2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of...

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Michigan Region 1 2016 Q2 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, regional, and statewide TAP reports are provided quarterly. This report shows modules and locations where the specified region 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, under their original baselines. Numbers in red show how many infections the region 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 region according to the HHS target SIR. A corresponding SIR for each module and location are provided as well. Bar graphs containing CAD values from all letter-coded SHARP-participating hospitals in the region by module and location are available below. These graphs allow each facility in the region to view their rank within each module and location compared to other nearby facilities. Hospital letters are provided in password-protected individual TAP reports. Letters are re-assigned each quarter. A CAD greater than zero indicates the number of infections a facility needs to prevent to achieve the HHS Target SIR for that module. A number less than zero indicates the number of infections a facility prevented beyond what was expected based on the HHS Target SIR.

Transcript of 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of...

Page 1: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

Michigan Region 1 2016 Q2 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, regional, and statewide TAP reports are provided quarterly.

This report shows modules and locations where the specified region 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, under their original baselines. Numbers in red show how many infections the region 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 region according to the HHS target SIR. A corresponding SIR for each module and location are provided as well.

Bar graphs containing CAD values from all letter-coded SHARP-participating hospitals in the region by module and location are available below. These graphs allow each facility in the region to view their rank within each module and location compared to other nearby facilities. Hospital letters are provided in password-protected individual TAP reports. Letters are re-assigned each quarter. A CAD greater than zero indicates the number of infections a facility needs to prevent to achieve the HHS Target SIR for that module. A number less than zero indicates the number of infections a facility prevented beyond what was expected based on the HHS Target SIR.

Page 2: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

2016 Q2 Targeted Assessment for Prevention Report

NHSN Module Number of Facilities

Location SIR1 Significant (Y/N)2 CAD3 Prevented or Need to Prevent

CAUTI 12 All 0.2 Y -12.0 Prevented 9 ICU 0.3 ---- -5.3 Prevented 12 Ward 0.2 ----- -6.6 Prevented

CLABSI 12 All 0.3 Y -3.0 Prevented 9 ICU 0.6 ----- 1.1 Need to Prevent 12 Ward 0 ----- -3.4 Prevented <5 NICU ----- ----- ----- -----

CDI 10 Facility-wide 0.54 Y -12.4 Prevented MRSA Bac 10 Facility-wide 0.17 Y -3.4 Prevented SSI COLO 10 ---- 1.2 N 2.9 Need to Prevent SSI HYST 9 ---- 0.54 N -0.4 Prevented

1SIR: 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. 2Significant (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. 3CAD=Cumulative Attributable Difference. The number of infections that the region 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

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

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Page 3: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

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Page 4: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

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Page 5: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

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Page 6: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

Michigan Region 2N 2016 Q2 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, regional, and statewide TAP reports are provided quarterly.

This report shows modules and locations where the specified region 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 region 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 region according to the HHS target SIR. A corresponding SIR for each module and location are provided as well.

Bar graphs containing CAD values from all letter-coded SHARP-participating hospitals in the region by module and location are available below. These graphs allow each facility in the region to view their rank within each module and location compared to other nearby facilities. Hospital letters are provided in password-protected individual TAP reports. Letters are re-assigned each quarter. A CAD greater than zero indicates the number of infections a facility needs to prevent to achieve the HHS Target SIR for that module. A number less than zero indicates the number of infections a facility prevented beyond what was expected based on the HHS Target SIR.

Page 7: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

2016 Q2 Targeted Assessment for Prevention Report

NHSN Module Number of Facilities

Location SIR1 Significant (Y/N)2 CAD3 Prevented or Need to Prevent

CAUTI 14 All 0.6 Y -12.2 Prevented 14 ICU 0.5 ---- -12.4 Prevented 14 Ward 0.8 ---- 0.1 Need to Prevent

CLABSI 14 All 0.5 Y -1.1 Prevented 14 ICU 0.5 ---- 0.8 Need to Prevent 14 Ward 0.4 ---- -1.2 Prevented <5 NICU ----- ---- ----- ----

CDI 14 Facility-wide 0.84 Y 32.9 Need to Prevent MRSA Bac 14 Facility-wide 0.59 N -3.2 Prevented SSI COLO 14 ---- 1.6 Y 16.6 Need to Prevent SSI HYST 14 ---- 0.21 N -2.6 Prevented

1SIR: 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. 2Significant (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. 3CAD=Cumulative Attributable Difference. The number of infections that the region 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

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

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Page 8: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

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Page 9: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

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Page 10: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

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Page 11: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

Michigan Region 2S 2016 Q2 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, regional, and statewide TAP reports are provided quarterly.

This report shows modules and locations where the specified region 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 region 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 region according to the HHS target SIR. A corresponding SIR for each module and location are provided as well.

Bar graphs containing CAD values from all letter-coded SHARP-participating hospitals in the region by module and location are available below. These graphs allow each facility in the region to view their rank within each module and location compared to other nearby facilities. Hospital letters are provided in password-protected individual TAP reports. Letters are re-assigned each quarter. A CAD greater than zero indicates the number of infections a facility needs to prevent to achieve the HHS Target SIR for that module. A number less than zero indicates the number of infections a facility prevented beyond what was expected based on the HHS Target SIR.

Page 12: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

2016 Q2 Targeted Assessment for Prevention Report

NHSN Module Number of Facilities

Location SIR1 Significant (Y/N)2 CAD3 Prevented or Need to Prevent

CAUTI 16 All 0.6 Y -18.1 Prevented 16 ICU 0.5 ---- -13.6 Prevented 16 Ward 0.6 ---- -4.6 Prevented

CLABSI 16 All 0.4 Y -8.9 Prevented 16 ICU 0.4 ---- -6.7 Prevented 16 Ward 0.5 ---- -0.8 Prevented 6 NICU 0.3 ---- -1.4 Prevented

CDI 16 Facility-wide 0.87 Y 46.2 Need to Prevent MRSA Bac 16 Facility-wide 1.13 N 9.4 Need to Prevent SSI COLO 14 ---- 0.63 N -2.8 Prevented SSI HYST 13 ---- 0.18 Y -3.2 Prevented

1SIR: 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. 2Significant (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. 3CAD=Cumulative Attributable Difference. The number of infections that the region 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

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

Bar Graphs

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Page 13: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

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Page 14: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

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Page 15: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

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Page 17: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

Michigan Region 3 2016 Q2 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, regional, and statewide TAP reports are provided quarterly.

This report shows modules and locations where the specified region 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 region 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 region according to the HHS target SIR. A corresponding SIR for each module and location are provided as well.

Bar graphs containing CAD values from all letter-coded SHARP-participating hospitals in the region by module and location are available below. These graphs allow each facility in the region to view their rank within each module and location compared to other nearby facilities. Hospital letters are provided in password-protected individual TAP reports. Letters are re-assigned each quarter. A CAD greater than zero indicates the number of infections a facility needs to prevent to achieve the HHS Target SIR for that module. A number less than zero indicates the number of infections a facility prevented beyond what was expected based on the HHS Target SIR.

Page 18: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

2016 Q2 Targeted Assessment for Prevention Report

NHSN Module Number of Facilities

Location SIR1 Significant (Y/N)2 CAD3 Prevented or Need to Prevent

CAUTI 15 All 0.5 Y -13.3 Prevented 13 ICU 0.5 ----- -6.4 Prevented 15 Ward 0.5 ----- -6.9 Prevented

CLABSI 15 All 0.2 Y -10.2 Prevented 13 ICU 0.2 ---- -5.7 Prevented 15 Ward 0.2 ---- -4.2 Prevented <5 NICU ----- ---- ----- -----

CDI 14 Facility-wide 0.81 Y 15.1 Need to Prevent MRSA Bac 14 Facility-wide 0.69 N -0.8 Prevented SSI COLO 11 ---- 1.08 N 3.6 Need to Prevent SSI HYST 10 ---- 0.91 N 0.5 Need to Prevent

1SIR: 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. 2Significant (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. 3CAD=Cumulative Attributable Difference. The number of infections that the region 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

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

Bar Graphs

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Hospital Letter

Region 3 CAUTI (ICU)

CR

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Region 3 CAUTI (Ward)

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Region 3 CLABSI (Overall)

Page 20: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

CR

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BN

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Region 3 CLABSI (ICU)

CH

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Region 3 CLABSI (Ward)

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Hospital Letter

Region 3 C.diff LabID (Facility-wide Inpatient)

Page 21: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

BGR CJ

CH

BW BP BB BH ATF A

BN CM

CR

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-1

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Region 3 MRSA Bacteremia LabID (Facility-wide Inpatient)

A

CR

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Region 3 SSI Colon Surgeries

CJ

BN F BB R BG A CM CHCR-1

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Region 3 SSI Abdominal Hysterectomies

Page 22: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

Michigan Region 5 2016 Q21 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, regional, and statewide TAP reports are provided quarterly.

This report shows modules and locations where the specified region 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 region 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 region according to the HHS target SIR. A corresponding SIR for each module and location are provided as well.

Bar graphs containing CAD values from all letter-coded SHARP-participating hospitals in the region by module and location are available below. These graphs allow each facility in the region to view their rank within each module and location compared to other nearby facilities. Hospital letters are provided in password-protected individual TAP reports. Letters are re-assigned each quarter. A CAD greater than zero indicates the number of infections a facility needs to prevent to achieve the HHS Target SIR for that module. A number less than zero indicates the number of infections a facility prevented beyond what was expected based on the HHS Target SIR.

Page 23: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

2016 Q2 Targeted Assessment for Prevention Report

NHSN Module Number of Facilities

Location SIR1 Significant (Y/N)2 CAD3 Prevented or Need to Prevent

CAUTI 10 All 0.4 Y -10.0 Prevented 10 ICU 0.1 ---- -8.0 Prevented 10 Ward 0.6 ---- -1.9 Prevented

CLABSI 10 All 0.6 N 1.3 Need to Prevent 10 ICU 0.3 ---- -1.8 Prevented 10 Ward 1.0 ---- 4.1 Need to Prevent <5 NICU ---- ---- ---- ----

CDI 11 Facility-wide 0.78 N 4.5 Need to Prevent MRSA Bac 11 Facility-wide 0 Y -4.7 Prevented SSI COLO 9 ---- 1.3 N 4.1 Need to Prevent SSI HYST 7 ---- 0.62 N -0.21 Prevented

1SIR: 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. 2Significant (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. 3CAD=Cumulative Attributable Difference. The number of infections that the region 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

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

Bar Graphs

CNCH

AZ AW AM AO

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Region 5 CAUTI (Overall)

Page 24: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

CH

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Region 5 CAUTI (ICU)

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Region 5 CAUTI (Ward)

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Region 5 CLABSI (Overall)

Page 25: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

KAM

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Region 5 CLABSI (ICU)

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Region 5 C.diff LabID (Facility-wide Inpatient)

CH

BZ BY AW AZ AOAM

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Region 5 MRSA Bacteremia LabID (Facility-wide Inpatient)

Page 26: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

AMAO

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Region 5 SSI Colon Surgeries

AM

AZ AO U

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Region 5 SSI Abdominal Hysterectomies

Page 27: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

Michigan Region 6 2016 Q2 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, regional, and statewide TAP reports are provided quarterly.

This report shows modules and locations where the specified region 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 region 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 region according to the HHS target SIR. A corresponding SIR for each module and location are provided as well.

Bar graphs containing CAD values from all letter-coded SHARP-participating hospitals in the region by module and location are available below. These graphs allow each facility in the region to view their rank within each module and location compared to other nearby facilities. Hospital letters are provided in password-protected individual TAP reports. Letters are re-assigned each quarter. A CAD greater than zero indicates the number of infections a facility needs to prevent to achieve the HHS Target SIR for that module. A number less than zero indicates the number of infections a facility prevented beyond what was expected based on the HHS Target SIR.

Page 28: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

2016 Q2 Targeted Assessment for Prevention Report

NHSN Module Number of Facilities

Location SIR1 Significant (Y/N)2 CAD3 Prevented or Need to Prevent

CAUTI 15 All 0.6 Y -4.1 Prevented 15 ICU 0.7 ---- -0.5 Prevented 15 Ward 0.3 ---- -3.6 Prevented

CLABSI 15 All 0.4 Y -1.3 Prevented 15 ICU 0.4 ---- -1.3 Prevented 14 Ward 0.4 ---- -0.5 Prevented <5 NICU ---- ---- ---- ----

CDI 16 Facility-wide 0.71 Y 0.5 Need to Prevent MRSA Bac 16 Facility-wide 0.73 N -0.1 Prevented SSI COLO 15 ---- 0.92 N 2.0 Need to Prevent SSI HYST 15 ---- 0.83 N 0.2 Need to Prevent

1SIR: 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. 2Significant (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. 3CAD=Cumulative Attributable Difference. The number of infections that the region 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

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

Bar Graphs

CKCG CF

BF BI BJ BK BLAS AN AQ

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Region 6 CAUTI (Overall)

Page 29: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

BSCF

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Region 6 CAUTI (ICU)

CK

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Region 6 CAUTI (Ward)

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Region 6 CLABSI (Overall)

Page 30: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

W

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Region 6 CLABSI (ICU)

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Region 6 CLABSI (Ward)

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Region 6 C.diff LabID (Facility-wide Inpatient)

Page 31: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

CF

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Region 6 MRSA Bacteremia LabID (Facility-wide Inpatient)

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Region 6 SSI Colon Surgeries

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Region 6 SSI Abdominal Hysterectomies

Page 32: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

Michigan Region 7 2016 Q2 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, regional, and statewide TAP reports are provided quarterly.

This report shows modules and locations where the specified region 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 region 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 region according to the HHS target SIR. A corresponding SIR for each module and location are provided as well.

Bar graphs containing CAD values from all letter-coded SHARP-participating hospitals in the region by module and location are available below. These graphs allow each facility in the region to view their rank within each module and location compared to other nearby facilities. Hospital letters are provided in password-protected individual TAP reports. Letters are re-assigned each quarter. A CAD greater than zero indicates the number of infections a facility needs to prevent to achieve the HHS Target SIR for that module. A number less than zero indicates the number of infections a facility prevented beyond what was expected based on the HHS Target SIR.

Page 33: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

2016 Q2 Targeted Assessment for Prevention Report

NHSN Module Number of Facilities

Location SIR1 Significant (Y/N)2 CAD3 Prevented or Need to Prevent

CAUTI 7 All 0.4 Y -5.6 Prevented 6 ICU 0.8 ---- 0.2 Need to Prevent 7 Ward 0.3 ---- -5.7 Prevented

CLABSI 7 All 0.3 Y -1.7 Prevented 6 ICU 0.7 ---- 0.6 Need to Prevent 7 Ward 0.2 ---- -2.3 Prevented <5 NICU ---- ---- ---- ----

CDI 6 Facility-wide 0.79 N 2.9 Need to Prevent MRSA Bac 7 Facility-wide 0.50 N -0.51 Prevented SSI COLO 7 ---- 1.74 N 4.56 Need to Prevent SSI HYST 7 ---- 1.70 N 1.12 Need to Prevent

1SIR: 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. 2Significant (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. 3CAD=Cumulative Attributable Difference. The number of infections that the region 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

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

Bar Graphs

BD BEAV

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Region 7 CAUTI (Overall)

Page 34: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

AA

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Region 7 CAUTI (ICU)

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Region 7 CAUTI (Ward)

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Region 7 C.diff LabID (Facility-wide Inpatient)

Page 35: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

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Region 7 MRSA Bacteremia LabID (Facility-wide Inpatient)

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Region 7 SSI Colon Surgeries

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Region 7 SSI Abdominal Hysterectomies

Page 36: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

Michigan Region 8 2016 Q2 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, regional, and statewide TAP reports are provided quarterly.

This report shows modules and locations where the specified region 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 region 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 region according to the HHS target SIR. A corresponding SIR for each module and location are provided as well.

Bar graphs containing CAD values from all letter-coded SHARP-participating hospitals in the region by module and location are available below. These graphs allow each facility in the region to view their rank within each module and location compared to other nearby facilities. Hospital letters are provided in password-protected individual TAP reports. Letters are re-assigned each quarter. A CAD greater than zero indicates the number of infections a facility needs to prevent to achieve the HHS Target SIR for that module. A number less than zero indicates the number of infections a facility prevented beyond what was expected based on the HHS Target SIR.

Page 37: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

2016 Q2 Targeted Assessment for Prevention Report

NHSN Module Number of Facilities

Location SIR1 Significant (Y/N)2 CAD3 Prevented or Need to Prevent

CAUTI 7 All 0.6 N -1.1 Prevented 5 ICU 0.6 ---- -0.7 Prevented 7 Ward 0.6 ---- -0.4 Prevented

CLABSI 6 All 0.2 N -1.3 Prevented 5 ICU 0.3 ---- -0.5 Prevented 6 Ward 0 ---- -0.6 Prevented <5 NICU ---- ---- ---- ----

CDI 7 Facility-wide 1.03 N 5.1 Need to Prevent MRSA Bac 7 Facility-wide ---- ---- 0.35 Need to Prevent SSI COLO 7 ---- 1.48 N 1.5 Need to Prevent SSI HYST 7 ---- ---- ---- -0.2 Prevented

1SIR: 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. 2Significant (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. 3CAD=Cumulative Attributable Difference. The number of infections that the region 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

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

Bar Graphs

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Region 8 CAUTI (Overall)

Page 38: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

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Region 8 CAUTI (ICU)

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Region 8 CLABSI (Overall)

Page 39: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

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Attr

ibut

able

Diff

eren

ce (C

AD)

Hospital Letter

Region 8 C.diff LabID (Facility-wide Inpatient)

CL

BO BQ BA AY AJ AF-0.25

0

0.25

0.5

0.75

Cum

ulat

ive

Attr

ibut

able

Diff

eren

ce (C

AD)

Hospital Letter

Region 8 MRSA Bacteremia LabID (Facility-wide Inpatient)

CL

AF AY BA BQAJ

-0.5

0

0.5

1

1.5

2

Cum

ulat

ive

Attr

ibut

able

Diff

eren

ce (C

AD)

Hospital Letter

Region 8 SSI Colon Surgeries

Page 40: 2016 Q2 Regional TAP Report - Michigan · 2016 Q2 Aggregate TAP Report . Michigan Department of Health and Human Services . ... are provided quarterly. This report shows modules and

AY

AJBO

AF

BA

CL-0.07

-0.06

-0.05

-0.04

-0.03

-0.02

-0.01

0

Cum

ulat

ive

Attr

ibut

able

Diff

eren

ce (C

AD)

Hospital Letter

Region 8 SSI Abdominal Hysterectomies