Infection Rates
Quality Report Findings for February 2011 - January 2013 Within Top 10% Better than National Median Worse than National Median |
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| Hospital Quality Measures | Methodist Healthcare | University | South | North | Germantown | Top 10% Teaching Hospitals* | Top 10% Non-Teaching Hospitals | Top 50% Teaching Hospitals* | Top 50% Non-Teaching Hospitals | ||||
| ICU Central Line Associated Blood Stream Infections per 1000 line days | 0.19 | 0.14 | 0.00 | 0.60 | 0.00 | 0.00 | 0.00 | 1.0 | 0.7 | ||||
| Ventilator Associated Pneumonia Infections per 1000 ventilator days | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | 1.0 | 0.0 | ||||
Methodist Fayette Hospital does not have an intensive care unit (ICU) or patients on ventilators.
*Methodist University Hospital is a Major Teaching Hospital through its affiliation with the University of Tennessee Health Science Center.
CLABSI (Central Line Associated Blood Stream Infections)
What These Indicators Means & Why It's Important to You
Central Line - A central line is an intravenous (IV) line that is placed in one of the large blood vessels (or veins) close to the heart.
Central Line-Associated Bloodstream Infection (CLABSI) is a primary bloodstream infection (BSI) in a patient that had a central line within the 48-hour period before the development of the BSI. Most bloodstream infections are associated with the presence of a central line. This is a serious infection that develops when germs (bacteria) from outside the body enter the line.
Having a central venous line (CVL) puts patients at a greater risk for getting a BSI while in the hospital. Therefore, proper precautions must be taken to ensure that this does not happen. Patients whose bloodstreams become infected have increased illness and may stay in the hospital longer to receive treatment for the infection. While some patients have higher risks than others, most of these infections are preventable.
How we measure
We have a team of Associates that reviews patient information for our hospital to identify any central line infections. This information is used for the purpose of quality and patient safety.
The CLABSI rate is defined as the number of central line-associated infections per 1,000 central line days. One central line day is defined as a patient having a central line for one day. In order to measure our central line infection rates, we need to know each day how many patients in our intensive care units have a central line. This information is gathered by the nurses. Our associates in the Infection Prevention department then review lab results and patient charts looking for signs and symptoms of infections. This is then converted to a rate.
For example, if 10 patients had central lines during a month and each patient had a central line for 3 days, the number of central line days would be 10 x 3 = 30 central line days for that month. Of those 10 patients, if 3 patients developed a BSI during that month, the central line-associated blood stream infection rate per 1,000 central line days then would be (3/30) x 1,000 = 100, or a rate of 100 central line-associate blood stream infections per 1,000 line days.
What we are doing to reduce central line infection rates
To improve the quality of care delivered to patients requiring a central line, we are following recommended standards for preventing infections during the insertion of the line as well as for maintenance. These “best practices” are recommended by the Centers for Disease Control and Prevention (CDC). They include:
- Hand hygiene prior to insertion of the central line and prior to line care. There is a program in place for observing staff members and physicians at the bedside to ensure that hand cleansing is being performed appropriately. See hand hygiene report.
- Use of protective barriers such as sterile gloves, surgical mask, hair cover, gown and large drape similar to those used in the Operating Room during line insertion.
- “Bundling” all needed supplies in one area (e.g., cart or kit) to ensure items are available for use during line insertion.
- Use of an antiseptic for skin cleansing prior to insertion.
- Daily checks to determine if the central line can be removed when no longer needed.
- Patient bathing with an antiseptic product to keep skin as free from germs as possible.
- Use of best practices for line care and accessing ports.
- Providing education on central lines to patients, family and staff.
We participate in the CDC’s National Healthcare Safety Network (NHSN), a nationally recognized internet-based database. NHSN analyzes data and publishes reports that we use for monitoring hospital acquired infections, for comparisons with other hospitals in the nation, and for quality improvement projects to reduce infections. This report provides us with a benchmark so we can see how we are doing compared to other hospitals.
VAP (Ventilator Associated Pneumonia)
What These Indicators Mean & Why It's Important to You
Pneumonia - The term “pneumonia” most frequently refers to an infection or inflammation that occurs in the lungs and is caused by a bacteria, virus, or fungus. Pneumonia is the second most common healthcare associated infection in the United States and is associated with substantial morbidity and mortality.
Ventilator - A “ventilator” is a machine that helps a patient breathe by giving oxygen through a tube. The tube can be placed in a patient’s mouth, nose, or through a hole in the front of the neck. The tube is connected to a ventilator
Ventilator Associated Pneumonia (VAP) - Patients that are on a ventilator have a high risk of developing pneumonia and can make a patient much sicker, prolong recovery, and increase hospital length of stay and costs. A “ventilator-associated pneumonia” or “VAP” is a lung infection or pneumonia that develops in a patient who is on a ventilator. Germs (bacteria) may enter the lungs through the tube and cause a lung infection.
How We Measure
The VAP rate is defined as the number of ventilator-associated pneumonia cases per 1,000 ventilator days. One ventilator day is defined as a patient receiving ventilation for one day. In order to measure our ventilator-associated pneumonia rates, we need to know each day how many patients in our intensive care units are on a ventilator. This information is gathered by the nurses. Our associates in the Infection Prevention department then review patient charts, looking for signs and symptoms of pneumonia. This is then converted to a rate.
For example, if 20 patients were ventilated during a month and each patient was on ventilator for 2 days, the number of ventilator days would be 20 x 2 = 40 ventilator days for that month. Of those 20 patients, if 5 patients developed VAP during that month, the ventilator-associated pneumonia rate per 1,000 ventilator days then would be (5/40) x 1,000 = 125, or a rate of 125 ventilator-associated pneumonia cases per 1,000 ventilator days.
Working to Ensure the Best Patient Care
Centers for Disease Control and Prevention (CDC), in collaboration with other organizations, has developed guidelines for the prevention of VAP:
- Keep the head of the patient’s bed raised between 30 and 45 degrees unless other medical conditions do not allow this to occur.
- Check the patient’s ability to breathe on his or her own every day so that the patient can be taken off of the ventilator as soon as possible.
- Caregivers should clean their hands with soap and water or an alcohol-based hand rub before and after touching the patient or the ventilator.
- Clean the inside of the patient’s mouth on a regular basis.
- Clean or replace equipment between uses on different patients.
We participate in the CDC’s National Healthcare Safety Network (NHSN), a nationally recognized internet-based database. NHSN analyzes data and publishes reports that we use for monitoring hospital acquired infections, for comparisons with other hospitals in the nation, and for quality improvement projects to reduce infections. This report provides us with a benchmark so we can see how we are doing compared to other hospitals.