Methods: In 2014, hospitals reported HAI data to CDPH via the National Healthcare Safety Network (NHSN) as required by California state mandates; 392 hospitals reported data for central line-associated bloodstream infection (CLABSI), multidrug-resistant organism (MDRO) bloodstream infection (BSI), and Clostridium difficile infection (CDI); 345 (88.5%) hospitals reported data for surgical site infection (SSI). As part of the CDPH HAI Program’s 20-component Data Quality Review Plan, descriptive analyses were conducted to examine the quality of CLABSI, SSI, MDRO BSI, and CDI denominator data.
Results: Fifty-four (13.8%) hospitals had some type of denominator data quality issue. For CLABSI surveillance, 11 (20.4%) hospitals reported central line days out-of-plan and/or outlier device utilization ratios. For SSI, 21 (38.9%) hospitals underreported contaminated or dirty wound classifications for their total number of surgeries. For MDRO BSI surveillance, 6 (11.1%) hospitals reported outlier patient days not consistent with their reported number of beds, and for CDI, 16 (29.6%) hospitals with neonatal intensive care units or well-baby nurseries reported the same number of patient days for CDI as for MDRO BSI. CDPH HAI Program staff contacted all 54 hospitals to help correct their HAI denominator data. Twenty-seven (50.0%) hospitals complied and corrected their data, 7 (13.0%) hospitals stated their data were correct, and 20 (37.0%) hospitals are in the process of correcting their data.
Conclusion: These results suggest that CDPH HAI Program outreach interventions helped to immediately resolve HAI denominator data discrepancies in two-thirds of 54 California hospitals identified. Implementation of a comprehensive data quality review process has improved the accuracy and completeness of HAI data reported by California hospitals, and thereby will both aid local HAI prevention activities and ensure publication of a more accurate state report.
L. Janssen, None
N. Kazerouni, None