Definition of Terms for Hospital Acquired Infections (HAI) Reports
February 1, 2008
Terms:
- SC Hospital Infections Disclosure Act (HIDA) Reporting Requirements
- Central Line Associated Bloodstream Infection (CLABSI)
- Surgical Site Infection (SSI)
- Confidence Intervals
- Links to Internet Websites
Definitions:
South Carolina Hospital Infections Disclosure Act (HIDA) Reporting Requirements
- National Healthcare Safety Network (NHSN)
- DHEC, with the Advice of the Hospital Infections Disclosure Act Advisory Committee, selected this reporting system to meet the requirements of the South Carolina Hospital Infections Disclosure Act (HIDA). This is the Centers for Disease Control and Prevention (CDC)’ system for monitoring hospital acquired infections.
- Hospitals must use the NHSN reporting procedures and follow the Patient Safety Protocols for identifying and reporting infections to DHEC.
- Reporting requirements are being phased in over time and can be found on this web site under Information about Healthcare Acquired Infections (HAIs)
- NHSN definitions make it possible to report infection rates for procedures and locations using a standard definition in every hospital. It is not possible to combine the numbers into one infection rate for each hospital. Separate rates identify where the problem might be so that prevention processes can be improved in that area.
- Healthcare Associated Infection (HAI): For the purposes of NHSN surveillance, and reporting infections to DHEC, in the acute care setting, the CDC defines an HAI as a localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s). There must be no evidence that the infection was present or incubating at the time of admission to the acute care setting. HAIs may be caused by infectious agents from the patient’s body such as the skin or gastrointestinal tract where microorganisms usually live. Also, infections can be caused by sources external to the patient, such as patient care personnel, visitors, patient care equipment, medical devices, or the health care environment.
Central Line Associated Bloodstream Infection (CLABSI):
These are bloodstream infections that were not already present in the patient and are associated with the presence of a central line, or an umbilical catheter in newborn infants in intensive care, at the time of or before the onset of the infection. According to the CDC, an estimated 200,000 CLABSIs occur in U.S. hospitals each year. Primary bloodstream infections are usually serious infections that often cause longer hospital stays, higher cost, and higher risk of death. CLABSI can be prevented through proper management of the central line. Each patient with an infection that meets the definition of a CLABSI is counted and reported for the month into NHSN along with the number of patient days with a central line.
- Central line
A “central line” is a flexible tube that is inserted near the patient’s heart or into one of the large veins or arteries leading directly from or into the heart. A central line can be used to give fluids, measure the
amount of fluid in the body, or to give medications or nutrition. Because of
where it is located, it can cause potentially dangerous bloodstream infections. - Central line days
"Central line days” are the total number of days a central line is in place for patients in Intensive Care Units (ICU) or other specific clinical locations. The central line count is performed each day on each patient with one or more central lines at the same time every day. To report the rate of infection, each day’s total count of central lines is added together to get the total for the month. - Intensive Care Unit (ICU)
ICU's are hospital units that provide intensive observation and treatment for patients either dealing with, or at risk of developing, life threatening problems. Intensive care units are described by the types of patients in them; smaller hospitals typically care for both medical and surgical patients in a combined medical/surgical ICU, while larger hospitals have a separate ICU for medical patients and surgical patients.
Surgical Site Infection (SSI):
According to the CDC: An estimated 27 million surgical procedures are performed each year in the United States. SSIs are the third most common hospital acquired infection, accounting for 14% to 16% of all hospital acquired infections among hospitalized patients. Among surgical patients, 38% of all reported infections were SSIs. When surgical patients with SSI died, 77% of the deaths were reported to be related to the infection, and the majority (93%) were serious infections involving organs or spaces accessed during the operation (CDC, unpublished data).
Advances in infection control practices include improved operating room ventilation, sterilization methods, barriers, surgical technique, and availability of antimicrobial prophylaxis. Despite these activities, SSIs remain a substantial cause of illness and death among hospitalized patients.
Surveillance (case finding) of SSI with feedback of appropriate data to surgeons has been shown to be an important component of strategies to reduce SSI risk. A successful surveillance program includes the use of epidemiologically sound infection definitions and effective surveillance methods, stratification of SSI rates according to risk factors associated with SSI development, and data feedback. The CDC’s recommendations for preventing SSIs were published in 1999.
- SSI Basic Risk Index:
A score used to predict a surgical patient’s risk of acquiring a surgical site infection. The risk index score, ranging from 0 to 3, is the number of risk factors present among the following:- a patient with an American Society of Anesthesiologists’ physical status classification score of 3, 4, or 5,
- an operation classified as contaminated or dirty infected, and
- an operation lasting longer than the Duration cut point hours, where the Duration cut point depends upon the operation being performed.
- “M” is a modified category used in cholecystectomy (gallbladder) procedures when there are no risk factors present and it was performed with laparoscope. This is the lowest risk category for this surgery.
ASA Score:
Assessment by the anesthesiologist of the patient’s preoperative physical condition using the American Society of Anesthesiologist’ (ASA) Classification of Physical Status. Used as one element of the SSI Basic Risk index.
- Normally healthy patient
- Patient with mild systemic disease
- Patient with severe systemic disease that is not incapacitating
- Patient with an incapacitating systemic disease that is a constant threat to life
- Moribund patient who is not expected to survive for 24 hours with or without
the operation
Wound Class
An assessment of the degree of contamination of a surgical wound at the time of the operation. The wound class system used in NHSN is an adaptation of the American College of Surgeons wound classification schema11. Wounds are divided into four classes:
- Clean: An uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered. In addition, clean wounds are primarily closed and, if necessary, drained with closed drainage. Operative incisional wounds that follow nonpenetrating (blunt) trauma should be included in this category if they meet the criteria.
- Clean-Contaminated:Operative wounds in which the respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major break in technique is encountered.
- Contaminated: Open, fresh, accidental wounds. In addition, operations with major breaks in sterile technique (e.g., open cardiac massage) or gross spillage from the gastrointestinal tract, and incisions in which acute, nonpurulent inflammation is encountered are included in this category.
- Dirty or Infected:Includes old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation.
- Coronary Artery Bypass Graft (Chest and Donor Incision) – Five (5) hours
- Coronary Artery Bypass Graft (Chest Incision Only) – Four (4) hours
- Abdominal Hysterectomy – Two (2) hours
- Vaginal Hysterectomy – Two (2) hours
- Hip prosthesis (replacement) – Two (2) hours
- Knee prosthesis (replacement) – Two (2 ) hours
- Cholecystectomy / cholecystotomy (gallbladder) – Two (2) hours
For the HIDA Annual Report due February 1, 2009, DHEC is required to compare the risk adjusted hospital acquired infection rates for each individual hospital in South Carolina and to make these comparisons as easy for the public to understand as possible. DHEC and the Advisory Committee have begun to develop methods to assist the public to compare the infection rates in each hospital. One potential method is to use “Confidence Intervals” for each rate and to place the numbers on a chart to compare hospitals. For the August 1, 2008 report a confidence interval is given for the 19 largest hospitals in the state with over 200 licensed beds. Work is continuing on ways to create a comparison chart. For now, do not make comparisons between hospitals for the reasons described in the disclaimer. The following description provides information on confidence intervals.
The confidence interval for a hospital's infection rate is the range of possible rates within which we are 95% confident that the REAL infection rate for that hospital lies, given the specific number of infections that were observed in that hospital in the time period, and the number of surgical procedures or patient-days with a central venous line that patients experienced to get those infections. Thus if two hospitals are found to have apparently different infection rates, but the confidence intervals for those two infection rates overlap each other, then it is reasonably possible that the REAL rates are the same. (Discussion of Confidence Intervals) (pdf)
- National Healthcare Safety Network (NHSN)
- Descriptions of procedures, protocols, and definitions can be found in the NHSN Manual: Patient Safety Protocols