SIR Presentation

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					   Sharing and explaining the
standardized infection ratio (SIR):
   Does your audience prefer
 words, colors, and/or δymβφĨs?

         Dana Burshell, MPH, CPH, CIC
               HAI Epidemiologist
         Virginia Department of Health
 What is a standardized infection ratio?
• The standardized infection ratio (SIR) is a
  summary measure used to track healthcare-
  associated infections (HAIs) at a national, state,
  or local level over time. The SIR adjusts for
  patients of varying risk within each facility.

  - The National Healthcare Safety Network (NHSN)
            The SIR calculation
• In HAI data analysis, the SIR compares the actual
  number of HAIs reported (observed) with the
  baseline U.S. experience (expected/predicted),
  adjusting for several risk factors that have been
  found to be significantly associated with
  differences in infection incidence.
          SIR = number of observed (O) CLABSIs
                number of expected (E) CLABSIs
  – NHSN aggregate data are used as the standard
    population and considered the baseline U.S. experience
  – NHSN baseline data used in an SIR are used to calculate
    the expected or predicted number of HAIs adjusting for
    the identified risk factors.
What does the SIR number mean?
• Accounting for differences in the types of patient
   – An SIR greater than 1.0 indicates that more HAIs were
     observed than predicted.
   – An SIR less than 1.0 indicates that fewer HAIs were
     observed than predicted.
   – An SIR equal to 1.0 indicates the same number of
     HAIs were observed than predicted.

• However, the SIR alone does not imply statistical
     Statistical significance of the SIR:
   P-value and 95% confidence intervals
• The SIR is only a point estimate and needs additional
  information to indicate if it is statistically significantly
  different from 1.
• A 95% confidence interval (CI) and a p-value are calculated
  by NHSN for each SIR and determines statistical
   – A 95% CI assesses the magnitude and stability of an SIR.
     Therefore, a 95% CI is the range of estimated SIR values that
     has a 95% probability of including the true SIR for the
   – If the 95% CI does not contain the value 1, the SIR is
     "statistically significant".
   – If the p-value is less than 0.05, the SIR is “statistically
    Explaining and interpreting the SIR: Virginia data
 Summary      CLABSIs      CLABSIs      Central line
                                                       SIR     p-value     95% CI
Time Period observed (#) expected (#)    days (#)
  2011Q3         58          87.323        46,058      0.664   0.0006    0.504, 0.859

   • During the third quarter of 2011, there were 58 CLABSIs identified and
     46,058 central line days observed in Virginia adult intensive care units.
   • Based on the NHSN 2006-2009 baseline data and the composition of
     locations in Virginia facilities, 87.323 CLABSIs were expected.
   • This result is an SIR of 0.664 (O/E= 58/87.323), signifying that during this
     time period, Virginia facilities identified 34% fewer CLABSIs than expected.
   • The p-value (0.0006) and 95% confidence (0.504, 0.859) interval indicate
     that the number of observed CLABSIs is statistically significantly lower
     than the number of expected CLABSIs. (Reminder: If the p-value is less
     than 0.05 and the 95% CI does not cross 1, the SIR is statistically
What does a significant SIR mean?
• While in many cases, significantly high SIRs may
  reflect a need for stronger prevention efforts for
  the given type of infection and significantly low
  SIRs may support already existing strong
  prevention efforts for that infection type, several
  other factors such as validation of reported data
  may play a role.
• The real measure of success will come when SIRs
  can be followed over time to indicate if positive
  progress occurs and is sustained. The ultimate
  goal is zero HAIs, so efforts are never complete.
                                         Central line-associated bloodstream infection (CLABSI)
                                              standardized infection ratio (SIR) by quarter,
                                             Virginia adult intensive care units, 2009-2011
                                                                                    Trendline added
    Standardized Infection Ratio (SIR)

                                                                                    using Excel to
                                         0.7                                        visually show
                                         0.6                                        overall decrease
                                         0.5                                        over time
                                         0.4                                          SIR
                                         0.3   Line graph of                          Linear (SIR)
                                         0.2   SIR point
                                         0.1   estimates

• Since 2009, Virginia facilities have identified fewer CLABSIs than expected in adult ICUs,
  reflecting already existing strong infection prevention efforts.
• Although there is not a consistent decrease in SIR from quarter to quarter, the overall trend
  since 2009 has been a downward one.
• Because the ultimate goal is sustaining zero CLABSIs, individual hospitals should continue
  effective prevention efforts and identify and address areas for improvement when they occur.
How to generate NHSN SIR outputs
1. Log into NHSN --> enter the Patient Safety Module
2. Starting from the blue navigation menu on the left, click
   “Analysis” --> “Generate Data Set” --> “Generate New”
   (note: this will take some time to load)
3. Click “Analysis” --> “Output Options”
4. On the white screen, click “Device-Associated Module”
   --> “Central Line-Associated BSI” --> “CDC Defined
   Output” --> “SIR – In-Plan CLAB Data”
5. Select “Run” for data aggregated by 6-month intervals
   and CDC location type or select “Modify” to customize
   the output
How can I visually display SIR data?
SIR data presentation: Components to consider
                                            Stratification type
  Presented data            Format                                  Interpretation
                                             and time period
• # infections        • Format              • Aggregate by        • Cues
• # CL days             • Table               • Hospital            • Color
• Rate                  • Bar graph           • Adult/PICU          • Symbols
  • p-value           • Order                   and NICU            • Words
• SIR                   • Alphabetical        • Unit              • SIR Language
  • # expected          • By SIR (if same   • Time period           • Expected
  • p-value               SIR, by number      • Annual              • Predicted
  • 95% CI                of CL days)         • Semi-annual       • SIR language (as
  • Comparison        • Considerations        • Quarterly           significantly
    • National          • No infections                             related to 1)
    • State             • <1 expected                               • Better/lower
    • Hospital                                                      • No different/
  • Historical data
                                                                    • Worse/higher

         Always customize for your audience whenever possible.
The following slides show how some states
have included certain SIR and visual
components for public reporting:

• Which components do you think are

• Which examples would be most useful for you
  and the audiences within your settings?
         Table (color and words)
                     New Hampshire

† = Less than 1 HAI expected
Summary table (words)
        Table (color and symbols)
Maryland: Chosen by and designed for consumers
Horizontal bar graph (color and visual)
Maryland: Chosen by and designed for clinicians
   Horizontal bar graph (color, visual)
Tennessee comparison to national and state rates
Horizontal bar graph (color, visual)
Vertical bar graph (visual)

             ICU type
Vertical bar graph (visual):
Tennessee comparison to state SIR

             ICU type
       Horizontal bar graph (color, visual)
                           Virginia explores the SIR

More infections than expected   Observed number of infections     Fewer infections than expected
  (statistically significant)   similar to expected                   (statistically significant)
                                (not statistically significant)
                                No infections
Building your SIR report: Choosing components

Please share your templates and/or reports with the VDH HAI Team.
       About Data Presentation
• Research shows that when healthcare facilities
  are aware of their infection issues and implement
  concrete strategies to prevent them, rates of
  certain hospital infections can be decreased by
  more than 70 percent.
• Infection data can give healthcare facilities,
  patients, and public health agencies the
  knowledge needed to design and implement
  prevention strategies that protect patients and
  save lives.
   Benefits of Data Presentation
• Increase awareness of HAIs
• Feed back data to those who can make a
• Provide benchmark data to support
  improvement initiatives
• Keep HAIs in the spotlight
• CDC's National Healthcare Safety Network
  (NHSN) Healthcare-associated Infections
  Summary Data Reports Q and A

• NHSN e-News: SIRs Special Edition
          Data quality resources
• Use your Alerts to help ensure your data are accurate
   – Alerts Guide:

• Helpful Tips for CLABSI Reporting for the Centers for
  Medicare and Medicaid Services’ Hospital Inpatient
  Quality Reporting Program (CMS Reporting Program)

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