowsformonitoringCLABSI in inpatientunits.InNH in2014,CLABSIweremonitored inall ICU (includingpediatricandneonatal ICU)andnot inother inpatientlocations.

Onehospital reclassified its ICU typehalfway through2014,making comparisonovermultipleyearsimpossible.

Validation of 20092010 data showed that there was approximately 43% underreporting of CLABSI across all NH hospitals. This underreportingwasmostly due tomisunderstandings about the NHSN definition for CLABSI. In addition to underreporting, the validation studies also found 11% of overreporting (i.e., reporting aninfection thatwasnot trulyaCLABSI).The2014CLABSIdatapresented in this reporthavenotbeenvalidatedandmustbeinterpretedwiththeunderstandingthatingeneraltherearebothunderandoverreportingofinfections.



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G.CentralLineInsertionPracticesMonitoringCLIPmonitoringassesseskeyinfectionpreventionpracticesthatoccurduringtheinsertionofacentralline.Acentrallineisanyintravascularcatheterusedforinfusion,bloodwithdrawal,orhemodynamicmonitoringthatterminatesatorclosetotheheartorinoneofthegreatvessels.Inordertocomplywithallinfectionpreventionpracticesduringtheinsertion,theinsertermust1)performhandhygienepriortoinsertion;2)useallfivebarriers(gloves,gown,cap,mask,anddrape);3)useanappropriateskinpreparationagent;and4)ensureskinisdrypriortoinsertion.HospitalsmonitorandreportCLIPdatathroughNHSNusingallNHSNprotocolsanddefinitions.In2014,hospitalswererequiredtomonitorallcentral line insertionsthatwereplaced in ICU(which includes pediatric, neonatal, and step down units). The NHSN CLIP protocols areavailableat:http://www.cdc.gov/nhsn/PDFs/pscManual/5psc_CLIPcurrent.pdf.Occupationalgroupsarecomparedwith theoverallStatecompliancepercentage since therearenonationaldataforcomparison.GroupswithaconfidenceintervalthatoverlapstheStatesconfidence interval are considered to be similar to the State adherence percentage. Anyoccupation or hospitalwith a confidence interval that is higher than the States confidenceinterval is considered to have a significantly higher percentage than the State adherencepercentage.GroupswithaconfidenceintervalthatislowerthantheStatesconfidenceintervalareconsideredtohaveasignificantlylowerpercentagethantheStateadherencepercentage.Limitationsforcentrallineinsertionpracticesmonitoring:

InNH,CLIPwasmonitored inallICU(includingpediatricandneonatalICUs)andnot inother settingswhere central linesmay be inserted (e.g., operating room, procedurerooms,emergencyroom,dialysiscenters).

The person recording the insertion practicesmay differ in each hospital. This personmaybeanobserverorthepersondoingtheinsertion,whichmayimpactqualityofdataonadherencereported.

H.CatheterAssociatedUrinaryTractInfectionsSurveillanceA CAUTI is a urinary tract infection that develops after insertion of an indwelling urinarycatheter and is not secondary to an infection at another body site. An indwelling urinarycatheterisadrainagetubethatisinsertedintotheurinarybladderthroughtheurethraandleftinplace,andisconnectedtoadrainagebag.TheyaresometimescalledFoleycathetersandareused for intermittent or continuous irrigation or urine drainage. Hospitals are required tomonitor and report CAUTI in all ICU (excluding neonatal ICU and step down units). Thismonitoringincludesreportingthenumberofinfectionsidentifiedaswellasthetotalnumberofcatheter days in the unit. These metrics are monitored following NHSN protocols anddefinitionsandreportedinNHSN.Catheterdaysrepresentthenumberofpatientswithoneormoreindwellingurinarycathetersofanytype,countedatthesametimeeachdayandaggregatedoverthereportingperiod.Forexample,apatientwithacatheterinplaceforfivedayswouldbecountedasfivecatheterdays;



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onepatientwith a catheter foroneday and anotherwith a catheter for fourdays are alsocountedasfivecatheterdays.DetaileddescriptionsoftheNHSNCAUTIsurveillanceprotocolsareavailableat:http://www.cdc.gov/nhsn/PDFs/pscManual/7pscCAUTIcurrent.pdf.LimitationsforCAUTIsurveillance:

NHSNonlyallowsformonitoringCAUTIininpatientunits.InNHin2014,CAUTIweremonitoredinallICU(excludingneonatalICU)andnotinotherinpatientlocations.

The 2014 CAUTI data presented in this report have not been validated andmust beinterpretedwith the understanding that in general there are both under and overreportingofinfections.

I.SurgicalSiteInfectionsSurveillanceAnSSIisaninfectionthatdevelopsatthesiteofasurgicalprocedure.Therearedifferentwaysto classify an SSI, such as whether it is superficial, in deep tissue, or in the organ/space.MonitoringforanSSImaycontinueforaslittleas30daysoraslongas90daysbasedondepthandproceduretype(e.g.,kneearthroplasty,CABG).In2014,hospitalswererequiredtomonitorandreportSSIforthreeprocedures:

CoronaryArteryBypassGraft(chestincisionanddonorsite)o NHSNOperativeProceduresCBGC(coronaryarterybypassgraftprocedureswith

chestincisionsiteonly)andCBGB(coronaryarterybypassgraftprocedureswithbothachestanddonorsiteincision)(ICD9:36.1036.17,36.19,36.2)

ColonSurgery(incision,resection,oranastomosisofthe large intestine; includes largetosmallandsmalltolargebowelanastomosis;doesnotincluderectaloperations)

o NHSNOperativeProcedureCOLO(ICD9:17.3117.36,17.39,45.03,45.26,45.41,45.49,45.52,45.7145.76,45.79,45.8145.83,45.9245.95,46.03,46.04,46.10,46.11,46.13,46.14,46.43,46.52,46.75,46.76,46.94)

AbdominalHysterectomy(includesthatbylaparoscope)o NHSNOperativeProcedureHYST(ICD9:68.31,68.39,68.41,68.49,68.61,68.69)

KneeArthroplastyo NHSNOperativeProcedureKPRO(ICD9:00.8000.84,81.54,81.55)

SSI monitoring includes total counts as well as patientlevel information for all patientsundergoingthesameprocedure.Thisallows forappropriateriskadjustment,becauserisk fordevelopmentofanSSIcanbeinfluencedbypatientandprocedurespecificfactors.Patientandprocedure risk factors thatareconsideredwhenassessingSSISIRbyhospitalvaryby typeofprocedurebutincludefactorssuchas:

Operationlastingmorethanthedurationofcutpointhours5 5Cutpointsareassignedbaseduponthetimethatthemajority(75%)ofaspecificproceduretakestoperform.Thedurationcutpointismeasuredinminutesandisthetimebetweentheskinincisionandskinclosure.



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Contaminated(ClassIII)orDirty/Infected(ClassIV)surgicalwoundclass American Society of Anesthesiologists (ASA) Classification of Physical Status

scoreof3,4,or5(seebelow) Ageofthepatient Genderofthepatient Hospitalbedsize Hospitalsmedicalschoolaffiliation Whetherthesurgerywastheresultoftrauma

Thewoundclassisawayofdetermininghowcleanordirtytheoperativebodysitewasatthetimeoftheoperation.Operationbodysitesaredividedintofourclasses:

Class I/Clean:An uninfected operation body site is encountered and the respiratory,digestive,genital,oruninfectedurinarytractsarenotentered.Class II/CleanContaminated:Operationbody sites inwhich the respiratory,digestive,genital,orurinarytractsareenteredundercontrolledconditionsandwithoutunusualcontamination.Class III/Contaminated: Operation body sites that have recently undergone trauma,operationswithmajorbreaksinsteriletechnique(e.g.,opencardiacmassage),orgrossspillagefromthegastrointestinaltract.ClassIV/DirtyorInfected:Includesoldtraumaticwoundswithretaineddeadtissueandthosethatinvolveexistinginfectionorperforatedintestines.

TheASAscoreisascaleusedbytheanesthesiologisttoclassifythepatientsphysicalconditionprior to surgery. It is one of the factors that help determine a patients risk of possiblydevelopinganSSI.TheASAscaleis:

1.Normallyhealthypatient2.Patientwithmildsystemicdisease3.Patientwithseveresystemicdisease4.Patientwithanincapacitatingsystemicdiseasethatisaconstantthreattolife5.Apatientwhoisnotpredictedtosurvivewithorwithouttheoperation

AllSSImetricsaremonitoredfollowingNHSNprotocolsanddefinitionsandreportedinNHSN.TheNHSNSSIprotocolsareavailableat:http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf.In general, most SSI identified during the initial hospital encounter or those that requirereadmission are thought to be wellrepresented in HAI surveillance data. However, theinfections thatdevelopafter thepatient isdischargedhome thatdonot require readmissionare thought to be lesswellrepresented, as inclusion in surveillance requires the healthcarefacilitytoproactivelyseekouttheseinfections,aprocessknownaspostdischargesurveillance.



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Theproportionofinfectionsdetectedthroughpostdischargesurveillanceincomparisontothestate average may provide an indicator of how well the facility is able to identify theseinfections,whichultimatelycanimpactthefacilitysSSISIR(bettersurveillancemayresultinahigherSIR).SSIdatadetectedthroughpostdischargesurveillancewereanalyzedfor20132014andinfectioncontrolstaffwereinterviewedregardingmethodsofSSIsurveillancein2011.Thepercent of SSI detected postdischargewas calculated for each hospital and compared to amoving state average (hospital vs. all other hospitals). Statistical significancewas calculatedusingtheNHSNStatisticsCalculator.LimitationsforSSIsurveillance:

Hospitals do not use a standard method of postdischarge surveillance to identifyinfections once a patient has been discharged. This poses a challenge for datainterpretation,becauseahigherSSIrate(forexample)atagivenhospitalmayrepresenteitherpoorinfectionpreventionpracticesor,conversely,abettersystemforidentifyinginfections. Postdischarge surveillancemethods were analyzed to better understandthesedifferencesbetweenfacilitiesandarepresentedinthisreportonpage57.

SSI reporting in NHSN requires not only reporting of infections but also detailedinformationoneachpatientundergoingtheprocedurebeingmonitored.Thisallowsforriskadjustment.Assuch,DHHShaselectedtomonitorasubsetofproceduresbasedonnational recommendations since it would not be feasible for hospitals to reportinformation on every patient receiving a surgical procedure due to the burden ofreporting.

Some procedures requiremonitoring for SSI for up to 90 days after the proceduredependingonthedepthofinfection(inNH,thisincludesCABGandkneearthroplasty).Due to the reportingdeadlines required forproducingadata reportsuchas this, it ispossiblethatdeepororgan/spaceSSIassociatedwithsurgeriesperformedattheendof2014maynotbeincludedinthisreport.Assuch,thisreportmaynotaccountforallSSIthatdevelopedasaresultofproceduresperformedin2014.

TheSSIdatapresentedinthisreportincludesalltypesofinfections,includingsuperficialSSI,whichcanoccurasaresultofcareinthehospitalbutalsoasaresultofthepatientscareofthewoundsiteoncedischarged.

Validation of 20092010 data showed that there was approximately 31% underreporting of SSI across all NH hospitals. This underreporting was mostly due tomisunderstandings about theNHSN definition for SSI. In addition to underreporting,the validation studies also found 12%overreporting (i.e., reporting an infection thatwasnottrulyaSSI).The2014SSIdatapresentedinthisreporthavenotbeenvalidatedandmustbe interpretedwiththeunderstandingthat ingeneraltherearebothunderandoverreportingofinfections.

J.SurgicalAntimicrobialProphylaxisAdministrationMonitoringAll NH hospitals report surgical antimicrobial prophylaxis data and othermeasures to CMSthroughtheSurgicalCare ImprovementProject (SCIP).Forthisreason,DHHSdoesnotcollectsurgicalantimicrobialprophylaxisdatadirectly fromhospitals. Inaddition toothermeasuresrequiredbyCMS,measuresrelativetoNHRSA151:33includethefollowing:



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SCIP1:Numberandpercentageofpatientswhoreceivedprophylacticantibioticwithin

onehourpriortosurgery SCIP2:Numberandpercentageofpatientswhoreceivedtheappropriateprophylactic

antibiotic SCIP 3: Number and percentage of patients whose prophylactic antibiotic was

discontinuedwithin24hoursaftersurgery

Theseprocessmeasuresshowahospitalsadherenceratetobestpracticesdesignedtoreducesurgicalcomplications.Hospitals followtheCMSspecificationmanualappropriatetothedateofdischargefoundat:http://qualitynet.org/dcs/ContentServer?cid=1141662756099&pagename=QnetPublic%2FPage%2FQnetTier2&c=Page.In previous years, DHHS accessed hospital data on surgical antimicrobial prophylaxisadministration from the New Hampshire Quality Care website at:http://www.nhqualitycare.org/.AsofJuly1,2015,SCIP2014datareportedtoCMSwasunavailableandtheHAIProgramwasunabletoconductfurtheranalysisofthismeasureasroutinelyincludedinthisreport.K.InfluenzaVaccinationPercentageMonitoringHCPcanbecome infectedwiththe influenzavirusthroughcontactwith infectedpatientsandcan transmit influenza to patients and other HCP. Despite documented benefits of HCPinfluenza vaccination on patient outcomes and HCP absenteeism nationally, vaccinationcoverage among HCP remains low. In a CDC survey, influenza vaccination coverage in HCPnationally was 75.2% during the 201314 influenza season.x Because HCP provide care topatientsathigh risk for complicationsof influenza, they shouldbeoffered influenza vaccineeachyear.Currentlytherearenoregulationsrequiringvaccination inNH,andHCParefreetodecline vaccination for any reason. However, some hospitals do have policies requiringmandatoryHCPvaccination.Vaccinationcoverage inhospitalHCPhavebeenmonitored inNHforseveralyears.All hospitals are required to reportHCP and patient vaccination data directly toDHHS. Thisreporting occurs either solely via awebbased survey provided to facilities, or viaNHSN incombinationwithanabbreviatedwebbased survey,newly for the201415 influenza seasonandaccordingtofacilitydiscretion.SeeAppendix2forthe201415surveyquestionsregardinginfluenza vaccination. Data for the 201415 influenza season were reported by 24 (71%)hospitalsonorbeforeApril30,2015;theremaining10(29%)hospitalsreportedatalaterdate.SubmissionofthesedatameetstherequirementsofboththeHAIlaw(RSA151:3235)andthehealthcareimmunizationlaw(RSA151:9b).HCPinfluenzavaccinationpercentageswerecalculatedbydividingthetotalnumberofHCPthatworkedorvolunteered ineach facility forat leastoneworkingdaybetweenOctober1,2014



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andMarch31,2015bythetotalnumberofHCP immunizedagainst influenzaforthe201415influenzaseason.Limitationsforinfluenzavaccinationmonitoring:

The data collection tools ask for the total number of HCP vaccinated. Thismay notreflectthenumberofHCPtowhomthevaccinewasoffered.Hospitalsmayvaryintherefusal percentage for vaccination among HCP and the reasons for such refusal.Additionally,someHCPmaynotbeeligibletoreceivethevaccine.DHHSattemptedtoassesswhy unvaccinatedHCP did not receive the vaccine; however, not all hospitalswereabletoreportthisinformation.

Becausethewebbasedsurveydidnot includeoptionsforfacilitiestoreportunknownvaccinationstatus,patientsandHCPwithunknownvaccinationstatuswereanalyzedasthoughtheywerenotvaccinated.Thisresultsinaconservativeestimateofvaccinationstatus(e.g.,lowerthaninreality).

Vaccination status is not uniformly available by locationwhere the vaccinationwasreceived(e.g.,atthereportingfacilityorelsewhere).

Data collection techniques at hospitalsmay vary from season to season, potentiallyaffectingcomparisonofdata.DHHScontinues towork towards improving thevalidityand utility of thismeasure in order to eliminate issues that pose problems for suchcomparison.

Reporting patient vaccination percentages is limited by availability of vaccine and byhospitals ability to trackwhy patients did not receive the vaccine. For example, thesurveyasksforadmissionsthroughMarch31,2015,bywhichtimesomehospitalsmayhaveusedtheirvaccinesupplyandareunabletoordermore.Thisscenariowouldresultin a lower vaccination percentage because the survey counts all admissions throughMarch,eventhoughtherewasnoopportunitytovaccinatethesepatientsduetosupply.DHHShaselectednot to reportpatientvaccinationpercentagesuntilabetterway tocollect the information is identified so that results are reliable, accurate, andinformative.

For the 201415 influenza season, CMS newly required all facilities sharing the sameCMSCertificationNumber(CCN)toreportthismeasureinaggregateviaNHSN.Becausesome ASC and hospitalsmay share the same CCN, it is possible that HCP influenzavaccinationdatacontainsmoreduplicatedatathaninpriorinfluenzaseasons.



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III.STATEWIDEDATA HAIdataarepresentedthroughoutthisreportasbothSIRandratesasappropriate.PresentingdataasaSIRallowsforaggregatingdataacrossriskgroups,procedures,andhospitalstogainabetter understanding of the incidence of HAIwhile still adjusting for underlying patient orhospital factors that may affect the occurrence of infections. The SIR allows comparisonbetweenhowmanyinfectionsactuallyoccurredandhowmanywerepredictedtooccurbasedon national data. Specific annual rate information is also provided where possible, whichrepresentsthenumberof infectionsthatoccurred.Ratedataare limited inthattheymustbestratifiedbycertainfactors,suchashospitalandtypeof ICU;theycannotbeaggregatedoverthesecategoriesforthepurposeofanalysis.Seetechnicalnotesforadditional informationonratesandtheSIR.Because a SIR is a comparison of the number of actual observed infections to the numberpredicted based on national data, an SIR of 1.0 means that exactly the same number ofinfectionswasobservedaswaspredicted.AnSIRoflessthanonemeansthatfewerinfectionswereobservedthanwerepredicted(forexample,SIR=0.70wouldbeinterpretedas30%fewerinfectionsobservedthanpredicted).AnSIRofmorethanonemeansthatmoreinfectionswereobserved thanwere predicted (for example, SIR = 1.30would be interpreted as 30%moreinfectionsobservedthanpredicted).Aconfidence interval iscalculatedtodeterminewhetherthe difference between observed and predicted infections is statistically significant. If thedifference isnotstatisticallysignificant,theobservedandpredictednumbersof infectionsareconsideredsimilar.Seetechnicalnotesforadditionalinformationonconfidenceintervals.ThisreportprovidescomparisonswithnationalandStatedatawhereappropriate.Comparisonsarecolorcodedconsistentlythroughout.Forinfections,yellowrepresentsinfectionratesorSIRthat are similar to national data, red represents infection rates or SIR that are significantlyhigher than nationaldata, and green represents infection ratesor SIR that are significantlylowerthannationaldata.

Forprocessmeasures,yellowrepresentspercentagesthataresimilartotheStatepercentage,red representspercentages thataresignificantly lower than theStatepercentage,andgreenrepresentspercentagesthataresignificantlyhigherthantheStatepercentage.

Statisticalsignificance isaffectedbysamplesize. Ifavalue isalmostor justbarelysignificant,just a few additional observations can push significance one way or the other (i.e., notsignificantorsignificant).A.StatewideStandardizedInfectionRatios In2014,219HAIwerereportedbyall26acutecarehospitalsinNH.TheseinfectionsrepresentCLABSIandCAUTI in ICUandSSIfollowingcolon,kneearthroplasty,abdominalhysterectomy,andCABGprocedures.Atotalof256.34infectionswerepredictedbasedonnationaldata;the



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overallobservednumberofHAIwas15%fewerthanpredicted.Morespecifically,therewere39%fewerCLABSIand22%fewerSSI.Therewere26%moreCAUTI,butthisdifference isnotstatisticallysignificantandthenumberof infectionsobserved isconsideredsimilartonationaldata.LookingindividuallyatthespecificprocedurestrackedforSSIbyNHhospitals,therewere72% fewer infections following CABG procedures, 6% fewer infections following colonprocedures, 26% fewer infections following abdominal hysterectomy procedures, and 28%fewer infections followingkneearthroplastyprocedures.However, thedifferences for colon,abdominalhysterectomy,andkneearthroplastyproceduresarenotstatisticallysignificant,andthe number of infections observed are considered similar to national data. These data areshowninTable1andFigure2.



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Table1.Statewidestandardizedinfectionratios,Jan1Dec31,2014 Observed

InfectionsPredictedInfections

StandardizedInfectionRatio(SIR)

95%ConfidenceInterval

ComparisontoPredictedNumberofInfectionsOverallHAISIR 219 256.34 0.85 0.74,0.98 Lower

TheoverallobservednumberofHAIinNewHampshirehospitalswas15%fewerthanpredictedbasedonnationaldata.Thisdifferenceisstatisticallysignificant,whichmeanstheoverallnumberofHAIinthestateisLOWERthanthenumberseennationally.

CLABSISIR 27 44.27 0.61 0.41,0.88 LowerTheoverallobservednumberofCLABSIinNewHampshirehospitalswas39%fewerthanpredictedbasedonnationaldata.Thisdifferenceisstatisticallysignificant,whichmeanstheoverallnumberofCLABSIinthestateisLOWERthanthenumberseennationally.

CAUTISIR 68 53.78 1.26 0.99,1.59 SimilarTheoverallobservednumberofCAUTIinNewHampshirehospitalswas26%morethanpredictedbasedonnationaldata.Thisdifferenceisnotstatisticallysignificant,whichmeanstheoverallnumberofCAUTIinthestateisSIMILARtothenumberseennationally.

OverallSSISIR 124 158.29 0.78 0.65,0.93 LowerTheoverallobservednumberofSSIinNewHampshirehospitalswas22%fewerthanpredictedbasedonnationaldata.Thisdifferenceisstatisticallysignificant,whichmeanstheoverallnumberofSSIinthestateisLOWERthanthenumberseennationally.

CABGSIR 5 17.75 0.28 0.10,0.62 LowerTheoverallobservednumberofCABGinfectionsinNewHampshirehospitalswas72%fewerthanpredictedbasedonnationaldata.Thisdifferenceisstatisticallysignificant,whichmeanstheoverallnumberofCABGinfectionsinthestateisLOWERthanthenumberseennationally.

COLOSIR 74 78.71 0.94 0.74,1.17 SimilarTheoverallobservednumberofCOLOinfectionsinNewHampshirehospitalswas6%fewerthanpredictedbasedonnationaldata.Thisdifferenceisnotstatisticallysignificant,whichmeanstheoverallnumberofCOLOinfectionsinthestateisSIMILARtothenumberseennationally.

HYSTSIR 17 22.91 0.74 0.45,1.16 SimilarTheoverallobservednumberofHYSTinfectionsinNewHampshirehospitalswas26%fewerthanpredictedbasedonnationaldata.Thisdifferenceisnotstatisticallysignificant,whichmeanstheoverallnumberofHYSTinfectionsinthestateisSIMILARtothenumberseennationally.

KPROSIR 28 38.92 0.72 0.49,1.03 SimilarTheoverallobservednumberofKPROinfectionsinNewHampshirehospitalswas28%fewerthanpredictedbasedonnationaldata.Thisdifferenceisnotstatisticallysignificant,whichmeanstheoverallnumberofKPROinfectionsinthestateisSIMILARtothenumberseennationally.

HAI:Healthcareassociated infection, CLABSI:Central lineassociatedbloodstream infections,CAUTI:Catheterassociatedurinarytract infections,SSI:Surgicalsite infections,CABG:Surgicalsite infectionsassociatedwithcoronaryarterybypassgraftprocedures, COLO:Surgicalsite infectionsassociatedwithcolonprocedures, HYST:Surgicalsiteinfectionsassociatedwithabdominalhysterectomyprocedures,KPRO:Surgicalsiteinfectionsassociatedwithkneearthroplastyprocedures



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Figure2.Statewidestandardizedinfectionratios,Jan1Dec31,2014

HAI:HealthcareassociatedinfectionCLABSI:CentrallineassociatedbloodstreaminfectionsCAUTI:CatheterassociatedurinarytractinfectionsSSI:SurgicalsiteinfectionsCABG:SurgicalsiteinfectionsassociatedwithcoronaryarterybypassgraftproceduresCOLO:SurgicalsiteinfectionsassociatedwithcolonproceduresHYST:SurgicalsiteinfectionsassociatedwithabdominalhysterectomyproceduresKPRO:SurgicalsiteinfectionsassociatedwithkneearthroplastyproceduresB.OverallStandardizedInfectionRatiosbyHospital Table2 and Figure3below show the totalnumberofHAI reportedbyeachhospital.TheseinfectionsrepresentCLABSIandCAUTIinICUandSSIfollowingcolon,abdominalhysterectomy,kneearthroplasty,andCABGprocedures.Twentytwohospitalshadsufficientlyrobustdatatopresent. Of these, four hospitals had an overall number of infections thatwas lower thanpredictedbasedonnationaldata.Twohospitalsobservedmoreinfectionsthanwerepredicted.Theremaining16observedasimilarnumberofinfectionsaswerepredictedbasedonnationaldata.



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Table2.Overallhealthcareassociatedinfectionsstandardizedinfectionratios,Jan1Dec31,2014

Dataarenotshownforhospitalswithlessthanonepredictedinfection.*Observednumberof infections includesall infectionsthatarerequiredtobereported (central lineassociatedbloodstreaminfections,catheterassociatedurinarytractinfections,andsurgicalsiteinfectionsfollowingcoronaryarterybypass,colon,abdominalhysterectomy,andkneearthroplastyprocedures).

Hospital ObservedInfections*

PredictedInfections



ComparisontoPredictedNumber

ofInfectionsAlicePeckDayMemorial 0 1.06 0.00 ,13.74 SimilarAndroscogginValley 1 1.91 0.52 0.01,2.92 SimilarCatholicMedicalCenter 14 24.23 0.58 0.32,0.97 LowerCheshireMedicalCenter 6 5.78 1.04 0.38,2.26 SimilarConcordHospital 22 22.43 0.98 0.61,1.48 SimilarCottageHospital DHMC 69 82.85 0.83 0.65,1.05 SimilarElliotHospital 26 22.37 1.16 0.76,1.70 SimilarExeterHospital 20 11.54 1.73 1.06,2.68 HigherFranklinRegional FrisbieMemorial 1 3.22 0.31 ,1.73 SimilarHugginsHospital 0 1.10 0.00 ,3.33 SimilarLakesRegionGeneral 3 10.19 0.29 0.06,0.86 LowerLittletonRegional 9 3.68 2.45 1.12,4.64 HigherMonadnockCommunity 4 1.68 2.38 0.64,6.10 SimilarNewLondonHospital 1 2.29 0.44 0.01,2.43 SimilarParklandMedicalCenter 0 5.57 0.00 ,0.66 LowerPortsmouthRegional 9 18.90 0.48 0.22,0.90 LowerSouthernNHMedical 6 12.25 0.49 0.18,1.07 SimilarSpeareMemorialHospital 2 1.15 1.74 0.20,6.28 SimilarSt.JosephHospital 7 8.48 0.83 0.33,1.70 SimilarTheMemorialHospital 4 1.32 3.04 0.82,7.78 SimilarUpperConnecticutValley ValleyRegionalHospital WeeksMedicalCenter 0 1.03 0.00 ,3.57 SimilarWentworthDouglass 11 11.31 0.97 0.48,1.74 Similar

StateTotal 219 256.34 0.85 0.74,0.98 Lower



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Figure3.Overallhealthcareassociatedinfectionsstandardizedinfectionratios,Jan1Dec31,2014

Note:Data arenot shown forhospitalswith less thanonepredicted infection.Observednumberof infectionsincludesall infectionsthatarerequiredtobereported (central lineassociatedbloodstream infections,catheterassociatedurinarytract infectionsandsurgicalsite infectionsfollowingcoronaryarterybypass,colon,abdominalhysterectomy,andkneearthroplastyprocedures).



34

OverallStatewideStandardizedInfectionRatios:Comparisonto2013DataTable3showsthatthestatewideSIR in2014 increased incomparisonto2013;however,thisdifference was not statistically significant. In 2014, a total of 219 HAI were reported,representing124SSI,27CLABSI,and68CAUTIcomparedto183HAI(112SSI,15CLABSI,and56CAUTI)in2013.Table 3.Overall healthcareassociated infections standardized infection ratios, comparisonbetween2013and2014

Hospital StandardizedInfectionRatio(SIR)

2014

95%ConfidenceInterval2014


2013


2014Comparedto

2013

OverallHAISIR 0.85 0.74,0.98 0.70 0.60,0.81 SimilarCLABSISIR 0.61 0.41,0.88 0.34 0.20,0.54 SimilarCAUTISIR 1.26 0.99,1.59 1.04 0.79,1.34 SimilarOverallSSISIR 0.78 0.65,0.93 0.68 0.57,0.82 Similar

CABGSIR 0.28 0.10,0.62 0.52 0.25,0.95 SimilarCOLOSIR 0.94 0.74,1.17 0.84 0.66,1.06 SimilarHYSTSIR 0.74 0.45,1.16 0.70 0.43,1.09 SimilarKPROSIR 0.72 0.49,1.03 0.42 0.26,0.66 Similar



35

Figure4.Statewidestandardizedinfectionratios,comparisonbetween20102014

HAI: Healthcareassociated infection, CLABSI: Central lineassociated blood stream infections, CAUTI: Catheterassociated urinary tractinfections,SSI:Surgical site infections,CABG:SSIassociatedwith coronaryarterybypassgraftprocedures,COLO:SSIassociatedwith colonprocedures,HYST:SSIassociatedwithabdominalhysterectomyprocedures,KPRO:SSIassociatedwithkneearthroplastyproceduresNote:CAUTIandHYSTwerenotreportablefrom2009to2011.



36

Table 4.Overall healthcareassociated infections standardized infection ratios by hospital,comparisonbetween2013and2014

Dataarenotshownforhospitalswithlessthanonepredictedinfection.N/Aornotapplicable:Comparisonbetweentwoyearsofdataatagivenfacilityisnotapplicableifnodatawerereportedbythatfacilityand/orifdatamustbecensoredforoneormoreoftheyearspresented.

Hospital StandardizedInfectionRatio(SIR)

2014



2013


2014Comparedto

2013

AlicePeckDayMemorial 0.00 ,13.74 N/AAndroscogginValley 0.52 0.01,2.92 0.00 ,2.26 SimilarCatholicMedicalCenter 0.58 0.32,0.97 0.60 0.32,1.02 SimilarCheshireMedicalCenter 1.04 0.38,2.26 0.35 0.04,1.25 SimilarConcordHospital 0.98 0.61,1.48 1.02 0.66,1.52 SimilarCottageHospital 0.84 0.01,4.67 N/ADHMC 0.83 0.65,1.05 0.73 0.56,0.93 SimilarElliotHospital 1.16 0.76,1.70 0.91 0.57,1.37 SimilarExeterHospital 1.73 1.06,2.68 0.64 0.26,1.32 SimilarFranklinRegional FrisbieMemorial 0.31 ,1.73 0.00 ,1.54 SimilarHugginsHospital 0.00 ,3.33 0.00 ,1.80 SimilarLakesRegionGeneral 0.29 0.06,0.86 0.11 ,0.62 SimilarLittletonRegional 2.45 1.12,4.64 0.52 0.06,1.90 SimilarMonadnockCommunity 2.38 0.64,6.10 0.00 ,2.19 SimilarNewLondonHospital 0.44 0.01,2.43 0.00 ,2.09 SimilarParklandMedicalCenter 0.00 ,0.66 0.79 0.26,1.85 SimilarPortsmouthRegional 0.48 0.22,0.90 0.43 0.18,0.84 SimilarSouthernNHMedical 0.49 0.18,1.07 0.58 0.25,1.13 SimilarSpeareMemorialHospital 1.74 0.20,6.28 1.47 0.17,5.31 SimilarSt.JosephHospital 0.83 0.33,1.70 1.00 0.46,1.90 SimilarTheMemorialHospital 3.04 0.82,7.78 1.28 0.14,4.62 SimilarUpperConnecticutValley ValleyRegionalHospital WeeksMedicalCenter 0.00 ,3.57 0.00 ,3.11 SimilarWentworthDouglass 0.97 0.48,1.74 0.68 0.27,1.39 Similar

StateTotal 0.85 0.74,0.98 0.70 0.60,0.81 Similar



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D.CentralLineAssociatedBloodstreamInfectionsTables4through6andFigures5and6showthenumberofCLABSIthatwasidentifiedinadultICUateachhospitalinNH.TheanalysespresentedTable5andFigure6showthatallcategoriesof ICUsawsimilarratesofCLABSI incomparsiontonationalrates forthesame ICUcategory,withtheexceptionofmedical/surgicalICUatmajorteachinghospitals,whichsawahigherrateincomparisontothenationalrate.Table7showsthatamongICUwithsufficientlyrobustdatatopresent,all ICUobservedasimilarCLABSIratetonationalrateswiththeexceptionofonehospital,whichsawahigherrateincomparisontothenationalrateinitsmedical/surgicalICU.AsshowninTable6and8andFigure5,BirthweightcategoryD,orneonateswithbirthweightsbetween1,501and2,500grams, sawa significantlyhigherCLABSI rate incomparison to thenationaldataforweightrange.Seemethodsforadditionalinformationondatacollection.StatewideCentralLineAssociatedBloodstreamInfectionsRatesThestatewideCLABSIrateatthemedical/surgicalICUinthemajorteachinghospitalwassignificantlyhigherthanthenationalrate,whileallotherstatewideratesforCLABSIreportedfortheotherICUcategoriesweresimilartothenationalrate.Table 5. Statewide rates for central lineassociated bloodstream infections, Jan 1Dec 31,2014

Note:ForCLABSI,denominatorisnumberofcentrallinedays.CLABSIrateisthenumberofinfectionsper1,000centrallinedays.

CLABSIRates Infections Centrallinedays

StateRate

NationalRate

pvalue StateRateComparedtoNationalRate

Medical/SurgicalICU>15beds(n=4) 4 7,725 0.5 0.8 0.365 SimilarMedical/SurgicalICU15beds(n=7) 1 5,906 0.2 0.8 0.055* SimilarCriticalAccessMedical/SurgicalICU(n=8) 0 302 0.0 0.5 0.867 SimilarMedical/SurgicalICUMajorTeachingHospital(n=1) 14 6,590 2.1 1.1 0.032 HigherMedicalICU(n=2) 0 615 0.0 1.1 0.515 SimilarCriticalAccessMedicalICU(n=2) 0 107 0.0 0.5 0.951 SimilarMedicalCardiacICU(n=1) 2 1,209 1.7 1.0 0.473 SimilarPediatricMedicalICU(n=1) 0 174 0.0 0.8 0.870 SimilarPediatricMedical/SurgicalICU(n=1) 0 443 0.0 1.2 0.579 Similar



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Table 6. Statewide rates for central lineassociated bloodstream infections in neonatalintensivecareunitsbybirthweightcategory,Jan1Dec31,2014

Figure 5. Statewide rates for central lineassociated bloodstream infections in neonatalintensivecareunitsbybirthweightcategory,Jan1Dec31,2014

BirthweightCategory Infections Centrallinedays

StateRate

NationalRate

pvalue

StateRateComparedtoNationalRate

BWCategoryA750g 2 235 8.5 2.2 0.110 SimilarBWCategoryB=7511000g 1 310 3.2 1.9 0.554 SimilarBWCategoryC=10011500g 1 599 1.7 1.0 0.551 SimilarBWCategoryD=15012500g 2 509 3.9 0.6 0.047 HigherBWCategoryE>2500g 0 451 0.0 0.5 0.783 Similar



39

Figure6.Statewideratesforcentrallineassociatedbloodstreaminfections,Jan1Dec31,2014

Med/Surg = medical surgical ICU = intensive care unit



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Table7.Centrallineassociatedbloodstreaminfectionsrates,Jan1Dec31,2014

Note:AlicePeckDayMemorialHospitalandValleyRegionalHospitaldidnothaveanintensivecareunitinwhichtomonitorinfections.UpperConnecticutValleydidnothaveanypatientswithcentrallinesinplaceintheICUin2014.ParklandMedicalCenterchangedthecategorizationofitsICUhalfwaythrough2014.Dataarenotshownforhospitalswithfewerthan50centrallinedays. Med/Surg=medicalsurgicalICU=intensivecareunitPed=pediatric

UnitType Infections Centrallinedays

HospitalRate

NationalRate

Pvalue HospitalRateComparedtoNationalRate

AndroscogginValley MedicalICU 0 77 0.0 0.5 0.964 SimilarCatholicMedical Med/SurgICU 3 3,371 0.9 0.8 0.825 SimilarCheshireMedical MedicalICU 0 264 0.0 1.1 0.752 SimilarConcordHospital Med/SurgICU 0 1,760 0.0 0.8 0.235 SimilarCottageHospital Med/SurgICU

DHMCCardiacICU 2 1,209 1.7 1.0 0.473 Similar

Med/SurgICU 14 6,590 2.1 1.1 0.032 HigherPedMed/SurgICU 0 443 0.0 1.2 0.579 Similar

ElliotHospital Med/SurgICU 0 1,509 0.0 0.8 0.290 SimilarPedMedICU 0 174 0.0 0.8 0.870 Similar

ExeterHospital Med/SurgICU 0 1,200 0.0 0.8 0.375 SimilarFranklinRegional Med/SurgICU FrisbieMemorial Med/SurgICU 0 377 0.0 0.8 0.735 SimilarHugginsHospital Med/SurgICU 0 113 0.0 0.5 0.958 SimilarLakesRegionGeneral Med/SurgICU 0 361 0.0 0.8 0.744 SimilarLittletonRegional Med/SurgICU 0 105 0.0 0.5 0.952 SimilarMonadnockHospital Med/SurgICU NewLondonHospital Med/SurgICU ParklandMedical MedicalICU 0 351 0.0 1.1 0.685 Similar

Med/SurgICU 0 327 0.0 0.8 0.765 SimilarPortsmouthRegional Med/SurgICU 1 2,106 0.5 0.8 0.664 SimilarSouthernNHMedical Med/SurgICU 1 1,085 0.9 0.8 0.812 SimilarSpeareMemorial Med/SurgICU St.JosephHospital Med/SurgICU 0 505 0.0 0.8 0.662 SimilarTheMemorialHospital MedicalICU WeeksMedicalCenter Med/SurgICU WentworthDouglass Med/SurgICU 0 1,030 0.0 0.8 0.431 Similar



41

Table8.Centrallineassociatedbloodstreaminfectionsratesinneonatalintensivecareunitsbybirthweightcategory,Jan1Dec31,2014

Note:DHMC,Elliot,andSouthernNHMedicalhaveneonatalintensivecareunits.Allotherhospitalsdonotandassuch,hadnodatatoreport.Dataarenotshownforhospitalswithfewerthan50centrallinedaysforeachbirthweightcategory.

BirthweightCategory Infections Centrallinedays

HospitalRate

NationalRate Pvalue HospitalRateComparedtoNationalRate

DHMC

BWCategoryA750g 2 163 12.3 2.2 0.056 SimilarBWCategoryB=7511000g 0 179 0.0 1.9 0.717 SimilarBWCategoryC=10011500g 1 348 2.9 1.0 0.329 SimilarBWCategoryD=15012500g 1 274 3.6 0.6 0.172 SimilarBWCategoryE>2500g 0 225 0.0 0.5 0.885 Similar

ElliotHospital

BWCategoryA750g 0 72 0.0 2.2 0.854 SimilarBWCategoryB=7511000g 1 131 7.6 1.9 0.242 SimilarBWCategoryC=10011500g 0 241 0.0 1.0 0.794 SimilarBWCategoryD=15012500g 1 223 4.5 0.6 0.140 SimilarBWCategoryE>2500g 0 226 0.0 0.5 0.884 Similar

SouthernNHMedical

BWCategoryA750g BWCategoryB=7511000g BWCategoryC=10011500g BWCategoryD=15012500g BWCategoryE>2500g



42

CLABSIStandardizedInfectionRatiosOverall,theobservednumberofCLABSIwas39%fewerthanpredictedbasedonnationaldata.TheanalysispresentedinTable9andFigure7showsthatninehospitalsobservedasimilarnumberofinfectionsaspredicted,andnoneofthehospitalsobservedeitherfewerormoreinfectionsthanpredictedbasedonnationaldata.Table9. Centrallineassociatedbloodstreaminfectionsstandardizedinfectionratios,Jan1Dec31,2014

Note:AlicePeckDayMemorialandValleyRegionaldidnothaveintensivecareunitsinwhichtomonitorinfections.UpperConnecticutValleydidnothaveanypatientswithcentrallinesinplaceintheICUin2014.Dataarenotshownforhospitalswithlessthanonepredictedinfecon.FacilitydidnotreportanydatacontributingtoaSIRduringthistimeperiod.

ObservedInfections

PredictedInfections



ComparisontoPredictedNumber

ofInfectionsAlicePeckDayMemorial AndroscogginValley CatholicMedicalCenter 3 5.06 0.59 0.15,1.62 SimilarCheshireMedicalCenter ConcordHospital 0 2.64 0.00 ,1.14 SimilarCottageHospital DHMC 20 20.07 1.00 0.63,1.51 SimilarElliotHospital 2 4.17 0.48 0.08,1.59 SimilarExeterHospital 0 1.80 0.00 ,1.66 SimilarFranklinRegional FrisbieMemorial HugginsHospital LakesRegionGeneral LittletonRegional MonadnockCommunity NewLondonHospital ParklandMedicalCenter 0 1.16 0.00 ,2.59 SimilarPortsmouthRegional 1 3.16 0.32 0.02,1.56 SimilarSouthernNHMedical 1 1.66 0.60 0.03,2.97 SimilarSpeareMemorialHospital St.JosephHospital TheMemorialHospital UpperConnecticutValley ValleyRegionalHospital WeeksMedicalCenter WentworthDouglass 0 1.55 0.00 ,1.94 Similar

StateTotal 27 44.27 0.61 0.41,0.88 Lower



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Figure7.CentrallineassociatedbloodstreaminfectionsstandardizedinfectionratiosJan1Dec31,2014

Note:Dataarenotshownforhospitalswithlessthanonepredictedinfection.AlicePeckDayMemorialHospitalandValleyRegionalHospitaldidnothaveintensivecareunitsinwhichtomonitorinfections.UpperConnecticut

healthcare associated infections report 2014 hospital

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