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From SENIC to bundlesOuti Lyytikäinen, MD, senior medical officerFinnish Hospital Infection Program (SIRO)

Epidemiologic Surveillance and Response UnitDepartment of Infectious Disease Surveillance and Control

27/10/2011 From SENIC to bundles/O Lyytikäinen

27/10/2011 CD surveillance/O Lyytikäinen 2

Disclosures

• No financial or other conflict of interest to disclose• The findings and conclusions in this presentation have

not been formally disseminated by the National Institute for Health and Welfare and should not be construed to represent any agency determination or policy

From SENIC to bundles• Healthcare-associated infection (HAI) surveillance in

the US and Europe• Finnish hospital infection program (SIRO)


SENIC • Study on the Efficacy of Nosocomial Infection Control• About 1/3 of nosocomial infections preventable• Efficient surveillance and control programme

– one infection control nurse/250 beds– designated physician or microbiologist– feedback to reporting units– feedback to individual surgeons



2005-


Since 2003 mandates public reporting: Illinois, Missouri, Pennsylvania, Virginia and Florida, other states later


MRSA bacteremias 2001-, C. difficile 2004- and MSSA bacteremia 2011

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From SENIC to bundles/O Lyytikäinen

KISS: 9 surveillance modules 1997: 20 hospitals2008: 790 hospitalsGermany: in total 2000 hospitals

ICU-KISS

OP-KISS

DEVICE-KISS

AMBU-KISS

MRSA-KISS

NEO-KISS

CDAD-KISS

ONKO-KISS

HAND-KISS


Success stories, KISS/Germany

Finnish hospital infection program

• Improving nosocomial infection control

– Standardization of surveillance methods and timely feedback

• National database of nosocomial infections

• Hospitals can anonymously compare their own NI rates with other hospitals

– Training– Outbreak investigations– Infection control guidelines– Research– Surveillance of

antimicrobial resistance– Preparedness


Background - Finland • 5.3 million population

• Healthcare districts (n=20 plus Åland)– Acute care hospitals: 5 university,15 central and 30-40 other

• HAI surveillance not mandatory in hospitals• Communicable Disease Law passed in 2004

– All health care facilities should have infection control programs– Infection control teams on healthcare district level have a consulting

role in these activities• Infection control (IC)

– 2 surveys on IC resources and activities in 2000 and 2008– IC committees, IC nurses and IC doctors in all university and central

hospitals– Link nurse system common


SIRO - surveillance• Surveillance components

– Hospital-wide surveillance of nosocomial bloodstream infections (BSI) Sep 1998- (I)

– Surveillance of surgical-site infections in several procedure groups 1999- (II)

– Prevalence survey 2005 (III)– Clostridium difficile -associated disease (CDAD) 2008- (IV)

• Most hospitals perform both SSI (4>15) and BSI (4>12) but some only SSI

• Prevalence survey: 30 acute care hospitals• CDAD: 12 hospitals• Surveillance period minimum 3 months

– Almost all are taking part in on continuous basis


Organization

Participating hospitalsIC nurse and doctor, surgeon, microbiologist

SIRO teamPhysician, infection control/research nurse and information technologist

SIRO executive boardDepartment Unit heads from the THLand two external members

Expert groups


Methods• Site visits at participating hospitals• Expert groups with 4-6 members

– Surveillance definitions and protocols• Annual meeting

– Forum for discussion, planning & decision-making• Special meetings for IC nurses and surgeon

– Review of surveillance methods and data as well as controlmeasures

• Training – Course in hospital epidemiology 2000 and 2002– Antibiotic resistance (WhoNet/EARSS, MRSA)– Surveillance of antimicrobial usage– Communication and media– etc.


Principles

• Voluntary, confidential, collaborative & flexible

• No external comparison of hospitals

• Surveillance components– Hospital-wide surveillance (I)– Procedure-specific infections (II)– Prevalence study (III)– Clostridium difficile -associated disease

(CDAD) (IV)


Hospital-wide surveillance (I)• Blood culture positive infections (bloodstream infections, BSI) Sep

1998-

• Laboratory-based case finding– Links between IC nurses and microbiology laboratories

• CDC definition for nosocomial BSI– community/nosocomial– infection/contamination– primary/secondary

• Data collection– Infections on paper forms > electronic reporting– Patient-days by ward and specialty from hospital’s information

technology department > electronic reporting– Date of deaths from the national population register– Data collection form for central line-days


SIRO - feedback• Hospital-wide surveillance data on BSI 1999-

– Primary/secondary BSI and collect data on central lines > central line-associated BSIs

– BSI rates per 1000 patient-days of ward/unit and specialty• hospital specific data by hospitals’ own ward/unit

codes and by national specialty codes • aggregated data by national specialty codes

– Causative microbes and resistance by patient groups• hematological/non-hematological malignancy,

intensive care, surgery, newborns, obstetric care, hemodialysis, organ transplantation

– Case fatality (%) at 7 and 28 days by causative microbes– Central line-associated BSI rates per 1000 central line-days


From SENIC to bundles/O Lyytikäinen27/10/2011

Lyytikäinen O, Lumio J, Sarkkinen H, Kolho E, Kostiala A, Ruutu P and the Hospital Infection Surveillance Team. Nosocomial bloodstream infections in Finnish hospitals in 1999-2000. Clin Infect Dis 2002;35:e14-9.

Procedure-specific surveillance (II)• Surgical-site infections Jan 1999-

– Hip and knee prosthesis, femur fractures, and coronary surgery

– 2002 ’new’ procedure groups: abdominal hysterectomies, appendectomies, breast surgery and cesarean sections

– 2008 laminectomy, spinal fusion

• Data collection – Infections on paper forms > electronic reporting– Denominator data from hospital’s information technology

department (operation theater and administration) > electronic reporting

– Data for the calculation of NNIS risk index: wound class, ASA score and operation time

– Standardized form for post-discharge surveillance


SIRO - feedback• Surveillance data on SSI 1999-

– SSI rates per 100 procedures performed (%) by surgical procedure category

– Stratification• NNIS risk index categories (0-3)• Primary/revisions for hip prosthesis• Elective/emergency

– Distribution of SSI types• Superficial/deep/organ space

– Causative microbes and resistance


Reduction of 28% in SSI rates following hip and knee arthroplasties, 1999-2004 vs 2005 (adjusted OR, 0.72; 0.56-0.92)

SS

I rat

e (%

)

Table. SSI rates and deep SSI rates by procedure and time period.SSI rate Deep SSI rate

Operation Total 1999-2004 2005 Total 1999-2004 2005Total hip arthroplasty 3.8% 4.1% 2.4% 0.6% 0.6% 0.5%Partial hip arthroplasty 4.4% 4.9% 2.1% 1.5% 1.6% 0.8%Knee arthroplasty 2.4% 2.4% 2.5% 0.8% 0.8% 0.7%

Huotari K, LyytikHuotari K, Lyytikääinen O, Virtanen MJ, Hospital Infection Surveillance Team. Reducinen O, Virtanen MJ, Hospital Infection Surveillance Team. Reduction of orthopedic surgical site infections during active surveition of orthopedic surgical site infections during active surveillance. llance. 2424th Annual Meeting of the Scandinavian Society for Antimicrobial th Annual Meeting of the Scandinavian Society for Antimicrobial Chemotherapy (SSAC), Tampere, Finland, 6Chemotherapy (SSAC), Tampere, Finland, 6--9 September, 2007, poster presentation # P9 September, 2007, poster presentation # P--37.37.


• Postdischarge surveillance Huotari K, Lyytikäinen O and the Hospital Infection Surveillance Team. Impact of postdischarge surveillance on surgical site infection rates in orthopedic surgery. Infect Control Hosp Epidemiol 2006;27:1324-9.

• Validation study Huotari K, Agthe N, Lyytikäinen O. Validation of surgical site infection surveillance in orthopedicprocedures. Am J Infect Control 2007;35:216-21.

• Simultaneous bilateral hip and knee joint replacements Huotari K, Lyytikäinen O, Seitsalo S and the Hospital Infection Surveillance Team. Patientoutcomes after simultaneous bilateral total hip and knee joint replacements. J Hosp Infect 2007;65:219-25.

• Disease burden of prosthetic joint infections: capture-recapture estimation Huotari K, Lyytikäinen, Ollgren J, Virtanen MJ, Seitsalo S, Palonen R, Rantanen P and the Hospital Infection Surveillance Team. Disease burden of prosthetic joint infections after hip and knee joint replacement in Finland during 1999-2004: capture-recapture estimation. J Hosp Infect. 2010 Jul;75(3):205-8. .


Research: Orthopedic surgery, 1999-2004

Prevalence Study (III)• Feb-March 2005 the first national prevalence survey• Objectives

– To assess the magnitude of HAI problem in Finnish acute care hospitals

• distribution of HAI types• causative microbes• prevalence of predisposing factors• use of antimicrobials

– To improve hospitals’ own prevalence surveys by providing a common protocol with standardized HAI definitions

• Feedback to participating hospitals comprised the hospital-specific analysis, including and excluding HAIs originated from other institutions, and the overall results stratified by hospital type.


Prevalence survey - research • Prevalence, infection types and causative microbes

Lyytikäinen O, Kanerva M, Agthe N, Möttönen T, Ruutu P and the Finnish Prevalence Survey Study Group. Health care-associated infections in Finnish acute care hospitals: a national prevalence survey, 2005. J Hosp Infect 2008;69:288-94.

• Antimicrobial useKanerva M, Ollgren J, Lyytikäinen O, and the Finnish Prevalence Survey Study Group. Use of antimicrobials in Finnish acute care hospitals – data from national prevalence survey, 2005. J Antimicrobial Chemotherapy 2007;60:440-444.

• Annual burden of HAIKanerva M, Ollgren J, Virtanen MJ, Lyytikäinen O, on behalf of the prevalence survey study group. Estimating the annual burden of healthcare-associated infections in Finnish adult acute care hospitals. Am J Infect Control. 2009 Apr;37(3):227-30. Epub 2008 Dec 25.

– Prevalence > incidence and HAI-related deaths– Sensitivity of National hospital discharge register to detect HAIs– Some cost calculations

• Risk factors for deathKanerva M, Ollgren J, Virtanen MJ, Lyytikäinen O, on behalf of the prevalence survey study group. Risk factors for death in a cohort of patients with and without healthcare-associated infections in Finnish acute care hospitals. J Hosp Infect 2008;70:353-360.

• Case-mix adjustment and hospital ranking for HAI and antibiotic use Kanerva M, Ollgren J, Lyytikäinen O; on behalf of the Finnish Prevalence Survey Study Group. Interhospital differences and case-mix in a nationwide prevalence survey. J Hosp Infect 2010;76:135-138. Kanerva M, Ollgren J, Lyytikäinen O. Benchmarking antibiotic use in Finnish acute care hospitals by patient casemix-adjustment. J Antimicrob Chemother. 2011 Aug 16. [Epub ahead of print]

•27/10/2011 From SENIC to bundles/O Lyytikäinen


Research - HAIs in pediatrics

• Nosocomial BSIs in children Sarvikivi E, Lyytikäinen O, Vaara M, Saxen H. Nosocomial bloodstream infections in children: an eight-year experience at a tertiary care hospital in Finland. Clin Microbiol Infect 2008;14:1072-75.

• Serratia marcescens clusters in NICU Sarvikivi E, Lyytikäinen O, Salmenlinna S, Vuopio-Varkila J, Luukkainen P, Tarkka E, Saxen H. Clustering of Serratia marcescens infections in a neonatal intensive care unit. Infect Control Hosp Epidemiol 2004;25:723-9.

• Fluconazole resistance in Candida parapsilosis in NICUSarvikivi E, Lyytikäinen O, Soll DR, Pujol C, Pfaller MA, Richardson M, Koukila-Kähkölä P, Luukkainen P, Saxén H. Emergence of fluconazole resistance in a Candida parapsilosis strain that caused infections in a neonatal intensive care unit. J Clin Microbiol 2005;43:2729-2735.

• HAIs in cardiac surgery Sarvikivi E, Lyytikäinen O, Nieminen H, Sairanen H, Saxen H. Nosocomial infections after pediatric cardiac surgery. Am J Infect Control. 2008 Oct;36(8):564-9.

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Clostridium difficile


Clostridium difficile -associated disease (CDAD) (IV)• Jan 2008-• To detect severe cases of CDAD and outbreaks• Laboratory-based case finding

• Common surveillance protocol with European Centre for Disease Control and Prevention (ECDC) definitions (severe and recurrent cases, origin)

• One-day training of infection control nurses in Dec 2007 and Jan 2008

• Data collection– Infections on paper forms > electronic reporting– Patient-days by ward and specialty from hospital’s

information technology department > electronic reporting– Date of deaths from the national population register


SIRO - feedback• Hospital-wide surveillance data on CDAD 2008-

– Overall incidence of CDAD• All CDAD cases per 1000 patient-days

– Incidence of nosocomial CDAD• Nosocomial CDAD cases per 1000 patient-days

– CDAD prevalence among admitted patients• Community-associated cases and those associated

to other healthcare facility per 100 admissions– Proportion of severe cases (%)– Case fatality at 30 days (%)



• Overall rate: 0.71 per 1000 patient-days (range by hospitals, 0.10-1.92)• Nosocomial rate: 0.49 per 1000 patient-days (range, 0.05-1.15)• Prevalence at admission: 0.71 per 1000 admissions (range, 0.12-2.18)• PCR ribotype 027 in 5 hospitals: B, D, E, H, K• Germany/KISS 2008 corresponding rates: 0.66, 0.48 and 1.3• Canada 1997 0.66 and 2004-2005 0.65 (range in hospitals, 0.20-1.67)

SIRO surveillance, Jan-Sept 2008

SIRO - website• Closed website for participating hospitals

– IC nurses/doctors and microbiologists– Access by a code

• Hospitals have access to their own data• All hospitals have access to the aggregated data

– Generate and print out analysis tables whenever desired• Hospital specific data on monthly basis• Aggregated data on annual basis (hospital ranking)

– Abstracts and posters• Public website

– Other hospitals/experts, public and media– Annual reports on BSI and SSI– Domestic and international publications


Activities in long-term care - Central Finland



• Joint strategy actions in patient safety including HAIs• Coordinated by the division of health and social services • Communication, events and training• Collaborative projects and research • Development of indicators for HAIs and infection control

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27/10/2011From SENIC to bundles/O Lyytikäinen

Infection control in Nordic countries and Europe

• Surveillance– Mandatory reporting– Publicly available league

tables– Validity and comparability

of data– Misuse of data– Underreporting– Confidentiality– Positive climate

• Learning from each other– ESCMID/ESGNI– EU/HELICS and IPSE ad 2005– WHO patient safety/ HAI and

hand hygiene 2005-– ECDC activities on surveillance

(HAI, EARS, ESAC) and evidence-based guidance 2005-

– Council recommendation on patient safety 2009

– Nordic Infection Control/Nordisk Vårdhygienkonferens


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Acknowledgements• Infection control teams

in Finnish hospitals, including clinical microbiology laboratories

• Research collaborators: Mari Kanerva, Kaisa Huotari, Emmi Sarvikivi, Maija Rummukainen etc

• Colleagues at THL: Tommi Kärki, Teemu Möttönen, Jukka Ollgren etc

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