1. The epidemiology of HAI Scotland Dr Jacqui Reilly Consultant Epidemiologist Head of HAI and IC Group

2. 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

3. 1. Epidemiology of HAI in Scotland

4. 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.

5. SAB HEAT trajectory

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

7. 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

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

9. –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

10. 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

11. What was the overall prevalence of HAI? Acute hospitals 9.5% (8.8, 10.2) Non-acute hospitals 7.3% (6.0, 8.6)

12. What type of HAI were found in acute hospitals?

13. 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 Total10035 129 patients surveyed in ICUPrevalence = 35/129= 27.1%

14. How did HAI prevalence vary in different acute specialties?

15. Prevalence of HAI by ward type

16. Which organisms were most prevalent? CDC definition organism requirement Acute hospitals –540 microbiology reports for 1243 HAI –Most common types: Staph. Aureus, C.diff

17. 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

18. What were the most prevalent invasive devices in acute hospitals?

19. Prevalence of device use in the ICU Device Prevalence (%) No. of patients Peripheral Vascular Catheter 96.454 Central Venous Catheter75.042 Mechanical Ventilation69.639 Urinary Catheter82.146

20. 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%

21. 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

22. 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

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

24. 3. HAI surveillance in ICU

25. 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

26. 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.

27. Ventilator-associated PNEU rate* No. ICUs No. of VAP Ventilator days Pooled mean Median Medical/Surgical ICU Major Teaching 5830284,5303.62.5 All Others 99372135,5462.71.6 Burn ICU1212410,09812.3Not calculated** Coronary ICU4810035,7272.81.3 Surgical cardiothoracic ICU 4826546,7105.74.0 Surgical ICU6138473,2055.24.1 Medical ICU 64339109,2773.12.8 Trauma ICU1932932,29710.2Not 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 2006. Am J Infect Control 2007; 35:290-301 Pooled means and median of the distribution of Ventilator Associated Pneumonia rates by ICU type

28. Central line-associated BSI rate* No. ICUs No. CLAB Central Line Days Pooled Mean Median Medical/Surgical ICU Major Teaching 63304128,5022.41.9 All Others 102431198,5512.21.0 Burn ICU1412718,6126.8Not calculated** Coronary ICU5318163,9412.82.0 Surgical cardiothoracic ICU 5115092,4841.61.2 Surgical ICU72378197,4842.72.0 Medical ICU 73489170,7192.92.2 Trauma ICU2118239,6354.63.3 * 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 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

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

30. 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

31. 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

32. 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