Epidemiology of Surgical Site Infections

Maureen Spencer, RN, M.Ed., CICInfection Preventionist Consultant

Boston, MA

www.7sbundle.comwww.workingtowardzero.com

Healthcare-associated infections (HAIs) are a significant financial challenge for providers

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Top 5 HAIs: Top 5 HAIs:Incidence and cost1 Percent of total HAI cost1

1. Zimlichman E, Henderson D, Tamir O, et al. JAMA Intern Med. 2013;173(22):2039-2046

HAI type 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 = Clostridium difficile infection CAUTI = Catheter-associated urinary tract infectionCLABSI = Central line-associated bloodstream infectionSSI = Surgical site infection VAP = Ventilator-associated pneumonia

In the coming years, CMS initiatives will increase providers’ accountability for reducing HAIs

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HAC reduction program reduces

payment to facilities with high rates of infection, such as

CLABSIhttp://www.ssa.gov/history/briefhistory3.htmlhttp://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html

SSIs after colon and abdominal hysterectomy added to HAC

reduction program

Timeline of CMS initiatives

20132008 20172015 2016

VBP penalty increases to 2%

VBP penalty increases to 1.75%

VBP penalty increases to 1.5%

2014

VBP penalty increases to 1.25%

Value-based purchasing (VBP) withholds 1% of

Medicare reimbursement

Payment withheld on 10 hospital-acquired conditions (HAC)

1% payment penalty for high readmission rates after heart failure, AMI,

and pneumonia

2% penalty for readmission rates

3% penalty for readmission rates; COPD, total knee, and total hip added

Under Affordable Care Act (ACA), hospital HAI rates place significant reimbursement at risk

Under Affordable Care Act (ACA) hospital HAI rates place significant reimbursement at risk

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1. 2.

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

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%)

•Four “domains” are used to create aTotal Performance Score (TPS)

•TPS based on hospital’s:– Improvement (vs. hospital’s historical baseline)

– Achievement (vs. all other hospitals)

back

Reimbursement withholding increases through FY17

FY13 FY14 FY15 FY16 FY17

1.00%1.25%

1.50%1.75%

2.00%

Domain weighting shifts emphasis towards efficiency & outcomes

2013 2014 2015 2016

Hospital-acquired condition (HAC) reduction program will reduce Medicare payments to some

hospitalsOverview 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 ratesOverview of RRP

•Starting in FY2013, hospitals with above-average readmission rates for specific conditions will see a reduction in overall Medicare payments

Medicare payment reduction

Conditions evaluated under RRP

Acute myocardial infarction (AMI)

Heart failure

Pneumonia

COPD*

Total Hip Arthroplasty

Total Knee Arthroplasty

2013 2014 2015

CABG*

•COPD = chronic obstructive pulmonary disease •CABG = coronary artery bypass graft**PCI = percutaneous coronary intervention

1% 2% 3%

PCI**proposed

Estimates of Healthcare-Associated Infections Occurring in Acute Care Hospitals in the United States, 2011

Major Site of Infection Estimated No.Pneumonia 157,500Gastrointestinal Illness 123,100Urinary Tract Infections 93,300Primary Bloodstream Infections 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

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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 2009-2010 . Infection control and hospital epidemiology. 2013;34(1):1-14.

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.

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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 rehabFuture worry about the jointIn other words – DEVASTATING FOR THE

PATIENT AND SURGEON

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

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1. WHO Guidelines for Safe Surgery 2009.2. Engemann JJ et al. Clin Infect Dis. 2003;36:592-598.

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HAI Est Annual % Est Direct Cost Avg Length of Stay Attributable Mortality

Surgical Site Infection (SSI)

33.7% $20 785 ~11.days ~4%

MRSA SSI $42 300 ~23 days

Central Line Associated Bloodstream Infection (CLABSI)

18.9% $45 814 ~10 days ~26%

MRSA CLABSI ~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 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 surfacesOrganism 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

Klebsiella >10- 900 days.6,7

Salmonella typhimurium 10 days- 4.2 years.7

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)

60- 90 days.7

Blood-borne viruses (eg: HBV or HIV) >7 days.5

1. Beard-Pegler et al. 1988.. J Med Microbiol. 26:251-5.2. BIOQUELL trials, unpublished data.3. Bonilla et al. 1996. Infect Cont Hosp Epidemiol. 17:770-24. Boyce. 2007. J Hosp Infect. 65:50-4.5. Duckworth and Jordens. 1990. J Med Microbiol. 32:195-200.

6. French et al. 2004. ICAAC.

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 Likelihood of patient acquiring HAI based on prior room occupancy (comparing a previously ‘positive’ room with a previously ‘negative’ room)

Martinez 20031 VRE – cultured within room 2.6x

Huang 20062VRE – prior room occupant 1.6xMRSA – prior room occupant 1.3x

Drees 20083

VRE – cultured within room 1.9xVRE – prior room occupant 2.2xVRE – prior room occupant in previous two weeks

2.0x

Shaughnessy 20084 C. difficile – prior room occupant 2.4x

Nseir 20105A. baumannii – prior room occupant 3.8xP. aeruginosa – prior room occupant 2.1x

1. Martinez et al. Arch Intern Med 2003; 163: 1905-12.2. Huang et al. Arch Intern Med 2006; 166: 1945-51.3. Drees et al. Clin Infect Dis 2008; 46: 678-85.4. Shaughnessy. ICAAC/IDSA 2008. Abstract K-4194.5. Nseir et al. Clin Microbiol Infect 2010 (in press).

A 7 S BUNDLE APPROACH TO PREVENTING SURGICAL SITE INFECTIONS

AORN – 2014APIC - 2014

7 “S” Bundle to Prevent SSISAFETY – is your OPERATING ROOM safe?

SCREEN – are you screening for risk factors and presence of MRSA & MSSA

SKIN PREP – are you prepping the skin with alcohol based antiseptics such as CHG or Iodophor?

SHOWERS – do you have your patients cleanse their body the night before and morning of surgery with CHLORHEXIDINE (CHG)?

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?