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Infection Control Quality Data

Infection Control Quality Data

Infection Control Quality Data

At PinnacleHealth, we are committed to patient safety and infection prevention. We have implemented rigorous policies and process improvements aimed at reducing infections, including extensive and clearly defined policies on patient preparation, operating room inspections and hand-washing.

Hospital Inquired Infections Graph

Key Achievements:

  • The 2014 Pennsylvania Department of Health report reaffirmed PinnacleHealth’s leadership among state hospitals in low infection rates. In multiple categories, our infection rates were lower than the Department of Health predicted for a hospital of PinnacleHealth’s size and scope, and significantly lower than expected in some areas.
  • PinnacleHealth won the 2012 VHA APEX award for low incidence of central line–associated bloodstream infections.
  • We are recognized by the Centers for Medicare & Medicaid Services (CMS) for having a statistically lower rate of central line–associated bloodstream infections compared to the national rate.
  • We have had a significant impact on sepsis patient outcomes as published in the May 2012 edition of the American Journal of Respiratory and Critical Care Medicine.
  • PinnacleHealth was recognized in 2014 for having a significantly lower number of central line-associated bloodstream infections than predicted.

A Summary of PinnacleHealth’s Results

Catheter-Associated Urinary Tract Infections (CAUTI)*
  • The 2014 statewide rate of CAUTI was 1.82 per 1,000 catheter days
  • The PinnacleHealth 2015 rate of CAUTI was 0.77 per 1,000 catheter days
  • The predicted number of CAUTI was 63.33
  • The actual number of CAUTI was 48
Central Line–Associated Bloodstream Infections (CLABSI)-Adult*
  • The 2014 statewide rate of CLABSI was 0.73 per 1,000 line days
  • The PinnacleHealth 2015 rate of CLABSI was 0.38 per 1,000 line days
  • The predicted number of CLABSI was 20.18
  • The actual number of CLABSI was 4
Central Line–Associated Bloodstream Infections (CLABSI)-Neonatal Intensive Care Unit
  • Predicted number was 2.14
  • Actual number was 1
Number of Surgical Site Infections (SSI)-2015
  • Cardiac: Predicted number was 3.5; actual number was 0
  • Coronary artery bypass graft (CABG), single incision: Predicted number was 0.8; actual number was 1
  • CABG, dual incision: Predicted number was 4.9; actual number was 5
  • Knee replacement: Predicted number was 14.1; actual number was 12
  • Hip replacement: Predicted number was 12.0; actual number was 10
  • Spinal fusion: Predicted number was 10.5; actual number was 5
  • Laminectomy: Predicted number was 6.2; actual number was 0
  • Abdominal hysterectomy: Predicted number was 15.4; actual number was 5
Click here to download the full Pennsylvania Department of Health Report.

Key Initiatives for Infection Prevention


At PinnacleHealth, hand-washing is a priority. We educate our staff about when and how to wash their hands. Staff members and physicians are secretly observed to see if they are washing their hands when providing patient care. In 2015, there were over 4,000 hand-washing observations performed with a result of 92 percent compliance with hospital hand-washing requirements.

Staff Education
Our interventions have focused on educational programs for physicians, nurses and other clinical staff, utilizing guidelines by the Centers for Disease Control and Prevention (CDC) and best-practice recommendations by the Institute for Healthcare Improvement (IHI).
Management of Multidrug-Resistant Organisms (MDROs) 
PinnacleHealth has a consistently low rate of hospital-associated MDROs. Examples of MDROs are methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), Klebsiella pneumoniae carbapenemase or KPC-producing organisms, extended-spectrum beta-lactamase or ESBL-producing organisms, and Clostridium difficile.
We follow the guidelines in the CDC publication “Management of Multidrug-Resistant Organisms in Healthcare Settings.” Patients who have an MDRO are placed in contact precautions. This means that staff and visitors will wear gowns and gloves when going into the patient’s room, and in most cases the patient will have a private room.
Surgical Site Infection Reduction 
In order to prevent surgical site infections, PinnacleHealth follows the CDC “Guideline for Prevention of Surgical Site Infection” publication and the Surgical Care Improvement Project (SCIP) guidelines.
Recommendations include:
  • Giving preoperative antibiotics within the designated timeframe before surgery begins. Preoperative antibiotics are selected based on the current recommended guidelines. PinnacleHealth patients received the recommended preoperative antibiotic 98 percent of the time.
  • Discontinuing prophylactic antibiotics at the right time.
You can refer to the following Patient Education sheets for more information:

Contact Us

If you have questions about PinnacleHealth's quality information and data, please contact our Performance Improvement Department at (717) 231-8469.

Looking for an infectious disease specialist?  Click here. 



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