health care associated infections common but - there are now many interventions we can implement...
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Health Care associated Infections
Common but - there are now many
interventions we can implement that will reduce them
Prof Peter CollignonThe Canberra Hospital
Australian National University
What are health-care associated infections?
• Any infection that occurs following a health care procedure
– All “hospital onset” infections
– But many now also have a “community onset” but related to medical care
– wound infection– Many blood stream infections
Examples
• Blood stream infections• IV catheters
• Wound infections• After surgery• May be deep seated
• Urinary tract• Catheters
• Respiratory tract• Ventilators• drugs
Why do these infections occur?
• Breach normal defense barriers– Skin– Respiratory tract– Acid in stomach
• Lowered immune defenses– Chemotherapy– Part of disease
• Increased exposure– Resistant bacteria
Health care infections are common
• Very common; – various studies in many countries– Likely between 5 -10% of all admissions
develop a new infection
• Most are relatively minor– UTI, superficial wound
• But many Serious and Life threatening– Blood stream– Prosthetic joints etc
Patient safety is important• Hospitalisation is inherently hazardous
– Drug errors most common misadventure
– But infections are 2nd biggest problem
– Occur in at least 10% of acute admissions
• 50-80% potentially preventable
• Misadventures primarily result from system failures
not incompetence
• We need national and comparative data
Clinical Excellence Commission, 2005; Leape 2000; Wilson et al 1995
Serious infections are common
• Blood Stream infections– Most from IV catheters– In Australia likely about 4,000 per year– In USA more than 200,000 per year
• High mortality and morbidity attached– With MRSA blood stream infections - 35%– Central nervous system - lower but still >5%
– In Australia - about 400 deaths per year and USA 20,000 from JUST IV catheters!
How hazardous is healthcare?Dr. Lucien Leape Harvard Medical School. USA
Dangerous Regulated Ultrasafe(>1/1000) (< 1/100,000
Total liveslost per
year
1
10
100
1000
10,000
100,000
1 10 100 1000 10,000 100,000 1M 10M
Bungeejumping
Mountainclimbing
Healthcare
Driving
Chemicalmanufacturing
Charteredflights
Scheduled airlines European
railroadsNuclearpower
Number of encounters for each fatality
How hazardous is healthcare?Dr. Lucien Leape Harvard Medical School. USA
Dangerous Regulated Ultrasafe(>1/1000) (< 1/100,000
Total liveslost per
year
1
10
100
1000
10,000
100,000
1 10 100 1000 10,000 100,000 1M 10M
Bungeejumping
Mountainclimbing
Healthcare
Driving
Chemicalmanufacturing
Charteredflights
Scheduled airlines European
railroadsNuclearpower
Number of encounters for each fatality
Hospital-Acquired Blood stream infections;
8th leading cause of death in USA
Emerging Infectious Diseases April 2001
http://www.cdc.gov/ncidod/eid/vol7no2/wenzel.htm
Staphylococcus aureus
• Common– Many sites esp blood, wounds
• Bacteraemia likely 7,000 per year in Australia– 50% hospital onset– 1/3 of community onset are health care related
• High mortality in bacteraemia– Pre-antibiotics 82%– MSSA median 25%– MRSA median 35%
Antibiotic Resistance is common
• Penicillin
• Beta-lactams– MRSA
• Other common agents– macrolides etc
• Vancomycin– New forms of resistance
• New agents– linezolid
Serious Morbidity also common
Prosthetic joint infection (eg hip)– To cure need 2 major operations, 8- 10
weeks incapacitated.– > $100,000 per episode– 1 to 2% of all joint replacements
– when things go well!
Blood stream infections; serious morbidity
• Blood stream infections– Renal failure, osteomyelitis, prolonged
antibiotic therapy etc
Blood stream infections are common;and more than 60% of these are health care
associated
The Canberra Hospital 1998 1999 2000 2001 2002 2003 2004
Significant 337 307 320 288 271 316 354
Indeterminate 37 37 37 36 30 32 25
Contaminant 245 200 195 197 217 210 235
Total positive Blood cultures 619 544 552 521 518 558 614
This means that at the Canberra Hospital each year over 200 BSI episodes are Health-care associated
Many primary sites for BSI; but IV catheters main site at all major hospitals
Body system (TCH data) 1998 1999 2000 2001 2002 2003 2004 Total
IV Device 109 72 81 54 39 45 42 442
Respiratory 50 36 54 31 41 49 47 308
GIT 47 38 46 43 40 41 59 314
Genito-urinary 43 38 38 43 45 54 70 331
Skin 24 22 22 19 18 27 35 167
Unknown 19 39 32 37 32 28 27 214
Cardiovascular 13 9 10 12 8 19 14 85
Musculo-skeletal 10 14 5 13 12 20 19 93
Haematology 9 17 10 15 16 15 20 102
Maternal 9 4 5 5 6 3 2 34
Neurology 4 13 8 7 6 5 5 48
Other 0 0 2 1 1 1 0 5
Prim Bacteraemia 0 5 7 8 7 9 14 50
Infections can be reducedBSI from IV catheter sepsis (The Canberra
Hospital)
0
0.5
1
1.5
2
2.5
3
Epi
sode
s/1,
000
Sep
s (in
clud
ing
sam
e da
y)
Interventions that decreased IV sepsis
INTERVENTIONS HOSPITAL UNITS
Prospective surveillance of BSI's Hospital wide
Tunnelling of vascaths Renal medicine
CVC retention by exception ICU
Prevention of septic flush by correct alcohol usage Oncology / Haematology
Monitoring of peripheral IV policy compliance Aged care / General surgery
Blood culture collection poster Hospital wide
Patient information pamphlet for CVC care Hospital wide / community
Introduction of Alcoholic chlorhexidine skin prep Hospital wide
Reduction in the use of TPN Hospital wide
Notification of IVD BSI as a critical incident Hospital wide / Medical officer
Dissemination of BSI project information Hospital wide / GP's / Media
IV catheter infections can be reduced
• Too many used• In for too long• Poor selection of most
appropriate catheters• Poor selection of sites• Almost every doctor inserts
them• including CVC’s - even if little training
• CVC’s used instead of peripheral catheters
• for convenience BUT much higher per day risk
IV’s; what can be done?
• Protocols already exist• CDC, Australia, WHO• Guidelines for the Prevention of Intravascular Catheter-Related Infections,
2002http://www.cdc.gov/ncidod/hip/iv/iv.htm
• They need to be followed
• Will be discussion and disagreements on these protocols
• eg peripheral IV catheters – remove after 2-3 days • but these are relatively minor issues
Australian Guidelines
http://www.safetyandquality.org/intravascdevicejun05.pdf
We can have an impact on all types of infections
• Surgical site• Infection rates can be decreased• Hobart, Victoria, TCH, internationally
• Blood stream infections– Especially IV catheter
• Urinary tract• Pneumonia
• All types– If you recognize there is a problem
Alcohol-chlorhexidine hand-rub solution
+ culture change program• A new standard of healthcare
– CDC, WHO, AICA
• Does it work?
• Does it increase hand hygiene compliance?
• Does it reduce nosocomial MRSA infections?
250
0
25
50
75
100
50 75 100Opportunities for hand hygiene per hour of care
Co
mp
lian
ce w
ith h
and
hyg
ien
e (%
)
Pittet et al, Ann Intern Med 1999, 130:126
MRSA colonisation rates and hospital
contamination
Johnson et al. Med J Aust 2005 – 21st November issue
or www.mja.com.au
Health care worker hand-hygiene compliance
Johnson et al. Med J Aust 2005 – 21st November issue
or www.mja.com.au
Use of alcohol/chlorhexidine solution
Johnson et al. Med J Aust 2005 – 21st November issue
or www.mja.com.au
MRSA isolates and patient-episodes of bacteraemia
After 36 months:
Total MRSA isolates:
• 40% reduction (95% CI, 23%–58%)
• 1008 fewer clinical isolates
Patients with MRSA bacteraemia:
• 57% reduction in monthly rate (95% CI, 38%–74%)
• 53 fewer bacteraemias than expected (95% CI, 36–68 episodes)
Johnson et al. Med J Aust 2005 – 21st November issue
or www.mja.com.au
Program costs & financial impact
• $180,000 per year to maintain• Saved $325,000 per year on BSI*• 72,000 separations per year (inc.
day cases)
– $2.50 per patient – BigMac in Australia = $3.20
* Estimated cost: $20,000 AUD per case of MRSA BSI
What can we do?
• Recognize/admit there is a problem
• No self justification• Do we really need to hide the data?
• Measure what is happening
• Meaningful and easy• Research
• Change things• Education• Interventions “but –ins”
• Measure again
Epidemiologists; are they a hindrance?
• Too much time and effort to get the perfect denominator
• This is Not research but quality improvement
Need to collect and have readily available some easy to measure
but important RATES
• Will not be popular with hospitals
– Always reasons why my rates are worse than someone else's
BUT
• We need to do it
US; report cards
What do we need to measure in all hospitals:
Infections
• S. aureus blood stream infection rates
– All episodes- community and hospital onset
– Separate MRSA and MSSA– Per 1,000 hospital separations– Should be on the web for each hospital– Based on pathology systems
AGAR: Rates at different hospitals (total)
Staph. aureus Bacteraemia
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
rate
/ 10
00 a
dm
issi
on
s
Collignon P, Nimmo GR, Gottlieb T, Gosbell IB; Australian Group on Antimicrobial Resistance.Staphylococcus aureus bacteremia, Australia.Emerging Infect Dis. 2005 Apr;11(4):554-61.
Hospital onset
Hospital Acquired Staph. aureus Bacteraemia
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
rate
/100
0 ad
mis
sion
s
MRSA Bacteraemia 1998 - 2004 By separations at Canberra Hospital
0.27
0.21
0.06
0.64
0.50
0.14
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
MRSA hosp. acq MRSA comm. acq MRSA
Ra
te /
1,0
00
se
ps
/1000 separations
/1000 seps >24 hrs
We can improve things
• Need to be motivated• Both internal and external
pressure for better QA is needed• We need to aim for major
improvements
• This can be achieved
Conclusions• Hospital safety is important
• Data can be measured reliably using existing practical, commonsense definitions
• “Simple” interventions can make a huge difference
• But changing human behaviour is not simple and commonsense is not common
• Open transparent reporting is the best form of “risk management”
Conclusions• Hospital safety is important
• Data can be measured reliably using existing practical, commonsense definitions
• “Simple” interventions can make a huge difference
• But changing human behaviour is not simple and commonsense is not common
• Open transparent reporting is the best form of “risk management”
Conclusions• Hospital safety is important
• Data can be measured reliably using existing practical, commonsense definitions
• “Simple” interventions can make a huge difference
• But changing human behaviour is not simple and commonsense is not common
• Open transparent reporting is the best form of “risk management”
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