2016 Q1 Aggregate TAP Report - Michigan · statewide aggregate report. Beginning with the 2015...

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 [email protected] with questions, comments, or suggestions. All aggregate reports are posted at www.michigan.gov/hai.

mailto:[email protected]

http://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


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


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


-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 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


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


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


-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



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


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


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


-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


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


-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



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


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


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



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


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


-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



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


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


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


-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



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


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


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



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


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


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


-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



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


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


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 Aggregate TAP Report - Michigan · statewide aggregate report. Beginning with the 2015...

Documents

Transcript of 2016 Q1 Aggregate TAP Report - Michigan · statewide aggregate report. Beginning with the 2015...