Post on 15-Aug-2020
State of Michigan 2016 Q1 Aggregate TAP Report Michigan Department of Health and Human Services Surveillance for Healthcare-Associated and Resistant Pathogens (SHARP) Unit ---------------------------------------------------------------------------------------------------------------------------------------------------------------- The Michigan Department of Health and Human Services (MDHHS) Surveillance for Healthcare-Associated and Resistant Pathogens (SHARP) Unit began including the new targeted assessment for prevention (TAP) reports in the 2014 annual statewide aggregate report. Beginning with the 2015 Quarter 1 report, individual TAP reports are provided quarterly.
This report shows modules and locations where the State of Michigan either needs to focus additional prevention efforts or is excelling in infection prevention. The table presents a cumulative attributable difference (CAD) determined using the HHS target standardized infection ratios (SIRs) for each module. Numbers in red show how many infections the state needs to prevent quarterly in order to reach the HHS target SIR. Numbers in green show the number of infections prevented beyond what was expected for the state according to the HHS target SIR. Corresponding SIRs for each module and location type are provided as well.
2016 Q1 Targeted Assessment for Prevention Report
NHSN Module
Number of Facilities1
Location SIR2 Significant (Y/N)3 CAD4 Prevented or Need to Prevent
CAUTI 89 All 0.6 Y -68.4 Prevented 82 ICU 0.6 ---- -22.5 Prevented 88 Ward 0.5 ---- -45.9 Prevented
CLABSI 74 All 0.4 Y -20.2 Prevented 59 ICU 0.4 ---- -8.8 Prevented 62 Ward 0.4 ---- -2.6 Prevented 16 NICU 0.4 ---- -8.7 Prevented
CDI 91 Facility-wide 0.87 Y 161.04 Need to Prevent MRSA Bac 93 Facility-wide 0.78 Y 2.07 Need to Prevent SSI COLO 76 ---- 1.04 N 24.45 Need to Prevent SSI HYST 76 ---- 1.09 N 7.24 Need to Prevent
1Note: facilities in which an SIR could not be calculated with a CAD of 0 were excluded from this table 2SIR: Standardized Infection Ratio: Ratio of observed events compared to the number of predicted events, accounting for unit type or other variables. An SIR of 1 can be interpreted as having the same number of events as predicted. An SIR that is between 0 and 1 represents fewer events than predicted, while an SIR of greater than 1 represents more events than predicted. 3Significant (Y/N). A Y indicates that, based on the p-value and 95% Confidence Interval (CI), the SIR is statistically significantly different than 1. An N indicates that, based on the p-value and 95% CI, the SIR is not statistically significantly different than 1 (expected). Significance testing was only performed on overall SIRs, not location-specific. 4CAD=Cumulative Attributable Difference. The number of infections that your hospital either needs to prevent to meet the HHS target or has prevented beyond the HHS target. HHS CAUTI Target SIR = 0.75, HHS CLABSI Target SIR = 0.5, HHS CDI Target SIR = 0.7, HHS MRSA bacteremia Target SIR = 0.75, HHS SSI Target SIR = 0.75
Bar graphs containing CAD values from all letter-coded SHARP-participating hospitals by module and location are available below. These graphs allow each facility to view their rank within each module and location compared to all other SHARP-participating facilities. Note: facilities in which an SIR could not be calculated with a CAD of 0 were excluded from the bar graphs. Each participating facility will receive an individual, password-protected TAP report containing their letter. Letters are re-assigned each quarter. Aggregate reports are also available for each emergency preparedness region below. Please contact Allie Murad at murada@michigan.gov with questions, comments, or suggestions. All aggregate reports are posted at www.michigan.gov/hai.
Bar Graphs
-10
-5
0
5
10
15
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital (n=89)
2016 Q1 CAUTI All Hospitals, Overall
CV
CUCT
CR CSCQ CP CO CL CM CN CK CJ CI CH CF CG
BN BO BP BQ BR-2
0
2
4
6
8
10
12
14
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 CAUTI Quartile 1, Overall
Quartile 1 (most needed to improve)
Quartile 2 Quartile 3
Quartile 4 (prevented the
most infections)
BS BT BU
BD BE BF BG BH BI BJ BL BM
BB BC
AX AY AZ BA
AS AT AU AV AW
-0.6
-0.5
-0.4
-0.3
-0.2
-0.1
0
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 CAUTI Quartile 2, Overall
AO AP AQ ARAL AM AN
AH AI AJ AKAF AG
AD AEAB AC
AA Y ZW XX
V-1.6
-1.4
-1.2
-1
-0.8
-0.6
-0.4
-0.2
01
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 CAUTI Quartile 3, Overall
U T R S Q P O M N K L
J I H G FE
D C B
A-7
-6
-5
-4
-3
-2
-1
0
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 CAUTI Quartile 4, Overall
-10
-5
0
5
10
15
20Cu
mul
ativ
e At
trib
utab
le D
iffer
ence
(CAD
)
Hospitals (n=82)
2016 Q1 CAUTI All Hospitals, ICU
CV
CRCK CQ CU BW CM CS CH CJ J T AJ CP BR AP AQ AG BB
0
2
4
6
8
10
12
14
16
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 CAUTI Quartile 1, ICU
Quartile 1 (most needed to improve)
Quartile 2 Quartile 3 Quartile 4 (prevented the
most infections)
AB AH AM AO AS AU AX AZ BA BC BD BE BG BH BI BJ BM BN BP CI
AK AR
-0.25
-0.2
-0.15
-0.1
-0.05
0
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 CAUTI Quartile 2, ICU
AV AW AY CF V
AC AI AL AN Z
AT
AD CG
AA AE BO U Y
CO S XX-0.8
-0.7
-0.6
-0.5
-0.4
-0.3
-0.2
-0.1
0
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 CAUTI Quartile 3, ICU
QR W
OAF CT G K N P
H IL
A F DB
C
ME-5
-4.5
-4
-3.5
-3
-2.5
-2
-1.5
-1
-0.5
0
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 CAUTI Quartile 4, ICU
-6
-4
-2
0
2
4
6Cu
mul
ativ
e At
trib
utab
le D
iffer
ence
(CAD
)
Hospitals (n=88)
2016 Q1 CAUTI All Hospitals, Ward
CT
CU
M COCS
CL CN CI CG AF BO CP CF
AT BD BE BF BG BH BI BJ BM
-1
0
1
2
3
4
5
6
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 CAUTI Quartile 1, Ward
Quartile 1 (most needed to improve)
Quartile 2 Quartile 3 Quartile 4 (prevented the
most infections)
BN BQ BS BU CQ
AW AY BA BC BL CJ CR
AL AU AV AX AZ CM W
AE AN AO-0.45
-0.4
-0.35
-0.3
-0.25
-0.2
-0.15
-0.1
-0.05
0
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 CAUTI Quartile 2, Ward
AR AS BB EAA AD AI CH
AH AK AM BR XX YAC L
APCK P Z
AB AQ
-1.2
-1
-0.8
-0.6
-0.4
-0.2
0
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 CAUTI Quartile 3, Ward
R AG N K O U Q S V BW AJ C F
B D IH
TCV G
A
J-5
-4.5
-4
-3.5
-3
-2.5
-2
-1.5
-1
-0.5
0
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 CAUTI Quartile 4, Ward
-5
-4
-3
-2
-1
0
1
2
3
4
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospitals (n=74)
2016 Q1 CLABSI All Hospitals, Overall
CV ZE
CU BO
CR
AP TC H
AE CQ P
O
CGAG Y
AL AM AO AR AS AU AW AX-0.5
0
0.5
1
1.5
2
2.5
3
3.5
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 CLABSI Tertile 1, Overall
Tertile 1 (most needed to improve)
Tertile 2 Tertile 3 (prevented the
most infections)
AY BA BC BD BH BM BT
CF CI R
AB AI AK AN AV
AA AC AJ
AH BR CM CP
AD
AF BB
-0.8
-0.7
-0.6
-0.5
-0.4
-0.3
-0.2
-0.1
0
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 CLABSI Tertile 2, Overall
CO Q S F U
CK CS
G
AQ BW
I N V W
CT D K L M XX
AT B
A
J-4
-3.5
-3
-2.5
-2
-1.5
-1
-0.5
0
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 CLABSI Tertile 3, Overall
-3
-2
-1
0
1
2
3
4
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospitals (n=59)
2016 Q1 CLABSI All Hospitals, ICU
CV
CR
BO CU E
AE O
CG AGW H BW C CM AJ
AH AI AK AM-0.5
0
0.5
1
1.5
2
2.5
3
3.5
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 CLABSI Tertile 1, ICU
Tertile 1 (most needed to improve)
Tertile 2 Tertile 3 (prevented the
most infections)
AN AO AR AV AW AY
AA AC AD BR CP P
AT CO F Q S U Y
AP-0.45
-0.4
-0.35
-0.3
-0.25
-0.2
-0.15
-0.1
-0.05
0
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 CLABSI Tertile 2, ICU
AQ BB CS TAB M
J R V ZI
NAF CT
XXB K
D
AL
-3
-2.5
-2
-1.5
-1
-0.5
0
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 CLABSI Tertile 3, ICU
C
CU Z
D
AF
G K MA CQ CV L
EW
BW
CK
-1.5
-1
-0.5
0
0.5
1
1.5
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospitals (n=16)
2016 Q1 CLABSI All Hospitals, NICU
-4
-3
-2
-1
0
1
2
3
4
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospitals (n=62)
2016 Q1 CLABSI All Hospitals, Ward
Tertile 1 (most needed to improve)
Tertile 2 Tertile 3 (prevented the
most infections)
Z
AP T
CQ EH P
LAF R Y AB C CV BO
AA AI AK AN AO AR-0.5
0
0.5
1
1.5
2
2.5
3
3.5
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 CLABSI Tertile 1, Ward
AS AU AV AY BD
AC AE BB BR CP
AD AH CR CU K N
CG -0.4
AG AJ F-0.6
-0.5
-0.4
-0.3
-0.2
-0.1
0
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce
(CAD
)
Hospital Letter
2016 Q1 CLABSI Tertile 2, Ward
I O Q S CM CS U A D V XX CT AQ B BW GM W
AT
J-3.5
-3
-2.5
-2
-1.5
-1
-0.5
0
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 CLABSI Tertile 3, Ward
-10
-5
0
5
10
15
20
25
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospitals (n=91)
2016 Q1 C.diff LabID All Hospitals, Facility-Wide Inpatient
CK
G CCQ
AT CO AD BOCV A D N K BB W
XX CP CG F M AP CS
0
5
10
15
20
25
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 C.diff LabID Quartile 1, Facility-Wide Inpatient
Quartile 1 (most needed to improve)
Quartile 2 Quartile 3 Quartile 4 (prevented the
most infections)
AE
AA
Y JAV BW H
AF U CU I AN OCT AW AQ
CI BY R EAI BD BC
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 C.diff LabID Quartile 2, Facility-Wide Inpatient
BHCJ
AX
AH AK AGBX BZ BT CA CC
AZ AJ BE AS BS BM BNBQ BI
AO BGBF-0.6
-0.5
-0.4
-0.3
-0.2
-0.1
0
0.1
0.2
0.3
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 C.diff LabID Quartile 3, Facility-Wide Inpatient
AB CL BL AU AL BA Z CF S T CH AM BRV AR AC AY
LCR
Q
PB
CM-8
-7
-6
-5
-4
-3
-2
-1
01
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 C.diff LabID Quartile 4, Facility-Wide Inpatient
-3
-2
-1
0
1
2
3
4
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospitals (n=91)
2016 Q1 MRSA Bacteremia LabID All Hospitals, Facility-Wide Inpatient
RBO
MAT CG AP Z
CU NAK Y U O CS CV CR AJ AE AQ H P J
V
0
0.5
1
1.5
2
2.5
3
3.5
4
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 MRSA Bacteremia LabID Quartile 1, Facility-Wide Inpatient
Quartile 1 (most needed to improve)
Quartile 2 Quartile 3 Quartile 4 (prevented the
most infections)
CQ
CK
CD BX BZ BU CC CA BTBQ AZ BS BY BM BG T CL BH BL BC BI BN BF BE
-0.08-0.06-0.04-0.02
00.020.040.060.08
0.10.12
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 MRSA Bacteremia LabID Quartile 2, Facility-Wide Inpatient
AL CH AO BA AS AW CI AV AM AC AH AI BD AXCJ AY
AR ANCP
CT CF
BR A
-0.3
-0.25
-0.2
-0.15
-0.1
-0.05
0
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 MRSA Bacteremia LabID Quartile 3, Facility-Wide Inpatient
AD I AU AA CO BB S AG AF W C AB Q CMXX
KBW G
EB
F L
D-3
-2.5
-2
-1.5
-1
-0.5
0
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 MRSA Bacteremia LabID Quartile 4,Facility-Wide Inpatient
-3
-2
-1
0
1
2
3
4
5
6
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospitals (n=83)
2016 Q1 SSI COLO All Hospitals
DL
C
CG CQ
AJAA BM AF
J M U W A G CR BJ CV CI AX Z
0
1
2
3
4
5
6
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 SSI COLO Quartile 1
Quartile 1 (most needed to improve)
Quartile 2 Quartile 3 Quartile 4 (prevented the
most infections)
AD AY F
BR
BOAG
H VBW
BA CD BQ CC AZ AK AQ BD BL BC BE CN-0.2-0.1
00.10.20.30.40.50.60.70.80.9
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 SSI COLO Quartile 2
BF AL BH BNBI AO
CL P AUAM AV
BB CF CPAS S AW CJ AC O
-0.3
-0.25
-0.2
-0.15
-0.1
-0.05
0
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 SSI COLO Quartile 3
AH AN Y ARR CU AE T Q CO N AP AB XX
ICT
CM B CS E
CK
-2.5
-2
-1.5
-1
-0.5
01
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 SSI COLO Quartile 4
-1
-0.5
0
0.5
1
1.5
2
2.5
3
3.5
4
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospitals (n=76)
2016 Q1 SSI HYST All Hospitals
Z
L
R V
CK N C CGA
BOCV CU F D
AS AL-0.5
0
0.5
1
1.5
2
2.5
3
3.5
4
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 SSI HYST Quartile 1
Quartile 1 (most needed to improve)
Quartile 2 Quartile 3 Quartile 4 (prevented the
most infections)
AV AH BF BH BN CH CP AR
CF
AE AOS
BEAW BS AC
AM BDXX
BG-0.035
-0.03
-0.025
-0.02
-0.015
-0.01
-0.005
0
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 SSI HYST Quartile 2
CJ CR AI I AUAK CI
AQ
CL AX BIAF BR AD
AYAB BC BL AG
O-0.16
-0.14
-0.12
-0.1
-0.08
-0.06
-0.04
-0.02
0
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 SSI HYST Quartile 3
COBW AP Q B AJ P
CS W AA CM U E H G MCT
CQ
JT
-0.7
-0.6
-0.5
-0.4
-0.3
-0.2
-0.1
0
Cum
ulat
ive
Attr
ibut
able
Diff
eren
ce (C
AD)
Hospital Letter
2016 Q1 SSI HYST Quartile 4