1. Health Care associated Infections Common but - there are now many interventions we can implement that will reduce them Prof Peter Collignon The Canberra Hospital Australian National University

2. What are health-care associated infections? Any infection that occurs following a health care procedure –All “hospital onset” infections –But many now also have a “community onset” but related to medical care –wound infection –Many blood stream infections

3. Examples Blood stream infections IV catheters Wound infections After surgery May be deep seated Urinary tract Catheters Respiratory tract Ventilators drugs

4. Why do these infections occur? Breach normal defense barriers –Skin –Respiratory tract –Acid in stomach Lowered immune defenses –Chemotherapy –Part of disease Increased exposure –Resistant bacteria

5. Health care infections are common Very common; –various studies in many countries –Likely between 5 -10% of all admissions develop a new infection Most are relatively minor –UTI, superficial wound But many Serious and Life threatening –Blood stream –Prosthetic joints etc

6. Patient safety is important Hospitalisation is inherently hazardous –Drug errors most common misadventure –But infections are 2 nd biggest problem –Occur in at least 10% of acute admissions 50-80% potentially preventable Misadventures primarily result from system failures not incompetence We need national and comparative data Clinical Excellence Commission, 2005; Leape 2000; Wilson et al 1995

7. Serious infections are common Blood Stream infections –Most from IV catheters –In Australia likely about 4,000 per year –In USA more than 200,000 per year High mortality and morbidity attached –With MRSA blood stream infections - 35% –Central nervous system - lower but still >5% –In Australia - about 400 deaths per year and USA 20,000 from JUST IV catheters!

8. How hazardous is healthcare? Dr. Lucien Leape Harvard Medical School. USA DangerousRegulatedUltrasafe (> 1/1000 )(< 1/100,000 Total lives lost per year 1 10 100 1000 10,000 100,000 1 10100100010,000100,0001M10M Bungee jumping Mountain climbing Healthcare Driving Chemical manufacturing Chartered flights Scheduled airlines European railroads Nuclear power Number of encounters for each fatality

9. How hazardous is healthcare? Dr. Lucien Leape Harvard Medical School. USA DangerousRegulatedUltrasafe (> 1/1000 )(< 1/100,000 Total lives lost per year 1 10 100 1000 10,000 100,000 1 10100100010,000100,0001M10M Bungee jumping Mountain climbing Healthcare Driving Chemical manufacturing Chartered flights Scheduled airlines European railroads Nuclear power Number of encounters for each fatality

10. Hospital-Acquired Blood stream infections; 8 th leading cause of death in USA Emerging Infectious Diseases April 2001 http://www.cdc.gov/ncidod/eid/ vol7no2/wenzel.htm http://www.cdc.gov/ncidod/eid/ vol7no2/wenzel.htm

11. Staphylococcus aureus Common –Many sites esp blood, wounds Bacteraemia likely 7,000 per year in Australia –50% hospital onset –1/3 of community onset are health care related High mortality in bacteraemia –Pre-antibiotics 82% –MSSA median 25% –MRSA median 35%

12. Antibiotic Resistance is common Penicillin Beta-lactams –MRSA Other common agents –macrolides etc Vancomycin –New forms of resistance New agents –linezolid

13. Serious Morbidity also common Prosthetic joint infection (eg hip) –To cure need 2 major operations, 8- 10 weeks incapacitated. –> $100,000 per episode –1 to 2% of all joint replacements –when things go well!

14. Blood stream infections; serious morbidity Blood stream infections –Renal failure, osteomyelitis, prolonged antibiotic therapy etc

15. Blood stream infections are common; and more than 60% of these are health care associated The Canberra Hospital 1998199920002001200220032004 Significant337307320288271316354 Indeterminate37 36303225 Contaminant245200195197217210235 Total positive Blood cultures 619544552521518558614 This means that at the Canberra Hospital each year over 200 BSI episodes are Health-care associated

16. Many primary sites for BSI; but IV catheters main site at all major hospitals Body system (TCH data) 1998199920002001200220032004Total IV Device109728154394542442 Respiratory50365431414947308 GIT47384643404159314 Genito-urinary4338 43455470331 Skin2422 19182735167 Unknown19393237322827214 Cardiovascular13910128191485 Musculo-skeletal101451312201993 Haematology9171015161520102 Maternal945563234 Neurology4138765548 Other00211105 Prim Bacteraemia0578791450

17. Infections can be reduced BSI from IV catheter sepsis (The Canberra Hospital)

18. Interventions that decreased IV sepsis INTERVENTIONSHOSPITAL UNITS Prospective surveillance of BSI'sHospital wide Tunnelling of vascathsRenal medicine CVC retention by exceptionICU Prevention of septic flush by correct alcohol usageOncology / Haematology Monitoring of peripheral IV policy complianceAged care / General surgery Blood culture collection posterHospital wide Patient information pamphlet for CVC careHospital wide / community Introduction of Alcoholic chlorhexidine skin prepHospital wide Reduction in the use of TPNHospital wide Notification of IVD BSI as a critical incidentHospital wide / Medical officer Dissemination of BSI project informationHospital wide / GP's / Media

19. IV catheter infections can be reduced Too many used In for too long Poor selection of most appropriate catheters Poor selection of sites Almost every doctor inserts them including CVC’s - even if little training CVC’s used instead of peripheral catheters for convenience BUT much higher per day risk

20. IV’s; what can be done? Protocols already exist CDC, Australia, WHO Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2002 http://www.cdc.gov/ncidod/hip/iv/iv.htm http://www.cdc.gov/ncidod/hip/iv/iv.htm They need to be followed Will be discussion and disagreements on these protocols eg peripheral IV catheters – remove after 2-3 days but these are relatively minor issues

21. Australian Guidelines http://www.safetyandquality.org/intravascdevicejun05.pdf

22. We can have an impact on all types of infections Surgical site Infection rates can be decreased Hobart, Victoria, TCH, internationally Blood stream infections –Especially IV catheter Urinary tract Pneumonia All types –If you recognize there is a problem

23. Alcohol-chlorhexidine hand-rub solution + culture change program A new standard of healthcare –CDC, WHO, AICA Does it work? Does it increase hand hygiene compliance? Does it reduce nosocomial MRSA infections?

24. 250 0 50 75 100 5075100 Opportunities for hand hygiene per hour of care Compliance with hand hygiene (%) Pittet et al, Ann Intern Med 1999, 130:126

32. MRSA colonisation rates and hospital contamination Johnson et al. Med J Aust 2005 – 21 st November issue or www.mja.com.au

33. Health care worker hand-hygiene compliance Johnson et al. Med J Aust 2005 – 21 st November issue or www.mja.com.au

34. Use of alcohol/chlorhexidine solution Johnson et al. Med J Aust 2005 – 21 st November issue or www.mja.com.au

35. MRSA isolates and patient-episodes of bacteraemia After 36 months: Total MRSA isolates: 40% reduction (95% CI, 23%–58%) 1008 fewer clinical isolates Patients with MRSA bacteraemia: 57% reduction in monthly rate (95% CI, 38%–74%) 53 fewer bacteraemias than expected (95% CI, 36–68 episodes) Johnson et al. Med J Aust 2005 – 21 st November issue or www.mja.com.au

36. Program costs & financial impact $180,000 per year to maintain Saved $325,000 per year on BSI* 72,000 separations per year (inc. day cases) –$2.50 per patient –BigMac in Australia = $3.20 * Estimated cost: $20,000 AUD per case of MRSA BSI

37. What can we do? Recognize/admit there is a problem No self justification Do we really need to hide the data? Measure what is happening Meaningful and easy Research Change things Education Interventions “but –ins” Measure again

38. Epidemiologists; are they a hindrance? Too much time and effort to get the perfect denominator This is Not research but quality improvement

39. Need to collect and have readily available some easy to measure but important RATES Will not be popular with hospitals –Always reasons why my rates are worse than someone else's BUT We need to do it

40. US; report cards

41. What do we need to measure in all hospitals: Infections S. aureus blood stream infection rates –All episodes- community and hospital onset –Separate MRSA and MSSA –Per 1,000 hospital separations –Should be on the web for each hospital –Based on pathology systems

42. AGAR: Rates at different hospitals (total) Collignon P, Nimmo GR, Gottlieb T, Gosbell IB; Australian Group on Antimicrobial Resistance. Staphylococcus aureus bacteremia, Australia. Emerging Infect Dis. 2005 Apr;11(4):554-61.

43. Hospital onset

44. MRSA Bacteraemia 1998 - 2004 By separations at Canberra Hospital

45. We can improve things Need to be motivated Both internal and external pressure for better QA is needed We need to aim for major improvements This can be achieved

46. Conclusions Hospital safety is important Data can be measured reliably using existing practical, commonsense definitions “Simple” interventions can make a huge difference But changing human behaviour is not simple and commonsense is not common Open transparent reporting is the best form of “risk management”

47. Conclusions Hospital safety is important Data can be measured reliably using existing practical, commonsense definitions “Simple” interventions can make a huge difference But changing human behaviour is not simple and commonsense is not common Open transparent reporting is the best form of “risk management”

48. Conclusions Hospital safety is important Data can be measured reliably using existing practical, commonsense definitions “Simple” interventions can make a huge difference But changing human behaviour is not simple and commonsense is not common Open transparent reporting is the best form of “risk management”