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.

SAB HEAT trajectory

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

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

–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 National prevalence survey of HAI

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 Design of the Survey

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?

HAIs prevalence by type in the ICU InfectionPercentageNo. patients Blood Stream8.63 Central Nervous System2.91 Ear Nose Throat2.91 Gastrointestinal2.91 Lower respiratory25.79 Pneumonia14.35 Surgical site14.35 Urinary tract2.91 Multiple25.79 Total patients surveyed in ICUPrevalence = 35/129= 27.1%

How did HAI prevalence vary in different acute specialties?

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?

Prevalence of device use in the ICU Device Prevalence (%) No. of patients Peripheral Vascular Catheter Central Venous Catheter Mechanical Ventilation Urinary Catheter82.146

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= = 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?

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:

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 Infection Control and Hospital Epidemiology 28(3):314–318.

Ventilator-associated PNEU rate* No. ICUs No. of VAP Ventilator days Pooled mean Median Medical/Surgical ICU Major Teaching , All Others , Burn ICU , Not calculated** Coronary ICU , Surgical cardiothoracic ICU , Surgical ICU , Medical ICU , Trauma ICU , Not calculated** *Number of VAP X 1000 Number of ventilator-days **For percentile distributions, data from at least 20 locations are required National Healthcare Safety Network (NHSN) report, data summary for Am J Infect Control 2007; 35: Pooled means and median of the distribution of Ventilator Associated Pneumonia 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 ,6126.8Not calculated** Coronary ICU , Surgical cardiothoracic ICU , Surgical ICU , Medical ICU , Trauma ICU , * Number of CLAB X 1000 Number of Central Line days **For percentile distributions, data from at least 20 locations are required National Healthcare Safety Network (NHSN) report, data summary for Am J Infect Control 2007; 35: Pooled means and median of the distribution of central line-associated BSI rates by ICU type

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

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 Objectives of national surveillance of ICUAI

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. 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 delivery plan Targeted incidence of HAI surveillance in ICU –Aligned to Scottish Patient Safety Programme work