Download Table of Contents

Table of Contents
State of Michigan 2015 Q3 TAP Report……………………………………………………..………………………………………………2
Region 1 TAP Report…………………………………………………………………………………………………………………..………….24
Region 2N TAP Report……………………………………………………………………………………………………………………….……29
Region 2S TAP Report…………………………………………………………………………………………………………………….………34
Region 3 TAP Report………………………………………………………………………………………………………………………………40
Region 5 TAP Report…………………………………………………………………………………………………………..………………….45
Region 6 TAP Report………………………………………………………………………………………………………………………………50
Region 7 TAP Report………………………………………………………………………………………………………………………………55
Region 8 TAP Report………………………………………………………………………………………………………………..…………….60
State of Michigan
2015 Q3 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 TAP reports are provided quarterly.
This report shows modules and locations where the State of Michigan 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 state
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 state according to the HHS target SIR. Corresponding SIRs for each module
and location type are provided as well.
2015 Q3 Targeted Assessment for Prevention Report
NHSN
Module
CAUTI
CLABSI
CDI
MRSA Bac
SSI COLO
SSI HYST
Number of
Facilities1
96
77
87
94
59
61
15
88
90
81
75
Location
SIR2
Significant (Y/N)3
CAD4
Prevented or Need to Prevent
All
ICU
Ward
All
ICU
Ward
NICU
Facility-wide
Facility-wide
-------
0.7
0.7
0.6
0.6
0.6
0.6
0.5
0.87
0.86
0.94
1.31
Y
------Y
---------Y
N
N
N
-13.9
11.6
-25.5
24.44
15.7
8.9
-0.2
150.46
8.3679
14.974
11.969
Prevented
Need to Prevent
Prevented
Need to Prevent
Need to Prevent
Need to Prevent
Prevented
Need to Prevent
Need to Prevent
Need to Prevent
Need to Prevent
1Note:
facilities in which an SIR could not be calculated with a CAD of 0 were excluded from this table
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.
3Significant (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.
4CAD=Cumulative Attributable Difference. The number of infections that your hospital either needs to prevent to meet the HHS target or has
prevented beyond the HHS target.
2SIR:
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
Bar graphs containing CAD values from all letter-coded SHARP-participating hospitals by module and location are
available below. These graphs allow each facility to view their rank within each module and location compared to all
other SHARP-participating facilities. Note: facilities in which an SIR could not be calculated with a CAD of 0 were
excluded from the bar graphs. Each participating facility will receive an individual, password-protected TAP report
containing their letter. Letters are re-assigned each quarter. Aggregate reports are also available for each emergency
preparedness region below.
Please contact Allie Murad at [email protected] with questions, comments, or suggestions. All aggregate reports
are posted at www.michigan.gov/hai.
Bar Graphs
2015 Q3 CAUTI All Hospitals, Overall
12
8
6
Quartile 4
(prevented the
most infections)
Quartile 3
Quartile 2
4
2
0
-2
-4
-6
Quartile 1 (most
needed to improve)
-8
-10
Hospitals (n=96)
2015 Q3 CAUTI Quartile 1, Overall
Cumulative Attributable Difference (CAD)
Cumulative Attributable Differenc (CAD)
10
10
9
8
7
6
5
4
3
2
1
0
A
B
C
D
E
F
G
H
I
J
K
L
M
N
Hospital Letter
O
P
Q
R
S
T
U
V
W
X
Cumulative Attributable Difference (CAD)
2015 Q3 CAUTI Quartile 2, Overall
0
-0.02
Y
Z
AA
AB
AC
AD
AE
AF
AG
AH
AI
AK
AJ
AL
AN
AM
-0.04
-0.06
-0.08
-0.1
-0.12
-0.14
Hospital Letter
0
-0.1
AO
AP
AR
AQ
AS
AT
AU
AW
AV
AX
AY
BA
AZ
BB
BC
BD
BE
BG
BF
BH
BI
BJ
BK
BL
BM
BN
BO
BP
BQ
Cumulative Attributable Difference (CAD)
2015 Q3 CAUTI Quartile 3, Overall
-0.2
-0.3
-0.4
-0.5
-0.6
-0.7
Hospital Letter
Cumulative Attributable Difference (CAD)
2015 Q3 CAUTI Quartile 4, Overall
0
-1
BR BS BT BU BV BW BX BY BZ CA CB CC CD CE CF CG CH CI CJ CK CL CM CN CO CP CQ CR
-2
-3
-4
-5
-6
-7
-8
-9
Hospital Letter
2015 Q3 CAUTI All Hospitals, ICU
12
8
Quartile 2
Quartile 4
(prevented the
most infections)
Quartile 3
6
4
2
0
-2
-4
Quartile 1 (most
needed to improve)
-6
Hospitals (n=77)
2015 Q3 CAUTI Quartile 1, ICU
Cumulative Attributable Difference (CAD)
Cumulative Attributable Difference (CAD)
10
12
10
8
6
4
2
0
B
C
A
G
I
E
D
N BW M
F
AV AC CD
Hospital Letter
R
V
BH O
Y
CC CF
S
W
Cumulative Attributable Difference (CAD)
2015 Q3 CAUTI Quartile 2, ICU
0
AI AL AQ AR AT AW AX BC BK BM BN BP BS BU H
L
Q AU BA BJ BL BO BQ
-0.05
-0.1
-0.15
-0.2
-0.25
Hospital Letter
Cumulative Attributable Difference (CAD)
2015 Q3 CAUTI Quartile 3, ICU
0
-0.1
K
BR
BZ
BY
P
BT
CE
BI
CH
U
AZ
CA
CI
AJ
BV
CK
-0.2
-0.3
-0.4
-0.5
-0.6
-0.7
-0.8
-0.9
Cumulative Attributable Difference (CAD)
Hospital Letter
2015 Q3 CAUTI Quartile 4, ICU
0
-0.5
T
CB
BX
CJ
BG
CM
CO
CP
BF
CN
-1
-1.5
-2
-2.5
-3
-3.5
-4
-4.5
-5
Hospital Letter
CL
CQ
CG
CR
AH
AB
O
2015 Q3 CAUTI All Hospitals, Ward
4
Quartile 4
(prevented the most
infections)
Quartile 3
Quartile 2
2
0
-2
Quartile 1 (most
needed to improve)
-4
-6
Hospitals (n=87)
Cumulative Attributable Difference (CAD)
Cumulative Attributable Difference (CAD)
6
2015 Q3 CAUTI Quartile 1, Ward
6
5
4
3
2
1
0
D
E
H
BF CG
K
T
AU BG
J
F
P
U
Hospital Letter
L
AJ
Q
AZ
A
BI BX
S
BV
Cumulative Attributable Difference (CAD)
2015 Q3 CAUTI Quartile 2, Ward
0
AD AG AH AK AL AM AN AO AQ AR AS AT AX BA O AP AW AY BC BJ BL BT CL
-0.05
-0.1
-0.15
-0.2
-0.25
Hospital Letter
Cumulative Attributable Difference (CAD)
2015 Q3 CAUTI Quartile 3, Ward
0
-0.1
BB BD BE BK BN BO CA BM BP BQ BR
R
Y
BY
V
BS BU AC BZ
-0.2
-0.3
-0.4
-0.5
-0.6
-0.7
-0.8
Hospital Letter
Cumulative Attributable Difference (CAD)
2015 Q3 CAUTI Quartile 4, Ward
0
-0.5
CE B M BH CJ C CI
I AV CH CN CK N CC G CD CF CM CQ CO BW CP CR
-1
-1.5
-2
-2.5
-3
-3.5
-4
-4.5
Hospital Letter
2015 Q3 CLABSI All Hospitals, Overall
14
10
8
6
Quartile 4
(prevented the
most infections)
Quartile 3
Quartile 2
4
2
0
Quartile 1
(most needed
to improve)
-2
-4
-6
Hospitals (n=94)
2015 Q3 CLABSI Quartile 1, Overall
Cumulative Attributable Difference (CAD)
Cumulative Attributable Difference (CAD)
12
12
10
8
6
4
2
0
A
B
E
BF
CL
BX
CN
CE
N
Hospital Letter
BI
AZ
H
AR
BU
CC
D
CK
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
L
P
CJ
Q
S
C
BY
CH
CA
BL
M
AW
BP
AL
AG
AX
AI
AN
AM
J
BN
AP
AO
AE
AD
AQ
BE
BK
Z
AY
X
BD
BQ
AF
AA
BB
Cumulative Attributable Difference (CAD)
2015 Q3 CLABSI Quartile 2, Overall
Cumulative Attributable Difference (CAD)
Hospital Letter
2015 Q3 CLABSI Quartile 3, Overall
0
K
AK
BS
BA
BM
AS
CM
BZ
BJ
AU
BC
BO
BR
AT
V
CP
-0.05
-0.1
-0.15
-0.2
-0.25
Hospital Letter
Cumulative Attributable Difference (CAD)
2015 Q3 CLABSI Quartile 4, Overall
0
-0.5
AV AC BV
R
U CD
Y
F
CG W
CI
AJ BH BG CO
-1
-1.5
-2
-2.5
-3
-3.5
-4
-4.5
-5
Hospital Letter
I
T
CF
G
O CQ BW BT CR
2015 Q3 CLABSI All Hospitals, ICU
10
Tertile 1
(most needed
to improve)
8
6
Tertile 3
(prevented the
most infections)
Tertile 2
4
2
0
-2
-4
Hospitals (n=59)
2015 Q3 CLABSI Tertile 1, ICU
Cumulative Attributable Difference (CAD)
Cumulative Attributable Difference (CAD)
12
12
10
8
6
4
2
0
A
B
CL CE AZ BF AR BI
Q
L
BY CC BX M
Hospital Letter
E
CK CN BU
C
BL
D
T
Cumulative Attributable Difference (CAD)
2015 Q3 CLABSI Tertile 2, ICU
0
V
K
BZ
BJ
AU
CH
AC
R
BT
Y
P
U
CI
F
BV
CP
AJ
-0.1
-0.2
-0.3
-0.4
-0.5
-0.6
Hospital Letter
Cumulative Attributable Difference (CAD)
2015 Q3 CLABSI Tertile 3, ICU
0
-0.2
N
CM AV CO BH
CJ
BG BW W
G
-0.4
-0.6
-0.8
-1
-1.2
-1.4
-1.6
-1.8
-2
Hospital Letter
I
S
CR
O
CG
CF
CQ CD
CA
2015 Q3 CLABSI All Hospitals, Ward
6
Tertile 1
(most needed
to improve)
4
3
Tertile 2
Tertile 3
(prevented the
most infections)
2
1
0
-1
-2
-3
-4
Hospitals (n=61)
2015 Q3 CLABSI Tertile 1, Ward
Cumulative Attributable Difference (CAD)
Cumulative Attributable Difference (CAD)
5
6
5
4
3
2
1
0
E
B
N CN BU H
S
A
CJ BI CD P
BX CA CH CC CM CK G CP D BF AV CG
Hospital Letter
Cumulative Attributable Difference (CAD)
2015 Q3 CLABSI Tertile 2, Ward
0
-0.05
V
AK
BS BM AS
BV
L
BJ
Q
BO BR
C
AC AR
BL
CE
F
R
BY
BW
CR
BT
-0.1
-0.15
-0.2
-0.25
-0.3
-0.35
Hospital Letter
Cumulative Attributable Difference (CAD)
2015 Q3 CLABSI Tertile 3, Ward
0
-0.5
AJ
Y
U
CI
BH
BG
CF
M
I
CO
-1
-1.5
-2
-2.5
-3
-3.5
Hospital Letter
O
AZ
CQ
T
2015 Q3 CLABSI All Hospitals, NICU
1
0.5
0
BX
D
N
BF
C
CG
B
CL
A
CO
T
BW
CR
-0.5
-1
-1.5
Hospitals (n=15)
2015 Q3 C.diff LabID All Hospitals, Facility-Wide Inpatient
45
40
Cumulative Attributable Difference (CAD)
Cumulative Attributable Difference (CAD)
1.5
35
30
Quartile 1
(most needed
to improve)
Quartile 2
25
20
15
10
5
0
-5
-10
Hospitals (n=88)
Quartile 3
Quartile 4
(prevented the
most infections)
BU
Cumulative Attributable Difference (CAD)
2015 Q3 C.diff LabID Quartile 1, Facility-Wide Inpatient
45
40
35
30
25
20
15
10
5
0
T
A
S
I
BT BH
CI
CG CR
V
BF CP
N
M
AI
CJ
D
CL
E
BW BL
Cumulative Attributable Difference (CAD)
Hospital Letter
2015 Q3 C.diff LabID Quartile 2, Facility-Wide Inpatient
3
2.5
2
1.5
1
0.5
0
AZ G R BQ CF BZ BE J
H CB AX BN BX CE AP BR CH Y BO CK BY BC BI BM CN CA BJ
Hospital Letter
Cumulative Attributable Difference (CAD)
2015 Q3 C.diff LabID Quartile 3, Facility-Wide Inpatient
0
BK
BB
BV
BU
AT
Q
P
X
AF
AN AO BD AM CO AW AC
-0.1
-0.2
-0.3
-0.4
-0.5
-0.6
Hospital Letter
F
AL
AQ
Cumulative Attributable Difference (CAD)
2015 Q3 C.diff LabID Quartile 4, Facility-Wide Inpatient
0
CC AS AK
B
W AY AU BP AR
U
BS
K
BA AD
L
C
BG CQ CM AV CD
-1
-2
-3
-4
-5
-6
Hospital Letter
2015 Q3 MRSA bacteremia LabID All Hospitals, Facility-Wide Inpatient
3
Cumulative Attributable Difference (CAD)
2.5
2
Quartile 2
1.5
1
0.5
0
-0.5
-1
Quartile 1 (most
needed to improve)
-1.5
-2
Hospitals (n=90)
Quartile 3
Quartile 4
(prevented the
most infections)
Cumulative Attributable Difference (CAD)
2015 Q3 MRSA bacteremia LabID Quartile 1, Facility-Wide
Inpatient
3
CK
2.5
CL B
2
CG
E
1.5
BI
1
AU
0.5
Y M BY
D CI CC
BX H CQ BW CB CA CP
CJ
CD N
0
AV CE S
CF
Cumulative Attributable Difference (CAD)
Cumulative Attributable Difference (CAD)
Hospital Letter
2015 Q3 MRSA bacteremia LabID Quartile 2, Facility-Wide
Inpatient
0
-0.01
BB
-0.02
AT AO
Z AN
X AF
BD AM
-0.03
AW
-0.04
AL AK
AS
-0.05
AY
AP
BM
AQ
-0.06
AI
-0.07
-0.08
BN BS
BC BQ
Hospital Letter
AR
2015 Q3 MRSA bacteremia LabID Quartile 3, Facility-Wide
Inpatient
0
-0.05
-0.1
-0.15
AC
J
AD BA AX
K
BZ BP BR
L
BO BJ
BH
Q
-0.2
O
R
-0.25
BE
-0.3
-0.35
Hospital Letter
CM BT
BV
U
Cumulative Attributable Difference (CAD)
2015 Q3 MRSA bacteremia LabID Quartile 4, Facility-Wide
Inpatient
0
-0.2
-0.4
-0.6
V
AZ
BL
CH
C
BF
W
BG
CN
F
P
-0.8
-1
A
CO
-1.2
I
T
-1.4
-1.6
AJ
G
CR
-1.8
Hospital Letter
2015 Q3 SSI COLO All Hospitals
Cumulative Attributable Difference (CAD)
5
4
3
Quartile 2
Quartile 3
2
1
0
-1
-2
-3
Quartile 1 (most
needed to
improve)
Hospitals (n=80)
Quartile 4
(prevented the
most infections)
Cumulative Attributable Difference (CAD)
2015 Q3 SSI COLO Quartile 1
F
4.5
4
T
G
3.5
CL
3
CG
C
2.5
P
CD
2
AV
1.5
M
1
AW BD
X
H
O
BN
BC
BG
0.5
0
Hospital Letter
Cumulative Attributable Difference (CAD)
2015 Q3 SSI COLO Quartile 2
CC
0.7
BI
E
0.6
CJ
CK
BY
0.5
AC
0.4
BW
0.3
S
CE
0.2
CA
N
0.1
0
AU
Hospital Letter
Cumulative Attributable Difference (CAD)
2015 Q3 SSI COLO Quartile 3
0
-0.05
-0.1
-0.15
BE AQ
AB
R
AP
Q
AG
AY
I
AM AL BP
BA
-0.2
BZ BJ BO
-0.25
L
K BS
AJ BK
BR AI
Y
-0.3
Hospital Letter
2015 Q3 SSI COLO Quartile 4
Cumulative Attributable Difference (CAD)
0
-0.5
AX A AR
W BL BX
U AZ
BF CH BU
-1
CP BM CM
V BV
CI D CR
CQ
-1.5
CN
BH
CO
CF
-2
B
-2.5
Hospital Letter
2015 Q3 SSI HYST All Hospitals
5.5
Cumulative Attributable Difference (CAD)
5
4.5
4
3.5
Quartile 1
(most needed
to improve)
3
2.5
Quartile 2
Quartile 3
2
1.5
1
0.5
0
-0.5
-1
Hospitals (n=75)
Quartile 4
(prevented
the most
infections)
Cumulative Attributable Difference (CAD)
2015 Q3 SSI HYST Quartile 1
6
CL
5
4
3
CO
BY
2
P
AZ
T
F
1
S
N
M
AV
BI
C
BU
BH
G
CD
0
Hospital Letter
Cumulative Attributable Difference (CAD)
2015 Q3 SSI HYST Quartile 2
0
-0.005
-0.01
BO BJ
AR
K
AD
-0.015
AG AK
-0.02
AL
J
-0.025
AI AU
AM CQ BL
BA CM
-0.03
L
-0.035
-0.04
H
BP
AW
Hospital Letter
Cumulative Attributable Difference (CAD)
2015 Q3 SSI HYST Quartile 3
0
-0.02
-0.04
BC
-0.06
-0.08
-0.1
BS
AX
BE AC
CI
BK
Q
BV
D
CA AS
-0.12
-0.14
AQ AY
CE
CJ BG
CH
Hospital Letter
Y
U
Cumulative Attributable Difference (CAD)
2015 Q3 SSI HYST Quartile 4
0
-0.1
-0.2
-0.3
-0.4
BN
BX
E
BM
CN
CK
V
I
O
CP
BW
BF
-0.5
-0.6
-0.7
W
CF
A
CR
-0.8
Hospital Letter
B
CG
Michigan Region 1
2015 Q3 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.
2015 Q3 Targeted Assessment for Prevention Report
NHSN Module
CAUTI
CLABSI
CDI
MRSA Bac
SSI COLO
SSI HYST
Number of
Facilities
11
9
10
10
6
8
<5
10
10
10
9
Location
SIR1
Significant (Y/N)2
CAD3
Prevented or Need to Prevent
All
ICU
Ward
All
ICU
Ward
NICU
Facility-wide
Facility-wide
-------
0.6
1
0.2
0.6
0.7
0.8
----0.644
0.356
1.152
0.969
N
-------N
------------Y
N
N
N
-3.2
2.4
-5.7
2.4
1.7
1.9
-----4.05
-2.22
2.79
0.45
Prevented
Need to Prevent
Prevented
Need to Prevent
Need to Prevent
Need to Prevent
----Prevented
Prevented
Need to Prevent
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
Region 1 CAUTI (Overall)
Cumulative Attributable Difference
(CAD)
3
2
1
0
G
-1
-2
-3
-4
Q
AB
AC
AN
AR
AV
BA
BM
BO
CN
Region 1 CAUTI (ICUs)
Cumulative Attributable Difference
(CAD)
4
3
2
1
0
G
AV
AC
BM
AR
BA
Q
BO
CN
-1
-2
-3
Region 1 CAUTI (Wards)
Cumulative Attributable Difference
(CAD)
1
0.5
0
Q
BA
AN
AR
BO
BM
AC
AV
CN
G
AV
AC
G
-0.5
-1
-1.5
-2
Region 1 CLABSI (Overall)
Cumulative Attributable Difference
(CAD)
3
2
1
0
CN
-1
-2
-3
AR
Q
AN
BA
BM
BO
Region 1 CLABSI (ICUs)
Cumulative Attributable Difference
(CAD)
2.5
2
1.5
1
0.5
0
AR
-0.5
Q
CN
AC
AV
G
-1
-1.5
Region 1 CLABSI (Wards)
Cumulative Attributable Difference
(CAD)
2.5
2
1.5
1
0.5
0
CN
G
AV
BM
Q
BO
AC
AR
-0.5
Region 1 C.diff LabID (Facility-wide Inpatient)
Cumulative Attributable Difference
(CAD)
3
2
1
0
-1
-2
-3
-4
-5
G
BO
BM
CN
Q
AN
AC
AR
BA
AV
Cumulative Attributable Difference
(CAD)
Region 1 MRSA bacteremia LabID (Facility-wide
Inpatient)
0.4
0.2
0
-0.2
AV
AN
BM
AR
AC
BA
BO
Q
CN
G
AR
BM
CN
-0.4
-0.6
-0.8
-1
-1.2
-1.4
Region 1 SSI Colon Surgeries
Cumulative Attributable Difference
(CAD)
4
3
2
1
0
G
AV
AC
AB
Q
BA
BO
-1
-2
Region 1 SSI Abdominal Hysterectomies
Cumulative Attributable Difference
(CAD)
0.8
0.6
0.4
0.2
0
AV
-0.2
-0.4
G
BO
AR
BA
AC
Q
BM
CN
Michigan Region 2N
2015 Q3 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.
2015 Q3 Targeted Assessment for Prevention Report
NHSN Module
CAUTI
CLABSI
CDI
MRSA Bac
SSI COLO
SSI HYST
Number of
Facilities
14
13
13
14
12
11
<5
14
14
14
12
Location
SIR1
Significant (Y/N)2
CAD3
Prevented or Need to Prevent
All
ICU
Ward
All
ICU
Ward
NICU
Facility-wide
Facility-wide
-------
0.7
0.8
0.5
0.7
0.9
0.5
---0.93
0.73
0.71
1.95
N
-------
-5.8
3.7
-9.4
11
10.5
0.8
---55.37
-0.36
-0.70
6.15
Prevented
Need to Prevent
Prevented
Need to Prevent
Need to Prevent
Need to Prevent
---Need to Prevent
Prevented
Prevented
Need to Prevent
---------N
N
N
N
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
Region 2N CAUTI (Overall)
Cumulative Attributable Difference
(CAD)
12
10
8
6
4
2
0
-2
-4
-6
A
I
S
W
BE
BG
BR
BV
CC
CE
CF
CL
CO
CP
Region 2N CAUTI (ICUs)
Cumulative Attributable Difference
(CAD)
10
8
6
4
2
0
A
I
CC
CF
S
W
BR
CE
BV
BG
CO
CP
CL
CC
CF
CO
CP
I
CF
-2
-4
Region 2N CAUTI (Wards)
Cumulative Attributable Difference
(CAD)
1.5
1
0.5
0
-0.5
BG
A
S
BV
CL
BE
BR
CE
I
-1
-1.5
-2
-2.5
-3
Region 2N CLABSI (Overall)
Cumulative Attributable Difference
(CAD)
12
10
8
6
4
2
0
-2
-4
A
CL
CE
CC
S
BE
BR
CP
BV
W
BG
CO
Region 2N CLABSI (ICUs)
Cumulative Attributable Difference
(CAD)
12
10
8
6
4
2
0
A
CL
CE
CC
BV
CP
CO
BG
W
I
S
CF
I
CO
-2
Region 2N CLABSI (Wards)
Cumulative Attributable Difference
(CAD)
2
1.5
1
0.5
0
S
A
CC
CP
BV
BR
CE
BG
CF
-0.5
-1
Region 2N C.diff LabID (Facility-wide Inpatient)
Cumulative Attributable Difference
(CAD)
30
25
20
15
10
5
0
A
-5
S
I
CP
CL
CF
BE
CE
BR
BV
CO
CC
W
BG
Cumulative Attributable Difference
(CAD)
Region 2N MRSA bacteremia LabID (Facility-wide
Inpatient)
2.5
2
1.5
1
0.5
0
-0.5
CL
CC
CP
CE
S
CF
BR
BE
BV
W
BG
A
CO
I
CP
BV
CO
CF
-1
-1.5
Region 2N SSI Colon Surgeries
Cumulative Attributable Difference
(CAD)
4
3
2
1
0
CL
BG
CC
S
CE
BE
I
BR
A
W
-1
-2
Region 2N SSI Abdominal Hysterectomies
Cumulative Attributable Difference
(CAD)
6
5
4
3
2
1
0
CL
-1
CO
S
BE
BV
CE
BG
I
CP
W
CF
A
Michigan Region 2S
2015 Q3 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.
2015 Q3 Targeted Assessment for Prevention Report
NHSN Module
CAUTI
CLABSI
CDI
MRSA Bac
SSI COLO
SSI HYST
Number of
Facilities
16
16
15
15
14
15
5
16
16
14
13
Location
SIR1
Significant (Y/N)2
CAD3
Prevented or Need to Prevent
All
ICU
Ward
All
ICU
Ward
NICU
Facility-wide
Facility-wide
-------
0.8
0.9
0.8
0.6
0.7
0.6
0.4
0.93
1.04
0.92
1.55
N
------N
---------N
N
N
N
7.1
6.5
0.6
14.3
12.2
3.3
-1.2
65.82
6.93
3.13
4.64
Need to Prevent
Need to Prevent
Need to Prevent
Need to Prevent
Need to Prevent
Need to Prevent
Prevented
Need to Prevent
Need to Prevent
Need to Prevent
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
Region 2S CAUTI (Overall)
Cumulative Attributable Difference
(CAD)
10
8
6
4
2
0
B
-2
-4
E
P
R
T
U
AZ
BF
BL
BS
BT BU BW BY CB CK
Region 2S CAUTI (ICUs)
Cumulative Attributable Difference
(CAD)
12
10
8
6
4
2
0
-2
B
E
BW
R
BU BS
BL
BY BT
P
U
AZ CK
T
CB BF
-4
Region 2S CAUTI (Wards)
Cumulative Attributable Difference
(CAD)
4
3
2
1
0
E
BF
T
P
U
AZ
BT
BL
R
BY
BU
BS
B
CK BW
R
U
T
BW BT
-1
-2
-3
Region 2S CLABSI (Overall)
Cumulative Attributable Difference
(CAD)
10
8
6
4
2
0
-2
-4
-6
B
E
BF
AZ
BU
CK
P
BY
BL
BS
Region 2S CLABSI (ICUs)
Cumulative Attributable Difference
(CAD)
6
5
4
3
2
1
0
B
-1
AZ
BF
BY
E
CK
BU
BL
T
R
BT
P
U
BW
-2
Region 2S CLABSI (Wards)
Cumulative Attributable Difference
(CAD)
6
5
4
3
2
1
0
E
-1
B
BU
P
CK
BF
BS
BL
R
BY
U
AZ
T
BW BT
-2
-3
-4
Region 2S CLABSI (NICU)
Cumulative Attributable Difference
(CAD)
0.8
0.6
0.4
0.2
0
-0.2
-0.4
-0.6
-0.8
-1
-1.2
BF
B
T
BW
BU
Region 2S C.diff LabID (Facility-wide Inpatient)
Cumulative Attributable Difference
(CAD)
45
40
35
30
25
20
15
10
5
0
T
-5
BT
BF
E
BW BL
AZ
R
CB CK BY BU
P
B
U
BS
P
T
BU
B
Cumulative Attributable Difference
(CAD)
Region 2S MRSA bacteremia LabID (Facility-wide
Inpatient)
3
2.5
2
1.5
1
0.5
0
-0.5
BU CK
B
E
BY BW CB BS
R
BT
U
AZ BL
BF
-1
-1.5
Region 2S SSI Colon Surgeries
Cumulative Attributable Difference
(CAD)
4
3
2
1
0
T
-1
-2
-3
P
E
CK
BY
BW
R
BS
BL
U
AZ
BF
Region 2S SSI Abdominal Hysterectomies
Cumulative Attributable Difference
(CAD)
2
1.5
1
0.5
0
BY
-0.5
-1
P
AZ
T
BU
BL
BS
U
E
CK
BW
BF
B
Michigan Region 3
2015 Q3 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.
2015 Q3 Targeted Assessment for Prevention Report
NHSN Module
CAUTI
CLABSI
CDI
MRSA Bac
SSI COLO
SSI HYST
Number of
Facilities
14
10
12
14
9
10
<5
13
14
10
11
Location
SIR1
Significant (Y/N)2
CAD3
Prevented or Need to Prevent
All
ICU
Ward
All
ICU
Ward
NICU
Facility-wide
Facility-wide
-------
0.5
0.7
0.2
0.4
0.3
0.5
---0.64
0.74
0.97
0.83
N
--------N
---------Y
N
N
N
-14.6
-0.7
-13.9
-4.6
-4.7
0.6
----6.98
-0.09
2.28
0.27
Prevented
Prevented
Prevented
Prevented
Prevented
Need to Prevent
---Prevented
Prevented
Need to Prevent
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
Region 3 CAUTI (Overall)
Cumulative Attributable Difference
(CAD)
10
8
6
4
2
0
-2
-4
-6
-8
-10
C
Y
Z
AF
AM
AS
BI
BQ
CD
CH
CJ
CM CQ
CR
Region 3 CAUTI (ICUs)
Cumulative Attributable Difference
(CAD)
12
10
8
6
4
2
0
C
-2
CD
Y
BQ
CH
BI
CJ
CM
CQ
CR
-4
-6
Region 3 CAUTI (Wards)
Cumulative Attributable Difference
(CAD)
1
0.5
0
BI
-0.5
AS
AM
BQ
Y
CJ
C
CH
CD
CM
CQ
CR
-1
-1.5
-2
-2.5
-3
-3.5
-4
-4.5
Region 3 CLABSI (Overall)
Cumulative Attributable Difference
(CAD)
3
2
1
0
-1
-2
-3
-4
-5
BI
CJ
C
CH
AM
Z
BQ
AF
AS
CM
CD
Y
CQ
CR
Region 3 CLABSI (ICUs)
Cumulative Attributable Difference
(CAD)
1.5
1
0.5
0
BI
C
CH
Y
CM
CJ
CR
CQ
CD
-0.5
-1
-1.5
-2
Region 3 CLABSI (Wards)
Cumulative Attributable Difference
(CAD)
2
1.5
1
0.5
0
CJ
-0.5
BI
CD
CH
CM
AS
C
Y
CQ
CR
-1
-1.5
-2
-2.5
-3
Region 3 C.diff LabID (Facility-wide Inpatient)
Cumulative Attributable Difference
(CAD)
6
4
2
0
CR
-2
-4
-6
CJ
BQ
CH
Y
BI
AF
AM
AS
C
CQ
CM
CD
Cumulative Attributable Difference
(CAD)
Region 3 MRSA bacteremia LabID (Facility-wide
Inpatient)
1.5
1
0.5
0
-0.5
BI
Y
CQ
CJ
CD
Z
AF
AM
AS
BQ CM
CH
C
CR
-1
-1.5
-2
Region 3 SSI Colon Surgeries
Cumulative Attributable Difference
(CAD)
3
2.5
2
1.5
1
0.5
0
-0.5
C
CD
BI
CJ
AM
Y
CH
CM
CR
CQ
Y
CR
-1
-1.5
Region 3 SSI Abdominal Hysterectomies
Cumulative Attributable Difference
(CAD)
0.8
0.6
0.4
0.2
0
-0.2
-0.4
-0.6
-0.8
BI
C
CD
AM
CQ
CM
AS
CJ
CH
Michigan Region 5
2015 Q3 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.
2015 Q3 Targeted Assessment for Prevention Report
NHSN Module
CAUTI
CLABSI
CDI
MRSA Bac
SSI COLO
SSI HYST
Number of
Facilities
11
7
9
11
5
5
<5
9
10
9
7
Location
SIR1
Significant (Y/N)2
CAD3
Prevented or Need to Prevent
All
ICU
Ward
All
ICU
Ward
NICU
Facility-wide
Facility-wide
-------
0.7
0.7
0.6
0.6
0.6
0.5
---0.78
1.06
1.46
0.73
N
------N
---------N
N
N
N
-1.8
-0.3
-1.6
1.7
0.5
0.1
---3.12
1.46
4.87
-0.03
Prevented
Prevented
Prevented
Need to Prevent
Need to Prevent
Need to Prevent
---Need to Prevent
Need to Prevent
Need to Prevent
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
Region 5 CAUTI (Overall)
Cumulative Attributable Difference
(CAD)
0.8
0.6
0.4
0.2
0
-0.2
-0.4
-0.6
-0.8
-1
-1.2
L
M
O
X
AA
AW
BB
BD
BN
BX
CA
Region 5 CAUTI (ICUs)
Cumulative Attributable Difference
(CAD)
2
1.5
1
0.5
0
M
O
AW
BN
L
CA
BX
L
CA
BX
-0.5
-1
-1.5
Region 5 CAUTI (ICUs)
Cumulative Attributable Difference
(CAD)
2
1.5
1
0.5
0
M
O
AW
BN
-0.5
-1
-1.5
Region 5 CLABSI (Overall)
Cumulative Attributable Difference
(CAD)
3
2
1
0
BX
-1
-2
-3
L
CA
M
AW
BN
X
BD
AA
BB
O
Region 5 CLABSI (ICUs)
Cumulative Attributable Difference
(CAD)
1.5
1
0.5
0
L
BX
M
CA
O
M
O
-0.5
-1
-1.5
Region 5 CLABSI (Wards)
Cumulative Attributable Difference
(CAD)
1.5
1
0.5
0
BX
CA
L
-0.5
-1
-1.5
Region 5 C.diff LabID (Facility-wide Inpatient)
Cumulative Attributable Difference
(CAD)
4
3
2
1
0
M
-1
-2
BN
BX
CA
BB
X
BD
AW
L
Cumulative Attributable Difference
(CAD)
Region 5 MRSA bacteremia LabID (Facility-wide
Inpatient)
0.8
0.6
0.4
0.2
0
M
BX
CA
BB
X
BD
AW
BN
L
O
-0.2
-0.4
Region 5 SSI Colon Surgeries
Cumulative Attributable Difference
(CAD)
1.2
1
0.8
0.6
0.4
0.2
0
-0.2
M
AW
BD
X
O
BN
CA
L
BX
-0.4
-0.6
Region 5 SSI Abdominal Hysterectomies
Cumulative Attributable Difference
(CAD)
0.8
0.6
0.4
0.2
0
M
-0.2
-0.4
L
AW
CA
BN
BX
O
Michigan Region 6
2015 Q3 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.
2015 Q3 Targeted Assessment for Prevention Report
NHSN Module
CAUTI
CLABSI
CDI
MRSA Bac
SSI COLO
SSI HYST
Number of
Facilities
16
11
14
16
7
7
<5
14
15
12
12
Location
SIR1
Significant (Y/N)2
CAD3
Prevented or Need to Prevent
All
ICU
Ward
All
ICU
Ward
NICU
Facility-wide
Facility-wide
-------
0.8
0.7
1
0.6
0.3
1
---0.89
0.90
1.40
0.97
N
------N
---------N
N
N
N
1.9
-0.6
2.5
1.5
-2.9
3.3
---17.79
1.51
6.04
0.45
Need to Prevent
Prevented
Need to Prevent
Need to Prevent
Prevented
Need to Prevent
---Need to Prevent
Need to Prevent
Need to Prevent
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
Region 6 CAUTI (Overall)
Cumulative Attributable Difference
(CAD)
2.5
2
1.5
1
0.5
0
-0.5
-1
-1.5
-2
F
H
J
N
V
AD AE
AI
AJ
AL AO AP AQ AU BJ CG
Region 6 CAUTI (ICUs)
Cumulative Attributable Difference
(CAD)
3
2
1
0
N
F
V
AL
AI
AQ
H
BJ
AU
AJ
CG
-1
-2
-3
-4
Region 6 CAUTI (Wards)
Cumulative Attributable Difference
(CAD)
2
1.5
1
0.5
0
-0.5
H
CG
AU
J
F
AJ
AL
AO
AD
AQ
AP
BJ
V
N
-1
-1.5
-2
Region 6 CLABSI (Overall)
Cumulative Attributable Difference
(CAD)
3
2.5
2
1.5
1
0.5
0
-0.5
-1
-1.5
N
H
AL
AI
J
AP AO AE AD AQ BJ AU
V
F
CG AJ
Region 6 CLABSI (ICUs)
Cumulative Attributable Difference
(CAD)
0
V
BJ
AU
F
AJ
N
CG
F
AJ
-0.2
-0.4
-0.6
-0.8
-1
-1.2
-1.4
Region 6 CLABSI (Wards)
Cumulative Attributable Difference
(CAD)
2.5
2
1.5
1
0.5
0
N
H
CG
V
BJ
-0.5
-1
Region 6 C.diff LabID (Facility-wide Inpatient)
Cumulative Attributable Difference
(CAD)
6
5
4
3
2
1
0
-1
-2
CG
V
N
AI
J
H
AP
BJ
AO
F
AL
AQ
AU
AD
Cumulative Attributable Difference
(CAD)
Region 6 MRSA bacteremia LabID (Facility-wide
Inpatient)
2.5
2
1.5
1
0.5
0
-0.5
CG AU
H
N
AO
AL
AP AQ
AI
J
AD
BJ
V
F
AJ
-1
-1.5
Region 6 SSI Colon Surgeries
Cumulative Attributable Difference
(CAD)
5
4
3
2
1
0
F
CG
H
N
AU
AQ
AP
AL
BJ
AJ
AI
V
V
CG
-1
-2
Region 6 SSI Abdominal Hysterectomies
Cumulative Attributable Difference
(CAD)
1
0.8
0.6
0.4
0.2
0
-0.2
-0.4
-0.6
-0.8
-1
F
N
BJ
AD
AL
J
AI
AU
H
AQ
Michigan Region 7
2015 Q3 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.
2015 Q3 Targeted Assessment for Prevention Report
NHSN Module
CAUTI
CLABSI
CDI
MRSA Bac
SSI COLO
SSI HYST
Number of
Facilities
7
6
7
7
<5
<5
<5
7
7
7
7
Location
SIR1
Significant (Y/N)2
CAD3
Prevented or Need to Prevent
All
ICU
Ward
All
ICU
Ward
NICU
Facility-wide
Facility-wide
-------
0.6
0.5
0.6
0.1
---------1.01
0.8
0.24
0.93
N
------N
---------N
N
N
N
-2.7
-0.7
-1.9
-2.5
---------11.29
0.12
-2.07
0.19
Prevented
Prevented
Prevented
Prevented
---------Need to Prevent
Need to Prevent
Prevented
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
Region 7 CAUTI (Overall)
Cumulative Attributable Difference
(CAD)
1
0.5
0
K
-0.5
-1
-1.5
-2
-2.5
AX
AY
BC
BH
BP
CI
Region 7 CAUTI (ICUs)
Cumulative Attributable Difference
(CAD)
0.8
0.6
0.4
0.2
0
-0.2
BH
BP
AX
BC
K
CI
-0.4
-0.6
-0.8
Region 7 CAUTI (Wards)
Cumulative Attributable Difference
(CAD)
1.5
1
0.5
0
K
AX
BC
AY
BP
BH
CI
CI
BH
-0.5
-1
-1.5
Region 7 CLABSI (Overall)
Cumulative Attributable Difference
(CAD)
0
BP
-0.2
-0.4
-0.6
-0.8
-1
-1.2
-1.4
AX
AY
K
BC
Region 7 C.diff LabID (Facility-wide Inpatient)
Cumulative Attributable Difference
(CAD)
8
7
6
5
4
3
2
1
0
BH
-1
CI
AX
BC
AY
BP
K
-2
Cumulative Attributable Difference
(CAD)
Region 7 MRSA bacteremia LabID (Facility-wide
Inpatient)
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
-0.1
CI
AY
BC
AX
K
BP
BH
CI
BH
-0.2
Region 7 SSI Colon Surgeries
Cumulative Attributable Difference
(CAD)
1
0.5
0
BC
-0.5
-1
-1.5
AY
BP
K
AX
Region 7 SSI Abdominal Hysterectomies
Cumulative Attributable Difference
(CAD)
0.6
0.5
0.4
0.3
0.2
0.1
0
-0.1
-0.2
BH
K
BP
BC
AX
CI
AY
Michigan Region 8
2015 Q3 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.
2015 Q3 Targeted Assessment for Prevention Report
NHSN Module
CAUTI
CLABSI
CDI
MRSA Bac
SSI COLO
SSI HYST
Number of
Facilities
7
<5
7
6
<5
<5
<5
6
<5
<5
<5
Location
SIR1
Significant (Y/N)2
CAD3
Prevented or Need to Prevent
All
ICU
Ward
All
ICU
Ward
NICU
Facility-wide
Facility-wide
-------
1.5
---1.7
0.7
N
------N
---------N
----------
5.5
---3.9
0.8
Need to Prevent
---Need to Prevent
Need to Prevent
---------Need to Prevent
----------
------1.11
----------
------4.04
----------
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
Region 8 CAUTI (Overall)
Cumulative Attributable Difference
(CAD)
8
7
6
5
4
3
2
1
0
-1
-2
D
AG
AH
AK
AT
BK
BZ
Region 8 CAUTI (Wards)
Cumulative Attributable Difference
(CAD)
6
5
4
3
2
1
0
D
AK
AG
AH
AT
BK
BZ
-1
Region 8 CLABSI (Overall)
Cumulative Attributable Difference
(CAD)
1.2
1
0.8
0.6
0.4
0.2
0
D
AG
BK
AK
BZ
AT
-0.2
Region 8 C.diff LabID (Facility-wide Inpatient)
Cumulative Attributable Difference
(CAD)
3.5
3
2.5
2
1.5
1
0.5
0
-0.5
-1
D
BZ
BK
AT
AK