Methicillin-Resistant Staphylococcus Aureus (MRSA) Bacteraemia

Identifying Attributes

Care Settings
Hospital Care
Country
United States of America
Publishing Organisation
Centers for Medicare & Medicaid Services (CMS): Hospital-Acquired Condition (HAC) Reduction Program, Centers for Medicare & Medicaid Services (CMS): Hospital Value-Based Purchasing (VBP) Program, The Leapfrog Group
Type of Quality Indicator
Outcome
IOM Quality Dimension
Safety
Setting-Specific Domain
Infection and Sepsis

Defining Attributes

Definition

Standardised infection ratio (SIR) and Adjusted Ranking Metric (ARM) of hospital-onset unique blood source MRSA Laboratory-identified events (LabID events) among all inpatients in the facility.

Numerator

Total number of observed hospital-onset unique blood source MRSA LabID events among all inpatients in the facility per National Healthcare Safety Network (NHSN) protocols.

Denominator

Total number of predicted hospital-onset unique blood source MRSA LabID events, calculated from a negative binomial regression model and risk adjusted for facility's number of inpatient days, inpatient community-onset MRSA prevalence rate, average length of patient stay in the hospital, medical school affiliation, facility type, number of critical care beds in the hospital, and outpatient community-onset MRSA prevalence rate from emergency departments and observation units.

Exclusions

Data from patients who are not assigned to an inpatient bed in an applicable location are excluded from the denominator counts. Denominator counts exclude data from inpatient rehabilitation units and inpatient psychiatric units with different CMS Certification Numbers (CCN) from the acute care facility.

Use of Risk Adjustment
Yes
Risk Adjustments

See denominator for risk adjustment details.

Stratifications

By hospital and state.

Collection and Reporting Attributes

Type of Data Collection
Electronic/paper chart records
Data Collection Methods

Hospital information submitted to the National Healthcare Safety Network (NHSN)

Frequency of Data Collection
Quarterly
Frequency of Data Collection in Days
91
Reporting Methods

HAC Reduction Program data is displayed at data.cms.gov

Reporting Frequency
Annually
Reporting Frequency in Days
365
Indicator Has Recommended Targets
No

Source and Reference Attributes

Technical Specifications
Link to Measurement Tools
Domain
Infection and Sepsis
Quality Indicator Confirmed to be Part of a Program Used to Monitor Quality and Safety of Care Among Older People at a Population-Level between 2012-2022
Yes
Assessed by the Australian Consortium for Aged Care Collaborators as Generally Containing Good Properties (Importance and Scientific Acceptability)
Yes
Australian Consortium for Aged Care Endorsed
Yes
Can the Quality Indicator be Readily Implemented at a Population Level in Australia Given its Current Data Landscape?
No. Some data exists in a program or registry, but there is insufficient coverage.
Identified by PHARMA-Care Project
No
Upload Date
23 July 2025