Healthcare-Acquired Condition HAC



  • A healthcare-acquired condition (HAC) is an undesirable outcome or illness that occurs as a result of being in a hospital. Often, these conditions can be prevented when healthcare workers follow proper evidence-based safety guidelines. Examples of preventable HACs include surgical equipment being left in the patient, a fall at the hospital, or an infection related to improper hand hygiene

    The HAC scores are tracked and reported as a standardized infection ratio or SIR. The SIR compares the actual number of HACs to the predicted number of HACs. The predicted number is an estimate that is based on national data and it takes into account the fact that some hospitals (such as teaching hospitals) treat patients that are sicker and more prone to infection or injury. To determine the SIR, we divide the actual number of events by the predicted number of events. 

    • If the SIR is less than 1, it means there were fewer HACs than expected. 
    • If the SIR is greater than 1, it means the hospital had more HACs than expected.  

    Below are the most common HACs nationwide and Memorial's SIR.

    CAUTI – catheter-associated urinary tract infection caused by prolonged use of a urinary catheter. Catheters should be removed as soon as they are no longer needed. A lower score is better.

      Goal  Memorial SIR, January-December 2015
    Quality Measure
    CAUTI  Housewide Score 1.282 0.977 

    CLABSI – central line-associated blood stream infection occurs when germs enter a central line and spread through the body. A central line is a thin plastic tube used to give medicine, nutrients, or blood products over a long period of time. A lower score is better.

      Goal  Memorial SIR, January-December 2015
    Quality Measure
    CLABSI Housewide Score 0.392 0.532 

    SSI – surgical site infection, as the name implies, is an infection that occurs at the surgical location. It can be a skin infection around the wound, or an infection related to something within the body, such as medical implants. A lower score is better.

      Goal  Memorial SIR, January-November 2015
    Quality Measure
    SSI Colon Infection Housewide Score 0.636 1.063  
      Goal  Memorial SIR, January-November 2015
    Quality Measure
    SSI Hysterectomy Infection Housewide 0.759 1.018 

    C. Diff – clostridium difficile, also known as C. diff, is a major source of infection in the United States. C. diff is a pathogen that typically occurs in people taking antibiotics, and it is spread through the hands of healthcare workers. A lower score is better.

      Goal  Memorial SIR, January-June 2015
    Quality Measure
    C. Diff Housewide 0.9 1.038  

    MRSA – Methicillin-resistant Staphylococcus aureus is a type of bacteria that has become resistant to most antibiotics. It can cause bloodstream infections, pneumonia, and surgical site infections. Within a healthcare setting, MRSA is usually spread through the hands of healthcare workers. A lower score is better.

      Goal  Memorial SIR, January-June 2015
    Quality Measure
    MRSA Scores 1.0 1.084