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Surveillance Methodology and Economic Burden of SSIs Maureen Spencer, RN, M.Ed, CIC Infection Preventionist Consultant Boston, MA - USA.

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Presentation on theme: "Surveillance Methodology and Economic Burden of SSIs Maureen Spencer, RN, M.Ed, CIC Infection Preventionist Consultant Boston, MA - USA."— Presentation transcript:

1 Surveillance Methodology and Economic Burden of SSIs Maureen Spencer, RN, M.Ed, CIC Infection Preventionist Consultant Boston, MA - USA

2 Purpose of the Infection Control and Prevention Program Surveillance – detect cases Control - outbreaks, clusters or increasing trends in data Implement prevention measures

3 Surveillance System and CDC Definitions

4 Developed Algorithms For Surveillance (Each Category)

5 Case definition Case definitions are designed to capture all potential cases of a disease/condition without contaminating the dataset with extraneous materials NHSN is, by definition, our basic service Special case definitions may be required for specific issues or for outbreaks

6 Case definitions Outbreak ▫May want to date or unit define ▫May want to include symptoms or manifestations Case control studies ▫Permit selection of control group (those without the condition under study) ▫Associated with the event or process

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13 Data analysis Data are systematically compiled and interpreted ▫Data are analyzed using statistical methods ▫Date are compared over time to internal and external databases ▫Comparative databases are used when undesirable variation is identified

14 Numbers Numerator – the “top” number which is also the number of cases identified Denominator – the “bottom number” –(down below) is the total number of individuals studied Rate – the result of dividing the numerator by the denominator and multiplying by a factor

15 The “Factor” There is no established “factor” for most statistical math in epidemiology Generally report surgical and other similar infection as x/100 events Generally report device related infections by device day x/1000 device days

16 Measures of occurrence Incidence ▫Measure of frequency with which an event occurs in a population over a specified period of time  New cases Prevalence ▫Proportion of persons in a population with a particular disease at a specific point in time (point prevalence) or over a specified time period (period prevalence)  Existing cases

17 Studies Case Control – two groups, identical, but one with the characteristic under study, and other without. General 1:3 (power) Cohort – all people in a group (enter together, and then observe for occurrence of disease/condition) Prospective – looking forward Retrospective – looking backward

18 Bias Bias can be defined as “any systematic error in the design, conduct or analysis of a study that results in a mistaken estimate of an exposure’s effect on the risk of disease” Selection Bias Information Bias

19 The monthly record of cases Record demographic data for each case ▫Use consistent methods  Column A: Last Name  Column B: First Name Column C: Medical Record #Physician ▫Physician name ▫Physician identification # (check, as often there are two different numbers in the hospital) Age – useful in stratification Gender – equivocal data set Admission date (critical!) Onset date (used to calculate # hospital days admission to onset)

20 Line Listing  Line List: A line list is an organized, detailed list of each record of a surgical site infection Example  Suppose you are interested in looking at all CLABSIs in 2010 that occurred in the ICU and the Orthopedic Unit  You would like to produce a line list that includes basic patient demographics (patient ID, DOB, gender, and age at event), information on the event (date admitted, date of surgey, date of onset, location of patient when SSI developed

21 Line list heading – Depends on the HAI Infection site ▫Use standard nomenclature - NHSN  SSI  SST  CAUTI Procedure codes Procedure date Surgeon code Surgeon assistant and others in the room Date of Admission Date of Onset of Infection Antibiotics ASA score Incision time Closure time Patient room number

22 Next columns Organism ▫Use standard nomenclature!  CNS vs. Coag neg staph vs. S. epidermidis  Spell the words correctly Culture site Final attribution – Hosp Onset, Comm Onset, Comm Acquired Comment field– generally cannot sort by anything except the first word but useful for keeping notes

23 Frequency Table  Frequency Table: A frequency table is an organized display of counts and percentages  The data are organized by a row variable and a column variable, and the frequency table provides a count of the number of observations in the data set that meet the specifications of both the row and column variables Example  Suppose you are interested in looking at the distribution of each SSI across the different services in your facility, for all events that were identified in 2012

24 UHS HAI Dashboard EXAMPLE OF HAI FREQUENCY TABLE IN EXCEL FILE

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26 Descriptive Epidemiology ▫Cross tabulations:  infections/organisms  infections/nursing units  infections/services  infections/risk factors ▫Evaluate trends and clusters ▫Conduct studies and investigations  Retrospective case reviews, Case-Control Studies

27 Examples of Cross Tabulations CLABSI by ICUs CLABSI by device type CLABSI by organisms SSIs by services SSIs by surgeons SSIs by nursing unit Risk factors by SSIs SSI rates over a time period

28 SSI by Service SERVICECABGTOTAL HIP TOTAL KNEE ABD HYSTEC COLON Gen Surgery Cardiac Surgery Orthopedic Surgery Gynecology Surgery 00030

29 Example CLABSI Analysis Nursing Unit2011 (n=13)2012 (n = 4) SICU3424 NICU31 PICU21 MICU WEST10 5 SOUTH1623 What do these numerators mean? Next calculate rates by line days

30 CLABSI BY ORGANISMS NURS UNIT STAPH AUREUS MRSACNSALPHA STREP ECOLIPSEUD AERUG CANDIDA SICU NICU PICU MICU WEST SOUTH TOTALS

31 SSI RATES TYPE OF SURGERY # SSIs# PROCEDURES% RATE THA21002% TKA3754% CABG2258% COLON41527% ABD HYSTERCTOMY 31619%

32 SSIs BY SURGEONS - RATES SURGEON CODE CABGTKATHACOLONABD HYSTER A1.2 B1.0 C D E0.0 F5.6 G4.8 H0.0 (0/6 cases) I30.0 (3/10 cases)

33 Risk Factors for Infections SurgeryDiabetesObese (BMI > 30) Hema- toma DrainsStaplesSmokingSteroids THA 50%75%25%90% 20%10% TKA 60%80%35%85%95%10%5% CABG 70% 0% 50%60%45% COLON 50% 0%20%80%20%10% ABD HYSTER 70%80%0% 90%10% ? What percentage of non-infected patients had risk factors ? What percentage of Surgeon I patients had these risk factors Obesity diabetes risk factors at this institution Staples are used often which may be increasing the risk Drains being used in orthopedic surgery – increase risk

34 Pie Chart  Pie Chart: A pie chart is a graphical representation of data. The different slices of the pie represent different values of a variable, with the relative size of the slice representing the amount of data included in the slice

35 Pie Chart Example  The top value for each slice is the value of the “chart variable” (e.g., location).  The second value is a count of the number of events included in each slice of the pie Example:  Distribution of HAIs

36 Bar Chart  Bar Chart: A bar chart is a graphical representation of data where the length or height of the bars represents counts of cases or rates

37 Number of Cases by Surgery Date

38 Days from Surgery to Infection - HPRO & KPRO

39 Orthopedic Surgical Site Infection Rates OR Environmental controls: Traffic, Attire,Scrub, Air Handling Antibacterial sutures MRSA and Staph aureus Elimination Program CHG/Alcohol Prep Laminectomy outbreak due to locally administered steroids (depomedrol) 7 x increase risk of infection if obese and diabetic Increase in hematomas after use of Lovenox and Plavix

40 NEBH SSI Rates 2003 – 2010 (outpatient and inpatient infections) Total hip investigation – increase in post-op hematomas in infected patients being evaluated by a case-control study 2008 – Total knee investigation – noticed increase rate in patients receiving toradol, marcaine and duromorph – needle on syringe was not being changed between each vial – changed practice 2007 – Laminectomy rate increased – case control study revealed locally adminiistered steroids increased infection rate in obese/diabetic pts

41 Run Chart  Run Chart: A run chart (or control chart) is a line graph showing change in a variable over a selected time period  This is a useful output if you would like to view, for example, the change in rates over time and 2 standard deviation above the mean

42 Instituted AMD Gauze and Standardized dressing technique MRSA/MSSA Eradication Program

43 Standardized Infection Ratio (SIR) Standardized Infection Ratio (SIR), a statistic used to measure relative difference in HAI occurrence during a reporting period compared to a common referent period (i.e., standard population). SIR compares the actual number of HAIs with the predicted number based on the baseline U.S. experience (i.e., standard population), adjusting for several risk factors that have been found to be most associated with differences in infection rates

44 Next Step: Calculate SIR by HAI by facility and compare to national data from NHSN

45 The “p” value The p value is the probability that an event will occur in a given set of trials A p of 1 means it will occur every time the trial occurs (if there were 100 “z” in a pile of 100 scrabble tiles, the probability of getting a “z” is 1 “by chance” Thus, a p of 0.05 means that 95% of the time or 95/100 you will not get a “z” if there were a random mix of tiles with only one z

46  Patient-associated risk factors identified by studies in Malaysia and Vietnam Risk Factors for SSI 1. Praveen S et al. Asian J Surg (1): Yong KS, et al. Med J Malays Suppl C: Nguyen D et al. Infect Control Hosp Epidemiol (8): Sohn AH et al. Infect Control Hosp Epidemiol (7): Thu LTA et al. J Hosp Infect (4): CountrySource Risk variableSurgical procedure Risk estimate (95% CI) P value Malaysia Praveen Intra-operative adhesions Inguinal hernioplasty Not reported0.013 Post-operation haematoma Not reported0.001 Yong Type 2 diabetes Total hip replacement OR 21.4 (1.53, 300.2)0.023 ObesityOR 20.2 (2.13, 191.5)0.009 Vietnam Nguyen Dirty wound Any surgical procedure OR 5.67 (1.92, 16.74)0.002 Sohn Dirty wound Any surgical procedure OR 2.92 (1.35, 6.15)NR Thu Dirty wound All orthopaedic surgery OR 8.7 (4.55, 16.44)<0.001 ASA > 2OR 3.9 (1.77, 8.82)0.001

47 Surgical site infection 1. Duerink DO et al. J Hosp Infect (2): Sohn AH et al. Infect Control Hosp Epidemiol (7): Praveen S et al. Asian J Surg (1): Dhillon KS et al. Med J Malays (3): Syahrizal AB et al. Med J Malays Suppl D: Yang K et al. J Arthroplasty (1): Kehachindawat P et al. J Med Assoc Thai 2007;90(7): Thu LTA et al. Infect Control Hosp Epidemiol (8):  SSI classification by surgical procedure

48  Gastrointestinal surgery  Incidence of SSI: 4 – 56% Incidence of ssi 1.Mahadeva S et al. Int J Clin Pract (5): Thambidorai CR et al. Singapore Med J (12): CountrySourceSurgical procedureIncidence (%) Malaysia Mahadeva Percutaneous endoscopic gastrostomy 33/103 (32%) Thambidorai Appendectomy in children Open: 34/61(55.7%) Laparoscopic: 3/51 (5.9%)

49  Orthopaedic surgery  Incidence of SSI: 4 – 15% Incidence of ssi 1.Dhillon KS et al. Med J Malays (3): Syahrizal AB et al. Med J Malays Suppl D: Tay BH et al. Med J Malays Suppl C: CountrySourceSurgical procedureIncidence (%) Malaysia Dhillon All orthopaedic surgery48/703 (6.8%) Syahrizal Total knee arthroplasty11/100 (11.0%) Tay Total hip arthroplasty10/109 (9.2%)

50  Gynaecology & Obstetrics surgery  Incidence of SSI: 2 – 26% Incidence of ssi 1.Huam SH et al. Med J Malays (1): Ramli R et al. Int Med J (4): CountrySourceSurgical procedureIncidence (%) Malaysia Huam Caesarean section Antibiotic prophylaxis: 3/100 (3.0%) No prophylaxis: 13/100 (13.0%) Ramli Laparoscopic ovarian cystectomy2/37 (5.4%)

51  Other surgical procedures Incidence of SSI 1.Ahmad TS et al. Ann Acad Med Singapore (6): Hisham AN et al. ANZ J Surg (4): Ng CY et al. Asian Cardiovasc Thorac Ann (3): Praveen S et al. Asian J Surg (1): CountrySourceSurgical procedureIncidence (%) Malaysia Ahmad Free flap surgery10/61 (16.4%) Hisham Total thyroidectomy3/98 (3.1%) Ng CABG34/1594 (2.1%) Praveen Inguinal hernioplasty15/202 (7.4%)

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54 Patient FactorsSurgeon Technique Work Environmental Factors Pre-operative FactorsPeri-operative Team FactorsOrganizational and Management Factors Care Delivery problems (CDPs) SSI Fishbone Diagram Lack of hand hygiene Patient body colonization Lack of traffic control – too many in room Improper surgical hand antisepsis Improper surgical attire MRSA or MSSA nasal colonization Infection at another site Obese Diabetic Smoker Immunosuppressive agents Unsterile instruments Contaminated environment Inadequate surgical prophylaxis Poor surgical technique Use of Drains Lack of re-dosing of antibiotic Lack of pre-op shower Financial constraints Poor leadership Poor communication among team Poor staff levels Workload and shift patterns Design, availability and maintenance of equipment Environment and physical plant problems (air handling system) Surgical irrigation Non-coated sutures Use of Staples or steri-strips Contamination of incision post-op Inadequate staffing for post-op care Lack of discontinuation of antibiotics at 24 hrs Lack of foley catheter removal within 48 hrs Increase hospitalization days Contaminated environment Lack of hand hygiene

55 How Much Do These Infections Cost???

56 56 Relative Economic Burden Associated with HAIs SSI Surgical Site Infections CLA-BSI Central-Line Associated Blood Stream Infections VAP Ventilator Associated Pneumonia CA-UTI Catheter-Associated Urinary Tract Infections Other / MDROs* Multi-Drug Resistant Organisms (e.g., MRSA, C. difficile, VRE, etc.) Est. Annual # of Infections Direct Cost per Patient (2007$) Avg. Increased Length of Stay Attributable Mortality 290,485 (~17% of HAIs) 248,678 (~14% of HAIs) 250,205 (~15% of HAIs) 561,667 (~32% of HAIs) 386,090 (~22% of HAIs) $34,670 $29,156 $28,508 $1,007 ~$30,000 ~12 days ~10-24 days ~9-13 days 1 day ~9.1 days 4% 26% 24% 1% ~4% * NOTE: MDRO often cause other infection types (e.g., SSI, BSI, VAP, UTI); MDRO statistics reflect CDC estimates for methicillin-resistant Staphylococcus aureus (MRSA) only. SOURCES: Klevens, et al., “Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002,” Public Health Review, 2007; CDC: “The Direct Medical Cost of HAIs in U.S. Hospitals and the Benefits of Prevention”, March 2009; Kirkland, et al., “The Impact of Surgical Site Infections”, Infect Control Hosp Epidemiol, 1999; Arch Internal Med, 1988; Arch Internal Med, 1974; Infect Control Hosp Epidemiol, 2002; CareFusion MedMined Analysis, 2009.

57  Extended hospital stay associated with SSI  In Vietnam, SSI is associated with an increase in hospital stay of 7-19 days Economic burden of SSI 1. Nguyen D et al. Infect Control Hosp Epidemiol (8): Sohn AH et al. Infect Control Hosp Epidemiol (7): Thu LTA et al. J Hosp Infect (4): Thu LTA et al. Infect Control Hosp Epidemiol (8): Thu LTA et al. Infect Control Hosp Epidemiol (5): CountrySourceSurgical procedureType of stay Length of stay (days) SSINo SSIDifferenceP value Vietnam Nguyen Any surgical procedureTotal stay14 (SD: 10.8)9.1 (SD: 7.1)4.9<0.001 Sohn Any surgical procedurePost-operative261016< Thu All orthopaedic surgeryPost-operative <0.001 Thu Orthopaedic surgeryPost-operative21915<0.001 NeurosurgeryPost-operative271017<0.001 Thu NeurosurgeryPost-operative1697NR

58  In Thailand, SSI is associated with an increase in hospital stay of 7-19 days Economic cost of ssi 1. Danchaivijitr S et al. J Med Assoc of Thailand 2005;88 Suppl 10:S75-S Kasatpibal N et al. J Med Assoc of Thailand 2005;88(8): Lohsiriwat V et al. J Med Assoc of Thailand 2009;92(1):12-6. SourceSurgical procedureType of stay Length of stay (days) SSIno SSIDifferenceP value Danchaivijitr Any surgical procedurePost-operative stayNS 12.6NS Kasatpibal Craniotomy Post-operative stay < Colectomy Cholecystectomy Appendectomy < Mastectomy Herniorrhaphy < Lohsiriwat Colorectal surgeryHospital stay <0.001

59  Hospitalization cost associated with SSI in Thailand Economic cost of ssi Source: Kasatpibal N et al. J Med Assoc of Thailand 2005;88(8): Surgical procedure Mean hospitalization cost (THB) SSIno SSIDifferenceP value Craniotomy117,13550,01867,116< Colectomy69,95827,64242, Cholecystectomy52,97522,81230, Appendectomy27,6478,48219, Mastectomy23,41316,6996, Herniorrhaphy17,8016,88210, All 6 procedures75,54431,88643,658<0.0001

60 Edmiston, et al. APIC June 2012

61 Plus Antibacterial Sutures One year prospective study of 3789 total joints ▫ In July 2005, implemented a full-year evaluation of antibacterial sutures usage in an orthopedic setting ▫ Changed product over July 4th holiday and did not tell all surgeons (only those involved with study) At the end of the year-long trial period: ▫ 45% reduction in SSIs caused by Staph aureus and MRSA ▫ Reduction in total joint infections rate during trial period ▫ Infection rate dropped from 0.44% to 0.33% with three less infections 61  Spencer M, et al: Reducing the Risk of Orthopedic Infections: The Role of Innovative Suture Technology NAON Poster Presentation

62 Three Less Staph Aureus Infections Incremental cost: $ x $40,000 Sensitive Staph aureus = $120,000 3 x $100,000 MRSA = $300,000 UHS – to convert a 25 hospital system will increase the budget by 1% or $35,000

63 NEBH SSI Rates 2003 – 2010 (outpatient and inpatient infections) Total hip investigation – increase in post-op hematomas in infected patients being evaluated by a case-control study 2008 – Total knee investigation – noticed increase rate in patients receiving toradol, marcaine and duromorph – needle on syringe was not being changed between each vial – changed practice 2007 – Laminectomy rate increased – case control study revealed locally adminiistered steroids increased infection rate in obese/diabetic pts

64 64 Potential Savings Orthopedic Surgical Site Infections Cost: ~ $25,000/each FY03 – 63/8837 cases (0.7%) 1.6 million FY04 – 60/9669 cases (0.6%) 1.5 million FY05 – 49/9216 cases (0.5%) 1.2 million FY06 – 46/8986 cases (0.5%)1.1 million FY /9027 cases (0.4%) $975,000 FY /8884 cases (0.4%) $925,000

65 UHS Healthcare- Acquired Infections (through October) % Rate Reduction UHS 2011 Benchmark Rate # HAIs Reduced Potential Cost Savings Catheter Associated UTI (rate per Foley days) % 0.297$90,630 CLABSI rate by catheter days) % 0.059$1,486,956 VAP (rate by ventilator days) % 0.047$912,256 CABG SSI (overall rate by surgical procedures) % 0.04$138,680 Total Hip (overall rate by surgical procedures) % 0.06$208,020 Total Knee (overall rate by surgical procedures) % 0.012$416,040 C.Difficile (rate per 10,000 patient days) % $948,900 MRSA (rate per 1,000 patient days) % $7,560,000 Total627$11,761,482 First Year Potential Cost Savings

66 Healthcare Acquired Infections % Reduction UHS 2012 Benchmark Rate Infection Prevention Measures in Process Catheter Associated UTI (rate per Foley days) 57% 0.0Infection Control Foley Catheter Tray and Silver Foley Catheter, CHG washcloths CLABSI (rate by catheter days) 54% 0.0Central Line Insertion Kits, Alcohol Caps for Injection Hub Protection, CHG washcloths, Central Line Checklist VAP (rate by ventilator days)11% 0.0CHG rinse with oral care kits, VAP bundle checklist, CHG washcloths, nebulizer cleaning procedures, VAP rounds CABG SSI (overall rate by surgical procedures) 71% 0.0MRSA screening before surgery, CHG preop showers/cloths, Incisional sealants, CHG/alcohol skin prep Total Hip (overall rate by surgical procedures) 15% 0.0MRSA screening before surgery, CHG preop showers/cloths, Incisional sealants, CHG/alcohol skin prep Total Knee (overall rate by surgical procedures) 50% 0.0MRSA screening before surgery, CHG preop showers/cloths, Incisional sealants, CHG/alcohol skin prep C.Difficile (rate per 10,000 patient days) 12% 4.0/10,000 patient days Bleach wipes and bleach disinfectant solution, Rapid PCR Diagnostics for Early Diagnosis and Precautions, Enhanced environmental cleaning, cubicle curtain changes, room decontamination units for high rates MRSA (rate per 1,000 patient days) 62% 0.4CHG Washcloths, Pre-admission and Pre-op Screening, Rapid PCR Diagnostics for Early Diagnosis and Precautions

67  The overall incidence of SSI in South East Asia varies between 1-20%. SSI account for approximately 20% of all HAI.  Variability in SSI incidence related to surgical procedure and risk factors (eg, diabetes, wound classification).  SSI have a substantial economic impact through increased hospital stay, additional treatment and consequently loss of productivity  Clinical studies in patients undergoing abdominal, spinal and cardiac surgery show that VICRYL Plus sutures significantly reduce the incidence of SSI Conclusions


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