Transcript Epidemiology of Surgical Site Infections

Epidemiology of Surgical
Site Infections
Maureen Spencer, RN, M.Ed., CIC
Infection Preventionist Consultant
Boston, MA
www.7sbundle.com
www.workingtowardzero.com
Healthcare-associated infections (HAIs) are a
significant financial challenge for providers
Top 5 HAIs:
Incidence and cost1
HAI type
Top 5 HAIs:
Percent of total HAI cost1
Annual
occurrences
Average cost
per case
CLABSI
40,411
$45,814
VAP
31,130
$40,144
SSI
158,639
$20,785
C. difficile
133,657
$11,285
CAUTI
77,079
$896
C. difficile =
CAUTI =
CLABSI =
SSI =
VAP =
Clostridium difficile infection
Catheter-associated urinary tract infection
Central line-associated bloodstream infection
Surgical site infection
Ventilator-associated pneumonia
1. Zimlichman E, Henderson D, Tamir O, et al. JAMA Intern Med. 2013;173(22):2039-2046
2
In the coming years, CMS initiatives will increase
providers’ accountability for reducing HAIs
Timeline of CMS initiatives
2008
2013
2014
2015
2016
2017
VBP penalty
increases to 1.25%
VBP penalty
increases to 1.5%
VBP penalty
increases to 1.75%
VBP penalty
increases to 2%
2% penalty for
readmission rates
3% penalty for
readmission rates;
COPD, total knee,
and total hip added
Payment withheld on
10 hospital-acquired
conditions (HAC)
Value-based purchasing
(VBP) withholds 1% of
Medicare reimbursement
1% payment penalty for
high readmission rates
after heart failure, AMI,
and pneumonia
http://www.ssa.gov/history/briefhistory3.html
http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/HospitalAcqCond/Hospital-Acquired_Conditions.html
HAC reduction
program reduces
payment to facilities
with high rates of
infection, such as
CLABSI
SSIs after colon
and abdominal
hysterectomy
added to HAC
reduction program
3
Under Affordable Care Act (ACA) hospital HAI
Under Affordable Care Act (ACA), hospital HAI rates
rates
place
significant
reimbursement
at
risk
place significant reimbursement at risk
Medicare programs linking reimbursement with quality
• Hospital value-based purchasing (VBP) program
– Portion of Medicare reimbursement is withheld (up to 2%), but can be earned back
by achieving specific quality measures, such as reduced HAI rates
• Hospital-acquired condition (HAC) reduction program
– Reimbursement penalty (1%) for hospitals in top 25% of HAC and infection rates
• Hospital readmissions reduction program (RRP)
– Reimbursement penalty (up to 3%) for facilities with high 30-day readmission rates
1.
2.
4
Value-based purchasing creates financial
penalties and rewards for performance against
quality metrics
How does value-based purchasing work?
• Portion of Medicare reimbursement
withheld (up to 2%)
Reimbursement withholding increases
through FY17
1.00%
FY13
• Four “domains” are used to create a
Total Performance Score (TPS)
back
1.25%
FY14
1.50%
FY15
1.75%
FY16
2.00%
FY17
Domain weighting shifts emphasis
towards efficiency & outcomes
• TPS based on hospital’s:
– Improvement (vs. hospital’s historical baseline)
– Achievement (vs. all other hospitals)
2013
2014
2015
2016
Hospital-acquired condition (HAC) reduction
program will reduce Medicare payments to some
hospitals
Overview of HAC reduction program
• Starting in FY2015, CMS will penalize institutions in top 25% for HAC
rates by reducing overall Medicare payments by 1%
– Penalty is in addition to withheld Medicare reimbursement related to these conditions
• Several major infections will be tracked, including central line-associated
bloodstream infections (CLABSI) and surgical site infections (SSI)
The Hospital Readmissions Reduction Program
(RRP) will penalize institutions with high
readmission rates
Overview of RRP
• Starting in FY2013, hospitals with above-average readmission rates for
specific conditions will see a reduction in overall Medicare payments
Conditions evaluated
under RRP
Acute myocardial infarction (AMI)
Heart failure
Pneumonia
COPD*
Total Hip Arthroplasty
Total Knee Arthroplasty
proposed
2013
Medicare payment
reduction
1%
2014
2%
CABG*
PCI**
2015
3%
•COPD = chronic obstructive pulmonary
disease
•CABG = coronary artery bypass graft
**PCI = percutaneous coronary
intervention
Estimates of Healthcare-Associated Infections
Occurring in Acute Care Hospitals in the United
States, 2011
Major Site of Infection
Pneumonia
Gastrointestinal Illness
Urinary Tract Infections
Primary Bloodstream Infections
Estimated No.
157,500
123,100
93,300
71,900
Surgical site infections from any
inpatient surgery
157,500
Other types of infections
118,500
Estimated total number of
infections in hospitals
721,800
Magill SS, Edwards JR, Bamberg W, et al. Multistate Point-Prevalence Survey
of Health Care–Associated Infections. N Engl J Med 2014;370:1198-208
On the national level, the
report found:
■ 44 percent decrease in central line-associated
bloodstream infections between 2008 and 2012
■ 20 percent decrease in infections related to the 10
surgical procedures tracked in the report between
2008 and 2012
■ 4 percent decrease in hospital-onset MRSA
bloodstream infections between 2011 and 2012
■ 2 percent decrease in hospital-onset C. difficile
infections between 2011 and 2012
■ 3 percent increase in catheter-associated urinary tract
infections between 2009 and 2012
Despite current preventive measures, SSIs
remain a significant problem
• In the US (2006) there were ~ 80 million surgical procedures
• Between 2006 -2009 approximately 1.9% developed SSI1
• Between 2009-2010 SSIs accounted for 23% of 69,475 HAIs
reported to NHSN 2
1. Mu Y et al. Improving risk-adjusted measures of surgical site infections for the national
healthcare safety network. Infection control and hospital epidemiology. Oct 2011;32(10):970-986.
2. Sievert DM at al Antimicrobial resistant pathogens associated with healthcare associated
infections. Summary of data reported to the Centers for Disease Control and Prevention 20092010 . Infection control and hospital epidemiology. 2013;34(1):1-14.
11
Sievert DM at al Antimicrobial resistant pathogens associated with healthcare associated infections. Summary of
data reported to the Centers for Disease Control and Prevention 2009-2010 . Infection control and hospital
epidemiology. 2013;34(1):1-14.
Special Risk Population:
Orthopedic Implants
▫ Hip or Knee aspiration
▫ If positive – irrigation and
debridement
▫ Removal of hardware may be
necessary
▫ Insertion of antibiotic spacers
▫ Revisions at future date
▫ Long term IV antibiotics in
community or rehab
 Future worry about the joint
 In other words –
DEVASTATING FOR THE
PATIENT AND SURGEON
13
Pathogen Involved with SSIs
No (%) of SSI Pathogens
Rank
Staph aureus (includes MRSA)
6415 (30.4)
1
Coagulase neg staph
2477 (11.7)
2
E.Coli
1981 ( 9.4)
3
Enterococcus faecalis
1240 ( 5.9)
4
Pseudomonas aerug
1156 ( 5.5)
5
Enterobacter spp
849 (4.0)
6
Klebsiella spp
844 (4.0)
7
Enterococcus spp
685 (3.2)
8
Proteus spp
667 (3.2)
9
Enterococcus faecium
517 (2.5)
10
Serratia spp
385 (1.8)
11
Candida albicans
367 (1.3)
12
Acinetobacter baum
119 (0.6)
13
Other Candida spp
96 (0.5)
14
Other organisms
3399 (16.1)
Total
21,100 (100)
Sievert DM at al Antimicrobial resistant pathogens associated with healthcare associated infections. Summary of
data reported to the Centers for Disease Control and Prevention 2009-2010 . Infection control and hospital
epidemiology. 2013;34(1):1-14.
Mortality risk is high among
patients with SSIs
• A patient with an SSI is:
– 5x more likely to be readmitted after discharge1
– 2x more likely to spend time in intensive care1
– 2x more likely to die after surgery1
• The mortality risk is higher when SSI is due to
MRSA
– A patient with MRSA is 12x more likely to die after
surgery2
1.
2.
WHO Guidelines for Safe Surgery 2009.
Engemann JJ et al. Clin Infect Dis. 2003;36:592-598.
15
HAI
Surgical Site
Infection (SSI)
Est Annual %
33.7%
 MRSA SSI
Central Line
Associated
Bloodstream
Infection (CLABSI)
18.9%
Est Direct Cost
Avg Length of Stay
$20 785
~11.days
$42 300
~23 days
$45 814
~10 days
 MRSA CLABSI
Attributable
Mortality
~4%
~26%
~16 days
Ventilator
Associated
Pneumonia (VAP)
31.6%
$40 144
~13 days
~24%
Catheter
Associated Urinary
Tract Infection
(CAUTI)
<1%
$896
< 1 day
<1%
Clostridium difficile
Infection (CDI)
15.4%
$11 285
~ 3 days
~4%
Zimlichman. Et al: “Health Care–Associated Infections A Meta-analysis of Costs and Financial Impact on the US Health Care
16
System” JAMA Intern Med. September 2013
Cost of Surgical Site Infections
Cost of an SSI in a prosthetic joint
implant can exceed $90,0001,2
Cost of an SSI can exceed more than
$90,000 if it involves MRSA 3
Bozick KJ et al. The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization. The Journal
of bone and join surgery. American Volume. Aug 2005;87(8):1746-1751.
Kurtz SM et al. Economic burden of periprosthetic joint infection in the United States. The Journal of Arthroplasty. Sep
2012;27(8 Suppl):61-65 e61.
Engemann JJ et al. Adverse clinical and economic outcomes attributable to methicillin resistance among patients with
Staphylococcus aureus surgical site infection. Clinical Infectious Disease: an official publication of the Infectious Diseases
Society of America. March 1 2003;36(5):592-598.
Pathogens survive on surfaces
Organism
Survival period
Clostridium difficile
35- >200 days.2,7,8
Methicillin resistant Staphylococcus aureus (MRSA)
14- >300 days.1,5,10
Vancomycin-resistant enterococcus (VRE)
58- >200 days.2,3,4
Escherichia coli
>150- 480 days.7,9
Acinetobacter
150- >300 days.7,11
>10- 900 days.6,7
Klebsiella
10 days- 4.2 years.7
Salmonella typhimurium
Mycobacterium tuberculosis
120 days.7
Candida albicans
120 days.7
Most viruses from the respiratory tract (eg: corona, coxsackie,
influenza, SARS, rhino virus)
Few days.7
Viruses from the gastrointestinal tract (eg: astrovirus, HAV,
polio- or rota virus)
Blood-borne viruses (eg: HBV or HIV)
1.
2.
3.
4.
5.
6.
Beard-Pegler et al. 1988.. J Med Microbiol. 26:251-5.
BIOQUELL trials, unpublished data.
Bonilla et al. 1996. Infect Cont Hosp Epidemiol. 17:770-2
Boyce. 2007. J Hosp Infect. 65:50-4.
Duckworth and Jordens. 1990. J Med Microbiol. 32:195-200.
French et al. 2004. ICAAC.
60- 90 days.7
>7 days.5
7. Kramer et al. 2006. BMC Infect Dis. 6:130.
8. Otter and French. 2009. J Clin Microbiol. 47:205-7.
9. Smith et al. 1996. J Med. 27: 293-302.
10. Wagenvoort et al. 2000. J Hosp Infect. 45:231-4.
11. Wagenvoort and Joosten. 2002. J Hosp Infect. 52:226-7.
Prior room occupancy increases risk
Study
Healthcare associated pathogen
Martinez 20031
VRE – cultured within room
VRE – prior room occupant
MRSA – prior room occupant
VRE – cultured within room
VRE – prior room occupant
VRE – prior room occupant in previous
two weeks
C. difficile – prior room occupant
A. baumannii – prior room occupant
P. aeruginosa – prior room occupant
Huang 20062
Drees 20083
Shaughnessy 20084
Nseir 20105
1.
2.
3.
4.
5.
Martinez et al. Arch Intern Med 2003; 163: 1905-12.
Huang et al. Arch Intern Med 2006; 166: 1945-51.
Drees et al. Clin Infect Dis 2008; 46: 678-85.
Shaughnessy. ICAAC/IDSA 2008. Abstract K-4194.
Nseir et al. Clin Microbiol Infect 2010 (in press).
Likelihood of patient acquiring HAI
based on prior room occupancy
(comparing a previously ‘positive’
room with a previously ‘negative’
room)
2.6x
1.6x
1.3x
1.9x
2.2x
2.0x
2.4x
3.8x
2.1x
A 7 S BUNDLE APPROACH TO
PREVENTING SURGICAL SITE INFECTIONS
AORN – 2014
APIC - 2014
7 “S” Bundle to Prevent SSI
SAFETY – is your OPERATING ROOM safe?
SCREEN – are you screening for risk factors and presence of MRSA &
MSSA
SHOWERS – do you have your patients cleanse their body the night before
and morning of surgery with CHLORHEXIDINE (CHG)?
SKIN PREP – are you prepping the skin with alcohol based antiseptics
such as CHG or Iodophor?
SOLUTION - are you irrigating the tissues prior to closure to remove
exogenous contaminants? Are you using CHG?
SUTURES – are you closing tissues with antimicrobial sutures?
SKIN CLOSURE – are you sealing the incision or covering it with an
antimicrobial dressing to prevent exogenous contamination?