Welcome to the 2021 Annual Report of Healthcare Associated Infections in Utah

Prior reports were reported through 70+ pages of PDF files. This year the report has been updated as a dashboard to ensure easier delivery of data.

We recommend reading through the light green tabs first, which include the executive summary, foreword, and interpreting HAI data. Then, click on the dark purple Utah HAIs tab above to see drop down data pages on each HAI. The last About the data tab goes through the introduction, how Utah HAI data is collected, data quality validation, validation conclusions, references, and acknowledgements.

In the Overview and events tables, column headers may be underlined with light blue. Hover over these to read term definitions.

Thank you!

What does the standardized infection ratio (SIR) mean?

The SIR is the ratio of the observed number of infections (events) to the number of predicted infections (events) for a specific time period.

National baseline: Aggregated data reported to the National Healthcare Safety Network (NHSN) by all facilities during a baseline period is used to “predict” the number of infections expected to occur in a hospital, state, or in the country. In the 2021 National and State Healthcare-Associated Infections Progress Report, the number of predicted infections is an estimate adjusted for each facility through the use of variables known to be significant predictors of HAIs, such as the number of community-onset infections or the number of annual patient days. Incidence was also analyzed for each quarter in 2020 and compared with 2021, with appropriate risk adjustments made for the respective HAI, to assess the impact of COVID-19 on HAIs. Due to the high number of hospitalizations in 2020, the predicted number of infections was significantly higher than previous years for most HAIs.

Examples: 45 observed cases/30 expected cases: the SIR is 45/30 = 1.5 Since 1.5 is 50% greater than 1, the SIR indicated an excess of 50%.

15 observed cases/30 expected cases: the SIR is 15/30 = 0.5 Since 0.5 is 50% less than 1, a SIR = 0.5 would indicate a 50% decrease.

To enforce a minimum precision criterion, SIRs are only calculated when the number of predicted infections is greater than 1. This rule was instituted by NHSN to avoid the calculation and interpretation of statistically imprecise SIRs, which typically have extreme values.

Key:

Statistically FEWER infections than the national aggregate data

Statistically MORE infections than the national aggregate data

Predicted to have less than one infection for the year, and had ZERO infections, as defined by NHSN, in 2021

Predicted to have less than one infection for the year, but had one or more infections, as defined by NHSN, in 2021

NOT statistically different from the national aggregate data

Background

Healthcare-associated infections (HAIs) are infections people acquire while they are receiving treatment for another condition in a healthcare setting. HAIs can be acquired anywhere healthcare is delivered, including inpatient acute care hospitals (ACH), outpatient settings (e.g., ambulatory surgical centers and dialysis facilities), and long-term care facilities (e.g., nursing homes and rehabilitation centers). HAIs may be caused by any infectious agent, including bacteria, fungi, and viruses, as well as other less common pathogens. HAIs include central-line associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), surgical site infections (SSIs), methicillin-resistant Staphylococcus aureus (MRSA) bacteremia infections, and Clostridioides difficile-associated infections (CDIs).

Economic studies estimate HAI treatments cost more than $9 billion a year when looking from the hospital perspective (Scott et al., 2019). However, this does not address the societal cost perspective. HAIs can have devastating emotional, financial, and medical consequences for the person affected (HHS, 2022). Each day, approximately 1 in 31 U.S. patients has at least 1 infection associated with their hospital care. These infections can lead to significant morbidity and mortality, with tens of thousands of lives lost each year, which underscores the need for improvements in infection prevention practices in U.S. healthcare facilities (Agency for Healthcare Research and Quality [AHRQ], 2019; CDC, 2018).

The DHHS HAI/AR program’s mission is to prevent healthcare-associated infections and the spread of antimicrobial-resistant organisms through collaboration with partners; surveillance and response to outbreaks; data analysis; education; and policy change. As one of the activities under this mission, the program produces this annual report to document and analyze HAI trends in Utah healthcare facilities (reporting facilities outlined in executive summary). The NHSN statistics calculator was used to determine statistical significance. This calculator provides a relative ratio of SIRs, a two-tailed p-value, and a 95% confidence interval.

2021 HAI findings in Utah and the US

HAIs may be caused by various types of invasive devices, such as a central line or urinary catheter, used when patients are ill (Marschall et al., 2014). The longer these devices are in place, the greater the risk for infection (U.S. Department of Health and Human Services [HHS], 2022). In 2021, U.S. acute care facilities observed significant increases in annual HAI rates for CLABSIs and CAUTIs when compared with 2020. Specifically, acute care facilities reported a 7% increase in CLABSIs and a 5% increase in CAUTIs (Centers for Disease Control and Prevention [CDC], 2022a). In Utah, there were increases observed for both CLABSIs and CAUTIs (3% and 7%, respectively); however, the SIRs were not found to be significantly different when compared with 2020 (p=0.82 and p=0.57, respectively) (CDC NHSN, 2022).

HAIs may also occur as a result of complications following a surgical procedure or when infection control practices, such as hand washing, are not followed (Anderson et al., 2014). While advances have been made in infection control and prevention and antimicrobial prophylaxis, these infections are not uncommon and account for 20% of all HAIs (CDC National Healthcare Safety Network [NHSN], 2023). According to the 2021 National and State Healthcare-Associated Infections Progress Report, there was an 11% increase in abdominal hysterectomy SSIs at the national level. Utah, by comparison, experienced a 45% decrease which was found to be statistically significant when compared with Utah’s 2020 SIR (p= 0.03). The infection rates for colon surgery SSIs had no statistically significant change from 2020 for both Utah and the U.S. (CDC, 2022a).

MRSA is a bacterium resistant to many antibiotics and is common in healthcare facilities. In the community, most MRSA infections are skin infections. In medical facilities, MRSA may cause life-threatening bloodstream (or bacteremia) infections, endocarditis, pneumonia, and surgical site infections (Calfee et al., 2014). Although significant progress has been made to reduce MRSA bloodstream infections, MRSA still poses a formidable clinical threat, with persistently high morbidity and mortality (Turner et al., 2019). The total number of MRSA bacteremia cases reported both nationally and in Utah increased from 2020 to 2021. U.S. acute care facilities experienced a 14% increase between 2020 and 2021 (p= <0.0001) (CDC, 2022a). While Utah experienced more overall events, there was a 5% decrease when comparing SIRs from 2020 and 2021. This decrease was not found to be significant (p= 0.83). However, it is worth noting that 28 acute care facilities in Utah reported 0 cases of MRSA in 2021 (CDC NHSN, 2022).

Patients who receive medical care and take antibiotics for long periods of time are more susceptible to HAIs, such as CDIs. Although antibiotics quickly and effectively eliminate bacterial infections, they also get rid of the good bacteria that protects the body against harmful infections. Antibiotic misuse and subsequent antibiotic resistance has driven the growth of CDIs and the emergence of new strains (Spigaglia, 2016). CDIs are estimated to cause almost half a million infections in the United States each year, and now rival MRSA as the most common organism to cause HAIs in the U.S. (CDC 2022b; Dubberke et al., 2014). Furthermore, one in 11 patients older than age 65 with CDI die within a month of diagnosis (CDC, 2022b). Fortunately, there was a 3% decrease in hospital onset CDIs in the U.S. ACHs between 2020 and 2021 (p= <0.0001) (CDC, 2022a). Utah also experienced a 4% decrease; however, the difference in SIRs was not found to be statistically significant (p= 0.65) (CDC NHSN, 2022).

Patients who undergo dialysis treatment (a treatment for patients with inadequate kidney function) also have an increased risk for acquiring HAIs. They are at high risk because this artificial process to get rid of waste and fluid in the body requires frequent use of catheters to access the bloodstream. Dialysis patients may have weakened immune systems, which also increases their risk for infection (CDC, 2020). The raw number of dialysis event bloodstream infections (BSI) has continued to decrease each year both nationally and in Utah, with Utah 2021 data showing 8 fewer reported infections. As this downward trend continues, the predicted number of infections each year has also decreased, affecting the calculated SIR values. Given this, when comparing Utah dialysis BSI event SIRs from 2020 to 2021, a 16% increase was observed. Still, this difference was not found to be statistically significant (p= 0.48) (CDC NHSN, 2022).

The impacts to HAI incidence were particularly evident during the COVID-19 pandemic. Not only were there challenges in the healthcare response to rising hospitalization rates, there were also documented shortages in healthcare personnel, which led to decreased HAI prevention and surveillance by facilities (Wu et al., 2021). The nation continued to experience unprecedented challenges due to the COVID-19 pandemic in 2021; however, hospitals resumed mandated reporting of HAIs which resulted in a return to pre-pandemic numbers of facilities reporting into NHSN. CDC analysis reveals that many HAIs continued to increase in U.S. hospitals during 2021, the second year of the COVID-19 pandemic. Most notably, NHSN data shows a significantly higher incidence in central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia in 2021 compared with 2019 (CDC, 2022a).

These findings stress the importance of action from public health and healthcare facilities to eliminate infections that commonly threaten hospital patients, especially during times of emergent crises.

Background

The Department of Health and Human Services (DHHS) is required under Utah Title 26-6-31, Public Reporting of Healthcare-Associated Infections (HAIs), to validate data reported to NHSN. Guidance from the CDC helped direct the selection of infection types for validation of 2021 NHSN data. This guidance included the use of results from the targeted assessment for prevention (TAP) strategy to prioritize activities, an increased focus on antimicrobial resistance, and a focus on specific facility types, acute care hospitals (ACH) and dialysis facilities. This information led DHHS to perform validation of CLABSIs and CAUTI events.

The focus of these validation activities was to determine how NHSN CLABSI and CAUTI event surveillance definitions were interpreted and applied to data collection. The validations were performed by the DHHS HAI/AR program at healthcare facilities throughout the state. Facilities were chosen based on an NHSN targeted selection process from the NHSN External Validation Guidance and Toolkit for 2021. The facility selection process prioritized validation of facilities where HAIs were most expected. This method compared facilities’ SIR and cumulative attributable difference (CAD) scores to help identify those facilities with high risk of HAIs, and also those facilities whose scores showed they were performing well in their practices to prevent infection.

Validation activities are intended to compare reported information in NHSN with DHHS audit findings and outcomes to enhance accuracy and completeness of CLABSI and CAUTI reporting. A standardized validation method, as guided by NHSN, was chosen to serve as a test of proficiency in surveillance methods and accuracy in case findings. It should also be noted that results from these facilities may not be generalized to all facilities in the state. Also, because the audit sample was targeted and unweighted, aggregate findings are not necessarily indicative of NHSN data quality throughout the state.

Procedure

An on-site medical record audit was conducted at the chosen healthcare facilities (3 ACHs and 6 dialysis facilities). Each visit started with an interview of at least 1 member of the infection prevention staff to learn about surveillance methodology, data collection, and personnel training and education on applications of NHSN criteria. Additionally, CDC’s targeted assessment for prevention (TAP) tools were utilized at each facility to determine current prevention practices and make recommendations based on those responses. In each facility, as many as 20 charts were reviewed, including charts of patients identified by the facility as having a CLABSI event and charts of patients who had a positive blood culture but were not identified as having a CLABSI, to determine if any reportable infections were missed. Additionally, as many as 20 charts of patients who were determined to have a CAUTI in 2021 were reviewed to determine if they correctly met the CAUTI criteria. As many as 20 charts of patients who had a positive urine culture (a urine culture with no more than 2 species of organisms identified, at least 1 of which is a bacterium with >10 ^5 CFU/mL), but were not classified as a CAUTI, were also reviewed to determine if any reportable infections were missed. Results of the validation findings were reviewed with the facility to provide immediate on-site education to improve HAI surveillance and reporting. Facilities were expected to correct data in NHSN based on validation findings.

References