Practical risk-adjusted quality control charts for infection control

Am J Infect Control. 2000 Dec;28(6):406-14. doi: 10.1067/mic.2000.109883.


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.

Setting: 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.

MeSH terms

  • Bacteremia / epidemiology
  • Bacteremia / etiology
  • Bias
  • Catheterization, Central Venous / adverse effects
  • Cross Infection / epidemiology
  • Cross Infection / etiology
  • Data Interpretation, Statistical*
  • Databases, Factual
  • Forms and Records Control / standards*
  • Guidelines as Topic
  • Hospital Bed Capacity
  • Humans
  • Infection Control / organization & administration*
  • Information Management / standards*
  • Medical Records / standards*
  • Pneumonia / epidemiology
  • Pneumonia / etiology
  • Quality Control*
  • Respiration, Artificial / adverse effects
  • Risk Adjustment / organization & administration*
  • Sensitivity and Specificity
  • Surgical Wound Infection / epidemiology
  • Surgical Wound Infection / etiology
  • Surveys and Questionnaires
  • United States / epidemiology