The epidemiology of HAI Scotland

Dr Jacqui Reilly Consultant Epidemiologist Head of HAI and IC Group

Overview

1. Current epidemiology of HAI in Scotland 2. Contribution of the national HAI Prevalence survey of HAI in Scotland in understanding the burden and setting the future direction 3. HAI surveillance in ICU

1. Epidemiology of HAI in Scotland

Figure 1: Run chart of quarterly number of S. aureus bacteraemia in Scotland, 1st April 2005 to 31st March 2008 with HEAT target trajectory to 31st March 2010.

800 700 600 500 400 300 200 100 0 Ap r 0 5 Ju n 05 Ju l 0 5 Se p 05 O ct 0 5 D ec 0 5 Ja n 06 -M ar 0 6 Ap r 0 6 Ju n 06 Ju l 0 6 Se p 06 O ct 0 6 D ec 0 6 Ja n 07 -M ar 0 7 Ap r 0 7 Ju n 07 Ju l 0 7 Se p 07 O ct 0 7 D ec 0 7 Ja n 08 -M ar 0 8 Ap r 0 8 Ju n 08 Ju l 0 8 Se p 08 O ct 0 8 D ec 0 8 Ja n 09 -M ar 0 9 Ap r 0 9 Ju n 09 Ju l 0 9 Se p 09 O ct 0 9 D ec 0 9 Ja n 10 -M ar 1 0

Quarter

Quarterly number of S. aureus bacteraemias HEAT target

SAB HEAT trajectory

0.5

0.4

0.7

0.6

0.3

0.2

A pr 0 5 Ju n Ju 05 l 0 5 S ep O ct 0 0 5 5 D ec Ja 0 n 5 06 -M A ar pr 0 0 6 6 Ju n Ju 06 l 0 6 S O ep ct 0 0 6 6 D ec Ja 0 n 6 07 -M A ar pr 0 0 7 7 Ju n Ju 07 l 0 7 S ep O ct 0 0 7 7 D ec Ja 0 n 7 08 -M A ar pr 0 0 8 8 Ju n Ju 08 l 0 8 S O ep ct 0 0 8 8 D ec Ja 0 n 8 09 -M A ar pr 0 0 9 9 Ju n Ju 09 l 0 9 S O ep ct 0 0 9 9 D ec Ja 0 n 9 10 -M ar 1 0

Quarter

Prediction Low er Prediction Limit Upper Prediction Limit HEAT target (30% Reduction) 2005-2006 Rate Data

SSI

3.5% 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 0.0% 2002

Inpatient SSI rate for hip arthroplasty and caesarean sections. 2002 to 2007

2003 2004

Year

2005 2006 2007 Hip arthroplasty Caesarean section

CDAD • HPS mandatory surveillance outputs indicate around 6000 cases per annum • No trends can be assessed as yet – there appears to be more in the winter probably because more antibiotics are prescribed in winter - and – there is variation in numbers of cases between the NHS boards- although this is less obvious when standardised for the population aged 65 years and over by Health Board • There have been continuing clusters of cases and reported outbreaks in NHS boards

2. Contribution of the National Prevalence survey of HAI in Scotland for future developments

National prevalence survey of HAI

– baseline information on the total prevalence of HAI in Scottish hospitals – its burden in terms of health service utilisation and costs – a consistent methodology which will allow the evaluation of measures taken to reduce the burden of HAI

Design of the Survey

• Based on best methodologies from international epidemiological studies • Unique because: – Dedicated team of data collectors • Independent of hospitals being surveyed • Highly trained in diagnosing HAI • Validated diagnoses throughout study – Investigated the time of year survey undertaken as a factor affecting HAI prevalence – Looked at

all

specialties and

all

infection types – Sample of non-acute care (first national level survey in UK) – Collected information on economic burden of HAI

What was the overall prevalence of HAI?

• Acute hospitals 9.5% (8.8, 10.2) • Non-acute hospitals 7.3% (6.0, 8.6)

What type of HAI were found in acute hospitals?

HAI Type Bone and Joint Infection Blood Stream Infection Central Nervous System Infection Cardiovascular System Infections Eye, Ear, Nose, Throat or Mouth Infection

Gastrointestinal Infection

Lower Respiratory Tract Infection other than Pneumonia Pneumonia Reproductive System Infections Systemic Infection

Surgical Site Infection

Skin and Soft Tissue Infection

Urinary Tract Infection

Total N Infections 6 55 2 11 155

191

139 109 17 2

197

137

222

1243 % 0.5 4.4 0.2 0.9 12.5

15.4

11.2 8.8 1.4 0.2

15.9

11.0

17.9

100.0

HAIs prevalence by type in the ICU Infection

Blood Stream Central Nervous System Ear Nose Throat Gastrointestinal Lower respiratory Pneumonia Surgical site Urinary tract Multiple

Total 129 patients surveyed in ICU Percentage

8.6

2.9

2.9

2.9

25.7

14.3

14.3

2.9

25.7

100 Prevalence = 35/129= 27.1% No. patients

3 1 1 1 9 5 5 1 9

35

How did HAI prevalence vary in different acute specialties?

Specialty Care of the Elderly Dentistry Gynaecology Haematology Medicine Obstetrics Oncology Orthopaedics Other Psychiatry Surgery Urology Total Inpatients with HAI N 199 2 10 8 491 4 12 105 0 9 247 16 1103 HAI Prevalence within specialty % 11.9 12.5 4.8 6.7 9.6 0.9 8.8 9.2 0.0 3.5 11.2 6.3 9.5 95% CI Lower 10.0 4.1 1.2 2.0 8.5 0.0 2.0 7.3 - 0.3 9.5 3.0 8.8 Upper 13.7 20.9 8.4 11.3 10.7 1.9 15.7 11.1 - 6.7 12.9 9.5 10.2

Prevalence of HAI by ward type

Which organisms were most prevalent?

• CDC definition organism requirement • Acute hospitals – 540 microbiology reports for 1243 HAI – Most common types:

Staph. Aureus, C.diff

Antibiotics

• In acute hospitals 32.1% of inpatients were prescribed one or more antimicrobials • In ICU patients 69.8% were prescribed an antimicrobial and 70% of those on more than one

What were the most prevalent invasive devices in acute hospitals?

Invasive Device No Device

Urinary Catheter Peripheral Vascular Catheter (PVC) Central Vascular Catheter (CVC)

Invasive Mechanical Device Total Inpatients N 1868

660

% 57.3

20.2 987 104

16 3262

30.3 3.2

0.5 100.0 Invasive Devices N -

660

% -

36.2 1034 112

16 1822

56.8 6.1

0.9 100.0

Prevalence of device use in the ICU

Device

Peripheral Vascular Catheter Central Venous Catheter Mechanical Ventilation Urinary Catheter

Prevalence (%)

96.4

75.0

69.6

82.1

No. of patients

54 42 39 46

Using prevalence results for infection control planning

• The prevalence of HAI in a population of male patients aged 81+ years in a care of the elderly specialty during November to January is: • Hence α = -2.771+0.156+0.847+0.131+0 = -1.637

• Prevalence of HAI = exp (-1.637)/[1+exp (-1.637)] = 0.195/1.195

=0.163

• Thus the prevalence in this group is estimated to be 16.3%

What is the impact of HAI in terms of length of stay on NHS activity?

• Those patients with HAI stay in hospital 70% longer than those without • Normal LOS varies by specialty: – 3.2 additional days in obstetrics – 13.7 days in care of the elderly

What are the costs associated with HAI in Scotland?

• £183 million per year in Scotland in acute hospitals in Scotland • Costs by specialty ranged from: – £2 million per year in Obstetrics – £49 million per year in Medicine

How much cost saving might be anticipated as a result of HAI control?

% reduction of HAI Cost Saving £ millions 10 20 30 40 28.3 36.6 54.9 73.2

3. HAI surveillance in ICU

HAI surveillance: elements of a successful system

• Defining what outcomes to measure • Reliably collecting data in a standardised manner • • Analysing data for intra/ inter-hospital comparisons Using the data in a timely manner to improve quality of care

Gaynes & Solomon J Quality Improvement 1996; 22: 457 -467

Trends in ventilator-associated pneumonia (VAP) rates for all 283 intensive care units participating in the German nosocomial infection surveillance system (KISS) from January 1999 through June 2003. Infection Control and Hospital Epidemiology 28(3):314 –318.

Pooled means and median of the distribution of Ventilator Associated Pneumonia rates by ICU type Ventilator-associated PNEU rate* No. ICUs No. of VAP Ventilator days Pooled mean Median Medical/Surgical ICU Major Teaching All Others Burn ICU Coronary ICU Surgical cardiothoracic ICU Surgical ICU Medical ICU Trauma ICU

*Number of VAP Number of ventilator-days X 1000 58 99 12 48 48 61 64 19 302 372 124 100 265 384 339 329 84,530 135,546 10,098 35,727 46,710 73,205 109,277 32,297 3.6

2.7

12.3

2.8

5.7

5.2

3.1

10.2

2.5

1.6

Not calculated** 1.3

4.0

4.1

2.8

Not calculated** **For percentile distributions, data from at least 20 locations are required National Healthcare Safety Network (NHSN) report, data summary for 2006. Am J Infect Control 2007; 35:290-301

Pooled means and median of the distribution of central line-associated BSI rates by ICU type Central line-associated BSI rate* No. ICUs No. CLAB Central Line Days Pooled Mean Median Medical/Surgical ICU Major Teaching All Others Burn ICU

63 102 14 304 431 127 128,502 198,551 18,612 2.4

2.2

6.8

1.9

1.0

Not calculated**

Coronary ICU Surgical cardiothoracic ICU Surgical ICU

53 51 72 181 150 378 63,941 92,484 197,484

Medical ICU

73 489 170,719

Trauma ICU

21 182 39,635 * Number of CLAB X 1000 Number of Central Line days **For percentile distributions, data from at least 20 locations are required 2.8

1.6

2.7

2.9

4.6

2.0

1.2

2.0

2.2

3.3

National Healthcare Safety Network (NHSN) report, data summary for 2006. Am J Infect Control 2007; 35:290-301

Role of incidence surveillance in US in Monitoring and Preventing Healthcare-Associated Infections

During 1990-2004, rates of infections from medical devices decreased Bloodstream infections from central lines decreased by: 54% in medical ICUs 43% in coronary ICUs 43% in surgical ICUs 27% in paediatric ICUs Trends of ventilator-associated pneumonia rates were assessed and substantially decreased from 31% to 58% among these same ICU types.

* These data are derived from CDC′s NNIS and NHSN systems

Objectives of national surveillance of ICUAI

Surveillance of :

Ventilator Associated Pneumonia CVC Related Infections » Blood stream infections » Local CVC Infections » General CVC RI (Clinical sepsis) Blood Stream Infections (non CVC Related)

At Scottish Level

• Establish a national database of ICUAI surveillance data for Scotland • To provide a nationally agreed methodology for the collection of ICUAI data in Scotland • To provide training, protocols and support for data collection in participating units

At the EU Level

To contribute Scottish data to the European ICUAI dataset

Timescales

• Data collection for the National surveillance programme will begin in January 2009 • HPS will receive data for reporting in January/February 2010 • The first annual report of Scottish data will be produced in Spring 2010

Summary of the Epidemiology of HAI in Scotland

– HAI affects 1 in 10 in acute care at any one time – SSI, GI and UTI are most common in acute care –

S. aureus

and C.

delivery plan

difficile

are the most common organisms – VAP, LRTI and bacteraemia are prevalent in ICU – 30% of acute care patients and 70% of ICU patients are prescribed one or more antimicrobials at any one time – Device, intervention and antimicrobial associated HAI are where there is the most potential for prevention – Prevalence survey results have informed future SGHD policy for tackling HAI and underpin the new HAI task force • Targeted incidence of HAI surveillance in ICU – Aligned to Scottish Patient Safety Programme work