TECHNICAL REPORT FOR HEALTHCARE-ASSOCIATED INFECTIONS. New Jersey Department of Health Health Care Quality Assessment

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1 TECHNICAL REPORT FOR HEALTHCARE-ASSOCIATED INFECTIONS A SUPPLEMENT TO THE NEW JERSEY 2012 HOSPITAL PERFORMANCE REPORT New Jersey Department of Health Health Care Quality Assessment June 2013

2 Tables of Contents A. Healthcare-Associated Infections... 3 B. HAI Surveillance in New Jersey... 3 C. Source of Healthcare-Associated Infection Data... 4 D. Standardized Infection Ratio... 4 E. Data Limitations... 7 Table 1: 2010 Coronary Artery Bypass Graft Surgical Site Infections...8 Table 2: 2010 Abdominal Hysterectomy Surgical Site Infections. 9 Table 3: 2010 Knee Arthroplasty Surgical Site Infections...12 Table 4: 2010 Overall Surgical Site Infections Table 5: 2011 Central Line-Associated Blood Stream Infections...18 Table 6: 2011 Catheter-Associated Urinary Tract Infections..21 References

3 Background A. Healthcare-Associated Infections Healthcare-Associated Infections (HAIs) are defined as infections acquired by patients while being treated in a healthcare setting. Healthcare settings include acute-care and specialty care hospitals, outpatient clinics, nursing homes, rehabilitation facilities and ambulatory surgery centers. HAIs contribute significantly to morbidity and mortality in the United States. They account for approximately 1.7 million infections and 99,000 deaths annually 1. The estimated financial impact of HAIs is between $28 billion and $33 billion a year 2. There are a number of causes of HAIs which include medical devices (i.e., catheters, implants, ventilators), surgical procedure complications, the overuse of antibiotics and improper hand hygiene. Approximately 75 percent of HAIs can be attributed to four infection categories: 1. Surgical site infections; 2. Central line-associated bloodstream infections; 3. Ventilator-associated pneumonia, and; 4. Catheter-associated urinary tract infections. Two additional major contributors to HAIs are: 5. Clostridium difficile, and; 6. Methicillin-resistant Staphylococcus aureus (MRSA) 3. The most common healthcare-associated infections are urinary tract infections (32 percent), followed by surgical site infections (22 percent), pneumonias (15 percent), and bloodstream infections (14 percent) 1. B. HAI Surveillance in New Jersey Reducing preventable HAIs has become a priority for New Jersey hospitals, healthcare providers, state legislators and healthcare policy professionals. Signed in 2007, the public reporting law (PL of 2007, C 196) requires hospitals to report HAI data to the New Jersey Department of Health and for the data to be published in the Hospital Performance Report. Beginning January 1, 2009, all acute-care hospitals along with one specialty care hospital in New Jersey began submitting the following HAI data to the Department: 3

4 Central Line-Associated Bloodstream Infections (CLABSIs) in adult, pediatric and neonatal critical care units. Surgical Site Infections following Abdominal Hysterectomy procedures. Surgical Site Infections following Coronary Artery Bypass Graft procedures. In 2010, two additional HAIs were added to the surveillance efforts: Catheter-Associated Urinary Tract Infections in all adult critical care units. Surgical Site Infections following Knee arthroplasty. In 2012, acute care hospitals began HAI surveillance for Surgical Site Infections following Colon surgery procedures. C. Source of Healthcare-Associated Infection Data The Centers for Disease Control and Prevention s (CDC) Division of Healthcare Quality Promotion (DHQP) implemented a public health surveillance system known as the Healthcare Safety Network (NHSN) in The American Recovery and Reinvestment Act (ARRA) of 2009 provided the funding necessary to expand HAI surveillance and prevention efforts on both the national and state level. As a result, the NHSN system is used by various types of health care facilities in all 50 states, Washington, D.C. and Puerto Rico to monitor patient safety, healthcare personnel safety and biovigilance. Currently, more than 11,500 hospitals use the NHSN system and 30 states and the District of Columbia have mandates which require hospitals to report Healthcare-Associated Infections using NHSN 4. The NHSN system is a secure, internet-based system. The 71 acute care hospitals as well as one specialty care hospital in New Jersey use the NHSN system to report and survey HAIs. This year s report focuses on three types of HAIs; 2010 Surgical Site Infections (SSIs) following Coronary Artery Bypass Graft (CABG) surgery, Abdominal Hysterectomy procedures and Knee Arthroplasty procedures (new measure in the report this year); 2011 Central Line-Associated Bloodstream Infections (CLABSIs) that occurred in adult, pediatric and neonatal critical/intensive care units, and 2011 Catheter-Associated Urinary Tract Infections (CAUTIs) that occurred in adult intensive care units. Hospitals were provided the opportunity to verify the accuracy of their data. D. Standardized Infection Ratio This report presents composite statistics summarizing SSI, CLABSI and CAUTI data at the hospital level. The data are summarized using the Standardized Infection Ratio (SIR), a statistic used to measure relative difference in HAI occurrence during a reporting period compared to a common reference period (i.e. standard population). 4

5 What is a Standardized Infection Ratio (SIR)? The Standardized Infection Ratio (SIR) is a summary measure developed by CDC to be used to track HAIs at a national, state, local or hospital level over time. The SIR adjusts for the fact that each hospital treats different types of patients. The SIR compares the actual number of events reported by a hospital with the national baseline experience, adjusting for several risk factors that have been found to be significantly associated with differences in infection incidence 5, 7. How is the SIR Calculated? The SIR is calculated by applying the risk-adjustment method developed by CDC to the 2010 and 2011 New Jersey data. Calculating the SIR is similar to the Standardized Mortality Ratio (SMR), a summary statistic frequently used in public health. SIR is defined as the number of observed infections divided by the number of expected infections. The formula below depicts the calculation: The table below provides an example of how a hospital s CLABSI data from four different locations can be summarized into a single risk-adjusted summary statistic, i.e., the SIR. Type of ICU Location Observed Number of CLABSI Events Central Line-days CLABSI Rate (per 1000 central-days) NHSN Rate (per 1000 centraldays) Expected Number of CLABSI Events Medical cardiac Medical Med/Surgical Neurosurgical Total Overall CLABSI SIR = Observed/Expected = 8/4.15 = 1.93 The observed number of CLABSI events is the number of CLABSI events that occurred in an ICU or CCU in a hospital. The greater the total number of days that patients have central lines inserted (central line-days), the more CLABSI events are likely to occur. 5

6 The expected number of CLABSI events for an ICU or CCU is calculated by multiplying the total count of central line-days in the ICU or CCU by the NHSN rate and dividing by The NHSN rate is based on NHSN aggregate data. CLABSI rates were stratified by type of patient care locations and, in some cases, also by type of hospital or bed size of the patient-care locations 5, 6. The expected numbers of CLABSI events from all adult and pediatric ICUs and CCUs in a hospital are then summarized and used as the denominator for the overall SIR for the hospital. The expected number of CLABSI events shows the number of CLABSI events that would have occurred if the hospital s performance had been the same as the national experience. Following the NHSN methodology, the SIRs are calculated only if the number of expected events is >=1. When the number of expected events is <1, comparisons are not precise 7. SIRs for CAUTIs and SSIs are calculated in a similar manner. How to interpret the SIR? In trying to determine a hospital s performance, it is important to account for the fact that some differences occur simply due to chance or random variation. As shown in the tables, 95% confidence intervals are used to determine whether a hospital s SIR is statistically significantly higher or lower than 1.0. The hospital SIRs are compared to the national experience, which is a baseline SIR of 1.0. The results are summarized under the column, Comparison. This column classifies the hospitals performances by L as Lower than Expected, the letter S as Similar to Expected, or H as Higher than Expected. A hospital s SIR is statistically significantly lower than 1.0 if the upper limit of its 95% confidence interval falls completely below 1.0. The Comparison column for the hospital is noted with the letter L. This means fewer events were observed than expected, adjusting for differences in the types of patients treated. The hospital performed better than the national baseline experience. A hospital s SIR is statistically significantly higher than 1.0 if the lower limit of its 95% confidence interval falls completely above 1.0. The Comparison column for the hospital is noted with the letter H. This means more events were observed than expected, adjusting for differences in the types of patients treated. The hospital performed worse than the national baseline experience. A hospital s SIR is not statistically different from 1.0 if its 95% confidence interval includes 1.0. The Comparison column for the hospital is noted with the letter S. This means similar number of events was observed as expected, adjusting for differences in the types of patients treated. The hospital performed similar to the national baseline experience. 6

7 In examining the table, some SIRs may appear lower than others but are considered Similar" while other SIRs may appear higher but the Comparison indicates Lower. When using this report, it is important to remember that the data in the tables are designed to show whether a hospital s SIR is statistically significantly above, below or the same as the national baseline. Therefore, it is more important to view the confidence intervals in relation to the national baseline SIR of 1.0 and not make hospital-to-hospital comparisons. E. Data Limitations Please keep in mind some of the following issues before making conclusions about a hospital: Hospitals reviewed and verified the data used in this report is the data that was reported to the NHSN system. The risk-adjustment method may not fully capture how sick patients are in certain hospitals and locations. For example, the medical intensive care unit patients in one hospital might be intrinsically at greater risk for HAI compared to the medical intensive care unit patients from the national experience. Therefore, it is important to use caution when interpreting hospital HAI data. A hospital which performed lower than the Comparison, does not necessarily mean the hospital is better but that they may need to improve their HAI surveillance protocols. Conversely, a hospital which performed higher than the Comparison is not necessarily a poor performer. This hospital could have better infection control practices and processes instituted throughout their facility. 7

8 Table 1: 2010 Coronary Artery Bypass Graft (CABG) Surgical Site Infections Hospital Name Number of Procedures CABG Infections (O) Expected # of CABG 95 % Confidence Infections (E) a SIR b Interval AtlantiCare Regional Medical Center Mainland (0.090, 2.672) S Cooper Hospital/University Medical Center (0.062, 1.863) S Deborah Heart and Lung Center (1.017, 5.212) H Englewood Hospital and Medical Center (0.143, 4.270) S Hackensack University Medical Center (0.141, 1.323) S Jersey City Medical Center (,2.171) S Jersey Shore University Medical Center (0.645, 2.472) S Morristown Memorial Hospital (0.321, 1.645) S Newark Beth Israel Medical Center (0.085, 2.548) S Our Lady of Lourdes Medical Center (0.402, 2.890) S Robert Wood Johnson University Hospital (0.305, 1.808) S Saint Barnabas Medical Center (1.161, 4.821) H St. Francis Medical Center (,2.580) S St. Joseph's Hospital and Medical Center (0.008, 1.798) S St. Mary's Hospital (0.023, 5.116) S St. Michael's Medical Center (0.533, 3.158) S UMDNJ University Hospital Valley Hospital (0.075, 2.229) S Statewide (0.745, 1.238) S Source: New Jersey Healthcare Associated Infections for 2010 submitted through the Healthcare Safety Network (NHSN). a Expected (E)= # of infections predicted using the model fitted from the NHSN data from This data set will serve as the baseline/benchmark for future reports. Important to note that if Expected is <1, the SIR is not calculated as the result is not precise. b Standardized Infection Ratio (SIR)= Observed (O)/ Expected (E) Each hospital is compared to the Ratio=1. The Ratio is derived using the CDC's NHSN data from (AJIC, December 2009). L indicates hospital infections are LOWER than infections seen nationally. H indicates hospital infections are HIGHER than infections seen nationally. S indicates hospital infections are SIMILAR to infections seen nationally. SIR is not calculated because the Expected is < 1. 8

9 Table 2: 2010 Abdominal Hysterectomy Surgical Site Infections Hospital Name Procedure Count Abdominal Hysterectomy Infections (O) Expected # of Abdominal Hysterectomy Infections (E) a SIR b 95% Confidence Interval AtlantiCare Regional Medical Center City AtlantiCare Regional Medical Center Mainland Bayonne Medical Center Bayshore Community Hospital Bergen Regional Medical Center Cape Regional Medical Center Capital Health Medical Center Hopewell (0.178, 5.308) S Capital Health Regional Medical Center CentraState Medical Center Chilton Memorial Hospital Christ Hospital Clara Maass Medical Center Community Medical Center Cooper Hospital/University Medical Center (0.426, 2.527) S Deborah Heart and Lung Center N/A East Orange General Hospital Englewood Hospital and Medical Center Hackensack University Medical Center (0.011, 2.321) S Hackettstown Regional Medical Center Hoboken University Medical Center Holy Name Medical Center (,3.009) S Hunterdon Medical Center Jersey City Medical Center Jersey Shore University Medical Center (,1.734) S JFK Medical Center/Anthony M Yelensics (,3.480) S Kennedy University Hospital Kennedy University Hospital/UMC Cherry Hill Kennedy University Hospital/UMC Stratford Kimball Medical Center Lourdes Medical Center of Burlington Cty

10 Table 2: 2010 Abdominal Hysterectomy Surgical Site Infections (continued) Hospital Name Procedure Count Abdominal Hysterectomy Infections (O) Expected # of Abdominal Hysterectomy Infections (E) a SIR b 95% Confidence Interval Meadowlands Hospital Medical Center Memorial Hospital of Salem County Monmouth Medical Center (0.015, 3.334) S Morristown Memorial Hospital (0.878, 4.499) S Mountainside Hospital (,3.493) S Newark Beth Israel Medical Center (,1.595) S Newton Memorial Hospital Ocean Medical Center Our Lady of Lourdes Medical Center (,3.267) S Overlook Medical Center Palisades Medical Center of New York (PHS) Raritan Bay Medical Center Old Bridge N/A Raritan Bay Medical Center Perth Amboy Riverview Medical Center Robert Wood Johnson University Hospital (1.828, 9.365) H Robert Wood Johnson University Hospital at Hamilton Robert Wood Johnson University Hospital at Rahway Saint Barnabas Medical Center (0.491, 4.611) S Shore Medical Center Somerset Medical Center South Jersey Healthcare Elmer South Jersey Healthcare Regional Medical Center (,2.578) S Southern Ocean Medical Center St. Clare's Hospital Denville St. Clare's Hospital Dover N/A St. Clare's Hospital Sussex St. Francis Medical Center St. Joseph's Hospital and Medical Center St. Joseph's Wayne Hospital St. Luke's Warren Hospital

11 Table 2: 2010 Abdominal Hysterectomy Surgical Site Infections (continued) Hospital Name Procedure Count Abdominal Hysterectomy Infections (O) Expected # of Abdominal Hysterectomy Infections (E) a SIR b 95% Confidence Interval St. Mary's Hospital St. Michael's Medical Center St. Peter's University Hospital (,1.625) S Trinitas Regional Medical Center (0.014, 3.008) S UMDNJ University Hospital Underwood Memorial Hospital University Medical Center at Princeton Valley Hospital (0.016, 3.595) S Virtua Marlton Virtua Mem. Hospital of Burlington County (,3.056) S Virtua West Jersey Health System Berlin Virtua West Jersey Health System Voorhees (1.443, 5.993) H Statewide (0.644, 1.164) S Source: New Jersey Healthcare Associated Infections for 2010 submitted through the Healthcare Safety Network (NHSN). a Expected (E)= # of infections predicted using the model fitted from the NHSN data from which serves as the baseline for future reports. Important to note that if Expected is <1, the SIR is not calculated as the result is not precise. b Standardized Infection Ratio (SIR)= Observed (O)/ Expected (E) Each hospital is compared to the Ratio=1. The Ratio is derived using the CDC's NHSN data from (AJIC, December 2009). L indicates hospital infections are LOWER than infections seen nationally. H indicates hospital infections are HIGHER than infections seen nationally. S indicates hospital infections are SIMILAR to infections seen nationally. SIR is not calculated because the Expected is < 1. N/A hospital is not licensed to perform procedure(s) or did not perform procedure(s) in

12 Table 3: 2010 Knee Arthroplasty Surgical Site Infections Hospital Name AtlantiCare Regional Medical Center City Procedure Count N/A Knee Arthroplasty Infections (O) Expected # of Knee Arthroplasty Infections (E) a SIR b 95% Confidence Interval AtlantiCare Regional Medical Center Mainland (0.318, 1.886) S Bayonne Medical Center Bayshore Community Hospital Bergen Regional Medical Center Cape Regional Medical Center Capital Health Medical Center Hopewell Capital Health Regional Medical Center CentraState Medical Center Chilton Memorial Hospital Christ Hospital Clara Maass Medical Center (0.562, 7.970) S Community Medical Center (0.011, 2.506) S Cooper Hospital/University Medical Center (,3.051) S Deborah Heart and Lung Center N/A East Orange General Hospital Englewood Hospital and Medical Center (,2.549) S Hackensack University Medical Center (0.425, 1.938) S Hackettstown Regional Medical Center Hoboken University Medical Center Holy Name Medical Center (,3.294) S Hunterdon Medical Center Jersey City Medical Center Jersey Shore University Medical Center (0.111, 3.314) S JFK Medical Center/Anthony M Yelensics (0.713, 5.122) S Kennedy University Hospital Kennedy University Hospital/UMC Cherry Hill Kennedy University Hospital/UMC Stratford Kimball Medical Center

13 Table 3: 2010 Knee Arthroplasty Surgical Site Infections (continued) Hospital Name Procedure Count Knee Arthroplasty Infections (O) Expected # of Knee Arthroplasty Infections (E) a SIR b 95% Confidence Interval Lourdes Medical Center of Burlington Cty Meadowlands Hospital Medical Center Memorial Hospital of Salem County Monmouth Medical Center (0.013, 2.810) S Morristown Memorial Hospital (0.187, 1.755) S Mountainside Hospital Newark Beth Israel Medical Center (0.022, 4.853) S Newton Memorial Hospital Ocean Medical Center (,1.974) S Our Lady of Lourdes Medical Center Overlook Medical Center (0.288, 4.082) S Palisades Medical Center of New York (PHS) Raritan Bay Medical Center Old Bridge Raritan Bay Medical Center Perth Amboy Riverview Medical Center (0.100, 2.990) S Robert Wood Johnson University Hospital (0.470, 6.667) S Robert Wood Johnson University Hospital at Hamilton (,2.633) S Robert Wood Johnson University Hospital at Rahway Saint Barnabas Medical Center (,2.385) S Shore Medical Center Somerset Medical Center (0.019, 4.211) S South Jersey Healthcare Elmer South Jersey Healthcare Regional Medical Center Southern Ocean Medical Center St. Clare's Hospital Denville St. Clare's Hospital Dover St. Clare's Hospital Sussex N/A St. Francis Medical Center St. Joseph's Hospital and Medical Center (0.124, 3.697) S 13

14 Table 3: 2010 Knee Arthroplasty Surgical Site Infections (continued) Hospital Name Procedure Count Knee Arthroplasty Infections (O) Expected # of Knee Arthroplasty Infections (E) a SIR b 95% Confidence Interval St. Joseph's Wayne Hospital St. Luke's Warren Hospital St. Mary's Hospital St. Michael's Medical Center St. Peter's University Hospital (0.010, 2.238) S Trinitas Regional Medical Center UMDNJ University Hospital Underwood Memorial Hospital (0.021, 4.639) S University Medical Center at Princeton (0.666, 4.788) S Valley Hospital (0.360, 3.387) S Virtua Marlton (0.111, 3.323) S Virtua Mem. Hospital of Burlington County (0.065, 1.925) S Virtua West Jersey Health System Berlin Virtua West Jersey Health System Voorhees N/A N/A Statewide (0.746, 1.193) S Source: New Jersey Healthcare Associated Infections for 2010 submitted through the Healthcare Safety Network (NHSN). a Expected (E)= # of infections predicted using the model fitted from the NHSN data from which serves as the baseline for future reports. Important to note that if Expected is <1, the SIR is not calculated as the result is not precise. b Standardized Infection Ratio (SIR)= Observed (O)/ Expected (E) Each hospital is compared to the Ratio=1. The Ratio is derived using the CDC's NHSN data from (AJIC, December 2009). L indicates hospital infections are LOWER than infections seen nationally. H indicates hospital infections are HIGHER than infections seen nationally. S indicates hospital infections are SIMILAR to infections seen nationally. SIR is not calculated because the Expected is < 1. N/A hospital is not licensed to perform procedure(s) or did not perform procedure(s) in

15 Table 4: 2010 Overall Surgical Site Infections Hospital Name Procedure Count Overall Surgical Site Infections (O) Expected # of Overall Surgical 95% Confidence Site Infections (E) a SIR b Interval AtlantiCare Regional Medical Center City AtlantiCare Regional Medical Center Mainland (0.395, 1.639) S Bayonne Medical Center Bayshore Community Hospital Bergen Regional Medical Center Cape Regional Medical Center Capital Health Medical Center Hopewell (1.181, 7.006) S Capital Health Regional Medical Center CentraState Medical Center (,2.160) S Chilton Memorial Hospital Christ Hospital Clara Maass Medical Center (1.157, 6.863) S Community Medical Center (0.220, 3.120) S Cooper Hospital/University Medical Center (0.337, 1.537) S Deborah Heart and Lung Center (1.017, 5.212) H East Orange General Hospital Englewood Hospital and Medical Center (0.068, 2.023) S Hackensack University Medical Center (0.379, 1.216) S Hackettstown Regional Medical Center Hoboken University Medical Center Holy Name Medical Center (,1.572) S Hunterdon Medical Center (0.019, 4.158) S Jersey City Medical Center (,1.566) S Jersey Shore University Medical Center (0.528, 1.785) S JFK Medical Center/Anthony M Yelensics (0.486, 3.496) S Kennedy University Hospital (0.021, 4.545) S Kennedy University Hospital/UMC Cherry Hill Kennedy University Hospital/UMC Stratford Kimball Medical Center Lourdes Medical Center of Burlington Cty

16 Table 4: 2010 Overall Surgical Site Infections (continued) Hospital Name Procedure Count Overall Surgical Site Infections (O) Expected # of Overall Surgical 95% Confidence Site Infections (E) a SIR b Interval Meadowlands Hospital Medical Center Memorial Hospital of Salem County Monmouth Medical Center (0.066, 1.977) S Morristown Memorial Hospital (0.599, 1.598) S Mountainside Hospital (,2.108) S Newark Beth Israel Medical Center (0.098, 1.393) S Newton Memorial Hospital Ocean Medical Center (,1.640) S Our Lady of Lourdes Medical Center (0.304, 2.188) S Overlook Medical Center (0.197, 2.797) S Palisades Medical Center of New York (PHS) Raritan Bay Medical Center Old Bridge Raritan Bay Medical Center Perth Amboy Riverview Medical Center (0.074, 2.220) S Robert Wood Johnson University Hospital (0.907, 2.578) S Robert Wood Johnson University Hospital at Hamilton (,1.958) S Robert Wood Johnson University Hospital at Rahway Saint Barnabas Medical Center (0.947, 3.041) S Shore Medical Center (,2.916) S Somerset Medical Center (0.013, 2.804) S South Jersey Healthcare Elmer South Jersey Healthcare Regional Medical Center (,1.692) S Southern Ocean Medical Center St. Clare's Hospital Denville (, 3.432) S St. Clare's Hospital Dover St. Clare's Hospital Sussex St. Francis Medical Center (,2.403) S St. Joseph's Hospital and Medical Center (0.190, 1.785) S St. Joseph's Wayne Hospital (,3.497) S St. Luke's Warren Hospital

17 Table 4: 2010 Overall Surgical Site Infections (continued) Hospital Name Procedure Count Overall Surgical Site Infections (O) Expected # of Overall Surgical 95% Confidence Site Infections (E) a SIR b Interval St. Mary's Hospital (0.015, 3.301) S St. Michael's Medical Center (0.621, 2.834) S St. Peter's University Hospital (0.005, 1.171) S Trinitas Regional Medical Center (0.264, 3.737) S UMDNJ University Hospital (,1.867) S Underwood Memorial Hospital (0.157, 4.694) S University Medical Center at Princeton (0.524, 3.763) S Valley Hospital (0.360, 1.846) S Virtua Marlton (0.111, 3.311) S Virtua Mem. Hospital of Burlington County (0.049, 1.457) S Virtua West Jersey Health System Berlin Virtua West Jersey Health System Voorhees (1.443, 5.993) H Statewide (0.806, 1.081) S Source: New Jersey Healthcare Associated Infections for 2010 submitted through the Healthcare Safety Network (NHSN). a Expected (E)= # of infections predicted using the model fitted from the NHSN data from which serves as the baseline for future reports. Important to note that if Expected is <1, the SIR is not calculated as the result is not precise. b Standardized Infection Ratio (SIR)= Observed (O)/ Expected (E) Each hospital is compared to the Ratio=1. The Ratio is derived using the CDC's NHSN data from (AJIC, December 2009). L indicates hospital infections are LOWER than infections seen nationally. H indicates hospital infections are HIGHER than infections seen nationally. S indicates hospital infections are SIMILAR to infections seen nationally. SIR is not calculated because the Expected is < 1. N/A hospital is not licensed to perform procedure(s) or did not perform procedure(s) in

18 Table 5: 2011 Central Line Associated Bloodstream Infections HOSPITAL NAME CLABSI (O) Expected # of CLABSI CLABSI SIR b 95 % Confidence (E) a Interval AtlantiCare Regional Medical Center City (0.150, 0.889) L AtlantiCare Regional Medical Center Mainland (0.502, 1.924) S Bayonne Medical Center (0.145, 4.318) S Bayshore Community Hospital (0.538, 3.864) S Bergen Regional Medical Center (0.208, 6.212) S Cape Regional Medical Center (0.251, 3.555) S Capital Health Medical Center Hopewell (0.128, 1.821) S Capital Health Regional Medical Center (0.022, 0.671) L CentraState Medical Center (1.048, 6.216) H Chilton Memorial Hospital (0.008, 1.712) S Christ Hospital (0.235, 3.329) S Clara Maass Medical Center (1.346, 3.019) H Community Medical Center (0.564, 2.343) S Cooper Hospital/University Medical Center (0.577, 1.295) S Deborah Heart and Lung Center (0.312, 2.239) S East Orange General Hospital (0.005, 1.207) S Englewood Hospital and Medical Center (0.005, 1.172) S Hackensack University Medical Center (0.420, 1.120) S Hackettstown Regional Medical Center Hoboken University Medical Center Holy Name Medical Center (0.130, 1.846) S Hunterdon Medical Center (0.007, 1.544) S Jersey City Medical Center (0.086, 0.807) L Jersey Shore University Medical Center (0.160, 0.731) L JFK Medical Center/Anthony M Yelensics (0.270, 1.232) S Kennedy University Hospital (0.223, 1.603) S Kennedy University Hospital/UMC Cherry Hill (0.072, 2.151) S Kennedy University Hospital/UMC Stratford (0.014, 3.186) S Kimball Medical Center (0.825, 4.891) S 18

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