2 Introduction

Healthcare-associated infections, commonly referred to as HAIs, are infections that patients acquire during treatment for conditions within a health care setting, such as a hospital, ambulatory surgical center, nursing home, or outpatient care center. HAIs are one of the major types of complications or adverse events that can occur when receiving medical treatment in a health care facility. These infections can be relatively minor and easily treatable (such as a minor skin infection) or can be devastating to both patients and their families due to lost time and wages, the need for additional treatment, additional days in the hospital, and increased medical costs. This report addresses a subset of HAIs that were reported from hospitals to National Healthcare Safety Network (NHSN). This report quantifies the number of HAIs reported to NHSN by hospitals and provides a measure of each hospital’s success in having fewer HAIs than a statistical model predicted based on the hospital’s characteristics and the rate of HAIs that were reported in 2015.

In 2007, Pennsylvania was one of the first states to pass HAI legislation assigning specific responsibilities to the Department of Health (Department), the Pennsylvania Safety Authority (PSA) and Pennsylvania Health Care Cost Containment Council (PHC4) to monitor and reduce HAIs in healthcare facilities. The Department continues work to reduce HAIs per requirements of Act 52, which includes tracking HAIs; distributing quarterly validation reports to hospitals regarding HAIs reported to NHSN; publishing Pennsylvania NHSN HAI data, guidance and technical support to health care facilities regarding NHSN; and reviewing infection control plans for newly opened hospitals, long-term care facilities, and ambulatory surgical facilities. Recently, the Department expanded its role through work with the Centers for Disease Control and Prevention (CDC). These expanded roles include:

  • Validating HAIs reported to NHSN
  • Conducting on-site assessments of infection prevention and control practices in nursing homes;
  • Making recommendations for practice changes to fill gaps in implementation of national guidelines;
  • Assisting inpatient healthcare facilities to prevent and manage outbreaks that involve multidrug-resistant organisms;
  • Assisting healthcare facilities prevent and mitigate the effects of infection control breaches;
  • Training the healthcare workforce in basic infection prevention and control principles and germ theory; and
  • Assisting providers and facilities with implementing better antimicrobial stewardship programs.

While Pennsylvania continues to see a statewide reduction in HAIs reported to NHSN through 2019, they continue to be an important patient safety concern being addressed by the Department and CDC. In 2015, CDC reported there were an estimated 687,000 HAIs in United States acute care hospitals and about 72,000 deaths associated with HAIs1. In a 2009 report published by CDC, it was estimated that the direct costs of HAIs to US hospitals was more than 28 billion dollars, of which 70% was estimated as preventable3. In 2009, HHS issued a five-year National Action Plan to Prevent Health Care-Associated Infections4 in a variety of healthcare settings. In 2016, it was updated to establish new reduction goals and defined a new five-year period for NHSN HAIs (2015-2020). HHS is currently working to update this plan with new indicator targets, data, and intervention efforts, as well as include a review of the impact of the COVID-19 public health emergency on HAIs5. This 2019 Pennsylvanian HAI report focuses on the five types of NHSN HAIs benchmarked in Pennsylvania and targeted by HHS for reduction in the 2016 HAI National Action Plan. These infections include:

  1. Central line-associated bloodstream infection (CLABSI);
  2. Catheter-associated urinary tract infection (CAUTI);
  3. Surgical site infection (SSI) [for seven procedure types];
  4. Laboratory-identified bloodstream infection (LabID) events caused by MRSA; and
  5. Laboratory-identified infection (LabID) events caused by Clostridioides difficile (CDI).

This report is generated by the Department as a requirement of Act 52 and serves as a resource for health care providers and for the general public seeking information about HAI prevention and reduction progress. Hospitals can use the downloadable data included in this report as a benchmark to assess their HAI reduction strategies and progress. Health care consumers in Pennsylvania can use this report to have an awareness of HAI risk at the hospital they may choose.

This is the fourth report to use an online format which was produced using version 4.2.2 of R statistical software6. This report displays the number of HAIs reported by each hospital between January 1, 2019 and December 31, 2019. The number of infections alone cannot be used to determine how well a facility ranks in their efforts to prevent infections. Because factors intrinsic to the hospital and patient contribute to the development of HAIs, a metric which adjusts for some of those factors has also been included in this report. This metric should also be evaluated to determine how well a facility ranks in the efforts to prevent infections. That metric is called the standardized infection ratio.

2.1 Catheter-Associated Urinary Tract Infection (CAUTI)

A urinary tract infection (UTI) is an infection involving any part of the urinary system, including the urethra, bladder, ureter, and kidney. Among UTIs acquired during a hospitalization, approximately 75% are associated with an indwelling urinary catheter, a tube inserted into the bladder and left in place to drain urine7. These UTIs may be classified as a catheter-associated UTI (CAUTI) if the urinary catheter that was inserted into the urinary bladder has been in place for more than two calendar days and certain other criteria are met8. Between 15% and 25% of hospitalized patients receive urinary catheters during their hospital stay; many catheters are not needed and/or stay in place longer than needed.7

The most effective way to reduce CAUTIs is to reduce unnecessary urinary catheter placement by establishing clear indications for use and minimizing the length of time it remains in place by removing it as soon as the medical necessity no longer exists. Each day that a patient has a catheter in place the risk for developing a CAUTI increases by 3% to 7%.9 ,10 The 2016 attributable cost to Medicare inpatients with a CAUTI ranged between $1,764 and $10,197 depending on the patient’s location in the hospital.11. The Centers for Medicare and Medicaid Services (CMS) no longer reimburses hospitals for additional costs generated by CAUTIs.

Many resources are available for health care providers that outline strategies and guidelines for prevention of CAUTIs including those published by the Society for Healthcare Epidemiology of America (SHEA)9 and the Association for Professionals in Infection Control and Epidemiology (APIC). Strategies to prevent CAUTIs are discussed in CDC’s Healthcare Infection Control Practices Advisory Committee (CDC/HICPAC) document, Guideline for Prevention of Catheter-Associated Urinary Tract Infection12.

2.2 Central Line-Associated Bloodstream Infection (CLABSI)

A central line is a device used to administer fluids, medications, blood, and nutrition, or to collect blood needed for laboratory testing or to measure a patient’s status. Unlike short peripheral intravenous catheters, these catheters are inserted to access major vessels located near the heart and are placed via a large vein in the neck, chest, groin, or through veins in the arms. A central line can stay in place for weeks to months13.

After bacteria or other organisms enter a patient’s bloodstream through a central line and a bloodstream infection is detected, it is classified as a CLABSI. When a different NHSN infection is identified elsewhere in the body (e.g., the lungs or skin) and later moves to the bloodstream, it is not classified as a CLABSI even though a central line may be in place.

CLABSIs continue to be a serious patient safety issue as well as an economic burden to health care facilities even though United States CLABSI rates decreased 46% from 2008-201314. An estimated 30,100 CLABSIs still occur in United States hospitals each year. Each CLABSI is estimated to cost $70,696 (2012 dollars)15. The CMS no longer reimburses hospitals for additional costs generated by CLABSIs16. In 2011, research indicated that between 65% and 70% of CLABSIs were preventable by implementing evidence-based strategies and CLABSIs were associated with the highest number of preventable deaths17. A review of articles published between 2005 and 2016 revealed that the pooled incidence rate ratio associated with multifaceted CLABSI interventions was 0.459 (95% CI, 0.381–0.554)2.This means that 45.9% of CLABSIs could be prevented through use of multifaceted interventions.

In 2022, the SHEA/IDSA/APIC Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals, also known as the Compendium, published updated recommendations for preventing CLABSIs18. APIC’s 2015 Implementation Guide to Preventing Central Line-Associated Bloodstream Infections13 and the CDC/HICPAC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 201119 are also evidenced-based guidelines.

2.3 Surgical Site infections (SSIs)

Surgical site infections (SSIs) are attributed to a specific surgical procedure and vary in complexity and infection depth. The depth ranges from superficial incisional infections to those located deep into muscle and those penetrating deeper than the fascial/muscle layer layer (organ/space).8

Patients with an SSI have a two to 11 times higher risk of death compared with operative patients without an SSI. The number of SSIs in the United States has significantly decreased since 2011 and account for 20% to 22% of all HAIs1. In 2002, Klevens et.al.20 estimated there were 290,485 SSIs. By 2011, the estimated SSIs decreased to 157,50021 and, by 2015, the number further decreased to 110,8001. Between 2006 and 2008, the SSI rate from all procedure types in 39 states was 1.9%22. Similar data from 2010-2012 determined the SSI rate to be 0.82%23 or 0.97%21. By 2015, the national SSI rate dropped to 0.56%1.

Surgical site infections are associated with human and financial costs related to lost work time, increased days in the hospital (on average an added 9.7 days)24, added treatment costs including return to the OR, emergency department visits, and readmissions to the hospitals. Per CDC’s 2017 Guideline for the Prevention of Surgical Site Infection, the cost of an SSI ranges from $10,443 to $25,546 per infection, and costs can exceed $90,000 when the SSI involves a prosthetic joint implant or antibiotic-resistant organism25.

A review of articles published between 2005 and 2016 revealed that the pooled incidence rate ratio associated with multifaceted SSI interventions was 0.461 (95% CI, 0.389–0.546)2. Facility SSI reduction efforts as recommended in APIC’s 2015 Implementation Guide: (Infection Preventionist’s Guide to the OR)26 should include resources so that hospital infection prevention and control programs can support the perioperative team to implement the most current and evidence-based surgical infection prevention and control strategies, as well as tracking and communicating surgical infection rates to the perioperative team. Guidelines and evidence-based recommendations to prevent SSIs include CDC’s updated Guideline for the Prevention of Surgical Site Infection,25 and the American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update24. It is recommended that facilities incorporate evidence-based strategies as well as multifaceted interventions into a comprehensive surgical quality improvement program to reduce SSIs.

2.4 Clostridioides difficile infection (CDI) in the stool

Clostridioides difficile is an anaerobic, Gram-positive, spore-forming bacillus (bacteria) that can produce two exotoxins, toxin A and toxin B. It was considered nonpathogenic until 1978 when it was first identified as the primary cause of pseudomembranous colitis following antibiotic exposure27. C. difficile infection (CDI) is the leading cause of antibiotic-associated diarrhea in the United States1, has become the most commonly identified cause of HAIs in United States adults, is a major health threat to hospitalized patients, and, in recent years, has become established as a community acquired pathogen. Prior to May 2019 Clostridioides difficile was called Clostridium difficile.

The development of CDI most commonly requires two components: exposure to antibiotics and new acquisition of C. difficile from the ingestion of spores (fecal-oral transmission). Antibiotics suppress or disrupt the normal bowel microbiota (bacteria) that allow for C. difficile to flourish when spores are ingested. In the health care setting, exposure to C. difficile spores occur via the contaminated hands of health care personnel or contact with contaminated environmental surfaces or equipment. A significant risk factor for CDI is occupying a room where a prior occupant had CDI29. A modifiable risk factor is exposure to antibiotics; however, the point prevalence of a hospitalized patient receiving 1 or more antimicrobial medication on a single day was 49.5% in 201530. Other risk factors for CDI are advanced age, long hospitalization stays, and severe underlying illness.

A study funded by the CDC to assess the burden of C. difficile in the United States in 2011 estimated that C. difficile was responsible for almost 500,000 infections and associated with approximately 29,000 deaths. Fifty-eight percent (N=293,300) of the infections were healthcare-associated, meaning that onset followed a visit to a health care setting. Thirty-seven percent of the healthcare-associated infections were estimated to occur during a hospital visit (hospital onset). Thirty-six percent were classified as occurring in nursing homes (nursing home onset) and 27% were classified as having onset dates in the community after the patient had recently visited a health care facility (community onset). Of the patients with hospital onset, community onset after hospital stay, or nursing home onset, the rate of death within 30 days was 9.3%. The mortality rate was about 10 times higher among people aged 65+ compared with those aged 45-6431. Recent United States hospital discharge data indicate that the number of hospital discharges with a diagnosis of CDI plateaued at historic highs between 2011 and 201332. Approximately 1.9 million and 600,000 patients discharged from United States hospitals across six study years had a C. difficile infection as a discharge and principal diagnosis, respectively in 2004 and 2014. C. difficile-associated fatality decreased from 3.6% in 2004 to 1.6% in 2014, meanwhile the mean hospital charges increased from 2004 ($24,535) to 2014 ($35,898)33. In a Canadian study, patients with CDI had an increased hospital stay of six days34. Approximately 14% to 26% of individuals who recover from CDI experience a recurrence. In the patients who experienced a single recurrence, the risk of additional recurrences may be as high as 65%35.

SHEA and the Infectious Diseases Society of America (IDSA) updated their clinical practice guidelines for C. difficile in 201732. In 2013, APIC developed their Guide to Preventing Clostridium difficile Infections36.

2.5 Methicillin-resistant Staphylococcus aureus (MRSA) found in the blood

Staphylococcus aureus is a bacterium often called “staph” that is commonly found on the skin and does not typically cause an infection. However, when staph enters the bloodstream, it can cause a serious infection and even death. Staph infections that cannot be treated with the antibiotic methicillin are named methicillin-resistant Staphylococcus aureus (MRSA). About 2% of people carry MRSA in their nose or skin37. MRSA can be spread by someone who is infected or colonized with MRSA to another person through direct contact or contact with contaminated equipment or shared personal items. Outbreaks of MRSA have occurred in daycare centers, on sports teams, in group homes, and in health care facilities. In hospitals, MRSA can be passed from one person to another through contaminated hands of health care workers and on surfaces contaminated with MRSA, such as bedrails or medical equipment. Anyone can get MRSA, but persons living in or involved with activities that take place in crowded settings (i.e. athletes, military barracks), as well as hospitalized patients who have surgery, have received broad spectrum antimicrobials, have had devices inserted into their bodies, or have been admitted into a room in which the previous occupant was colonized or infected with MRSA are at an increased risk for acquisition of MRSA38. Per the CDC, persons who inject drugs are 16 times more likely to develop a serious staph infection39 and of all patients treated in United States hospitals, 5% carry MRSA in their nose or on their skin, which is known as being colonized37.

A 2019 study published in MMWR reported that MRSA bloodstream infections in health care settings decreased nationally by approximately 17% each year from 2005 until 201340. Recent NHSN data show that the lowest national MRSA bacteremia standardized infection ratios (SIR = 0.82) were reported in 201941. This is much higher than the 2020 HHS Healthy People goal of 0.50.

MRSA infection prevention and control remains a priority for the CDC because MRSA is estimated to cause more than 70,000 severe infections and 9,000 deaths per year42. Based on the current evidence, CDC continues to recommend the use of contact precautions for MRSA-colonized or infected patients43 as does SHEA44. Health care facilities and infection preventionists are encouraged to monitor MRSA community and admission prevalence rates and health care data to determine which prevention strategy to implement, as well as to evaluate the effectiveness of their infection prevention and control practices.