hospital-acquired infections in pennsylvania - Pennsylvania Health

100 Pages·2008·0.99 MB·English

H -
ospital acquired
i
nfections
p
in ennsylvania
calendar year 2006
Pennsylvania Health Care
Cost Containment Council
April 2008
The Pennsylvania Health Care Cost Containment Council (PHC4) was
established as an independent state agency by the General Assembly
and the Governor of the Commonwealth of Pennsylvania in 1986. To help
improve the quality and restrain the cost of health care, PHC4 promotes
health care competition through the collection, analysis and public
dissemination of uniform cost and quality-related information.
t c
able of ontents
report HigHligHts ........................................................................................1
reader’s guide ................................................................................................2
calendar year 2006 data
statewide ....................................................................................................10
peer Group 1.............................................................................................11
peer Group 2.............................................................................................19
peer Group 3.............................................................................................29
peer Group 4.............................................................................................45
comparison of quarter 4 data - cy 2005 & cy 2006
statewide ....................................................................................................58
peer Group 1 .............................................................................................59
peer Group 2 .............................................................................................66
peer Group 3 .............................................................................................74
peer Group 4 .............................................................................................87
Hospital-acquired infections in pennsylvania
R H
epoRt igHligHts
• This report includes information on infections that were contracted by patients in Pennsyl-
vania hospitals in 2006. It is the Pennsylvania Health Care Cost Containment Council’s
second hospital-specific report on these types of infections.
• Data on hospital-acquired infections is provided for each of Pennsylvania’s 165 general acute
care hospitals. Because not all hospitals treat the same types of patients, they were catego-
rized by “peer groups” so that hospitals that offer similar types and complexity of services and
treat similar numbers of patients are displayed together.
• In 2006, hospitals reported that 30,237 patients contracted an infection during their hos-
pitalization, a rate of 19.2 per 1,000 cases. This rate is higher than the 12.2 per 1,000 cases
reported in 2005 due, in large part, to an expansion in the hospital-acquired infection report-
ing categories and improved reporting by hospitals as the process became more established.
• Differences in mortality, length of stay, and average hospital charges can be observed between
patients with hospital-acquired infections and those without, as shown in the table below.
The differences in mortality, length of stay, and charges may not be entirely attributable to
the infections. The degree to which the presence of hospital-acquired infections influenced
these numbers is not known. In almost all cases, hospitals do not receive full reimbursement
of charges; on average statewide in 2006, for all inpatient cases (not just infections), hospitals
were paid approximately 27% of established charges.
Average Length
Infection
Mortality of Stay in Days Average Charge
Number Rate
of Cases Per 1,000 Number Percent Mean Median Mean Median
Total Cases 1,574,170 NA 36,119 2.3 4.7 3.0 $36,001 $18,900
Cases with a hospital-
acquired infection 30,237 19.2 3,716 12.3 19.3 14.0 $175,964 $79,670
Cases without a hospital-
acquired infection 1,543,933 NA 32,403 2.1 4.4 3.0 $33,260 $18,538
• The expansion of hospital-acquired infection reporting requirements from 2005 to 2006 re-
stricts the comparisons that can be made between the two years; however, some limited com-
parative data is included in the report for the two most similar data collection time periods:
Quarter 4, 2005 and Quarter 4, 2006. The hospital-acquired infection rate decreased from
16.3 per 1,000 cases to 15.1 per 1,000 cases between these two time periods. The number of
hospital-acquired infections decreased from 6,226 in Quarter 4, 2005 to 5,859 in Quarter 4,
2006. (“Quarter 4” represents the time period October 1 through December 31.)
• The collection and reporting of hospital-acquired infections is still evolving. PHC4 believes
the most important use of the report is to measure individual hospital performance over time
and as a tool to ask physicians and hospital representatives informed questions about infec-
tion control and prevention, rather than to compare hospitals to each other.
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Hospital-acquired infections have As Pennsylvania was the first state in the
emerged as one of the most important pub- nation to report this information, there is
lic health challenges over the past few years. little, if any, comparative information by
The Pennsylvania Health Care Cost Con- which one can evaluate infection patterns
tainment Council (PHC4) contributed to and trend data. In addition to reporting
the body of knowledge all four quarters of the
about the significant im- most recent data –
A hospital-acquired infection
pact of these infections calendar year 2006, this
is an infection that a patient
when it began publicly report provides some
contracts while hospitalized.
reporting actual state- limited comparative
At the time of admission, the
wide numbers in July information by
infection would not have been
2005. displaying the two most
either present or developing.
Hospital-acquired similar data collection
infections represent a time periods: Quarter
direct threat to patient safety and health care 4, 2005 and Quarter 4, 2006. Over time,
quality. Hospital-acquired infections, in the Pennsylvania’s reports will be able to provide
aggregate, have a significant overall impact more detailed comparative information
upon the cost of care, as well as on patient as part of a broader process of evaluating
care outcomes and should not be dismissed interventions and best practices in order to
as an inevitable risk. prevent and control infections. Currently,
This publication, which is PHC4’s however, this cannot be accomplished by
second hospital-specific report, can be useful comparing the entirety of calendar years
for health care consumers and purchasers in 2005 and 2006, due to the expansion of
evaluating the quality of care, and for hospi- reporting requirements over that time
tals and clinicians in improving the quality period, as well as improvements in hospital
of care. It also can help initiate discussions reporting.
between patients and their doctors and
How to use the report
nurses, and serve as a tool among hospital
providers about what needs to be done to This report should be used to measure
eliminate infections and improve health care individual hospital performance over time,
quality. rather than to compare hospitals to each
It is important to point out that the other. It should be used as a tool to ask
collection and reporting of hospital- physicians and hospital representatives in-
acquired infection data is still evolving. formed questions, especially about infection
Hospital Comments
Hospital comments about this report can be very insightful to consumers as they use
the information in this report to engage in discussions with their doctors and nurses.
Copies of these comments are available on the PHC4 Web site at www.phc4.org.
 • Hospital-acquired infections in pennsylvania
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control and prevention. It is not intended tal-acquired infection was $24,027, while
to be the sole source of information in mak- the median total payment for a case without
ing decisions about hospital care, nor should one was $5,440. The payment figures do
it be used to generalize about the overall not include Medicare or Medicaid.
quality of care provided by hospitals. The It is important to note that the degree
measurement of quality is highly complex, to which the presence of hospital-ac-
and the information used to capture such quired infections influenced these num-
measures is limited. bers is unknown. Some of the differences
Within this report, differences in mor- in mortality, lengths of stay and charges may
tality, length of stay and hospital charges be influenced by other factors, including
can be observed among patients with and the complex medical needs of the patient
without a hospital-acquired infection. For that necessitated hospitalization. Hospitals
example, the mortality rate for patients with and physicians may do everything right and
a hospital-acquired infection was 12.3%, still, a hospital death or complication can be
while the mortality rate for patients without an unavoidable consequence of a patient’s
a hospital-acquired infection was 2.1%. The medical condition. Where hospital charges
mean length of stay for patients with a hos- are concerned, in almost all cases, hospitals
pital-acquired infection was 19.3 days, while do not receive full charges from private
the mean length of stay for patients without insurance carriers or government payors. In
a hospital-acquired infection was 4.4 days. fact, on an average basis, across all inpatient
The median length of stay for patients with hospital cases statewide (not just infection
a hospital-acquired infection was 14.0 days, cases), hospitals are reimbursed or paid for
while the median length of stay for patients approximately 27% of established charges.*
without a hospital-acquired infection was Several studies published in the Novem-
3.0 days. The mean total hospital charge ber 2006 issue of the American Journal of
for patients with a hospital-acquired infec- Medical Quality challenged the idea that
tion was $175,964, while the mean for infections are driven primarily by patient
those patients without such infections was risk factors or severity of illness levels, as
$33,260. The median total hospital charge opposed to improper hand hygiene or other
for patients with a hospital-acquired infec- inconsistencies in the best practice applica-
tion was $79,670, while the median for tions of infection prevention and control.
those patients without such infections was One study in particular (Johannes et al.,
$18,538. The mean total commercial insur- 2006) concluded that the variations in mor-
ance payment for a case with a hospital- tality, length of hospitalization, and hospital
acquired infection was $51,096, while the charges observed in the 2004 hospital-ac-
mean total payment for a case without one quired infection data could not be explained
was $9,181. The median total commercial by differences in severity of illness. While
insurance payment for a case with a hospi- the additional mortality, length of stay,
* The statewide/regional revenue-to-charge ratios are derived from the annual net inpatient revenue and inpatient charges
provided by each hospital as part of their annual financial filings to PHC4.
Hospital-acquired infections in pennsylvania • 
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and additional charges for patients with a and to give readers, as much as possible,
hospital-acquired infection as compared to an “apples-to-apples” comparison between
patients without a hospital-acquired infec- the two years of data. The reader should
tion may not be entirely attributable to not make any direct comparisons of overall
those infections, it is reasonable to assume numbers, or draw conclusions about the
that infections are a contributing factor to reported differences because 2006 was the
these differences. The debate over the role first year in which all hospital-acquired
of risk factors in the contraction of a hospi- infections were required to be reported to
tal-acquired infection is certain to continue, PHC4.
and further study is warranted. The first report released in November
2006 represented a snapshot of activity over
Preventing hospital-acquired a one-year period (calendar year 2005). It
infections included hospital-acquired infections identi-
fied, confirmed and submitted by Pennsyl-
Many hospital-acquired infections can
vania hospitals for the following categories:
be prevented. There are simple and effective
central line-associated bloodstream infec-
methods that can dramatically reduce the
tions, ventilator-associated pneumonia,
incidence of hospital-acquired infections:
indwelling catheter-associated urinary tract
hand washing; using gloves and properly
infections and surgical site infections for cir-
sterilized equipment; and following evi-
culatory, neurological and orthopedic pro-
denced-based best practices every time, all
cedures. For the third and fourth quarters
the time, for procedures like the insertion of
of 2005, the surgical site infection category
an intravenous catheter to deliver fluids and
was expanded to include all surgical proce-
medication.
dures. For the fourth quarter of 2005, the
Patients also can play a role by becoming
pneumonia, bloodstream and urinary tract
informed consumers and advocates for stel-
infection categories were expanded to in-
lar care. Wash your hands. Make sure your
clude hospital-acquired infections that were
health care providers and hospital visitors
not device-related. As of January 2006,
have washed theirs as well. And ask ques-
the phase-in of reporting requirements was
tions of your doctors and hospital about
complete, and Pennsylvania hospitals were
their infection control processes.
required to submit data on all hospital-ac-
quired infections to PHC4.
What’s different about this report and
With this second report, PHC4 had
why?
originally intended to show the most
This is Pennsylvania’s second hospital-
current one-year period of data (calendar
specific report on hospital-acquired infec-
year 2006). However, since it was likely
tions. The format of this second report has
that readers would compare 2005 to 2006
been modified due to changes in hospital
totals which cannot be done because of
reporting requirements from 2005 to 2006
the phased-in reporting requirements, the
 • Hospital-acquired infections in pennsylvania
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decision was made to essentially create two redefined a two-character data field (Field
reports in one. 21d) on the Pennsylvania Uniform Claims
Hospital-specific information for all and Billing Form, which is submitted along
of 2006 is presented in one section, while with administrative and billing data for
a comparison of each hospital’s Quarter each inpatient hospital admission. Hospital
4, 2005 and Quarter 4, 2006 numbers is personnel enter one of a defined set of codes
displayed in another. Quarter 4, 2005 and into this field when the relevant hospital-ac-
Quarter 4, 2006 are the two quarters for quired infection is present.
which the reporting requirements were the Hospitals differ in terms of the volume
most alike. Still, the Council has repeat- and types of care provided, and the com-
edly stressed that trending over time, and pleteness of infection reporting may vary
not a single one-year snapshot, will be most across hospitals and maybe even within the
instructive because the ultimate goal shared same hospital. For example, a low number
by all is the reduction in occurrence of these of infections reported by a hospital could
infections. mean that it is doing an excellent job in
reducing its infection rate and ensuring
Data Issues patient safety. On the other hand, it could
indicate the hospital is underreporting its
PHC4 does not use billing data to
infection numbers to PHC4. Conversely,
identify hospital-acquired infections; the
a hospital with a high number of infections
hospital-acquired infections listed were
might appear to be less effective at patient
identified, confirmed and submitted by
safety. Yet, in reality, it may be doing a
Pennsylvania hospitals. To define a hospi-
very good job of identifying and report-
tal-acquired infection, PHC4 adopted the
ing infections. Hospitals using electronic
Centers for Disease Control and Prevention
surveillance approaches may report higher
(CDC) definition: an infection is a local-
numbers for this reason, and these hospitals
ized or systemic condition that 1) results from
are noted in the report.
adverse reaction to the presence of an infectious
Pennsylvania hospitals are making every
agent(s) or its toxin(s) and 2) was not present
effort to comply with the hospital-acquired
or incubating at the time of admission to the
infection reporting requirements; however,
hospital. In simple terms, patients did not
some data submission disparities among
have it when they entered the hospital, and
hospitals still exist, and some underreport-
they contracted it while they were there.
ing may be occurring. During the past two
PHC4 also adopted, with minor adjust-
years, PHC4 has undertaken a series of in-
ments, the CDC’s 13 major site categories
dependent audits of Pennsylvania hospitals
that define the hospital-acquired infection
to evaluate the accuracy of the reporting,
location, and expanded the list of 13 to
and the most recent audits have demonstrat-
include a category for multiple infections
ed noticeable improvement.
and to differentiate device related and
non-device related infections. PHC4 then
Hospital-acquired infections in pennsylvania • 
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Interpreting the numbers numbers of patients are displayed together.
The debate about the relationship of
The national discussion regarding the
patient risk factors and characteristics to
public reporting of hospital-acquired infec-
hospital-acquired infections will certainly
tion data has included an ongoing debate
continue, and PHC4 intends to follow and
about how, or whether, to risk-adjust this
contribute to this dialogue.
information. That is, should patient charac-
teristics, including the presence of other dis-
• Cases included in the report
eases or conditions, along with how ill the
This report includes information on
patient is, be considered when analyzing the
1,574,170 patients treated in the 165
data? PHC4’s Technical Advisory Group
Pennsylvania general acute care hospitals
has had discussion and has looked at de-
during calendar year 2006. Information
tailed data analysis in considering this issue
was provided on cases for which the hos-
of risk-adjustment. One argument against
pital was required to report hospital-ac-
risk-adjusting hospital-acquired infection
quired infections, which includes patients
data is that we should all strive toward the
that were at least two years old and were
goal of zero hospital-acquired infections.
hospitalized for reasons other than mental
The reporting of actual numbers, rather
disorders or alcohol and drug related dis-
than risk-adjusted numbers, highlights
orders. Patients that were hospitalized for
actual results and encourages root cause
an organ transplant, complications of an
analysis of every patient who contracted an
organ transplant, and/or burn treatment
infection while in the hospital.
were not included in the report.
For purposes of this report, PHC4 is pre-
senting actual numbers of infections. The
• Measures reported
report does recognize that certain patients
The following information is presented
may be at greater risk for the development
for cases in the report:
of infections, including patients being
Number of Cases – The number of cases
treated for burns, undergoing organ trans-
with infections represents the hospital-ac-
plants, or being treated for complications
quired infections identified and reported
of an organ transplant. These patients are
by the hospital.
excluded from the report because they are
at a significantly greater risk of acquiring an Infection Rate – This is the rate of infec-
infection while in a hospital. It would be tion per 1,000 cases. The rate is based on
unfair to list hospitals specializing in these the number of patients for which hospitals
conditions alongside those who treat few or were required to report hospital-acquired
no patients with these conditions if these infections, with one exception. For surgi-
cases were included. PHC4 also decided cal site infections, only patients undergo-
to present the data by hospital peer groups, ing surgical procedures were included.
in which hospitals that offer similar types
Mortality – The number and percent of
and complexity of services and treat similar
 • Hospital-acquired infections in pennsylvania
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mortality represents the number/percent hospital is actually reimbursed. Generally,
of patients who died during the hospital- hospitals do not receive full reimburse-
ization. It is important to note that the ment of charges because insurance compa-
cause of death may not have been related nies and other large purchasers of health
to the hospital-acquired infection. care usually negotiate large discounts.
Mean and Median Length of Stay and • Understanding how like hospitals are
grouped together (peer groups)
Hospital Charge – Both the mean and
the median are averages. The mean length
The four peer groups identified in this
of stay represents the number of days a
report were developed to assist the reader
patient would have been in the hospital,
in recognizing “like” hospitals. Hospitals
if all patients had an equal length of stay.
were grouped according to the complexity
The mean charge represents the amount
of services offered, the number of pa-
that a patient would have been charged for
tients treated, and the percent of surgical
their hospital care, if all the patients had
procedures performed. Unlike the first
equal charges. The mean is the measure
report, hospitals using electronic hospital-
most often referred to as the average.
acquired infection surveillance were not
The median length of stay represents the
separated out from their respective peer
midpoint of all the lengths of stay for
group; they were, however, noted as using
all patients in a particular hospital. In
electronic surveillance.
other words, half of the stays are longer
Peer Group 1 includes hospitals that
in length than the median and half are
provide more complex services and treat
shorter in length than the median. The
a larger number of patients than Peer
median charge represents the midpoint of
Groups 2, 3, and 4. Hospitals that are
all charges for all the patients in a particu-
designated as trauma centers were includ-
lar hospital. In other words, half of the
ed in this group. All of the hospitals in
charges are more than the median and half
Peer Group 1 perform open-heart surgery.
are less than the median. Both the mean
They treat an average of 25,430 patients
and the median include extreme values,
a year. On average, 39 percent of these
also known as outliers. Because outliers
patients undergo surgical procedures.
have more of an effect on the mean than
the median, the mean offers greater insight Peer Group 2 includes hospitals that
regarding the presence of extreme lengths provide more complex services and treat
of stay or charges. On the other hand, the a larger number of patients than Peer
median offers greater insight into mid- Groups 3 and 4. All of the hospitals in
range lengths of stay or charges. Peer Group 2 perform open-heart surgery.
They treat an average of 11,000 patients
Neither mean nor median hospital charges
a year. On average, 34 percent of these
include professional fees (e.g., physician
patients undergo surgical procedures.
fees) and do not reflect the amount that a
Hospital-acquired infections in pennsylvania • 
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Peer Group 3 includes hospitals that Electronic surveillance systems assist in
treat a larger number of patients than Peer reviewing laboratory, pharmaceutical, and
Group 4. They treat an average of 7,400 radiology information. Because the data is
patients a year. On average, 24 percent of available in real time, facilities can reduce
these patients undergo surgical procedures. preventable infections, improve safety,
decrease costs, and report infections more
Peer Group 4 hospitals treat an average
accurately.
of 1,950 patients a year. On average, 18
During the period covered by this report,
percent of these patients undergo surgical
13 hospitals were using a form of electronic
procedures.
surveillance software for at least one quar-
ter to identify hospital-acquired infections.
The role of electronic surveillance
The extent to which a hospital utilizes their
Infection surveillance is the process used
electronic surveillance software to submit
within hospitals to identify those patients
hospital-acquired infection data to PHC4
who might either have entered the hospital
varies. Some facilities may use the electron-
with an infection or who may have acquired
ic surveillance software as a screening tool
an infection while hospitalized, as well as
only. That is, cases flagged by the electronic
to assess disease outbreaks that might occur
surveillance software as having a potential
within a health care facility. Traditional
hospital-acquired infection are reviewed
infection surveillance is a time-consuming
by an infection control professional, who
process; infection control staff must review
makes the final determination of whether or
numerous reports generated by different
not a hospital-acquired infection is present.
departments within the hospital in order to
Hospitals using electronic surveillance
identify hospital-acquired infections, infec-
software were listed in their respective peer
tion trends, and other issues. As a result,
group. These facilities were identified with
“targeted” surveillance has often been used.
a notation made for the first quarter in
Over the last several years, hospitals have
which the electronic surveillance software
started to consider how the surveillance
was used. This notation was made to alert
process can be automated to assist infec-
the reader that in the instances where higher
tion control professionals in this important
numbers of infections were reported, this
job. Electronic surveillance systems enable
may be due to more comprehensive report-
integration of data from multiple depart-
ing, and not that these hospitals have, in
ments, assist in fast identification of patients
reality, a higher infection rate than facilities
with an infection or at risk for an infection,
not using such strategies. Over time, it will
and improve the productivity of the infec-
become clearer as to whether differences
tion control staff, thus allowing greater time
reported are due to higher infection rates or
for professional and patient education on
better identification and reporting of infec-
infection prevention.
tions.
 • Hospital-acquired infections in pennsylvania