Epidemiology of Surgical Site Infections

1. Epidemiology of Surgical Site Infections Maureen Spencer, RN, M.Ed., CIC Infection Preventionist Consultant Boston, MA www.7sbundle.com www.workingtowardzero.com

2. Healthcare-associated infections (HAIs) are a significant financial challenge for providers Top 5 HAIs: Top 5 HAIs: Incidence and cost1 Percent of total HAI cost1 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 1. Zimlichman E, Henderson D, Tamir O, et al. JAMA Intern Med. 2013;173(22):2039-2046

3. In the coming years, CMS initiatives will increase providers’ accountability for reducing HAIs Timeline of CMS initiatives 2008 2014 2013 2015 2016 2017 Payment withheld on 10 hospital-acquired conditions (HAC) Value-based purchasing (VBP) withholds 1% of Medicare reimbursement VBP penalty increases to 1.5% VBP penalty increases to 1.75% VBP penalty increases to 2% VBP penalty increases to 1.25% 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 HAC reduction program reduces payment to facilities with high rates of infection, such as CLABSI SSIs after colon and abdominal hysterectomy added to HAC reduction program http://www.ssa.gov/history/briefhistory3.html http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html

4. 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 1. 2.

5. back Value-based purchasing creates financial penalties and rewards for performance against quality metrics Reimbursement withholding increases through FY17 • 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) 2.00% 1.75% 1.50% 1.25% 1.00% FY13 FY14 FY15 FY16 FY17 2013 2014 2015 2016 Domain weighting shifts emphasis towards efficiency & outcomes

6. 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)

7. 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 Conditions evaluated under RRP Acute myocardial infarction (AMI) Heart failure Pneumonia COPD* Total Hip Arthroplasty Total Knee Arthroplasty CABG* proposed PCI** 2013 2014 2015 Medicare payment reduction 1% 2% 3% • COPD = chronic obstructive pulmonary disease • CABG = coronary artery bypass graft **PCI = percutaneous coronary intervention

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

10. 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

11. 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 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.

12. 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.

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 13

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.

15. 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 • WHO Guidelines for Safe Surgery 2009. • Engemann JJ et al. Clin Infect Dis. 2003;36:592-598.

16. 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

17. 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.

18. Pathogens survive on surfaces 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. 17:770-2 4. 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 ClinMicrobiol. 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.

19. Prior room occupancy increases risk 1. Martinez et al. Arch Intern Med 2003; 163: 1905-12. 2. Huang et al. Arch Intern Med 2006; 166: 1945-51. 3. Dreeset al. Clin Infect Dis2008; 46: 678-85. 4. Shaughnessy. ICAAC/IDSA 2008. Abstract K-4194. 5. Nseir et al. ClinMicrobiol Infect 2010 (in press).

20. A 7 S Bundle Approach to Preventing Surgical Site Infections AORN – 2014 APIC - 2014

21. 7 “S” Bundle to Prevent SSI SAFETY – is your OPERATING ROOM safe? SCREEN – are you screening for risk factors and presence of MRSA & MSSA SHOWERS – do you have your patients cleanse their body the night before and morning of surgery with CHLORHEXIDINE (CHG)? SKIN PREP – are you prepping the skin with alcohol based antiseptics such as CHG or Iodophor? 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?