Supporting Maine DHHS Healthcare-Associated Infection Validations

Dates: 2013

State: Maine

Client(s): Maine Department of Health & Human Services

Technical Expertise: Patient Safety

Healthcare-associated infections (HAIs) are infections that patients acquire during the course of receiving healthcare treatment for other conditions. HAIs put the patient at risk, increase the days of hospitalization required for patients, and add to healthcare costs.

Many states require hospitals to report certain HAIs using the CDC’s National Healthcare Safety Network (NHSN) according to uniform definitions so that infection rates can be determined and reported to the public. NHSN reporting allows facilities to identify problem areas and measure progress in infection prevention with the goal to eliminate HAIs. However, the accuracy of the reported NHSN data must be assured if this indicator is to be meaningful in determining the quality of care and informing consumer choices.

JSI has worked with several states in the area of data validation, case finding, and data verification. As part of this project, JSI focused on one of the most common HAI indicators, central line associated bloodstream infections (CLASBI), for 12 acute care facilities in Maine. Specific clinical and laboratory data was used to validate CLABSI cases to identify possible missed cases. The cases were selected for audit according to CDC’s protocol.

JSI's team of specially trained clinicians, epidemiologists, and researchers conducted 6 site visits and 6 remote validations. The audit team applied each case against the NHSN definitions and compared findings with the hospital infection prevention team. Discrepancies were discussed and adjudicated after the visit. At the conclusion of the 12 validations the findings and validation results were summarized in a report and were provided to the Maine Department of Health.