A Case Study: Healthcare-Associated Infections (HAIs)
Definition of HAI
Healthcare-associated infections
(HAIs) are infections that occur while receiving health care, developed in a
hospital or other health care facility but are neither present nor incubating upon patient's admission to the hospital; generally that first appear 48 hours or more after
hospital admission, or within 30 days after having received health care.
HAIs are big problems for patient safety. HAIs can cause serious health problems, prolonged hospital stay, long-term disabilities, even death to patients; and also bring additional medical costs to the patients and the healthcare system. Below are resources about HAIs and patient safety.
Standardized infection ratio (SIR)
CDC's NHSN is a HAI tracking system, and provides data for monitoring and evaluation. NHSN uses Standardized infection ratio (SIR) as a measure for HAIs. SIR is a standardized method calculated by dividing the number of observed events by the number of predicted events in a hospital or other health care facility. The number of predicted events, served as a national baseline, is calculated using probabilities estimated from logistic regression models using 2015 data. SIR is
adjusted for risk factors that may impact infection rates, allowing for
comparisons among hospitals in local, state or national levels. A SIR of 1.0 means the number of HAIs is
exactly what would have been expected. Less than 1.0 means there were fewer
HAIs than predicted; more than 1.0 indicates more HAIs than would have been
predicted.
Types of HAIs
Device-associated
CLABSI - Central Line-Associated Bloodstream Infection
CLIP - Central Line Insertion Practice Adherence
CAUTI - Catheter-Associated Urinary Tract Infection
VAP - Ventilator-associated pneumonia
Procedure-associated
SSI - Surgical Site Infections (for colon and abdominal
hysterectomy procedures)
MDROs - Multidrug-Resistant
Organisms
MRSA - Methicillin-resistant Staphylococcus aureus
infection
VRE - Vancomycin resistant Enterococcus
CDI - Clostridium Difficile (C. Diff) infections
Risk factors of HAIs
- Age: older patients could have a higher chance to get HAIs than younger patients.
- Gender: the HAI prevalence was higher in the male than in the female patients.
- The presence of indwelling or invasive medical devices, such as an urinary catheter, an intubation tube, or an intravascular line.
- Extended hospital stay (more than 8 days)
- Patients were admitted in a large hospital (≥ 400 beds)
- Patients who were receiving mechanical ventilator support, or were in a critical care unit
- Antimicrobial overuse.
- Pre-existing condition on admission, such as chronic wounds, respiratory problems, skin and soft tissue lesions.
- Readmission and several admission in the past year. Emergency surgery.
Figure 1 compares the SIRs of six HAIs among US states in 2019. The data were extracted from the Centers for Medicare & Medicaid Services (CMS) Hospital data archive. Among the six HAIs, most states had SIR<1 for CLABSI, CAUTI and CDI (Figure 1 A, B and F), which implied that most hospitals in those states had fewer number of observed HAIs than the number of predicted HAIs. For the surgical site infections (SSI) and MRSA (Figure 1 C, D and E), more states have their average SIRs above one. Although those states had the SIR confidence interval (CI) include the value of one, showing the SIR was not significantly different than one, i.e. the number of observed HAIs was not significantly different than the number of predicted HAIs, it is easy to have the impression that the situations of surgical site infections and MRSA were worse than those of CLABSI, CAUTI and CDI. On the other hand, if most units can meet the standards, the system may raise the standards. HAIs may never be eliminated. Fewer HAIs is always the goal.
(Figure 1 Compare SIRs among states of US in 2019. Click on the graph for a larger view)
SIRs can be monitored over time. For example in Figure 2, comparing SIRs among southeast states during 2013-2020, both Alabama and Florida had fewer colon surgery site HAIs than expected (SIR<1) during those eight years, while West Virginia had more colon surgery site HAIs than expected (SIR>1) during most of those eight years. Over the years, some states improved with colon surgery SSI with decreased SIRs, such as South Carolina and Virginia, while some state did worse with colon surgery SSI with increased SIRs, such as Mississippi. Timely monitoring and evaluation is critical for quality improvement. If there is no comparison (evaluation), it would never know how well the unit works. Quality improvement is a never-ending effort for all service units.
Furthermore, increased SIRs for MRSA were observed in 2020 compared with 2019 in all southeast states of US (Figure 3). West Virginia had the highest increase, up to 58%. Alabama and Louisiana came the next, both jumped around 30%. North Carolina had smallest increase, around 1%. Before 2020, the hospital acquired MRSA infections had been declined in some states, such as Alabama, Kentucky and North Carilina. This nation-wide increase on MRSA HAIs was suspected to be due to Covid-19 pandemic. Staphylococcus aureus (S. aureus) is a leading bacterial pathogen that can cause co-infection with viral infection. The impact of Covid-19 on HAIs had been investigated and a report was published in 2021. Co-infection of S. aureus and Covid-19 significantly increases the patient mortality rates.
(Figure 3 Increased SIRs were observed in 2020 compared with 2019. Click on the graph for a larger view)
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