This story has been updated.

Delaware once again is one of the worst states in hospital safety, according to a recent national report.

Like last year, the First State tied for last, or 49th place, with the District of Columbia and North Dakota in Leapfrog's "Hospital Safety Grade." The watchdog organization, which seeks public information about patient safety and quality, assigns letter grades to 2,600 U.S. hospitals every six months.

Delaware earned last place because none of its hospitals earned an A grade. The state has seen a drastic decline since Leapfrog began releasing grades in 2012. In the organization's first year, Delaware was ranked No. 8 in the country.

Delaware's six hospitals received the following grades for fall 2018:

Bayhealth Kent General — C

Beebe Healthcare — C

Christiana Care Health System, Christiana Hospital — C

Christiana Care Health System, Wilmington Hospital — C

Nanticoke Memorial Hospital — B

Saint Francis Hospital — C

Nemours/A.I. duPont Hospital for Children was not included in the rankings because Leapfrog only analyzes general acute-care hospitals.

Leapfrog tends to give tougher grades than the Centers for Medicare and Medicaid Services, which rates about 90 percent of U.S. hospitals as "average." The organization's grades take into account medical errors, injuries and infections, responses from patient surveys and data from the CMS, the American Hospital Association.

Leapfrog officials say about 440,000 people die every year from preventable errors made in hospitals.

Several of the Delaware health systems declined to fill out Leapfrog's survey this year because it was too time intensive.

Christiana Care Health System's two hospitals — Wilmington and Christiana hospitals — received its lowest grade since 2015. Last year, the health system received Bs in the fall and the spring of 2017.

The health system was one of several that declined to provide the watchdog group information in several categories, including data about handwashing and if the hospital has enough qualified nurses.

Sharon Anderson, Christiana Care's senior vice president of quality and patient safety, said in a statement that the hospital system "opted not to participate in the written survey, which is why some of our data is identified as 'not reported' in the Leapfrog report."

The survey can be "resource-intensive to complete," she said.

Anderson noted that Christiana Care was one of the few U.S. hospitals to recently receive a five-star rating from the Centers for Medicare & Medicaid Services' Hospital Compare website.

Bayhealth also declined to fill out the survey this year and is more "focused on improving those measures," said hospital chief medical officer Dr. Gary Siegelman. He attributes some of the low marks to Leapfrog not having all of the hospital's up-to-date data.

Leapfrog, which looked at 2016 and 2017 data, said Bayhealth was "below average" for doctors trained in critical care medicine. Yet Kent General's ICU rates measuring mortality and a patient's length of stay have improved in the past year, Siegelman said.

He credits this to the 24-7 availability of the hospital ICU team, which is comprised of seven people. Bayhealth is "well below" Medicare's benchmark for hospital acquired infection rates for five of the six measured infections, he said.

Beebe Healthcare also received a lower grade from Leapfrog this year. Specifically, it received low marks in infections that patients acquire in the hospital.

Rick Schaffner, executive vice-president of Beebe, said in a statement that rates for central line associated blood stream infections and clostridium difficile (C-Diff) infections are currently "well below" the benchmarks reported through Leapfrog.

Like the other hospital executives, Schaffner said the hospital infection data "is older data, and reflects our performance for 2017."

Saint Francis received poor scores in the "practices to prevent errors" and declined to report information on handwashing, safe medication administration and the number of qualified nurses.

The hospital declined to fill out the survey as well, said spokeswoman Samantha Raftovich.

Raftovich said the hospital is the only one in Delaware to "receive recognition at the highest level for achieving key performance targets in hospital readmissions, perinatal care, surgical safety and hospital infection prevention."

Nanticoke Memorial Hospital, in Seaford, received the highest grade among Delaware hospitals. It was deemed "below average" for not having enough qualified nurses and doctors trained in critical care medicine.

Spokeswoman Sharon Harrington said in an email that "comparing very large health systems with small community hospitals can become quite complicated." The operational and staff models can vary depending on the hospital system, she said.

Harrington gave an example of how the hospital staffs its intensive care unit. Nanticoke ICU physicians are at the hospital seven days a week, but not exclusive to the ICU as they see patients on other inpatient floors.

The ICU also provides bed for cardiac care patients. This means the cardiologists, who only see these patients in the ICU, are not certified in critical care medicine.

"The Leapfrog scoring system does not recognize the alternate ways that small hospitals have to work in order to meet the ultimate goal of safety and quality," she said.

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Contact Meredith Newman at (302) 324-2386 or at mnewman@delawareonline.com. Follow her on Twitter at @merenewman.