Infection Rates

Published On 07/11/2011
Quality Report Findings for April 2013 - March 2014
 Within Top 10%        Better than National Median        Worse than National Median
Hospital Quality Measures Methodist Healthcare University South North Germantown Olive Branch 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 0.03 0.06
0.00

0.00

0.00

0.00
0.00 0.00 1.4 0.6
Ventilator Associated Pneumonia Infections per 1000 ventilator days 0.10 0.18
0.00

0.00

0.00

0.00
0.00 0.00 1.0 1.2

ICU Catheter Associated Urinary Tract Infection

3.18 4.13 3.07 2.08 1.45
0.00
0.0 0.2 1.4 1.7
CBGB Surgical Site Infection Rate 2.57 1.45 3.57 3.84 2.53 N/A - 0.0 - 0.0
CBGC Surgical Site Infection Rate 0.00
0.00

0.00

0.00

0.00
N/A - 0.0 - 0.0
Colon Surgical Site Infection rate

5.19

7.10 3.70 1.85 4.79
0.00
- 0.0 - 4.3
Hip Surgical Site Infection Rate 0.87 0.62
0.00
2.67 0.59 N/A - 0.0 - 1.4
Knee Surgical Site Infection Rate 0.53 1.24
0.00

0.00
0.45 N/A - 0.0 - 0.0
Total Abdominal Hysterectomy Surgical Site Infection Rate 0.63 0.98 1.03
0.00
0.52
0.00
- 0 - 4.3

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.

View the NHSN Report (PDF)


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.

View the NHSN Report (PDF)


ICU CAUTI (ICU Catheter Associated Urinary Tract Infections)
What These Indicators Mean & Why It’s Important to You

A urinary catheter is a tube that is placed in the bladder to drain urine. Your urine will drain through the tube into a bag that collects the urine. Urinary Catheters are frequently used in the hospital if you are not able to urinate on your own, during and after certain types of surgery, for strict measurement of the amount of urine you are making, and during certain diagnostic tests on the bladder and the kidneys. 

A Catheter-Associated Urinary Tract Infection (CAUTI) is a urinary tract infection (also called “UTI”) in the urinary system, which includes the bladder (holds your urine) and the kidneys (which filter blood to make urine).   

Patients who have a urinary catheter in place are at a much higher risk for germs (for example, bacteria or yeasts) which do not normally live in these areas to travel along the catheter and cause an infection in your bladder or your kidneys. These infections are called Catheter-Associated Urinary Tract Infections (CAUTIs), and they can cause additional illness or be deadly. CAUTIs are mostly preventable when healthcare providers use infection control steps recommended by the Centers for Disease Control and Prevention (CDC).

How we measure

We have a team of Associates that review patient information for our hospital to identify any catheter associate urinary tract infections.  This information is used for the purpose of quality and patient safety.

The CAUTI rate is defined as the number of catheter-associated urinary tract infections per 1,000 catheter days.

What We Are Doing to Reduce Catheter-Associated Urinary Tract Infection Rate

To improve the quality of care delivered to patients requiring a urinary catheter, we are following recommended standards for preventing infections during the insertion of the urinary catheter as well as maintenance. These “best practices” are recommended by the Centers of Disease Control and Prevention (CDC).  They include:

Catheter Insertion:

  • Catheters are put in only when necessary and they are removed as soon as possible.
  • Only properly trained persons insert catheters using sterile (“clean”) technique.
  • The skin in the area where the catheter will be inserted is cleaned before inserting the catheter.
  • Other methods to drain the urine are sometimes used, such as External catheters in men (these look like condoms and are placed over the penis rather than into the penis) or using a temporary catheter to drain the urine and removing it right away. This is called intermittent urethral catheterization.

Catheter Care

  • Hand hygiene prior to insertion of the urinary catheter and prior to catheter 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.
  • “Bundling” to improve compliance by evaluating the patient’s necessity for having the urinary catheter, ensuring that the catheter is secured properly to the patients leg to prevent pulling on the catheter and to prevent twisting and kinking of the catheter.  Checking to make there is proper drainage bag placement while transporting the patient to other areas of the hospital.
  • Checking to make sure the red seal is intact.  This ensures that the catheter has not disconnected from the drain tube. Maintaining the red seal helps to pre­vent germs from getting into the catheter tube.
  • Empty the bag regularly and prevent the drainage spout from touching anything while emptying the bag.
  • Provide education on urinary catheters to patient, family and staff.

We share our infection rates with the CDC’s National Healthcare Safety Network (NHSN).  This report provides us with a benchmark so we can see how we are doing compared to other hospitals.

View the NHSN Report (PDF)

Surgical Site Infections (SSIs)
What These Indicators Mean & Why It’s Important to You

Surgical Site Infection

Your skin protects you against infection, and cutting of that skin during a surgical procedure could lead to an infection that doctors refer to as surgical site infections (SSIs).

A Surgical Site Infection (SSIs) can occur within 30 -90 days after your surgery.   

Germs can infect a surgical wound through various forms of contact, such as from the touch of a contaminated caregiver or surgical instrument, through microorganisms in the air, or through germs that are already on or in your body and then spread into the wound. These infections are called Surgical Site Infections (SSIs), and they can be deadly.  SSIs are mostly preventable when healthcare providers use infection control steps recommended by the Centers for Disease Control and Prevention (CDC).

How We Measure

As a patient, you are watched closely for a surgical site infection.

The SSI rate is measured percentage of surgeries that develop a SSI.

What We Are Doing to Reduce Surgical Site Infection Rate

To improve the quality of care for patients who have surgery, we are following recommended standards to prevent infections during and after the procedure.  These “best practices” for Surgical Care Improvement Project are recommendations by the Center of Medicaid and Medicare Services (CMS).  They include:

Correct Use of Antibiotics

  • The right antibiotics protect against germs that may occur during your specific surgery.
  • Each type of surgery has an antibiotic that should be given within one hour before the skin is cut.
  • Antibiotics should be stopped after surgery if there is no infection.  Keeping a patient on antibiotics for too long could lead to another infection not related to your surgery.

Keeping Blood Sugar Normal

  • Patients that are having heart surgery will be followed closely to keep their blood sugar normal.  Normal blood sugar helps decrease infections, kidney problems, blood transfusions, time spent on a breathing machine and the time in the hospital.

Body Temperature in Surgery

  • It is important during surgery that your body temperature is normal.   For some surgeries, warmers may be used to keep your temperature normal.  Keeping your temperature normal will decrease infections, blood transfusions, possible heart attack and time on the breathing machine.

We share our infection rates with CDC’s National Healthcare Safety Network (NHSN). This report provides us with a benchmark so we can see how we are doing compared to other hospitals.

View the NHSN Report (PDF)