Scrub Em!

Employee hand hygiene campaign at  St. Dominic’s

8:15am | Doctors, nurses, executives and staff start their day caring for patients.  They aren’t the only ones, however.  There are other unseen, sinister characters lurking about, ready to do harm…

Why is Measuring Important?

Healthcare-associated infections, or HAIs, are infections that people get while receiving treatment for another condition in a healthcare setting. HAIs can occur in all settings of care, including acute care hospitals, long term acute care hospitals, rehabilitation facilities, surgical centers, cancer hospitals and skilled nursing facilities. Many of these infections can be prevented through the use of proper procedures and precautions. Below, different HAIs are compared to national and state benchmarks.

What is a Standardized Infection Ratio?

Calculations for the HAI measures adjust for differences in the characteristics of hospitals and patients using a Standardized Infection Ratio (SIR). The SIR is a summary measure that takes into account differences in the types of patients a hospital treats. The SIR may take into account the type of patient care location, number of patients admitted with MRSA or C. difficile, laboratory methods, hospital affiliation with a medical school, bed size of the hospital, patient age and American Society of Anethesiologists’ (ASA) classification of physical health. It compares the actual number of HAIs in a facility or state to a national benchmark based on previous years of reported data and adjusts the data based on several factors. Generally healthcare providers seek to achieve ratios as close to zero as possible.

Healthcare Associated Infection Results April – June 2019

The closer to zero the better the performance. Generally, results <1 indicate positive overall performance for the period.

Healthcare Associated Infection Ratios
St. Dominic’s
State Avg.
National Avg.
CABG SIR
Coronary Artery Bypass Grafting Surgical Site Infections
Not calc
N=2
N/A
0.55
CAUTI SIR
Catheter-Associated Urinary Tract Infections
0.508
N=3
1.07
1.00
CLABSI SIR
Central-Line Associate Bloodstream Infections
0.264
N=1
0.76
0.50
COLO SIR
Colon Surgical Site Infections
2.587
N=3
0.62
0.98
HYST SIR
Abdominal Hysterectomy Surgical Site Infections
Not calc
N=0
0.53
0.83
HPRO
Hip Surgical Site Infections
Not calc
N=0
N/A
0.78
KPRO
Knee Surgical Site Infections
Not calc
N=1
N/A
0.59
St. Dominic’s data source: Centers for Disease Control and Prevention National Healthcare Safety Network (CDC/NHSN) Patient Safety Module
State and National Avg. data source: Centers for Disease Control and Prevention National and State Healthcare Associated Infections Progress Report. Published in 2016.
Healthcare Associated Infection Ratios
St. Dominic’s
State Avg.
National Avg.
CABG
Coronary Artery Bypass Grafting Surgical Site Infections
0.57
Not Avail.
0.55
CAUTI
Catheter-Associated Urinary Tract Infections
1.41
1.07
1.00
CLABSI
Central-Line Associate Bloodstream Infections
0.68
0.76
0.50
COLO
Colon Surgical Site Infections
0.00
0.62
0.98
HYST
Abdominal Hysterectomy Surgical Site Infections
0.61
0.53
0.83
HPRO
Hip Surgical Site Infections
0.67
Not Avail.
0.78
KPRO
Knee Surgical Site Infections
0.00
Not Avail.
0.59
Healthcare Associated Infection Ratios
St. Dominic’s
State Avg.
National Avg.
CABG
Coronary Artery Bypass Grafting Surgical Site Infections
0.34
Not Avail.
0.55
CAUTI
Catheter-Associated Urinary Tract Infections
1.48
Not Avail.
1.00
CLABSI
Central-Line Associate Bloodstream Infections
0.46
Not Avail.
0.50
COLO
Colon Surgical Site Infections
.34
Not Avail.
0.98
HYST
Abdominal Hysterectomy Surgical Site Infections
0.45
Not Avail.
0.83
HPRO
Hip Surgical Site Infections
1.31
Not Avail.
0.78
KPRO
Knee Surgical Site Infections
1.90
Not Avail.
0.59
Healthcare Associated Infection Ratios
St. Dominic’s
State Avg.
National Avg.
CABG
Coronary Artery Bypass Grafting Surgical Site Infections
0
Not Avail.
0.55
CAUTI
Catheter-Associated Urinary Tract Infections
1.652
Not Avail.
1.00
CLABSI
Central-Line Associate Bloodstream Infections
1.946
0.76
0.50
COLO
Colon Surgical Site Infections
0.388
0.62
0.98
HYST
Abdominal Hysterectomy Surgical Site Infections
0
0.53
0.83
HPRO
Hip Surgical Site Infections
0
Not Avail.
0.78
KPRO
Knee Surgical Site Infections
0
Not Avail.
0.59

Healthcare Associated Infection Results Jan – March 2018

The closer to zero the better the performance. Generally, results <1 indicate positive overall performance for the period.

Healthcare Associated Infection Ratios
St. Dominic’s
State Avg.
National Avg.
CABG
Coronary Artery Bypass Grafting Surgical Site Infections
SIR= n/a
N=2
Not Avail.
0.55
CAUTI
Catheter-Associated Urinary Tract Infections
SIR=0.56
N=2
Not Avail.
1.00
CLABSI
Central-Line Associate Bloodstream Infections
SIR=0.87
N=3
0.76
0.50
COLO
Colon Surgical Site Infections
SIR=0.00
N=0
0.62
0.98
HYST
Abdominal Hysterectomy Surgical Site Infections
SIR=n/a
N=0
0.53
0.83
HPRO
Hip Surgical Site Infections
SIR=n/a
N=0
Not Avail.
0.78
KPRO
Knee Surgical Site Infections
SIR=n/a
N=0
Not Avail.
0.59
Healthcare Associated Infection Ratios
St. Dominic’s
State Avg.
National Avg.
CABG
Coronary Artery Bypass Grafting Surgical Site Infections
SIR= n/a
N=1
Not Avail.
0.55
CAUTI
Catheter-Associated Urinary Tract Infections
SIR=0.87
N=4
Not Avail.
1.00
CLABSI
Central-Line Associate Bloodstream Infections
SIR=0.82
N=3
0.76
0.50
COLO
Colon Surgical Site Infections
SIR=1.30
N=0
0.62
0.98
HYST
Abdominal Hysterectomy Surgical Site Infections
SIR=n/a
N=0
0.53
0.83
HPRO
Hip Surgical Site Infections
SIR=n/a
N=0
Not Avail.
0.78
KPRO
Knee Surgical Site Infections
SIR=n/a
N=1
Not Avail.
0.59
Healthcare Associated Infection Ratios
St. Dominic’s
State Avg.
National Avg.
CABG SIR
Coronary Artery Bypass Grafting Surgical Site Infections
N=1
Not Avail.
0.55
CAUTI SIR
Catheter-Associated Urinary Tract Infections
0.36
N=4
Not Avail.
1.00
CLABSI SIR
Central-Line Associate Bloodstream Infections
1.46
N=7
0.76
0.50
COLO SIR
Colon Surgical Site Infections
0.96
N=0
0.62
0.98
HYST SIR
Abdominal Hysterectomy Surgical Site Infections
N=0
0.53
0.83
HPRO
Hip Surgical Site Infections
N=0
Not Avail.
0.78
KPRO
Knee Surgical Site Infections
N=0
Not Avail.
0.59
St. Dominic’s data source: Centers for Disease Control and Prevention National Healthcare Safety Network (CDC/NHSN) Patient Safety Module
State and National Avg. data source: Centers for Disease Control and Prevention National and State Healthcare Associated Infections Progress Report. Published in 2016.
Healthcare Associated Infection Ratios
St. Dominic’s
State Avg.
National Avg.
CABG SIR
Coronary Artery Bypass Grafting Surgical Site Infections
N=0
Not Avail.
0.55
CAUTI SIR
Catheter-Associated Urinary Tract Infections
0.4
N=2
1.07
1.00
CLABSI SIR
Central-Line Associate Bloodstream Infections
1.1
N=5
0.76
0.50
COLO SIR
Colon Surgical Site Infections
0.8
N=1
0.62
0.98
HYST SIR
Abdominal Hysterectomy Surgical Site Infections
N=0
0.53
0.83
HPRO
Hip Surgical Site Infections
N=0
Not Avail.
0.78
KPRO
Knee Surgical Site Infections
N=1
Not Avail.
0.59
Healthcare Associated Infection Ratios
St. Dominic’s
State Avg.
National Avg.
CABG SIR
Coronary Artery Bypass Grafting Surgical Site Infections
N=0
Not Avail.
0.55
CAUTI SIR
Catheter-Associated Urinary Tract Infections
0.2
N=1
1.07
1.00
CLABSI SIR
Central-Line Associate Bloodstream Infections
1.1
N=5
0.76
0.50
COLO SIR
Colon Surgical Site Infections
0.0
N=1
0.62
0.98
HYST SIR
Abdominal Hysterectomy Surgical Site Infections
N=0
0.53
0.83
HPRO
Hip Surgical Site Infections
N=0
Not Avail.
0.78
KPRO
Knee Surgical Site Infections
N=0
Not Avail.
0.59

Improvement Efforts

CAUTI and CLABSI Prevention

  • St. Dominic’s follows evidence based guidelines that include, but are not limited to the following:
    • Inserted only by qualified, trained healthcare workers
    • Only placed for approved medical necessity
    • Assessed daily for removal
    • Routine care and maintenance according to an established standard of care

Surgical Site Infection Prevention

  • St. Dominic’s follows evidence based guidelines that include, but are not limited to the following:
    • Provide skin cleaning liquid solution to patients for use prior to surgery
    • Give patients antibiotic just prior to surgery to reduce risk of infection
    • Clean the skin at the site of surgery with a special soap that kills germs just prior to surgery
    • Practice aseptic and sterile techniques during surgery