Current HAI Progress Report

Executive summary

The Centers for Disease Control and Prevention (CDC) is committed to protecting patients and healthcare personnel from adverse healthcare events and promoting safety, quality, and value in healthcare delivery. Preventing healthcare-associated infections (HAIs) is a top priority for CDC and its partners in public health and healthcare.

Facilities

The 2023 annual National and State Healthcare-Associated Infections (HAI) Progress Report provides a summary of select HAIs across four healthcare settings: acute care hospitals (ACHs), critical access hospitals (CAHs), inpatient rehabilitation facilities (IRFs) and long-term acute care hospitals (LTACHs). Data from CAHs are provided in the detailed technical tables but not in the report itself. The designation of CAH is assigned by the Centers for Medicare and Medicaid Services (CMS) to hospitals with 25 or fewer acute care inpatient beds and that maintain an annual average length of stay of 96 hours or less for acute care patients. IRFs include hospitals, or part of a hospital, that provide intensive rehabilitation services using an interdisciplinary team approach. LTACHs provide treatment for patients who are generally very sick and stay, on average, more than 25 days. To view HAI data from individual hospitals, LTACHs and IRFs, please see CMS Care Compare.

Content and details

This report, along with the detailed technical tables, provides national- and state-level data about HAI incidence during 2023. The report is designed to be accessible to many audiences. National and state HAI reports will be available for viewing, downloading, and printing from the Antimicrobial Resistance and Patient Safety Portal. For detailed methods, references, and definitions, please refer to the Technical Appendix and Glossary within this report. For more information, please visit CDC's Healthcare-Associated Infection Data Reports website.

Scope

CDC’s mission in healthcare safety includes tracking infections, responding to outbreaks, providing infection prevention expertise and guidance, implementing prevention interventions in collaboration with partners, spearheading prevention research, and serving as the nation’s gold standard microbiology laboratory for the pathogens most often implicated in HAIs. CDC’s National Healthcare Safety Network (NHSN), the nation’s most widely used HAI surveillance system, is a shared resource for HAI prevention. More than 38,000 active hospitals, long-term care facilities, and other healthcare facilities provide data to NHSN, which in turn is used for national- and state-level analyses, including for this HAI Report, and for targeted prevention initiatives by healthcare facilities, states, regions, quality groups, and national public health agencies, including CDC.

Pathogens and measures

The 2023 National and State HAI Progress Report provides data on central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated events (VAEs), surgical site infections (SSIs), methicillin-resistant Staphylococcus aureus (MRSA) bloodstream events, and Clostridioides difficile (C. difficile) events. For each of the four healthcare settings, the report consists of detailed technical tables, which include additional statistics about HAIs, reporting mandates, and data validation efforts in each state and select US territories. The report includes infection-specific standardized infection ratios (SIRs), which measure progress in reducing HAIs compared to the 2015 baseline time period. The SIR is the ratio of the observed number of infections (events) to the number of predicted infections (events) for a summarized time period. In addition to the SIRs, the report includes the standardized utilization ratios (SURs), which measure device use by comparing the number of observed device days to the number of predicted device days. The SIR and SUR metrics are calculated using the 2015 national baseline and risk adjustment methodology. More information about these metrics can be found at:

• NHSN's Guide to the SIR
• NHSN's Guide to the SUR

This 2023 annual report includes national and state data for the following HAIs and facility types

Acute Care Hospitals (ACHs)

• CLABSI
• CAUTI
• VAE
• SSI*
• C. difficile
• MRSA bacteremia

Inpatient Rehabilitation Facilities (IRFs)

• CLABSI
• CAUTI
• C. difficile
• MRSA bacteremia

Long-Term Acute Care Hospitals (LTACHs)

• CLABSI
• CAUTI
• VAE
• C. difficile
• MRSA bacteremia

* National SSI data includes 39 inpatient surgical procedure categories reported to NHSN. For event and infection definition, see the HAI module specific NHSN protocols.

NHSN recognizes that changes to the CMS payment policies and changes in state and local reporting mandates may impact the number and characteristics of healthcare facilities participating in NHSN.

Data highlights

Nationally, among acute care hospitals, the 2023 highlights in this report include

• Overall, CLABSI, CAUTI, VAE, MRSA, and CDI continue to decline in 2023 compared to 2022
  • CAUTI, MRSA, and CDI 2023 SIRs are below pre-pandemic (2019) SIRs
    
• Overall, about 15% decrease in CLABSI between 2022 and 2023
  • Decreases observed in all location settings – ICU (20%), NICU (13%), and Wards (8%)
• Overall, 11% decrease in CAUTI between 2022 and 2023
  • Decreases observed across ICU locations (16%) and Ward locations (8%)
• Overall, there was a 5% decrease in VAE between 2022 and 2023
  
  • A 5% decrease observed in ICU locations
  • However, a 9% increase observed in Ward locations
    
• Overall, there was a 3% increase in SSI combined SCIP procedures between 2022 and 2023
  • The 10 select procedures are Surgical Care Improvement Project (SCIP) procedures. Note: The initial set of acute care hospital targets and metrics included a measure on SCIP processes. That measure is no longer part of the HAI Action Plan because these processes are now widely accepted as standards of practice.
  • 8% increase in abdominal hysterectomy SSIs
  • No significant changes in colon surgery SSIs
• Observed a 16% decrease in hospital onset MRSA bacteremia between 2022 and 2023
• Observed a 13% decrease in hospital onset C. difficile infections between 2022 and 2023

On the state level compared to itself from 2022 to 2023

• 30 states performed better on at least two infection types
  • 21 states performed better on at least three infection types
  • 9 states performed better on at least four infection types
• 2 states performed worse on two or more infection types
  

Highlights of state performance compared to the 2015 baseline SIR of 1

• 49 states performed better on at least three infection types
  • 36 states performed better on at least four infection types
  • 20 states performed better on at least five infection types
• 4 states performed worse on at least two or more infection types
  

Highlights of state performance compared to 2023 national SIR

• 21 states performed better on at least two infection types
  • Of these, 10 states performed better on at least three infection types
  • Of these, 3 states performed better on at least four infection types
• 24 states performed worse on two or more infection types
  • Of these, 15 states performed worse on at least three infection types
  • Of these, 3 states performed worse on at least four infection types

The number of states and territories performing better than the 2015 national baseline, by infection and facility type

The number of states and territories that performed worse than the 2015 national baseline, by infection and facility type

Public health importance and next steps

Prevalence

Each day, approximately one in 31 U.S. patients and 1 in 43 nursing home residents contracts at least one infection in association with their healthcare, underscoring the need for improvements in patient care practices in U.S. healthcare facilities. While much progress has been made, more needs to be done to prevent healthcare-associated infections in a variety of settings.

Sustaining progress

Full engagement between local, state and federal public health agencies and their partners in the healthcare sector through initiatives such as prevention collaboratives is vital to sustaining and extending HAI surveillance and prevention progress. CDC will continue its prevention, tracking, lab, and applied research activities to push the country further toward the goal of eliminating HAIs.

Feedback

Any comments and suggestions that would improve the usefulness of future publications are appreciated and should be sent to the Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop H16-3; Atlanta, Georgia, 30333. E-mail can also be used: patientsafety@cdc.gov.

Data tables

2023 SIR data

2023 SUR data

Technical appendix

Data and data quality

The 2023 National and State Healthcare-Associated Infections Data Report presents data reported to the National Healthcare Safety Network (NHSN) for the calendar year 2023. The healthcare-associated infection (HAI) data were reported in response to state or federal reporting requirements (via the Centers for Medicare and Medicaid Services, CMS123) or were reported voluntarily from healthcare facilities in all 50 states, Washington, D.C., Virgin Islands, Guam, and Puerto Rico. Data included in the annual report use standard NHSN definitions for central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated events (VAEs), surgical site infections (SSIs), laboratory-identified (LabID) methicillin-resistant Staphylococcus aureus (MRSA) bloodstream events, and LabID Clostridioides difficile (C. difficile) events.45678 To account for delays in reporting, 2023 data reported to NHSN through June 1, 2024, were included. The data used in preparing the report undergoes routine and rigorous data quality checks, which are part of NHSN's processes. Addressing data quality issues is integral to NHSN's ability to help facilities across the nation collect the data needed to identify areas needing prevention efforts, measure the progress of prevention efforts, monitor antibiotic use and resistance, and push toward HAI elimination. The NHSN Team routinely reviews the data reported to NHSN and will contact facilities to resolve confirmed and suspected data quality concerns. These data quality activities, which include data analyses and facility outreach, enhance the quality of the HAI data used in preparing this report.

National and state data included in this report are shown separately for acute care hospitals (ACHs), critical access hospitals (CAHs), long-term acute care hospitals (LTACHs), and inpatient rehabilitation facilities (IRFs, including CMS-certified IRF units within a hospital).

SIRs

The national and state standardized infection ratios (SIRs) published in this report compare the observed number of infections occurring in 2023 and reported to NHSN with the predicted number of infections based on the 2015 national baseline and risk adjustment calculations. The risk adjustment methodology used to produce the CLABSI, CAUTI, VAE, SSI, MRSA bacteremia, and C. difficile SIRs for all facility types are summarized in NHSN's SIR Guide.9 SSI data were risk adjusted using a logistic regression model (CDC's Complex Admission/Readmission model), and the device-associated (DA) and LabID event SIRs were risk adjusted using a negative binomial regression model.

SURs

This report also includes national and state standardized utilization ratios (SURs) to measure device utilization for central lines, urinary catheters, and ventilators among the four main facility types. The SUR provides a summarized risk adjusted metric which allows organizations to compare device use to a national 2015 baseline. SURs are calculated by dividing the number of observed device days by the number of predicted device days; the number of predicted device days is calculated using a logistic regression model. General information about SUR calculation can be found in NHSN's Guide to the SUR.10

Calculations

SIRs and SURs are produced when at least five healthcare facilities reported 2023 data for the specific stratum, and at least one infection or device day is predicted to occur. The state-specific SIRs and SURs were calculated for each HAI and device type, location category or surgical procedure by pooling 2023 data from all reporting facilities in the state. A complete list of risk factors used in the calculation of all SIRs and SURs can be found in the technical Data Tables associated with this report. SIRs and SURs were assessed for statistical significance using a mid-p exact test for the 95% confidence interval (CI). The 95% CI is used to determine statistical significance when the SIR or SUR is compared to the value of 1. The 95% CI is a statistical range of values for which we have a high degree of confidence that the true SIR or SUR lies within that range. If the CI does not include 1, then the SIR or SUR is significantly different than 1.0 (i.e., the number of observed infections is significantly different than the number predicted). In the instances where the current year's SIR or SUR is compared to the previous year's SIR or SUR, a two-tailed p-value is used to determine statistical significance of the percent differences. A P-value of less than 0.05 was considered a statistically significant result. A P-value was considered inestimable for the following scenarios:

• If the previous year's SIR or SUR is 0.000 and the current year's SIR or SUR does not equal 0.000. The percent change is listed as >>100.0%
• If both the previous year's SIR or SUR and the current year's SIR or SUR are 0.000. The percent change is listed as 0%
• Comparison to the previous year is not performed if SIR or SUR data is missing.

The CLABSI, CAUTI, and VAE data are inclusive of data reported from all eligible locations within healthcare facilities, however, the SIRs and SURs are also stratified by location type for critical care units (referred to as "ICUs"), neonatal critical care units (NICUs) (CLABSI only), and inpatient wards. For this report, "wards" included step-down units, mixed acuity units, and specialty care areas including hematology/oncology and bone marrow transplant units. The acute care hospital DA data are further stratified by specific CDC locations at the national level.

When sufficient data were available, national SSI SIRs were calculated for ACHs and CAHs for each of the 39 specific procedure categories defined by NHSN; the 10 select procedures that approximate the procedures included in the Centers for Medicare & Medicaid Services (CMS) Surgical Care Improvement Project (SCIP) are shown separately. National SIRs were stratified by adult and pediatric patients. State-level SSI SIRs were calculated for 15 select procedure types, including those within the SCIP and additional procedure categories with the highest volume of reported procedures. Due to insufficient pediatric SSI data at the state level, only adult SSI SIRs were calculated at the state level. Only deep incisional and organ/space SSIs, regardless of closure technique, detected during the same admission as the inpatient procedure or upon readmission to the same hospital that performed the inpatient procedure were included in the SSI SIRs; superficial incisional SSIs and those identified on post-discharge surveillance or upon readmission to another facility were excluded.

MRSA bacteremia and C. difficile LabID event SIRs included applicable specimens classified as hospital-onset (i.e., were collected on or after day 4 of admission) in which the specimen was collected from any inpatient location in the facility excluding CMS-certified inpatient psychiatric (IPF) units. C. difficile LabID event surveillance also excludes events from neonatal critical care units and well-baby units. Community-onset cases are reported to NHSN and are included in the risk adjustment of the LabID event SIRs.

National SIRs and SURs were calculated for all strata that met the inclusion criteria above. Each national metric was compared to the 2015 national baseline of 1 and was compared to the national metric from the prior year. Both comparisons provide information on a national level about the amount of device use and healthcare-associated infections in US hospitals.

Facility-specific SIRs and SURs were calculated if the facility had at least one predicted HAI (SIR) or device day (SUR). These facility-specific SIRs and SURs were used to create percentile distributions for each infection and device type if at least 20 facilities had sufficient data to calculate an SIR or SUR. Percentile distributions among the national data are shown in increments of 5, from 5-95%; key percentiles were calculated for state-level data (10%, 25%, 50%, 75%, 90%). Additionally, the facility-specific SIRs or SURs were compared to the nominal value equal to that of the same year's National SIR, for each infection and device type, if at least 10 facilities in each category had sufficient data to calculate the metric, the percent of facilities with an SIR or SUR significantly higher or lower than the national value was calculated both nationally and by state.

Each state's 2023 SIR was compared against three benchmarks to assess progress in HAI prevention: the current 2023 national SIR, the state's SIR from 2022, and the 2015 national baseline (i.e., compared to a value of 1). The 2023 national SIR was re-calculated for each state-to-national comparison with that state's data removed from the 2023 national SIR to ensure independence. This comparison was used to determine how the state's SIR compared to that from the rest of the nation. A comparison between the state's 2023 and 2022 SIRs provided information about HAIs in the state during 2023 and how this compared to the same state's SIR from the prior year. The final comparison assesses the state's 2023 SIR against the national 2015 baseline of 1. Together, the three benchmarks provide a complete assessment of each state's progress in HAI prevention.

For all comparisons, a P-value less than 0.05 was considered statistically significantly different than the hypothesized value (e.g., 1 for comparison to the 2015 baseline); while two-tailed P-values were used for these comparisons and are more conservative than one-tailed P-values, significant results were interpreted as a directional change of "increase" or "decrease" based on the actual SIR values in the comparison. The three comparisons listed above were also performed and interpreted in the same manner for state-specific SURs.

Most healthcare facilities in the US were required to report select HAI data to NHSN in 2023 for participation in various CMS Quality Reporting Programs (QRPs) and Pay for Performance Programs.11 The table below provides additional details on these requirements:

2023 required data elements for participation in CMS programs, by facility type

In addition to the NHSN data used to produce the SIRs in this report, the factsheets and the detailed technical tables, several external data sources were used to provide additional metrics. Several state health department HAI programs voluntarily provided CDC with the status and specific requirements of state HAI reporting mandates to NHSN and efforts to validate 2023 HAI data. An indicator for a state mandate was provided for mandates enacted by either the state health department or the state's hospital association. Validation efforts were classified into two categories for each HAI type – data checked for quality and additional in-depth data review. The following criteria were used to assign credit to states that performed data quality checks: state health department had access to 2023 NHSN data, performed regular data cleaning/quality checks on at least 6 months of 2023 data prior to June 1, 2024, and contacted hospitals if data errors, outliers, or missing information were found. A state received credit for additional in-depth data review if the state performed an audit of their hospitals' medical or laboratory records prior to June 1, 2024, meaning the state health department reviewed hospital records to confirm proper case ascertainment and data entry into NHSN. Validation efforts should be considered when evaluating an individual state's performance. States that perform more vigorous data validation activities are more likely to find hospital records of infections, and therefore these states may have higher SIRs compared to states that do not perform validation. Data validation efforts were self-reported by state health departments to CDC and may vary between states.

Glossary