Practical risk-adjusted quality control charts for infection control.
BACKGROUND
Control chart methodology has been widely touted for monitoring and improving quality in the health care setting. P charts and U charts are frequently recommended for rate and ratio statistics, but their practical value in infection control may be limited because they (1) are not risk-adjusted, and (2) perform poorly with small denominators. The Standardized Infection Ratio is a statistic that overcomes both these obstacles. It is risk-adjusted, and it effectively increases denominators by combining data from multiple risk strata into a single value.


METHODS
The AICE National Database Initiative is a voluntary consortium of US hospitals ranging in size from 50 to 900 beds. The infection control professional submits monthly risk-stratified data for surgical site infections, ventilator-associated pneumonia, and central line-associated bacteremia.


METHODS
Run charts were constructed for 51 hospitals submitting data between 1996 and 1998. Traditional hypothesis tests (P values <.05) flagged 128 suspicious points, and participating infection control professionals investigated and categorized each flag as a "real problem" or "background variation." This gold standard was used to compare the performance of 5 unadjusted and 11 risk-adjusted control charts.


RESULTS
Unadjusted control charts (C, P, and U charts) performed poorly. Flags based on traditional 3-sigma limits suffered from sensitivity <50%, whereas 2-sigma limits suffered from specificity <50%. Risk-adjusted charts based on the Standardized Infection Ratio performed much better. The most consistent and useful control chart was the mXmR chart. Under optimal conditions, this chart achieved a sensitivity and specificity >80%, and a receiver operating characteristic area of 0. 84 (P <.00001).


CONCLUSIONS
These findings suggest a specific statistic (the Standardized Infection Ratio) and specific techniques that could make control charts valuable and practical tools for infection control.
Gustafson
T L
TL
Infection Control and Prevention Analysts, Inc, Austin, TX 78735, USA.
D016470:Bacteremia / Q000453:epidemiology / Q000209:etiology; D015982:Bias; D002405:Catheterization, Central Venous / Q000009:adverse effects; D003428:Cross Infection / Q000453:epidemiology / Q000209:etiology; D003627:Data Interpretation, Statistical; D016208:Databases, Factual; D005568:Forms and Records Control / Q000592:standards*; D017408:Guidelines as Topic; D006742:Hospital Bed Capacity; D006801:Humans; D017053:Infection Control / Q000458:organization & administration*; D019451:Information Management / Q000592:standards*; D008499:Medical Records / Q000592:standards*; D011014:Pneumonia / Q000453:epidemiology / Q000209:etiology; D011786:Quality Control; D012121:Respiration, Artificial / Q000009:adverse effects; D020379:Risk Adjustment / Q000458:organization & administration*; D012680:Sensitivity and Specificity; D013530:Surgical Wound Infection / Q000453:epidemiology / Q000209:etiology; D011795:Surveys and Questionnaires; D014481:United States / Q000453:epidemiology