TECHNICAL REPORT FOR HEALTHCARE-ASSOCIATED INFECTIONS. New Jersey Department of Health Health Care Quality Assessment

Transcription

1 TECHNICAL REPORT FOR HEALTHCARE-ASSOCIATED INFECTIONS A SUPPLEMENT TO THE HOSPITAL PERFORMANCE REPORT, NEW JERSEY 2012 DATA New Jersey Department of Health Health Care Quality Assessment April 2015

2 Tables of Contents A. Healthcare-Associated Infections... 3 B. HAI Surveillance in New Jersey... 3 C. Source of Healthcare-Associated Infection Data... 4 D. Standardized Infection Ratio... 4 E. Data Limitations Data Tables Table 1: Central Line-Associated Bloodstream Infections..8 Table 2: Catheter-Associated Urinary Tract Infections.11 Table 3: Abdominal Hysterectomy Surgical Site Infections.14 Table 4: Knee Arthroplasty Surgical Site Infections.17 Table 5: Colon Surgical Site Infections.20 Table 6: Coronary Artery Bypass Graft Surgical Site Infections..23 Table 7: Overall Surgical Site Infections..24 References

3 Background A. Healthcare-Associated Infections Healthcare-Associated Infections (HAIs) are defined as infections acquired by patients while being treated in a healthcare setting. Healthcare settings include acute-care and specialty care hospitals, outpatient clinics, nursing homes, rehabilitation facilities and ambulatory surgery centers. HAIs contribute significantly to morbidity and mortality in the United States. The Centers for Disease Control and Prevention (CDC) conducted a large point-prevalence study in multiple states to provide an updated national estimate of HAIs in the United States. Survey findings indicated that approximately 1 in 25 hospital inpatients had at least one healthcare-associated infection. It is estimated that there were 722,000 HAIs in acute care hospitals in The estimated financial impact of HAIs is between $28 billion and $33 billion a year 2. There are a number of causes of HAIs which include medical devices (i.e., catheters, implants, ventilators), surgical procedure complications, the overuse of antibiotics and improper hand hygiene. Approximately 75 percent of HAIs can be attributed to four infection categories: 1. Surgical site infections; 2. Central line-associated bloodstream infections; 3. Ventilator-associated pneumonia, and; 4. Catheter-associated urinary tract infections. Two additional major contributors to HAIs are: 5. Clostridium difficile, and; 6. Methicillin-resistant Staphylococcus aureus (MRSA) 3. The most common healthcare-associated infections are urinary tract infections (32 percent), followed by surgical site infections (22 percent), pneumonias (15 percent), and bloodstream infections (14 percent) 1. B. HAI Surveillance in New Jersey Reducing preventable HAIs has become a priority for New Jersey hospitals, healthcare providers, state legislators and healthcare policy professionals. Signed in 2007, the public reporting law (PL of 2007, C 196) requires hospitals to report HAI data to the New Jersey Department of Health and for the data to be published in the Hospital Performance Report. Beginning January 1, 2009, all acute-care hospitals along with one specialty care hospital in New Jersey began submitting the following HAI data to the Department: 3

4 Central Line-Associated Bloodstream Infections (CLABSIs) in adult, pediatric and neonatal critical care units. Surgical Site Infections following Abdominal Hysterectomy procedures. Surgical Site Infections following Coronary Artery Bypass Graft procedures. In 2010, two additional HAIs were added to the surveillance efforts: Catheter-Associated Urinary Tract Infections in all adult critical care units. Surgical Site Infections following Knee arthroplasty. In 2012, acute care hospitals began HAI surveillance for Surgical Site Infections following Colon surgery procedures. C. Source of Healthcare-Associated Infection Data The Centers for Disease Control and Prevention s (CDC) Division of Healthcare Quality Promotion (DHQP) implemented a public health surveillance system known as the Healthcare Safety Network (NHSN) in The American Recovery and Reinvestment Act (ARRA) of 2009 provided the funding necessary to expand HAI surveillance and prevention efforts on both the national and state level. As a result, the NHSN system is used by various types of health care facilities in all 50 states, Washington, D.C. and Puerto Rico to monitor patient safety, healthcare personnel safety and biovigilance. Currently, more than 14,600 healthcare facilities use the NHSN system and 30 states and the District of Columbia have mandates which require hospitals to report Healthcare-Associated Infections using NHSN 4. The NHSN system is a secure, internet-based system. The 71 acute care hospitals as well as one specialty care hospital in New Jersey use the NHSN system to report and survey HAIs. This year s report focuses on the following HAIs: Surgical Site Infections (SSIs) following Coronary Artery Bypass Graft (CABG), Abdominal Hysterectomy, Knee Arthroplasty and Colon surgery procedures, Central Line-Associated Bloodstream Infections (CLABSIs) that occurred in adult, pediatric and neonatal critical/intensive care units and Catheter-Associated Urinary Tract Infections (CAUTIs) that occurred in adult intensive care units. In January 2012, hospitals began reporting colon surgery procedures and associated infections. Hospitals were provided the opportunity to verify the accuracy of their data. D. Standardized Infection Ratio This report presents composite statistics summarizing SSI, CLABSI and CAUTI data at the hospital level. The data are summarized using the Standardized Infection Ratio (SIR), a statistic used to measure relative difference in HAI occurrence during a reporting period compared to a common reference period (i.e. standard population). 4

5 What is a Standardized Infection Ratio (SIR)? The Standardized Infection Ratio (SIR) is a summary measure developed by CDC to be used to track HAIs at a national, state, local or hospital level over time. The SIR adjusts for the fact that each hospital treats different types of patients. The SIR compares the actual number of events reported by a hospital with the national baseline experience, adjusting for several risk factors that have been found to be significantly associated with differences in infection incidence 5, 7. How is the SIR Calculated? The SIR is calculated by applying the risk-adjustment method developed by CDC to the 2012 New Jersey data. Calculating the SIR is similar to the Standardized Mortality Ratio (SMR), a summary statistic frequently used in public health. SIR is defined as the number of observed infections divided by the number of expected infections. The formula below depicts the calculation: SSS = OOOOOOOO NNNNNN oo IIIIIIIIII EEEEEEEE NNNNNN oo IIIIIIIIII The table below provides an example of how a hospital s CLABSI data from four different locations can be summarized into a single risk-adjusted summary statistic, i.e., the SIR. Type of ICU Location Observed Number of CLABSI Events Central Line-days CLABSI Rate (per 1000 central-days) NHSN Rate (per 1000 centraldays) Expected Number of CLABSI Events Medical cardiac Medical Med/Surgical Neurosurgical Total Overall CLABSI SIR = Observed/Expected = 8/4.15 = 1.93 The observed number of CLABSI events is the number of CLABSI events that occurred in an ICU or CCU in a hospital. The greater the total number of days that patients have central lines inserted (central line-days), the more CLABSI events are likely to occur. 5

6 The expected number of CLABSI events for an ICU or CCU is calculated by multiplying the total count of central line-days in the ICU or CCU by the NHSN rate and dividing by The NHSN rate is based on NHSN aggregate data. CLABSI rates were stratified by type of patient care locations and, in some cases, also by type of hospital or bed size of the patient-care locations 5, 6. The expected numbers of CLABSI events from all adult and pediatric ICUs and CCUs in a hospital are then summarized and used as the denominator for the overall SIR for the hospital. The expected number of CLABSI events shows the number of CLABSI events that would have occurred if the hospital s performance had been the same as the national experience. Following the NHSN methodology, the SIRs are calculated only if the number of expected events is >=1. When the number of expected events is <1, comparisons are not precise 7. SIRs for CAUTIs and SSIs are calculated in a similar manner. How to interpret the SIR? In trying to determine a hospital s performance, it is important to account for the fact that some differences occur simply due to chance or random variation. As shown in the tables, 95% confidence intervals are used to determine whether a hospital s SIR is statistically significantly higher or lower than 1.0. The hospital SIRs are compared to the national experience, which is a baseline SIR of 1.0. The results are summarized under the column, Comparison. This column classifies the hospitals performances by L as Lower than Expected, the letter S as Similar to Expected, or H as Higher than Expected. A hospital s SIR is statistically significantly lower than 1.0 if the upper limit of its 95% confidence interval falls completely below 1.0. The Comparison column for the hospital is noted with the letter L. This means fewer events were observed than expected, adjusting for differences in the types of patients treated. The hospital performed better than the national baseline experience. A hospital s SIR is statistically significantly higher than 1.0 if the lower limit of its 95% confidence interval falls completely above 1.0. The Comparison column for the hospital is noted with the letter H. This means more events were observed than expected, adjusting for differences in the types of patients treated. The hospital performed worse than the national baseline experience. A hospital s SIR is not statistically different from 1.0 if its 95% confidence interval includes 1.0. The Comparison column for the hospital is noted with the letter S. This means similar number of events was observed as expected, adjusting for 6

7 differences in the types of patients treated. The hospital performed similar to the national baseline experience. In examining the table, some SIRs may appear lower than others but are considered Similar" while other SIRs may appear higher but the Comparison indicates Lower. When using this report, it is important to remember that the data in the tables are designed to show whether a hospital s SIR is statistically significantly above, below or the same as the national baseline. Therefore, it is more important to view the confidence intervals in relation to the national baseline SIR of 1.0 and not make hospital-to-hospital comparisons. E. Data Limitations Please keep in mind some of the following issues before making conclusions about a hospital: Hospitals reviewed and verified the data used in this report is the data that was reported to the NHSN system. The risk-adjustment method may not fully capture how sick patients are in certain hospitals and locations. For example, the medical intensive care unit patients in one hospital might be intrinsically at greater risk for HAI compared to the medical intensive care unit patients from the national experience. Therefore, it is important to use caution when interpreting hospital HAI data. A hospital which performed lower than the Comparison, does not necessarily mean the hospital is better but that they may need to improve their HAI surveillance protocols. Conversely, a hospital which performed higher than the Comparison is not necessarily a poor performer. This hospital could have better infection control practices and processes instituted throughout their facility. 7

8 Table 1: 2012 Central Line-Associated Bloodstream Infections (CLABSI) HOSPITAL NAME Observed # of CLABSI (O) Number of Central Line Days Expected # of CLABSI CLABSI SIR b p-value (E) a 95 % AtlantiCare Regional Medical Center-City Campus (0.366, 1.498) S AtlantiCare Regional Medical Center-Mainland Campus (0.803, 2.406) S Bayonne Medical Center (0.036, 3.505) S Bayshore Community Hospital (0.112, 2.200) S Bergen Regional Medical Center Cape Regional Medical Center (0.027, 2.654) S Capital Health Medical Center - Hopewell (0.606, 3.108) S Capital Health Regional Medical Center (RMC) (0.276, 1.248) S Centrastate Medical Center (0.146, 2.869) S Chilton Memorial Hospital (0.565, 3.416) S Christ Hospital (0.389, 4.165) S Clara Maass Medical Center (0.747, 2.072) S Community Medical Center (0.488, 1.996) S Cooper Hospital/University Medical Center (0.171, 0.565) L Deborah Heart and Lung Center (0.065, 1.286) S East Orange General Hospital (0.011, 1.109) S Englewood Hospital and Medical Center (0.010, 0.987) L Hackensack University Medical Center (0.565, 1.308) S Hackettstown Regional Medical Center Hoboken University Medical Center (0.041, 4.039) S Holy Name Medical Center (0.210, 2.243) S Hunterdon Medical Center (---,0.775) L Jersey City Medical Center (0.149, 0.900) L Jersey Shore University Medical Center (0.288, 0.903) L JFK Medical Center/Anthony M Yelensics (0.443, 1.553) S Kennedy University Hospital (0.007, 0.644) L Kennedy University Hospital/UMC-Cherry Hill (0.253, 2.710) S Kennedy University Hospital/UMC-Stratford (---,1.954) S 8

9 HOSPITAL NAME Observed # of CLABSI (O) Number of Central Line Days Expected # of CLABSI CLABSI SIR b p-value (E) a 95 % Kimball Medical Center (0.023, 2.315) S Lourdes Medical Center Burlington County (0.023, 2.232) S Meadowlands Hospital Medical Center (0.203, 4.005) S Memorial Hospital of Salem County Monmouth Medical Center (0.582, 2.380) S Morristown Medical Center (0.236, 0.827) L Mountainside (0.762, 2.673) S Newark Beth Israel Medical Center (0.656, 1.302) S Newton Medical Center (---,2.512) S Ocean Medical Center (0.082, 1.621) S Our Lady of Lourdes Medical Center (0.153, 0.925) L Overlook Medical Center (0.352, 1.164) S Palisades Medical Center of New York (PHS) (0.018, 1.730) S Raritan Bay Medical Center-Old Bridge (---,1.157) S Raritan Bay Medical Center-Perth Amboy (0.132, 1.409) S Riverview Medical Center (0.109, 2.144) S Robert Wood Johnson University Hospital (0.320, 0.811) L Robert Wood Johnson University Hospital at Hamilton (0.293, 2.221) S Robert Wood Johnson University Hospital at Rahway (0.075, 1.486) S Saint Barnabas Medical Center (0.154, 0.578) L Shore Medical Center (0.777, 3.988) S Somerset Medical Center (0.077, 1.509) S South Jersey Healthcare Regional Medical Center (0.168, 1.802) S South Jersey Healthcare-Elmer Southern Ocean Medical Center (0.028, 2.764) S St. Clare's Hospital-Denville (0.028, 2.759) S St. Clare's Hospital-Dover (0.046, 4.529) S St. Clare's Hospital-Sussex St. Francis Medical Center (0.017, 1.635) S St. Joseph's Regional Medical Center (0.511, 1.184) S St. Joseph's Wayne Hospital (0.216, 1.642) S St. Luke's Warren Hospital (---,2.042) S 9

10 HOSPITAL NAME Observed # of CLABSI (O) Number of Central Line Days Expected # of CLABSI CLABSI SIR b p-value (E) a 95 % St. Mary's Hospital (1.056, 3.704) H St. Michael's Medical Center (0.490, 1.843) S St. Peter's University Hospital (0.243, 1.248) S Trinitas Regional Medical Center (0.544, 2.460) S UMDNJ - University Hospital (0.988, 2.139) S Underwood Memorial Hospital (0.092, 1.820) S University Medical Center of Princeton (0.022, 2.191) S Valley Hospital (0.364, 1.368) S Virtua Marlton (0.014, 1.401) S Virtua-Memorial Hospital of Burlington County (---,0.671) L Virtua-West Jersey Health System-Berlin Virtua-West Jersey Health System-Voorhees (0.167, 1.267) S ICU (0.655, 0.811) L NICU (0.431, 0.775) L STATEWIDE (0.641, 0.783) L Source: New Jersey Healthcare-Associated Infections for 2012 submitted through the Healthcare Safety Network (NHSN). a b Expected (E)= # of infections predicted using risk-adjusted model fitted from the NHSN data from for CLABSI data. Important to note that if Expected is <1, the SIR is not calculated as the result is not precise. Standardized Infection Ratio (SIR)= Observed (O)/ Expected (E) Each hospital is compared to the Ratio=1 which is derived using the CDC's NHSN data from for CLABSI (AJIC, December 2009). L indicates hospital infections are LOWER than infections seen nationally. H indicates hospital infections are HIGHER than infections seen nationally. S indicates hospital infections are SIMILAR to infections seen nationally. SIR is not calculated because the Expected is < 1. 10

11 Table 2: 2012 Catheter-Associated Bloodstream Infections (CAUTI) HOSPITAL NAME Observed # of CAUTI (O) Number of Catheter Days Expected # of CAUTI (E) a CAUTI SIR b p-value 95 % AtlantiCare Regional Medical Center-City Campus (0.004, 0.347) L AtlantiCare Regional Medical Center-Mainland Campus (0.096, 1.025) S Bayonne Medical Center (0.387, 4.146) S Bayshore Community Hospital (0.200, 2.136) S Bergen Regional Medical Center (0.213, 4.198) S Cape Regional Medical Center (---,0.889) L Capital Health Medical Center - Hopewell (0.626, 3.212) S Capital Health Regional Medical Center (RMC) (0.413, 1.109) S Centrastate Medical Center (0.434, 2.228) S Chilton Memorial Hospital (0.089, 1.745) S Christ Hospital (---,1.482) S Clara Maass Medical Center (0.382, 1.263) S Community Medical Center (0.206, 0.842) L Cooper Hospital/University Medical Center (0.382, 0.903) L Deborah Heart and Lung Center (0.458, 2.070) S East Orange General Hospital (---,0.786) L Englewood Hospital and Medical Center (0.452, 1.846) S Hackensack University Medical Center (0.419, 1.063) S Hackettstown Regional Medical Center (---,2.063) S Hoboken University Medical Center (0.192, 3.788) S Holy Name Medical Center (0.072, 1.424) S Hunterdon Medical Center (0.424, 2.177) S Jersey City Medical Center (---,0.207) L Jersey Shore University Medical Center (0.195, 0.733) L JFK Medical Center/Anthony M Yelensics (0.565, 1.774) S Kennedy University Hospital (0.005, 0.495) L Kennedy University Hospital/UMC-Cherry Hill (0.265, 2.014) S Kennedy University Hospital/UMC-Stratford (0.014, 1.367) S Kimball Medical Center (0.249, 2.667) S Lourdes Medical Center Burlington County (0.018, 1.787) S Meadowlands Hospital Medical Center (0.139, 2.748) S 11

12 HOSPITAL NAME Observed # of CAUTI (O) Number of Catheter Days Expected # of CAUTI (E) a CAUTI SIR b p-value 95 % Memorial Hospital of Salem County (0.816, 6.195) S Monmouth Medical Center (0.784, 2.591) S Morristown Medical Center (0.223, 0.736) L Mountainside (1.092, 2.931) H Newark Beth Israel Medical Center (0.495, 1.289) S Newton Medical Center (0.019, 1.899) S Ocean Medical Center (0.672, 2.528) S Our Lady of Lourdes Medical Center (0.674, 2.020) S Overlook Medical Center (1.360, 2.427) H Palisades Medical Center of New York (PHS) (1.521, 5.723) H Raritan Bay Medical Center-Old Bridge (0.160, 3.155) S Raritan Bay Medical Center-Perth Amboy (0.342, 2.072) S Riverview Medical Center (1.134, 3.747) H Robert Wood Johnson University Hospital (1.166, 2.033) H Robert Wood Johnson University Hospital at Hamilton (0.303, 2.299) S Robert Wood Johnson University Hospital at Rahway (0.006, 0.629) L Saint Barnabas Medical Center (0.016, 0.314) L Shore Medical Center (1.658, 5.818) H Somerset Medical Center (0.447, 2.023) S South Jersey Healthcare Regional Medical Center (0.584, 1.831) S South Jersey Healthcare-Elmer (0.028, 2.758) S Southern Ocean Medical Center (0.081, 1.591) S St. Clare's Hospital-Denville (---,1.443) S St. Clare's Hospital-Dover (---,1.943) S St. Clare's Hospital-Sussex St. Francis Medical Center (0.166, 1.778) S St. Joseph's Regional Medical Center (0.827, 1.718) S St. Joseph's Wayne Hospital (0.395, 1.785) S St. Luke's Warren Hospital (2.020, 8.258) H St. Mary's Hospital (1.643, 4.410) H St. Michael's Medical Center (0.553, 1.942) S St. Peter's University Hospital (0.510, 1.791) S 12

13 HOSPITAL NAME Observed # of CAUTI (O) Number of Catheter Days Expected # of CAUTI (E) a CAUTI SIR b p-value 95 % Trinitas Regional Medical Center (0.200, 1.521) S UMDNJ - University Hospital (1.299, 2.349) H Underwood Memorial Hospital (0.414, 2.502) S University Medical Center of Princeton (0.221, 2.360) S Valley Hospital (1.105, 2.878) H Virtua Marlton (0.191, 2.046) S Virtua-Memorial Hospital of Burlington County (0.009, 0.855) L Virtua-West Jersey Health System-Berlin (---,2.381) S Virtua-West Jersey Health System-Voorhees (0.416, 2.517) S STATEWIDE (0.841, 0.992) L Source: New Jersey Healthcare-Associated Infections for 2012 submitted through the Healthcare Safety Network (NHSN). a b Expected (E)= # of infections predicted using risk-adjusted model fitted from the NHSN data from 2009 for CAUTI data. Important to note that if Expected is <1, the SIR is not calculated as the result is not precise. Standardized Infection Ratio (SIR)= Observed (O)/ Expected (E) Each hospital is compared to the Ratio=1. The Ratio is derived using the CDCs NHSN data from 2009 for CAUTI due to a definition change (AJIC, 2010). L indicates hospital infections are LOWER than infections seen nationally. H indicates hospital infections are HIGHER than infections seen nationally. S indicates hospital infections are SIMILAR to infections seen nationally. SIR is not calculated because the Expected is < 1. 13

14 Table 3: 2012 Abdominal Hysterectomy Surgical Site Infections Hospital Name Procedure Count Observed # of Abdominal Hysterectomy Infections (O) Expected # of Abdominal Hysterectomy Infections (E) a SIR b p-value 95% AtlantiCare Regional Medical Center-City Campus AtlantiCare Regional Medical Center-Mainland Campus Bayonne Medical Center Bayshore Community Hospital Bergen Regional Medical Center N/A Cape Regional Medical Center Capital Health Medical Center - Hopewell (0.740, 7.919) S Capital Health Regional Medical Center (RMC) Centrastate Medical Center Chilton Memorial Hospital Christ Hospital Clara Maass Medical Center Community Medical Center (0.633, 4.803) S Cooper Hospital/University Medical Center (0.242, 1.840) S Deborah Heart and Lung Center N/A East Orange General Hospital Englewood Hospital and Medical Center Hackensack University Medical Center (0.199, 2.132) S Hackettstown Regional Medical Center Hoboken University Medical Center Holy Name Medical Center (---,2.426) S Hunterdon Medical center Jersey City Medical Center Jersey Shore University Medical Center (0.028, 2.771) S JFK Medical Center/Anthony M Yelensics Kennedy University Hospital (---,2.060) S Kennedy University Hospital/UMC-Cherry Hill Kennedy University Hospital/UMC-Stratford Kimball Medical Center Lourdes Medical Center Burlington County Meadowlands Hospital Medical Center Memorial Hospital of Salem County

15 Hospital Name Procedure Count Observed # of Abdominal Hysterectomy Infections (O) Expected # of Abdominal Hysterectomy Infections (E) a SIR b p-value 95% Monmouth Medical Center (---,1.354) S Morristown Medical Center (1.147, 5.190) H Mountainside (---,1.502) S Newark Beth Israel Medical Center (---,0.868) L Newton Medical Center Ocean Medical Center Our Lady of Lourdes Medical Center Overlook Medical Center Palisades Medical Center of New York (PHS) Raritan Bay Medical Center-Old Bridge N/A Raritan Bay Medical Center-Perth Amboy Riverview Medical Center Robert Wood Johnson University Hospital (1.114, 5.039) H Robert Wood Johnson University Hospital at Hamilton Robert Wood Johnson University Hospital at Rahway N/A Saint Barnabas Medical Center (1.080, 5.542) H Shore Medical Center Somerset Medical Center South Jersey Healthcare Regional Medical Center (0.020, 2.002) S South Jersey Healthcare-Elmer Southern Ocean Medical Center St. Clare's Hospital-Denville St. Clare's Hospital-Dover St. Clare's Hospital-Sussex St. Francis Medical Center N/A N/A St. Joseph's Regional Medical Center (---,2.576) S St. Joseph's Wayne Hospital St. Luke's Warren Hospital St. Mary's Hospital St. Michael's Medical Center St. Peter's University Hospital (0.242, 2.590) S Trinitas Regional Medical Center (0.017, 1.661) S UMDNJ - University Hospital (0.215, 4.233) S 15

16 Hospital Name Procedure Count Observed # of Abdominal Hysterectomy Infections (O) Expected # of Abdominal Hysterectomy Infections (E) a SIR b p-value 95% Underwood Memorial Hospital University Medical Center of Princeton (0.039, 3.805) S Valley Hospital Virtua Marlton Virtua-Memorial Hospital of Burlington County (0.030, 2.929) S Virtua-West Jersey Health System-Berlin Virtua-West Jersey Health System-Voorhees (0.730, 3.748) S STATEWIDE (0.800, 1.293) S Source: New Jersey Healthcare-Associated Infections for 2012 submitted through the Healthcare Safety Network (NHSN). a b Expected (E)= # of infections predicted using the model fitted from the NHSN data from which serves as the baseline for future reports. Important to note that if Expected is <1, the SIR is not calculated as the result is not precise. Standardized Infection Ratio (SIR)= Observed (O)/ Expected (E) Each hospital is compared to the Ratio=1. The Ratio is derived using the CDC's NHSN data from (AJIC, December 2009). L H S indicates hospital infections are LOWER than infections seen nationally. indicates hospital infections are HIGHER than infections seen nationally. indicates hospital infections are SIMILAR to infections seen nationally. SIR is not calculated because the Expected is < 1. N/A hospital is not licensed to perform procedure(s) or did not perform procedure(s) in

17 Table 4: 2012 Knee Arthroplasty Surgical Site Infections Observed # of Knee Arthroplasty Infections (O) Expected # of Knee Arthroplasty Infections (E) a SIR b p-value 95% Procedure Hospital Name Count AtlantiCare Regional Medical Center-City Campus N/A AtlantiCare Regional Medical Center-Mainland Campus (0.384, 1.570) S Bayonne Medical Center Bayshore Community Hospital Bergen Regional Medical Center Cape Regional Medical Center Capital Health Medical Center - Hopewell (0.362, 3.877) S Capital Health Regional Medical Center (RMC) Centrastate Medical Center Chilton Memorial Hospital Christ Hospital Clara Maass Medical Center (---,2.458) S Community Medical Center (0.380, 4.064) S Cooper Hospital/University Medical Center (0.035, 3.498) S Deborah Heart and Lung Center N/A East Orange General Hospital Englewood Hospital and Medical Center (0.224, 4.405) S Hackensack University Medical Center (0.171, 1.295) S Hackettstown Regional Medical Center Hoboken University Medical Center Holy Name Medical Center (---,1.896) S Hunterdon Medical center Jersey City Medical Center Jersey Shore University Medical Center (0.268, 2.863) S JFK Medical Center/Anthony M Yelensics (1.573, 7.115) H Kennedy University Hospital (0.019, 1.851) S Kennedy University Hospital/UMC-Cherry Hill Kennedy University Hospital/UMC-Stratford Kimball Medical Center Lourdes Medical Center Burlington County Meadowlands Hospital Medical Center

18 Hospital Name Procedure Count Observed # of Knee Arthroplasty Infections (O) Expected # of Knee Arthroplasty Infections (E) a SIR b p-value 95% Memorial Hospital of Salem County Monmouth Medical Center (0.023, 2.311) S Morristown Medical Center (0.124, 1.331) S Mountainside Newark Beth Israel Medical Center Newton Medical Center Ocean Medical Center (---,1.172) S Our Lady of Lourdes Medical Center Overlook Medical Center (0.020, 1.946) S Palisades Medical Center of New York (PHS) Raritan Bay Medical Center-Old Bridge Raritan Bay Medical Center-Perth Amboy Riverview Medical Center (---,1.456) S Robert Wood Johnson University Hospital (1.707, 6.978) H Robert Wood Johnson University Hospital at Hamilton (---,1.992) S Robert Wood Johnson University Hospital at Rahway Saint Barnabas Medical Center (---,1.838) S Shore Medical Center (0.038, 3.714) S Somerset Medical Center (0.044, 4.368) S South Jersey Healthcare Regional Medical Center South Jersey Healthcare-Elmer Southern Ocean Medical Center St. Clare's Hospital-Denville (0.302, 5.942) S St. Clare's Hospital-Dover St. Clare's Hospital-Sussex N/A St. Francis Medical Center St. Joseph's Regional Medical Center (---,2.301) S St. Joseph's Wayne Hospital St. Luke's Warren Hospital St. Mary's Hospital St. Michael's Medical Center St. Peter's University Hospital (---,1.800) S Trinitas Regional Medical Center

19 Hospital Name Procedure Count Observed # of Knee Arthroplasty Infections (O) Expected # of Knee Arthroplasty Infections (E) a SIR b p-value 95% UMDNJ - University Hospital Underwood Memorial Hospital University Medical Center of Princeton (---,1.030) S Valley Hospital (0.738, 4.465) S Virtua Marlton (0.680, 3.488) S Virtua-Memorial Hospital of Burlington County (0.017, 1.668) S Virtua-West Jersey Health System-Berlin N/A Virtua-West Jersey Health System-Voorhees (0.024, 2.350) S STATEWIDE (0.683, 1.065) S Source: New Jersey Healthcare-Associated Infections for 2012 submitted through the Healthcare Safety Network (NHSN). a b Expected (E)= # of infections predicted using the model fitted from the NHSN data from which serves as the baseline for future reports. Important to note that if Expected is <1, the SIR is not calculated as the result is not precise. Standardized Infection Ratio (SIR)= Observed (O)/ Expected (E) Each hospital is compared to the Ratio=1. The Ratio is derived using the CDC's NHSN data from (AJIC, December 2009). L indicates hospital infections are LOWER than infections seen nationally. H indicates hospital infections are HIGHER than infections seen nationally. S indicates hospital infections are SIMILAR to infections seen nationally. SIR is not calculated because the Expected is < 1. N/A hospital is not licensed to perform procedure(s) or did not perform procedure(s) in

20 Table 5: 2012 Colon Surgical Site Infections Hospital Name Procedure Count Observed # of Colon Surgical Site Infections (O) Expected # of Colon Surgical Site Infections (E) a SIR b p-value 95% AtlantiCare Regional Medical Center-City Campus (---,2.168) S AtlantiCare Regional Medical Center-Mainland Campus (---,1.091) S Bayonne Medical Center (0.033, 3.255) S Bayshore Community Hospital (---,1.901) S Bergen Regional Medical Center Cape Regional Medical Center (---,1.252) S Capital Health Medical Center - Hopewell (0.450, 3.419) S Capital Health Regional Medical Center (RMC) (---,1.913) S Centrastate Medical Center (0.467, 2.395) S Chilton Memorial Hospital (0.999, 4.519) S Christ Hospital Clara Maass Medical Center (0.858, 3.881) S Community Medical Center (0.362, 1.857) S Cooper Hospital/University Medical Center (0.151, 1.612) S Deborah Heart and Lung Center East Orange General Hospital (0.039, 3.893) S Englewood Hospital and Medical Center (0.113, 1.205) S Hackensack University Medical Center (0.070, 0.750) L Hackettstown Regional Medical Center Hoboken University Medical Center Holy Name Medical Center (0.015, 1.498) S Hunterdon Medical Center (---,1.753) S Jersey City Medical Center (0.122, 2.403) S Jersey Shore University Medical Center (0.006, 0.629) L JFK Medical Center/Anthony M Yelensics (0.016, 1.531) S Kennedy University Hospital (---,0.978) L Kennedy University Hospital/UMC-Cherry Hill Kennedy University Hospital/UMC-Stratford Kimball Medical Center (---,2.957) S Lourdes Medical Center Burlington County (0.025, 2.424) S Meadowlands Hospital Medical Center Memorial Hospital of Salem County

21 Hospital Name Procedure Count Observed # of Colon Surgical Site Infections (O) Expected # of Colon Surgical Site Infections (E) a SIR b p-value 95% Monmouth Medical Center (0.010, 1.004) S Morristown Medical Center (0.330, 1.493) S Mountainside (0.134, 2.649) S Newark Beth Israel Medical Center (0.088, 1.743) S Newton Medical Center (0.150, 2.962) S Ocean Medical Center (---,0.617) L Our Lady of Lourdes Medical Center (0.230, 1.743) S Overlook Medical Center (0.299, 1.221) S Palisades Medical Center of New York (PHS) (---,2.845) S Raritan Bay Medical Center-Old Bridge Raritan Bay Medical Center-Perth Amboy (---,2.787) S Riverview Medical Center (---,0.450) L Robert Wood Johnson University Hospital (0.121, 0.922) L Robert Wood Johnson University Hospital at Hamilton (0.183, 1.954) S Robert Wood Johnson University Hospital at Rahway (0.163, 3.208) S Saint Barnabas Medical Center (0.353, 1.329) S Shore Medical Center (0.462, 2.792) S Somerset Medical Center (0.091, 1.793) S South Jersey Healthcare Regional Medical Center (0.451, 3.425) S South Jersey Healthcare-Elmer Southern Ocean Medical Center (0.049, 4.821) S St. Clare's Hospital-Denville (---,0.670) L St. Clare's Hospital-Dover (---,2.152) S St. Clare's Hospital-Sussex St. Francis Medical Center St. Joseph's Regional Medical Center (---,0.602) L St. Joseph's Wayne Hospital (0.248, 4.887) S St. Luke's Warren Hospital (0.508, 5.432) S St. Mary's Hospital (0.157, 3.098) S St. Michael's Medical Center (---,2.488) S St. Peter's University Hospital (0.128, 1.364) S Trinitas Regional Medical Center (0.015, 1.508) S UMDNJ - University Hospital (0.664, 3.004) S 21

22 Hospital Name Procedure Count Observed # of Colon Surgical Site Infections (O) Expected # of Colon Surgical Site Infections (E) a SIR b p-value 95% Underwood Memorial Hospital (0.013, 1.303) S University Medical Center of Princeton (0.071, 1.401) S Valley Hospital (1.153, 3.318) H Virtua Marlton (0.509, 3.862) S Virtua-Memorial Hospital of Burlington County (0.061, 1.194) S Virtua-West Jersey Health System-Berlin Virtua-West Jersey Health System-Voorhees (0.055, 1.083) S STATEWIDE (0.535, 0.735) L Source: New Jersey Healthcare-Associated Infections for 2012 submitted through the Healthcare Safety Network (NHSN). a b Expected (E)= # of infections predicted using the model fitted from the NHSN data from which serves as the baseline for future reports. Important to note that if Expected is <1, the SIR is not calculated as the result is not precise. Standardized Infection Ratio (SIR)= Observed (O)/ Expected (E) Each hospital is compared to the Ratio=1. The Ratio is derived using the CDC's NHSN data from (AJIC, December 2009). L indicates hospital infections are LOWER than infections seen nationally. H indicates hospital infections are HIGHER than infections seen nationally. S indicates hospital infections are SIMILAR to infections seen nationally. SIR is not calculated because the Expected is < 1. 22

23 Table 6: 2012 Coronary Artery Bypass Graft Surgical Site Infections Hospital Name Number of Procedures Observed # of CABG Infections (O) Expected # of CABG Infections (E) a SIR b p-value 95 % AtlantiCare Regional Medical Center-Mainland Campus (0.886, 4.548) S Cooper Hospital/University Medical Center (0.016, 1.550) S Deborah Heart and Lung Center (0.164, 3.228) S Englewood Hospital and Medical Center (0.139, 2.744) S Hackensack University Medical Center (0.249, 1.888) S Jersey City Medical Center (---,1.648) S Jersey Shore University Medical Center (0.454, 2.051) S Morristown Medical Center (0.083, 0.888) L Newark Beth Israel Medical Center (0.977, 5.014) S Our Lady of Lourdes Medical Center (0.693, 3.134) S Robert Wood Johnson University Hospital (0.181, 1.373) S Saint Barnabas Medical Center (0.102, 2.002) S St. Francis Medical Center (0.285, 5.609) S St. Joseph's Regional Medical Center (0.094, 1.850) S St. Mary's Hospital St. Michael's Medical Center (---,1.623) S UMDNJ - University Hospital Valley Hospital (0.291, 3.112) S STATEWIDE (0.629, 1.090) S Source: New Jersey Healthcare-Associated Infections for 2012 submitted through the Healthcare Safety Network (NHSN). a b Expected (E)= # of infections predicted using the model fitted from the NHSN data from This data set will serve as the baseline/benchmark for future reports. Important to note that if Expected is <1, the SIR is not calculated as the result is not precise. Standardized Infection Ratio (SIR)= Observed (O)/ Expected (E) Each hospital is compared to the Ratio=1. The Ratio is derived using the CDC's NHSN data from (AJIC, December 2009). L indicates hospital infections are LOWER than infections seen nationally. H indicates hospital infections are HIGHER than infections seen nationally. S indicates hospital infections are SIMILAR to infections seen nationally. SIR is not calculated because the Expected is < 1. CABG: includes procedures with either chest only or chest and donor site incisions. 23

24 Table 7: 2012 Overall Surgical Site Infections Hospital Name Procedure Count Observed # of Overall Surgical Site Infections (O) Expected # of Overall Surgical Site Infections (E) a SIR b p-value 95% AtlantiCare Regional Medical Center-City Campus (---,1.709) S AtlantiCare Regional Medical Center-Mainland Campus (0.504, 1.450) S Bayonne Medical Center (0.032, 3.127) S Bayshore Community Hospital (---,1.508) S Bergen Regional Medical Center Cape Regional Medical Center (0.017, 1.680) S Capital Health Medical Center - Hopewell (0.852, 2.991) S Capital Health Regional Medical Center (RMC) (---,1.504) S Centrastate Medical Center (0.376, 1.928) S Chilton Memorial Hospital (0.785, 3.549) S Christ Hospital (0.049, 4.821) S Clara Maass Medical Center (0.779, 2.932) S Community Medical Center (0.673, 2.018) S Cooper Hospital/University Medical Center (0.295, 1.108) S Deborah Heart and Lung Center (0.160, 3.153) S East Orange General Hospital (0.033, 3.301) S Englewood Hospital and Medical Center (0.273, 1.233) S Hackensack University Medical Center (0.292, 0.841) L Hackettstown Regional Medical Center (1.270, 9.639) H Hoboken University Medical Center (0.039, 3.826) S Holy Name Medical Center (0.008, 0.807) L Hunterdon Medical Center (---,1.076) S Jersey City Medical Center (0.065, 1.289) S Jersey Shore University Medical Center (0.338, 1.061) S JFK Medical Center/Anthony M Yelensics (0.611, 2.500) S Kennedy University Hospital (0.007, 0.687) L Kennedy University Hospital/UMC-Cherry Hill Kennedy University Hospital/UMC-Stratford (---,2.275) S Kimball Medical Center (0.250, 4.931) S Lourdes Medical Center Burlington County (0.020, 1.952) S Meadowlands Hospital Medical Center Memorial Hospital of Salem County

25 Hospital Name Procedure Count Observed # of Overall Surgical Site Infections (O) Expected # of Overall Surgical Site Infections (E) a SIR b p-value 95% Monmouth Medical Center (0.036, 0.714) L Morristown Medical Center (0.461, 1.113) S Mountainside (0.067, 1.320) S Newark Beth Israel Medical Center (0.415, 1.561) S Newton Medical Center (0.115, 2.261) S Ocean Medical Center (0.006, 0.630) L Our Lady of Lourdes Medical Center (0.591, 1.854) S Overlook Medical Center (0.275, 1.036) S Palisades Medical Center of New York (PHS) (---,2.379) S Raritan Bay Medical Center-Old Bridge Raritan Bay Medical Center-Perth Amboy (---,1.742) S Riverview Medical Center (0.005, 0.511) L Robert Wood Johnson University Hospital (0.666, 1.515) S Robert Wood Johnson University Hospital at Hamilton (0.796, 2.793) S Robert Wood Johnson University Hospital at Rahway (0.146, 2.878) S Saint Barnabas Medical Center (0.522, 1.360) S Shore Medical Center (0.438, 2.248) S Somerset Medical Center (0.145, 1.553) S South Jersey Healthcare Regional Medical Center (0.294, 1.781) S South Jersey Healthcare-Elmer Southern Ocean Medical Center (0.209, 4.120) S St. Clare's Hospital-Denville (0.056, 1.095) S St. Clare's Hospital-Dover (---,2.012) S St. Clare's Hospital-Sussex St. Francis Medical Center (0.359, 3.839) S St. Joseph's Regional Medical Center (0.030, 0.600) L St. Joseph's Wayne Hospital (0.311, 3.333) S St. Luke's Warren Hospital (0.556, 4.224) S St. Mary's Hospital (0.232, 2.482) S St. Michael's Medical Center (0.067, 1.327) S St. Peter's University Hospital (0.225, 1.155) S Trinitas Regional Medical Center (0.048, 0.949) L UMDNJ - University Hospital (0.844, 2.647) S 25