Epidemiology of Surgical Site Infections Maureen Spencer, RN, M.Ed., CIC Infection Preventionist Consultant Boston, MA

Healthcare-associated infections (HAIs) are a significant financial challenge for providers 2 Top 5 HAIs: Incidence and cost 1 Percent of total HAI cost 1 1. Zimlichman E, Henderson D, Tamir O, et al. JAMA Intern Med. 2013;173(22): HAI type Annual occurrences Average cost per case CLABSI40,411$45,814 VAP31,130$40,144 SSI158,639$20,785 C. difficile133,657$11,285 CAUTI77,079$896 C. difficile =Clostridium difficile infection CAUTI =Catheter-associated urinary tract infection CLABSI = Central line-associated bloodstream infection SSI =Surgical site infection VAP = Ventilator-associated pneumonia

In the coming years, CMS initiatives will increase providers’ accountability for reducing HAIs 3 HAC reduction program reduces payment to facilities with high rates of infection, such as CLABSI Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html SSIs after colon and abdominal hysterectomy added to HAC reduction program Timeline of CMS initiatives 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 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 a Total 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 FY13FY14FY15FY16FY % 1.25% 1.50% 1.75% 2.00% Domain weighting shifts emphasis towards efficiency & outcomes

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 Medicare payment reduction Conditions evaluated under RRP Acute myocardial infarction (AMI) Heart failure Pneumonia COPD* Total Hip Arthroplasty Total Knee Arthroplasty 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 InfectionEstimated No. Pneumonia157,500 Gastrointestinal Illness123,100 Urinary Tract Infections93,300 Primary Bloodstream Infections71,900 Surgical site infections from any inpatient surgery 157,500 Other types of infections118,500 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: Multistate Point-Prevalence Survey of Health Care–Associated Infections.

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 approximately 1.9% developed SSI 1 Between SSIs accounted for 23% of 69,475 HAIs reported to NHSN 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): Sievert DM at al Antimicrobial resistant pathogens associated with healthcare associated infections. Summary of data reported to the Centers for Disease Control and Prevention 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 Infection control and hospital epidemiology. 2013;34(1):1-14.

13 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

Pathogen Involved with SSIsNo (%) of SSI PathogensRank Staph aureus (includes MRSA)6415 (30.4)1 Coagulase neg staph2477 (11.7)2 E.Coli1981 ( 9.4)3 Enterococcus faecalis1240 ( 5.9)4 Pseudomonas aerug1156 ( 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 organisms3399 (16.1) Total21,100 (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 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 discharge 1 – 2x more likely to spend time in intensive care 1 – 2x more likely to die after surgery 1 The mortality risk is higher when SSI is due to MRSA – A patient with MRSA is 12x more likely to die after surgery WHO Guidelines for Safe Surgery Engemann JJ et al. Clin Infect Dis. 2003;36:

16 HAIEst Annual %Est Direct CostAvg Length of StayAttributable 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 $90,000 1,2  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): 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 ;36(5):

Pathogens survive on surfaces OrganismSurvival period Clostridium difficile35- >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> days. 7,9 Acinetobacter150- >300 days. 7,11 Klebsiella> days. 6,7 Salmonella typhimurium10 days- 4.2 years. 7 Mycobacterium tuberculosis120 days. 7 Candida albicans120 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) days. 7 Blood-borne viruses (eg: HBV or HIV)>7 days Beard-Pegler et al J Med Microbiol. 26: BIOQUELL trials, unpublished data. 3. Bonilla et al Infect Cont Hosp Epidemiol. 17: Boyce J Hosp Infect. 65: Duckworth and Jordens J Med Microbiol. 32: French et al ICAAC. 7. Kramer et al BMC Infect Dis. 6: Otter and French J Clin Microbiol. 47: Smith et al J Med. 27: Wagenvoort et al J Hosp Infect. 45: Wagenvoort and Joosten J Hosp Infect. 52:226-7.

Prior room occupancy increases risk StudyHealthcare associated pathogen Likelihood of patient acquiring HAI based on prior room occupancy (comparing a previously ‘positive’ room with a previously ‘negative’ room) Martinez VRE – cultured within room 2.6x Huang VRE – prior room occupant 1.6x MRSA – prior room occupant 1.3x Drees VRE – cultured within room 1.9x VRE – prior room occupant 2.2x VRE – prior room occupant in previous two weeks 2.0x Shaughnessy C. difficile – prior room occupant 2.4x Nseir A. baumannii – prior room occupant 3.8x P. aeruginosa – prior room occupant 2.1x 1.Martinez et al. Arch Intern Med 2003; 163: Huang et al. Arch Intern Med 2006; 166: Drees et al. Clin Infect Dis 2008; 46: Shaughnessy. ICAAC/IDSA Abstract K Nseir et al. Clin Microbiol Infect 2010 (in press).

A 7 S BUNDLE APPROACH TO PREVENTING SURGICAL SITE INFECTIONS AORN – 2014 APIC

7 “S” Bundle to Prevent SSI SAFETY – 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?