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

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

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... 7 2012 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... 27 2

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 2011 1. 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

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 2005. 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

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 2 380 5.26 2.0 0.76 Medical 1 257 3.89 2.6 0.67 Med/Surgical 3 627 4.78 1.5 0.94 Neurosurgical 2 712 2.81 2.5 1.78 Total 8 1976 4.05 --- 4.15 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

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 1000. The NHSN rate is based on 2006-2008 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

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

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 8 3734 10.1427 0.789 0.5246 (0.366, 1.498) S AtlantiCare Regional Medical Center-Mainland Campus 13 5313 9.0085 1.443 0.1991 (0.803, 2.406) S Bayonne Medical Center 1 938 1.407 0.711 0.8343 (0.036, 3.505) S Bayshore Community Hospital 2 2002 3.003 0.666 0.6212 (0.112, 2.200) S Bergen Regional Medical Center 2 406 0.7714 --- --- --- --- Cape Regional Medical Center 1 1239 1.8585 0.538 0.6016 (0.027, 2.654) S Capital Health Medical Center - Hopewell 6 2617 4.0151 1.494 0.3295 (0.606, 3.108) S Capital Health Regional Medical Center (RMC) 7 5430 11.0909 0.631 0.2124 (0.276, 1.248) S Centrastate Medical Center 2 1212 2.3028 0.869 0.9255 (0.146, 2.869) S Chilton Memorial Hospital 5 2163 3.2445 1.541 0.3379 (0.565, 3.416) S Christ Hospital 3 1307 1.9605 1.53 0.4485 (0.389, 4.165) S Clara Maass Medical Center 15 5807 11.6697 1.285 0.3316 (0.747, 2.072) S Community Medical Center 8 3661 7.6092 1.051 0.8444 (0.488, 1.996) S Cooper Hospital/University Medical Center 11 13244 33.8287 0.325 0 (0.171, 0.565) L Deborah Heart and Lung Center 2 2434 5.1374 0.389 0.1496 (0.065, 1.286) S East Orange General Hospital 1 2964 4.446 0.225 0.0756 (0.011, 1.109) S Englewood Hospital and Medical Center 1 2713 4.9988 0.2 0.0472 (0.010, 0.987) L Hackensack University Medical Center 22 11309 25.0421 0.879 0.5593 (0.565, 1.308) S Hackettstown Regional Medical Center 0 615 0.9225 --- --- --- --- Hoboken University Medical Center 1 814 1.221 0.819 0.95 (0.041, 4.039) S Holy Name Medical Center 3 2427 3.6405 0.824 0.8023 (0.210, 2.243) S Hunterdon Medical Center 0 1841 3.8661 0 0.0209 (---,0.775) L Jersey City Medical Center 5 5597 12.3088 0.406 0.0229 (0.149, 0.900) L Jersey Shore University Medical Center 12 10707 22.5815 0.531 0.0169 (0.288, 0.903) L JFK Medical Center/Anthony M Yelensics 10 6497 11.4755 0.871 0.6957 (0.443, 1.553) S Kennedy University Hospital 1 3168 7.653 0.131 0.0046 (0.007, 0.644) L Kennedy University Hospital/UMC-Cherry Hill 3 1335 3.0125 0.996 1 (0.253, 2.710) S Kennedy University Hospital/UMC-Stratford 0 730 1.533 0 0.2159 (---,1.954) S 8

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 1 1420 2.13 0.469 0.4908 (0.023, 2.315) S Lourdes Medical Center Burlington County 1 1473 2.2095 0.453 0.462 (0.023, 2.232) S Meadowlands Hospital Medical Center 2 1100 1.65 1.212 0.7207 (0.203, 4.005) S Memorial Hospital of Salem County 2 431 0.6465 --- --- --- --- Monmouth Medical Center 8 2713 6.3842 1.253 0.5052 (0.582, 2.380) S Morristown Medical Center 10 9287 21.5589 0.464 0.0065 (0.236, 0.827) L Mountainside 10 2667 6.6682 1.5 0.2142 (0.762, 2.673) S Newark Beth Israel Medical Center 33 16444 35.1865 0.938 0.7316 (0.656, 1.302) S Newton Medical Center 0 795 1.1925 0 0.3035 (---,2.512) S Ocean Medical Center 2 2717 4.0755 0.491 0.3134 (0.082, 1.621) S Our Lady of Lourdes Medical Center 5 7438 11.9795 0.417 0.0283 (0.153, 0.925) L Overlook Medical Center 11 7437 16.4189 0.67 0.1717 (0.352, 1.164) S Palisades Medical Center of New York (PHS) 1 1619 2.851 0.351 0.2803 (0.018, 1.730) S Raritan Bay Medical Center-Old Bridge 0 1726 2.589 0 0.0751 (---,1.157) S Raritan Bay Medical Center-Perth Amboy 3 2813 5.7957 0.518 0.2421 (0.132, 1.409) S Riverview Medical Center 2 2055 3.0825 0.649 0.5921 (0.109, 2.144) S Robert Wood Johnson University Hospital 18 13484 34.4046 0.523 0.0024 (0.320, 0.811) L Robert Wood Johnson University Hospital at Hamilton 4 2896 4.344 0.921 0.9312 (0.293, 2.221) S Robert Wood Johnson University Hospital at Rahway 2 2020 4.4466 0.45 0.2435 (0.075, 1.486) S Saint Barnabas Medical Center 9 10674 28.5701 0.315 0 (0.154, 0.578) L Shore Medical Center 6 2086 3.129 1.918 0.1379 (0.777, 3.988) S Somerset Medical Center 2 2249 4.3786 0.457 0.2552 (0.077, 1.509) S South Jersey Healthcare Regional Medical Center 3 2280 4.5303 0.662 0.5074 (0.168, 1.802) S South Jersey Healthcare-Elmer 0 367 0.6973 --- --- --- --- Southern Ocean Medical Center 1 939 1.7841 0.561 0.6355 (0.028, 2.764) S St. Clare's Hospital-Denville 1 1190 1.7873 0.56 0.634 (0.028, 2.759) S St. Clare's Hospital-Dover 1 726 1.089 0.918 1 (0.046, 4.529) S St. Clare's Hospital-Sussex 0 17 0.0255 --- --- --- --- St. Francis Medical Center 1 1995 3.0164 0.332 0.2457 (0.017, 1.635) S St. Joseph's Regional Medical Center 22 10299 27.6738 0.795 0.2799 (0.511, 1.184) S St. Joseph's Wayne Hospital 4 2798 5.8758 0.681 0.4647 (0.216, 1.642) S St. Luke's Warren Hospital 0 978 1.467 0 0.2306 (---,2.042) S 9

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 10 3208 4.812 2.078 0.0361 (1.056, 3.704) H St. Michael's Medical Center 9 5077 8.9621 1.004 0.9469 (0.490, 1.843) S St. Peter's University Hospital 6 4350 9.9992 0.6 0.1973 (0.243, 1.248) S Trinitas Regional Medical Center 7 3753 5.6295 1.243 0.5412 (0.544, 2.460) S UMDNJ - University Hospital 26 6804 17.5572 1.481 0.0567 (0.988, 2.139) S Underwood Memorial Hospital 2 2420 3.63 0.551 0.4202 (0.092, 1.820) S University Medical Center of Princeton 1 1477 2.251 0.444 0.4476 (0.022, 2.191) S Valley Hospital 9 7262 12.0692 0.746 0.3869 (0.364, 1.368) S Virtua Marlton 1 2347 3.5205 0.284 0.1633 (0.014, 1.401) S Virtua-Memorial Hospital of Burlington County 0 2978 4.467 0 0.0115 (---,0.671) L Virtua-West Jersey Health System-Berlin 0 647 0.9705 --- --- --- --- Virtua-West Jersey Health System-Voorhees 4 4049 7.6171 0.525 0.1785 (0.167, 1.267) S ICU 340 234037 465.8286 0.73 --- (0.655, 0.811) L NICU 45 29692 77.0457 0.584 0.0001 (0.431, 0.775) L STATEWIDE 385 263729 542.8743 0.709 --- (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 2006-2008 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 2006-2008 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

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 1 5317 14.2334 0.07 0 (0.004, 0.347) L AtlantiCare Regional Medical Center-Mainland Campus 3 4235 7.9681 0.377 0.0574 (0.096, 1.025) S Bayonne Medical Center 3 1515 1.9695 1.523 0.4525 (0.387, 4.146) S Bayshore Community Hospital 3 3186 3.8232 0.785 0.7339 (0.200, 2.136) S Bergen Regional Medical Center 2 787 1.574 1.271 0.6766 (0.213, 4.198) S Cape Regional Medical Center 0 2807 3.3684 0 0.0344 (---,0.889) L Capital Health Medical Center - Hopewell 6 3238 3.8856 1.544 0.2964 (0.626, 3.212) S Capital Health Regional Medical Center (RMC) 16 7676 22.9275 0.698 0.1378 (0.413, 1.109) S Centrastate Medical Center 6 2800 5.6 1.071 0.8179 (0.434, 2.228) S Chilton Memorial Hospital 2 2913 3.7869 0.528 0.3795 (0.089, 1.745) S Christ Hospital 0 1685 2.022 0 0.1324 (---,1.482) S Clara Maass Medical Center 11 6997 15.1328 0.727 0.2883 (0.382, 1.263) S Community Medical Center 8 8098 18.0398 0.443 0.0097 (0.206, 0.842) L Cooper Hospital/University Medical Center 21 13225 34.9332 0.601 0.0122 (0.382, 0.903) L Deborah Heart and Lung Center 7 2870 6.6892 1.046 0.8581 (0.458, 2.070) S East Orange General Hospital 0 2933 3.8129 0 0.0221 (---,0.786) L Englewood Hospital and Medical Center 8 3857 8.2273 0.972 0.9826 (0.452, 1.846) S Hackensack University Medical Center 18 11897 26.2498 0.686 0.0962 (0.419, 1.063) S Hackettstown Regional Medical Center 0 1117 1.4521 0 0.2341 (---,2.063) S Hoboken University Medical Center 2 1342 1.7446 1.146 0.7751 (0.192, 3.788) S Holy Name Medical Center 2 3866 4.6392 0.431 0.213 (0.072, 1.424) S Hunterdon Medical Center 6 2492 5.7316 1.047 0.861 (0.424, 2.177) S Jersey City Medical Center 0 6674 14.4922 0 0 (---,0.207) L Jersey Shore University Medical Center 9 10707 22.5328 0.399 0.0015 (0.195, 0.733) L JFK Medical Center/Anthony M Yelensics 12 7198 11.4976 1.044 0.8467 (0.565, 1.774) S Kennedy University Hospital 1 4033 9.9563 0.1 0.0006 (0.005, 0.495) L Kennedy University Hospital/UMC-Cherry Hill 4 2083 4.7909 0.835 0.7735 (0.265, 2.014) S Kennedy University Hospital/UMC-Stratford 1 1569 3.6087 0.277 0.1519 (0.014, 1.367) S Kimball Medical Center 3 2551 3.0612 0.98 1 (0.249, 2.667) S Lourdes Medical Center Burlington County 1 2300 2.76 0.362 0.3013 (0.018, 1.787) S Meadowlands Hospital Medical Center 2 1850 2.405 0.832 0.8758 (0.139, 2.748) S 11

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 4 1198 1.5574 2.568 0.0945 (0.816, 6.195) S Monmouth Medical Center 11 3195 7.3805 1.49 0.2002 (0.784, 2.591) S Morristown Medical Center 11 11112 25.972 0.424 0.0011 (0.223, 0.736) L Mountainside 16 3616 8.6768 1.844 0.0244 (1.092, 2.931) H Newark Beth Israel Medical Center 17 9480 20.6887 0.822 0.4272 (0.495, 1.289) S Newton Medical Center 1 1998 2.5974 0.385 0.3424 (0.019, 1.899) S Ocean Medical Center 9 5444 6.5328 1.378 0.3378 (0.672, 2.528) S Our Lady of Lourdes Medical Center 13 7172 10.7299 1.212 0.4765 (0.674, 2.020) S Overlook Medical Center 46 8680 25.0589 1.836 0.0002 (1.360, 2.427) H Palisades Medical Center of New York (PHS) 9 2220 2.886 3.119 0.0038 (1.521, 5.723) H Raritan Bay Medical Center-Old Bridge 2 1611 2.0943 0.955 1 (0.160, 3.155) S Raritan Bay Medical Center-Perth Amboy 5 2441 5.35 0.935 0.9362 (0.342, 2.072) S Riverview Medical Center 11 4252 5.1024 2.156 0.022 (1.134, 3.747) H Robert Wood Johnson University Hospital 50 12954 32.1672 1.554 0.0035 (1.166, 2.033) H Robert Wood Johnson University Hospital at Hamilton 4 3497 4.1964 0.953 0.9866 (0.303, 2.299) S Robert Wood Johnson University Hospital at Rahway 1 3171 7.8354 0.128 0.0039 (0.006, 0.629) L Saint Barnabas Medical Center 2 8439 21.0158 0.095 0 (0.016, 0.314) L Shore Medical Center 10 2553 3.0636 3.264 0.0016 (1.658, 5.818) H Somerset Medical Center 7 3423 6.846 1.022 0.9055 (0.447, 2.023) S South Jersey Healthcare Regional Medical Center 12 5017 11.1428 1.077 0.7648 (0.584, 1.831) S South Jersey Healthcare-Elmer 1 894 1.788 0.559 0.6337 (0.028, 2.758) S Southern Ocean Medical Center 2 2076 4.152 0.482 0.2977 (0.081, 1.591) S St. Clare's Hospital-Denville 0 1730 2.076 0 0.1254 (---,1.443) S St. Clare's Hospital-Dover 0 1186 1.5418 0 0.214 (---,1.943) S St. Clare's Hospital-Sussex 0 117 0.1521 --- --- --- --- St. Francis Medical Center 3 3051 4.5923 0.653 0.4904 (0.166, 1.778) S St. Joseph's Regional Medical Center 29 9890 23.9259 1.212 0.3022 (0.827, 1.718) S St. Joseph's Wayne Hospital 7 3372 7.7556 0.903 0.8317 (0.395, 1.785) S St. Luke's Warren Hospital 8 1415 1.8395 4.349 0.0008 (2.020, 8.258) H St. Mary's Hospital 16 4805 5.766 2.775 0.0004 (1.643, 4.410) H St. Michael's Medical Center 10 4850 9.1774 1.09 0.7512 (0.553, 1.942) S St. Peter's University Hospital 10 4288 9.9534 1.005 0.9474 (0.510, 1.791) S 12

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 4 5287 6.3444 0.63 0.3646 (0.200, 1.521) S UMDNJ - University Hospital 44 8746 24.9194 1.766 0.0005 (1.299, 2.349) H Underwood Memorial Hospital 5 3407 4.4291 1.129 0.7394 (0.414, 2.502) S University Medical Center of Princeton 3 2715 3.4592 0.867 0.8739 (0.221, 2.360) S Valley Hospital 17 5826 9.2654 1.835 0.0214 (1.105, 2.878) H Virtua Marlton 3 3326 3.9912 0.752 0.6746 (0.191, 2.046) S Virtua-Memorial Hospital of Burlington County 1 4805 5.766 0.173 0.0243 (0.009, 0.855) L Virtua-West Jersey Health System-Berlin 0 968 1.2584 0 0.2841 (---,2.381) S Virtua-West Jersey Health System-Voorhees 5 3677 4.4028 1.136 0.7299 (0.416, 2.517) S STATEWIDE 567 311722 620.366 0.914 --- (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

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 43 0 0.371 --- --- --- --- AtlantiCare Regional Medical Center-Mainland Campus 85 0 0.652 --- --- --- --- Bayonne Medical Center 4 0 0.028 --- --- --- --- Bayshore Community Hospital 5 0 0.035 --- --- --- --- Bergen Regional Medical Center N/A Cape Regional Medical Center 41 1 0.226 --- --- --- --- Capital Health Medical Center - Hopewell 119 3 1.031 2.91 0.107 (0.740, 7.919) S Capital Health Regional Medical Center (RMC) 1 0 0.019 --- --- --- --- Centrastate Medical Center 73 0 0.584 --- --- --- --- Chilton Memorial Hospital 24 0 0.276 --- --- --- --- Christ Hospital 32 0 0.222 --- --- --- --- Clara Maass Medical Center 123 2 0.845 --- --- --- --- Community Medical Center 277 4 2.009 1.991 0.198 (0.633, 4.803) S Cooper Hospital/University Medical Center 455 4 5.244 0.763 0.631 (0.242, 1.840) S Deborah Heart and Lung Center N/A East Orange General Hospital 12 0 0.118 --- --- --- --- Englewood Hospital and Medical Center 72 0 0.542 --- --- --- --- Hackensack University Medical Center 648 3 3.83 0.783 0.732 (0.199, 2.132) S Hackettstown Regional Medical Center 9 0 0.037 --- --- --- --- Hoboken University Medical Center 21 0 0.165 --- --- --- --- Holy Name Medical Center 181 0 1.235 0 0.291 (---,2.426) S Hunterdon Medical center 18 0 0.128 --- --- --- --- Jersey City Medical Center 23 0 0.18 --- --- --- --- Jersey Shore University Medical Center 236 1 1.78 0.562 0.638 (0.028, 2.771) S JFK Medical Center/Anthony M Yelensics 144 0 0.91 --- --- --- --- Kennedy University Hospital 156 0 1.454 0 0.234 (---,2.060) S Kennedy University Hospital/UMC-Cherry Hill 1 0 0.008 --- --- --- --- Kennedy University Hospital/UMC-Stratford 27 0 0.236 --- --- --- --- Kimball Medical Center 32 0 0.168 --- --- --- --- Lourdes Medical Center Burlington County 49 0 0.326 --- --- --- --- Meadowlands Hospital Medical Center 45 1 0.268 --- --- --- --- Memorial Hospital of Salem County 35 0 0.243 --- --- --- --- 14

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 288 0 2.213 0 0.109 (---,1.354) S Morristown Medical Center 544 7 2.668 2.624 0.026 (1.147, 5.190) H Mountainside 283 0 1.994 0 0.136 (---,1.502) S Newark Beth Israel Medical Center 284 0 3.453 0 0.032 (---,0.868) L Newton Medical Center 36 0 0.255 --- --- --- --- Ocean Medical Center 64 1 0.409 --- --- --- --- Our Lady of Lourdes Medical Center 113 1 0.932 --- --- --- --- Overlook Medical Center 146 0 0.962 --- --- --- --- Palisades Medical Center of New York (PHS) 21 0 0.132 --- --- --- --- Raritan Bay Medical Center-Old Bridge N/A Raritan Bay Medical Center-Perth Amboy 62 0 0.419 --- --- --- --- Riverview Medical Center 126 1 0.929 --- --- --- --- Robert Wood Johnson University Hospital 308 7 2.748 2.547 0.03 (1.114, 5.039) H Robert Wood Johnson University Hospital at Hamilton 99 7 0.698 --- --- --- --- Robert Wood Johnson University Hospital at Rahway N/A Saint Barnabas Medical Center 493 6 2.252 2.664 0.036 (1.080, 5.542) H Shore Medical Center 40 0 0.256 --- --- --- --- Somerset Medical Center 68 0 0.442 --- --- --- --- South Jersey Healthcare Regional Medical Center 263 1 2.463 0.406 0.38 (0.020, 2.002) S South Jersey Healthcare-Elmer 7 0 0.06 --- --- --- --- Southern Ocean Medical Center 19 0 0.122 --- --- --- --- St. Clare's Hospital-Denville 62 0 0.454 --- --- --- --- St. Clare's Hospital-Dover 1 0 0.005 --- --- --- --- St. Clare's Hospital-Sussex St. Francis Medical Center N/A N/A St. Joseph's Regional Medical Center 159 0 1.163 0 0.313 (---,2.576) S St. Joseph's Wayne Hospital 31 0 0.22 --- --- --- --- St. Luke's Warren Hospital 40 0 0.383 --- --- --- --- St. Mary's Hospital 39 0 0.232 --- --- --- --- St. Michael's Medical Center 105 0 0.959 --- --- --- --- St. Peter's University Hospital 399 3 3.153 0.951 1 (0.242, 2.590) S Trinitas Regional Medical Center 295 1 2.97 0.337 0.255 (0.017, 1.661) S UMDNJ - University Hospital 105 2 1.561 1.281 0.669 (0.215, 4.233) S 15

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 49 0 0.399 --- --- --- --- University Medical Center of Princeton 151 1 1.296 0.772 0.902 (0.039, 3.805) S Valley Hospital 137 3 0.935 --- --- --- --- Virtua Marlton 2 0 0.071 --- --- --- --- Virtua-Memorial Hospital of Burlington County 181 1 1.684 0.594 0.684 (0.030, 2.929) S Virtua-West Jersey Health System-Berlin 1 0 0.006 --- --- --- --- Virtua-West Jersey Health System-Voorhees 425 6 3.33 1.802 0.174 (0.730, 3.748) S STATEWIDE 8437 67 65.395 1.025 0.828 (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 2006-2008 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 2006-2008 (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 2012. 16

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 1263 8 9.674 0.827 0.622 (0.384, 1.570) S Bayonne Medical Center 6 0 0.034 --- --- --- --- Bayshore Community Hospital 59 0 0.377 --- --- --- --- Bergen Regional Medical Center 27 0 0.181 --- --- --- --- Cape Regional Medical Center 76 0 0.317 --- --- --- --- Capital Health Medical Center - Hopewell 289 3 2.106 1.425 0.515 (0.362, 3.877) S Capital Health Regional Medical Center (RMC) 35 0 0.407 --- --- --- --- Centrastate Medical Center 116 0 0.679 --- --- --- --- Chilton Memorial Hospital 103 0 0.562 --- --- --- --- Christ Hospital 15 0 0.108 --- --- --- --- Clara Maass Medical Center 204 0 1.219 0 0.296 (---,2.458) S Community Medical Center 355 3 2.009 1.493 0.47 (0.380, 4.064) S Cooper Hospital/University Medical Center 168 1 1.41 0.709 0.833 (0.035, 3.498) S Deborah Heart and Lung Center N/A East Orange General Hospital 11 0 0.109 --- --- --- --- Englewood Hospital and Medical Center 246 2 1.5 1.333 0.633 (0.224, 4.405) S Hackensack University Medical Center 1128 4 7.45 0.537 0.197 (0.171, 1.295) S Hackettstown Regional Medical Center 64 2 0.277 --- --- --- --- Hoboken University Medical Center 67 0 0.415 --- --- --- --- Holy Name Medical Center 223 0 1.58 0 0.206 (---,1.896) S Hunterdon Medical center 130 0 0.948 --- --- --- --- Jersey City Medical Center 49 0 0.377 --- --- --- --- Jersey Shore University Medical Center 352 3 2.852 1.052 0.863 (0.268, 2.863) S JFK Medical Center/Anthony M Yelensics 281 7 1.946 3.597 0.005 (1.573, 7.115) H Kennedy University Hospital 419 1 2.665 0.375 0.325 (0.019, 1.851) S Kennedy University Hospital/UMC-Cherry Hill 52 0 0.259 --- --- --- --- Kennedy University Hospital/UMC-Stratford 27 0 0.194 --- --- --- --- Kimball Medical Center 25 2 0.159 --- --- --- --- Lourdes Medical Center Burlington County 32 0 0.166 --- --- --- --- Meadowlands Hospital Medical Center 11 0 0.064 --- --- --- --- 17

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 10 0 0.057 --- --- --- --- Monmouth Medical Center 223 1 2.134 0.469 0.489 (0.023, 2.311) S Morristown Medical Center 1149 3 6.134 0.489 0.196 (0.124, 1.331) S Mountainside 76 0 0.517 --- --- --- --- Newark Beth Israel Medical Center 106 1 0.847 --- --- --- --- Newton Medical Center 92 0 0.437 --- --- --- --- Ocean Medical Center 453 0 2.557 0 0.078 (---,1.172) S Our Lady of Lourdes Medical Center 17 0 0.118 --- --- --- --- Overlook Medical Center 434 1 2.534 0.395 0.36 (0.020, 1.946) S Palisades Medical Center of New York (PHS) 12 0 0.074 --- --- --- --- Raritan Bay Medical Center-Old Bridge 6 0 0.032 --- --- --- --- Raritan Bay Medical Center-Perth Amboy 26 0 0.226 --- --- --- --- Riverview Medical Center 315 0 2.057 0 0.128 (---,1.456) S Robert Wood Johnson University Hospital 287 8 2.177 3.675 0.002 (1.707, 6.978) H Robert Wood Johnson University Hospital at Hamilton 262 0 1.504 0 0.222 (---,1.992) S Robert Wood Johnson University Hospital at Rahway 34 0 0.236 --- --- --- --- Saint Barnabas Medical Center 247 0 1.63 0 0.196 (---,1.838) S Shore Medical Center 229 1 1.328 0.753 0.882 (0.038, 3.714) S Somerset Medical Center 172 1 1.129 0.886 1 (0.044, 4.368) S South Jersey Healthcare Regional Medical Center 131 0 0.943 --- --- --- --- South Jersey Healthcare-Elmer 82 0 0.377 --- --- --- --- Southern Ocean Medical Center 76 1 0.459 --- --- --- --- St. Clare's Hospital-Denville 165 2 1.112 1.799 0.407 (0.302, 5.942) S St. Clare's Hospital-Dover 14 0 0.092 --- --- --- --- St. Clare's Hospital-Sussex N/A St. Francis Medical Center 10 0 0.103 --- --- --- --- St. Joseph's Regional Medical Center 151 0 1.302 0 0.272 (---,2.301) S St. Joseph's Wayne Hospital 127 1 0.879 --- --- --- --- St. Luke's Warren Hospital 68 1 0.397 --- --- --- --- St. Mary's Hospital 31 1 0.205 --- --- --- --- St. Michael's Medical Center 137 2 0.973 --- --- --- --- St. Peter's University Hospital 221 0 1.664 0 0.189 (---,1.800) S Trinitas Regional Medical Center 65 0 0.72 --- --- --- --- 18

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 64 3 0.925 --- --- --- --- Underwood Memorial Hospital 110 2 0.966 --- --- --- --- University Medical Center of Princeton 421 0 2.908 0 0.055 (---,1.030) S Valley Hospital 446 5 2.482 2.015 0.147 (0.738, 4.465) S Virtua Marlton 646 6 3.578 1.677 0.224 (0.680, 3.488) S Virtua-Memorial Hospital of Burlington County 535 1 2.957 0.338 0.258 (0.017, 1.668) S Virtua-West Jersey Health System-Berlin N/A Virtua-West Jersey Health System-Voorhees 415 1 2.099 0.476 0.503 (0.024, 2.350) S STATEWIDE 13898 78 90.913 0.858 0.171 (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 2006-2008 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 2006-2008 (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 2012. 19

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 63 0 1.382 0 0.251 (---,2.168) S AtlantiCare Regional Medical Center-Mainland Campus 97 0 2.746 0 0.064 (---,1.091) S Bayonne Medical Center 61 1 1.515 0.66 0.773 (0.033, 3.255) S Bayshore Community Hospital 60 0 1.576 0 0.207 (---,1.901) S Bergen Regional Medical Center 4 0 0.103 --- --- --- --- Cape Regional Medical Center 97 0 2.392 0 0.091 (---,1.252) S Capital Health Medical Center - Hopewell 102 4 2.822 1.417 0.469 (0.450, 3.419) S Capital Health Regional Medical Center (RMC) 50 0 1.566 0 0.209 (---,1.913) S Centrastate Medical Center 174 6 5.211 1.151 0.69 (0.467, 2.395) S Chilton Memorial Hospital 105 7 3.064 2.285 0.05 (0.999, 4.519) S Christ Hospital 33 1 0.694 --- --- --- --- Clara Maass Medical Center 126 7 3.568 1.962 0.1 (0.858, 3.881) S Community Medical Center 221 6 6.719 0.893 0.83 (0.362, 1.857) S Cooper Hospital/University Medical Center 143 3 5.064 0.592 0.376 (0.151, 1.612) S Deborah Heart and Lung Center 2 0 0.048 --- --- --- --- East Orange General Hospital 33 1 1.267 0.789 0.92 (0.039, 3.893) S Englewood Hospital and Medical Center 278 3 6.778 0.443 0.129 (0.113, 1.205) S Hackensack University Medical Center 338 3 10.888 0.276 0.007 (0.070, 0.750) L Hackettstown Regional Medical Center 33 2 0.687 --- --- --- --- Hoboken University Medical Center 28 1 0.708 --- --- --- --- Holy Name Medical Center 130 1 3.293 0.304 0.197 (0.015, 1.498) S Hunterdon Medical Center 67 0 1.709 0 0.181 (---,1.753) S Jersey City Medical Center 92 2 2.75 0.727 0.721 (0.122, 2.403) S Jersey Shore University Medical Center 259 1 7.844 0.127 0.004 (0.006, 0.629) L JFK Medical Center/Anthony M Yelensics 116 1 3.221 0.31 0.208 (0.016, 1.531) S Kennedy University Hospital 112 0 3.064 0 0.047 (---,0.978) L Kennedy University Hospital/UMC-Cherry Hill 25 0 0.625 --- --- --- --- Kennedy University Hospital/UMC-Stratford 37 0 0.887 --- --- --- --- Kimball Medical Center 35 0 1.013 0 0.363 (---,2.957) S Lourdes Medical Center Burlington County 90 1 2.035 0.491 0.527 (0.025, 2.424) S Meadowlands Hospital Medical Center 1 0 0.035 --- --- --- --- Memorial Hospital of Salem County 23 1 0.657 --- --- --- --- 20

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 176 1 4.911 0.204 0.051 (0.010, 1.004) S Morristown Medical Center 322 7 9.273 0.755 0.476 (0.330, 1.493) S Mountainside 86 2 2.494 0.802 0.834 (0.134, 2.649) S Newark Beth Israel Medical Center 121 2 3.792 0.527 0.378 (0.088, 1.743) S Newton Medical Center 90 2 2.231 0.896 0.962 (0.150, 2.962) S Ocean Medical Center 196 0 4.858 0 0.008 (---,0.617) L Our Lady of Lourdes Medical Center 171 4 5.536 0.723 0.55 (0.230, 1.743) S Overlook Medical Center 395 8 12.444 0.643 0.2 (0.299, 1.221) S Palisades Medical Center of New York (PHS) 40 0 1.053 0 0.349 (---,2.845) S Raritan Bay Medical Center-Old Bridge 21 0 0.586 --- --- --- --- Raritan Bay Medical Center-Perth Amboy 42 0 1.075 0 0.341 (---,2.787) S Riverview Medical Center 209 0 6.657 0 0.001 (---,0.450) L Robert Wood Johnson University Hospital 267 4 10.469 0.382 0.029 (0.121, 0.922) L Robert Wood Johnson University Hospital at Hamilton 126 3 4.179 0.718 0.612 (0.183, 1.954) S Robert Wood Johnson University Hospital at Rahway 63 2 2.06 0.971 1 (0.163, 3.208) S Saint Barnabas Medical Center 388 9 12.427 0.724 0.336 (0.353, 1.329) S Shore Medical Center 137 5 3.969 1.26 0.575 (0.462, 2.792) S Somerset Medical Center 134 2 3.686 0.543 0.405 (0.091, 1.793) S South Jersey Healthcare Regional Medical Center 120 4 2.817 1.42 0.467 (0.451, 3.425) S South Jersey Healthcare-Elmer 8 1 0.21 --- --- --- --- Southern Ocean Medical Center 44 1 1.023 0.978 1 (0.049, 4.821) S St. Clare's Hospital-Denville 112 0 4.468 0 0.012 (---,0.670) L St. Clare's Hospital-Dover 45 0 1.392 0 0.249 (---,2.152) S St. Clare's Hospital-Sussex 1 0 0.021 --- --- --- --- St. Francis Medical Center 26 1 0.846 --- --- --- --- St. Joseph's Regional Medical Center 143 0 4.98 0 0.007 (---,0.602) L St. Joseph's Wayne Hospital 60 2 1.352 1.479 0.547 (0.248, 4.887) S St. Luke's Warren Hospital 62 3 1.503 1.996 0.258 (0.508, 5.432) S St. Mary's Hospital 69 2 2.133 0.938 1 (0.157, 3.098) S St. Michael's Medical Center 53 0 1.204 0 0.3 (---,2.488) S St. Peter's University Hospital 185 3 5.984 0.501 0.215 (0.128, 1.364) S Trinitas Regional Medical Center 98 1 3.271 0.306 0.2 (0.015, 1.508) S UMDNJ - University Hospital 119 7 4.61 1.518 0.279 (0.664, 3.004) S 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% Underwood Memorial Hospital 130 1 3.786 0.264 0.131 (0.013, 1.303) S University Medical Center of Princeton 165 2 4.716 0.424 0.202 (0.071, 1.401) S Valley Hospital 232 14 6.911 2.026 0.017 (1.153, 3.318) H Virtua Marlton 91 4 2.498 1.601 0.351 (0.509, 3.862) S Virtua-Memorial Hospital of Burlington County 167 2 5.533 0.361 0.112 (0.061, 1.194) S Virtua-West Jersey Health System-Berlin 6 0 0.19 --- --- --- --- Virtua-West Jersey Health System-Voorhees 196 2 6.1 0.328 0.074 (0.055, 1.083) S STATEWIDE 8151 153 243.176 0.629 --- (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 2006-2008 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 2006-2008 (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

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 169 6 2.744 2.187 0.083 (0.886, 4.548) S Cooper Hospital/University Medical Center 241 1 3.181 0.314 0.215 (0.016, 1.550) S Deborah Heart and Lung Center 153 2 2.047 0.977 1 (0.164, 3.228) S Englewood Hospital and Medical Center 186 2 2.408 0.831 0.874 (0.139, 2.744) S Hackensack University Medical Center 374 4 5.11 0.783 0.671 (0.249, 1.888) S Jersey City Medical Center 154 0 1.818 0 0.162 (---,1.648) S Jersey Shore University Medical Center 541 7 6.75 1.037 0.877 (0.454, 2.051) S Morristown Medical Center 829 3 9.191 0.326 0.024 (0.083, 0.888) L Newark Beth Israel Medical Center 200 6 2.489 2.411 0.055 (0.977, 5.014) S Our Lady of Lourdes Medical Center 420 7 4.418 1.584 0.239 (0.693, 3.134) S Robert Wood Johnson University Hospital 526 4 7.028 0.569 0.251 (0.181, 1.373) S Saint Barnabas Medical Center 274 2 3.3 0.606 0.518 (0.102, 2.002) S St. Francis Medical Center 59 2 1.178 1.698 0.445 (0.285, 5.609) S St. Joseph's Regional Medical Center 258 2 3.572 0.56 0.436 (0.094, 1.850) S St. Mary's Hospital 61 0 0.719 --- --- --- --- St. Michael's Medical Center 125 0 1.846 0 0.158 (---,1.623) S UMDNJ - University Hospital 40 0 0.612 --- --- --- --- Valley Hospital 247 3 2.624 1.143 0.757 (0.291, 3.112) S STATEWIDE 4857 51 61.033 0.836 0.195 (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 2006-2008. 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 2006-2008 (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

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 106 0 1.753 0 0.173 (---,1.709) S AtlantiCare Regional Medical Center-Mainland Campus 1614 14 15.815 0.885 0.675 (0.504, 1.450) S Bayonne Medical Center 71 1 1.577 0.634 0.739 (0.032, 3.127) S Bayshore Community Hospital 124 0 1.987 0 0.137 (---,1.508) S Bergen Regional Medical Center 31 0 0.284 --- --- --- --- Cape Regional Medical Center 214 1 2.935 0.341 0.262 (0.017, 1.680) S Capital Health Medical Center - Hopewell 510 10 5.959 1.678 0.122 (0.852, 2.991) S Capital Health Regional Medical Center (RMC) 86 0 1.992 0 0.136 (---,1.504) S Centrastate Medical Center 363 6 6.474 0.927 0.904 (0.376, 1.928) S Chilton Memorial Hospital 232 7 3.902 1.794 0.146 (0.785, 3.549) S Christ Hospital 80 1 1.023 0.978 1 (0.049, 4.821) S Clara Maass Medical Center 453 9 5.633 1.598 0.178 (0.779, 2.932) S Community Medical Center 853 13 10.737 1.211 0.478 (0.673, 2.018) S Cooper Hospital/University Medical Center 1007 9 14.9 0.604 0.113 (0.295, 1.108) S Deborah Heart and Lung Center 155 2 2.096 0.954 1 (0.160, 3.153) S East Orange General Hospital 56 1 1.494 0.669 0.784 (0.033, 3.301) S Englewood Hospital and Medical Center 782 7 11.228 0.623 0.199 (0.273, 1.233) S Hackensack University Medical Center 2488 14 27.277 0.513 0.006 (0.292, 0.841) L Hackettstown Regional Medical Center 106 4 1.001 3.996 0.023 (1.270, 9.639) H Hoboken University Medical Center 116 1 1.289 0.776 0.906 (0.039, 3.826) S Holy Name Medical Center 534 1 6.108 0.164 0.018 (0.008, 0.807) L Hunterdon Medical Center 215 0 2.784 0 0.062 (---,1.076) S Jersey City Medical Center 318 2 5.125 0.39 0.151 (0.065, 1.289) S Jersey Shore University Medical Center 1388 12 19.226 0.624 0.086 (0.338, 1.061) S JFK Medical Center/Anthony M Yelensics 541 8 6.076 1.317 0.427 (0.611, 2.500) S Kennedy University Hospital 687 1 7.183 0.139 0.007 (0.007, 0.687) L Kennedy University Hospital/UMC-Cherry Hill 78 0 0.892 --- --- --- --- Kennedy University Hospital/UMC-Stratford 91 0 1.317 0 0.268 (---,2.275) S Kimball Medical Center 92 2 1.34 1.493 0.54 (0.250, 4.931) S Lourdes Medical Center Burlington County 171 1 2.527 0.396 0.362 (0.020, 1.952) S Meadowlands Hospital Medical Center 57 1 0.367 --- --- --- --- Memorial Hospital of Salem County 68 1 0.958 --- --- --- --- 24

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 687 2 9.258 0.216 0.006 (0.036, 0.714) L Morristown Medical Center 2844 20 27.266 0.734 0.156 (0.461, 1.113) S Mountainside 445 2 5.005 0.4 0.165 (0.067, 1.320) S Newark Beth Israel Medical Center 711 9 10.581 0.851 0.659 (0.415, 1.561) S Newton Medical Center 218 2 2.922 0.684 0.652 (0.115, 2.261) S Ocean Medical Center 713 1 7.825 0.128 0.004 (0.006, 0.630) L Our Lady of Lourdes Medical Center 721 12 11.004 1.091 0.733 (0.591, 1.854) S Overlook Medical Center 975 9 15.939 0.565 0.067 (0.275, 1.036) S Palisades Medical Center of New York (PHS) 73 0 1.259 0 0.284 (---,2.379) S Raritan Bay Medical Center-Old Bridge 27 0 0.618 --- --- --- --- Raritan Bay Medical Center-Perth Amboy 130 0 1.72 0 0.179 (---,1.742) S Riverview Medical Center 650 1 9.643 0.104 0.001 (0.005, 0.511) L Robert Wood Johnson University Hospital 1388 23 22.422 1.026 0.876 (0.666, 1.515) S Robert Wood Johnson University Hospital at Hamilton 487 10 6.381 1.567 0.173 (0.796, 2.793) S Robert Wood Johnson University Hospital at Rahway 97 2 2.296 0.871 0.929 (0.146, 2.878) S Saint Barnabas Medical Center 1402 17 19.608 0.867 0.575 (0.522, 1.360) S Shore Medical Center 406 6 5.552 1.081 0.802 (0.438, 2.248) S Somerset Medical Center 374 3 5.256 0.571 0.336 (0.145, 1.553) S South Jersey Healthcare Regional Medical Center 514 5 6.223 0.803 0.667 (0.294, 1.781) S South Jersey Healthcare-Elmer 97 1 0.646 --- --- --- --- Southern Ocean Medical Center 139 2 1.604 1.247 0.694 (0.209, 4.120) S St. Clare's Hospital-Denville 339 2 6.035 0.331 0.077 (0.056, 1.095) S St. Clare's Hospital-Dover 60 0 1.489 0 0.226 (---,2.012) S St. Clare's Hospital-Sussex 1 0 0.021 --- --- --- --- St. Francis Medical Center 95 3 2.127 1.41 0.524 (0.359, 3.839) S St. Joseph's Regional Medical Center 711 2 11.017 0.182 0.001 (0.030, 0.600) L St. Joseph's Wayne Hospital 218 3 2.45 1.224 0.675 (0.311, 3.333) S St. Luke's Warren Hospital 170 4 2.284 1.751 0.279 (0.556, 4.224) S St. Mary's Hospital 200 3 3.289 0.912 0.944 (0.232, 2.482) S St. Michael's Medical Center 420 2 4.981 0.402 0.167 (0.067, 1.327) S St. Peter's University Hospital 805 6 10.801 0.556 0.129 (0.225, 1.155) S Trinitas Regional Medical Center 458 2 6.962 0.287 0.038 (0.048, 0.949) L UMDNJ - University Hospital 328 12 7.707 1.557 0.143 (0.844, 2.647) S 25