Usefulness and challenges of SSI settings with limited ... · Dr Alex Aiken London School of ......

Dr Alex Aiken

London School of Hygiene and Tropical Medicine, UK

Usefulness

and challenges of SSI

surveillance in

settings with limited

resources: proposals for

feasible approaches

ICAN Conference, Harare, November 2013

Outline2

1. Why do surveillance for SSI ?

2. How to do SSI surveillance ?

3. How to do SSI surveillance with limited resources ?

4. Uses of SSI surveillance data ?

5. Challenges of SSI surveillance ?

What is a Surgical Site Infection (SSI)?

CDC/NHSN definition of SSI: “Infection occurring at the operation site within 30 days of the procedure.”

Less severe, but harder to

reliably diagnose

More severe, but

less common

ref: Horan TC, Am J Inf Cont 2008

SSI rates in high-income countries

USA: 2.6/100 surg. proc.

Europe: 3/100 surg. proc.

General surgery

3.1%

4.5%

4.7%

Abdominal surgery

23%

11%

Haridas et al, Surgery 2008

Misteli et al, Arch Surg 2009

Hawn et al, J Am Coll Surg ‘08

Greif et al, NEJM 2000

Duttaroy et al, Surg Infect 2009

Gaines RP et al, CID 2001

HELICS, SSI statistical report 2004

Allegranzi B et al.

Lancet 2011;377:228-41

Published on 5 May 2011

http://www.who.int/gpsc/en/

Bagheri Nejad S, et al. Bull OMS

2011;89:757-765

What about low and middle income countries ?

Africa Americas

Eastern

Med. Europe

South-East

Asia West Pacific Internat. Total

Type of

infection Adult Ped Adult Ped Adult Ped Adult Ped Adult Ped Adult Ped Adult Ped Adult Ped All

HAI

general 6 1 31 20 14 3 29 4 15 5 7 6 4 0 106 39 145

SSI 7 3 16 3 8 0 8 0 12 0 5 0 0 0 56 6 62

VAP 1 1 5 0 8 0 4 1 6 2 1 1 0 0 25 5 30

BSI 0 0 5 2 1 1 3 1 3 3 0 2 0 0 12 9 21

HAP 0 1 3 0 0 0 3 0 2 1 0 1 0 0 8 3 11

UTI 1 0 1 0 2 0 2 0 1 0 0 0 0 0 7 0 7

Total 15 6 61 25 33 4 49 6 39 11 13 10 4 0 214 62 276

Type of study by region (pre 2009)

All single centre studies, variable quality

Ethiopia: 21%

15%

Tanzania: 19%

24%

Uganda: 10%

Nigeria: 16-31%

Kenya: 19%

CAR: 18%

SSI incidence in Africa (studies from 1995-2009)

Bagheri Nejad S et al. WHO Bull 2011;89:757–765

Algeria: 12%

Ethiopia

12% & 18% (Obs)

SSI frequency in specific African countries

(studies from 2010-2013)

Nigeria

12% (Obs)

16% (Obs)

17% (Abd S)

20% & 24% (Ped)

Sudan

25% (GS)

Tanzania

26% (GS)

Kenya

7% (Ped)

Burkina

24% (GS)

Mali

12% (Ped)

Egypt

17% (GS)

Proportions of hospital-acquired infection, by type

29

24

19

1513

17

27

11

2421

20

36

11 11

22

0

5

10

15

20

25

30

35

40

L/M Income Europe USA

SSI

UTI

BSI

HAP/VAP

OTHERS

%

What is surveillance ? 10

“Epidemiological surveillance is the continued watchfulness over

the distribution and trends of incidence through the systematic

collection, consolidation and evaluation of morbidity and mortality

reports and other relevant data, and the regular dissemination of

data to all who need to know.”

Collection

Systematic Evaluation of disease data

Dissemination

NB: surveillance ≠ research

1. Why do SSI surveillance ? 11

SENIC: Study on the Efficacy of Nosocomial Infection

Control, conducted by CDC, USA 1974-80

This was conducted as there were:

Increasing numbers of “vulnerable” patients

Emerging bacterial resistance to antibiotics

Increasing rates of HAI observed in USA in 1960-70’s

SENIC study: methods12

Comparison 338 hospitals sampled from across the USA

Measured the rates of nosocomial infections in random samples of 500 patient-admissions from each hospital

Standardised definitions of HAI used.

Measured confounding factors: size and type of hospital, region, nurse-to-patient ratio and many others.

Assessed the quality of Hospital Infection Control Program in each hospital

Ref: Haley, RW. “Efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals”, Am J Epi 1985

SENIC study: SSI13

Excellent

Good

Fair

Poor

Excellent

Good

Fair

PoorSurveillance

Activity

Infection

Control Activity

Results: lowest rates of

nosocomial infection with

the combination of

surveillance and IC activity

SENIC study: results14

Hospitals with an “effective” infection control program had 32% lower rates of HAI, even after controlling for other differences between hospitals.

Recommendations from SENIC:

An “effective” Infection Control Program requires

1. A system of surveillance for detecting HAI

2. An Infection Control Physician

3. 1 Infection Control Nurse / 250 beds

4. A system of reporting infection rates to practicing surgeons

2. How to do SSI surveillance ? 15

In USA – following CDC recommendations

Other high-income countries typically follow these.

Important principles

Lead by infection control staff

30-day follow-up time-period

Both IP and OP periods

Combine data from diverse sources

Risk stratification by NNIS criteria

3. How to do SSI surveillance with limited $

In many African hospitals …

Lack of IPC facilities, materials, staff, budget

Limited microbiology services

Excessive (+ irrational?) antibiotic usage

Hard to discriminate prophylaxis v treatment ?

SSI surveillance very rarely performed

17

Kenya

AIC Kijabe Hospital, Nairobi

Jack Barasa, Carol Mwangi,

Peter N’thumba…

Uganda

1. Kisiizi Hospital, Kisiizi

Gabriel Okumu, Robert

Mugrobe, Agnes Katwsigye…

2. Mulago Hospital, Kampala

Peter Ongom, Alex Elobu,

Dorah Nakamwa…

Zimbabwe

Parirenyatwa Hospital, Harare

Sheba Chuma, Matthew Wazara,

Salome Biri…

Zambia

Ndola Central Hospital, Ndola

Joseph Musowoya, Margaret

Kasepa, Mayaba Maimbo…

Benedetta Allegranzi

Alex Aiken

Zeynep Kubilay

Joyce Hightower

Sean Berenholtz

Kathryn Taylor

And many, many others

Project planning throughout 2013,

SSI surveillance since Jan 2014 – currently ongoing

SUSP study format – ideally 18

SSI Surveillance

SUSP intervention

1

Start of data collection

approx Jan 2014

End data collection

approx Dec 2014

SSI Surveillance

SUSP intervention

2

SSI Surveillance

SUSP intervention

3

SSI Surveillance

SUSP intervention

4

SSI Surveillance5SUSP intervention

SUSP study format – actually 19

SSI Surveillance

SUSP intervention

1

Start of data collection

approx Jan 2014

End data collection

approx March 2015

SSI Surveillance

SUSP intervention

2

SSI Surveillance

SUSP intervention

3

SSI Surveillance

SUSP intervention

4

SSI Surveillance

SUSP intervention

5

Now

3. How to do SSI surveillance with limited $

There is no “right” method for surveillance …

(but there are probably some “wrong” ones !)

Important questions

- What data to collect, over what time-period ?

- How to evaluate the data ?

- What will you do these data ?

- How can you do all this at low cost ?

This is what we have

been doing in …

Risk factors for SSI

Operation factors

• Surgical Wound Class

•Procedure

•Contamination

• Surgeon’s skill

• Length of operation

• Use of prophylaxis

• Use of drains/prostheses

• Number of people in room

Patient-related factors

• Age

• ASA score

• Diabetes

• HIV status

• Nutritional status

• Smoking

Microbiological factors

• Skin/GI/nasal carriage of micro-organisms

• Bacterial virulence factors + drug resistance

• Length of pre-operative admission

Institutional factors

• Operating theatre construction: airflow, bacterial contamination, cleaning

• Staffing – nurse:patient ratio

• Crowding of patients

1. How long to follow-up ? How to contact patient ?

2. Relevant PROCESS data

3. Risk stratification data SWC, ASA, op duration

4. OUTCOME data SSI outcomes

What data to collect + when ?

Eg. Surgeon handwashing,

pt skin prep, door openings,

antibiotic prophylaxis use

How many

contacts with

patient in

30 days ?

Why we need 30 day follow-up23

Day 0 Day 3 Day 7 Day 10 Day 14 Day 28

Dete

ctio

n o

f SSI

Operation ? Discharge ?

Inpatient periodOut-patient period

Telephone calls after discharge

Clinician review

= GOLD STANDARD

No SSI SSI

Pho

ne c

all

sta

tus No SSI 66 7

SSI 0 16

On this basis

Sensitivity of phone call = 69.6% (95%CI 47.1-86.8%)

Specificity of phone call = 100% (95%CI 95-100%)

When phone calls and clinical reviews were within 48 hours of each other

Ref: Aiken et al, Evaluation of surveillance for SSI at Thika Hospital, Kenya; JHI, 2011

Risk stratification – NNIS system 25

Surgical Wound Class

0 if Clean or Clean-Contaminated

1 if Contaminated or Dirty/Infected

ASA score

0 if ASA score = 1 or 2

1 if ASA score = 3, 4 or 5

Length of operation

0 if < procedure-specific duration

1 if ≥ procedure-specific duration

Total score of 0 – 3 for each operation

Compares “like with like” within operation-type

Risk stratification with limited $ 26

Is NNIS system suitable ?

Measurable ?

Minimal additional cost / effort to collect data

Each component possible to record reliably

Easy to use system

Predictive of SSI risk ?

Different results in different studies

Surgical Wound Class most consistently predictive

SSI risk in developing countries

according to wound classification

SSI pooled means:

11.5, 16.6, 21.3, 38.8

episodes per 100 SP

(from clean to dirty)

◊ NNIS reports

Adapted from Allegranzi B et al. Lancet 2011;377:228-41

A standard definition of an SSI ?

CDC/NHSN definition of SSI: “Infection occurring at the operation site within 30 days of the procedure.”

ref: Horan TC, Am J Inf Cont 2008

What not to include in SSI surveillance?29

Risk factors that are…

Extremely rare eg. morbid obesity ?

Hard to measure eg. S.aureus colonisation ?

Process data that are

Hard to alter eg. theatre air-flow data ?

Outcomes that are

Unrelated to SSI eg wound cosmesis ?

SUSP method for surveillance

Peri-operative form Post-operative form

Slide 30/20

Plus Epi-Info database, handbook, regular quality feedback, other training materials …

Page 31

Francis Mwangi Kirathi

Perforated appendix

123456789029yrs

Male Number comes from EpiInfo !

Appendisectomy ( APPY)

Appendisectomy + washout

20/12/2013

Jack Barasa

Consultant

5

20/12/2013

4 15

4

6

11

Use of the peri-operative form …

SUSP tools for SSI surveillance

Peri-operative form Post-operative form

Slide 32/20

Plus Epi-Info database, handbook, regular quality feedback, other training materials …

Page 33

Appendisectomy

Seen on ward round – some wound pain only

20/12/2013

AA

AA

24/12/2013

2/1/2014

Re-admitted with wound breakdown and pus +++

Use of the post operative form …

28/12/2013 discharged AA

Page 34

02/01/2014

02/01/2014 swab E. coli

Ampicllin R Gent R Cipro S

Ceftria x S Erythro R Clinda S

06/01/14Alex Aiken

Recording an SSI should look like this…

Quality Improvement measures

Process eg “correct” use of antibiotics,

appropriate pre-op skin preparation

Outcome eg. occurrence of SSI

Balancing effects eg. costs, staff time

Continuous v step-wise improvements ?

4. Uses of SSI surveillance data ?

Following slides courtesy of

Robert Mugrobe (Kisiizi Hospital)

from SUSP webinar October 2014

36

Kenya

AIC Kijabe Hospital, Nairobi

Jack Barasa, Carol Mwangi,

Peter N’thumba…

Uganda

1. Kisiizi Hospital, Kisiizi

Gabriel Okumu, Robert

Mugrobe, Agnes Katwsigye…

2. Mulago Hospital, Kampala

Peter Ongom, Alex Elobu,

Dorah Nakamwa…

Zimbabwe

Parirenyatwa Hospital, Harare

Sheba Chuma, Matthew Wazara,

Salome Biri…

Zambia

Ndola Central Hospital, Ndola

Joseph Musowoya, Margaret

Kasepa, Mayaba Maimbo…

Monthly webinars for

- Progress reports

- (Re-)training

- Sharing experiences …

- SSI surveillance since Jan - Feb 2014

- Developed local multi-modal SUSP

intervention plan

- Started intervention phase of SUSP

in July 2014

Rural area of SW Uganda

- Independent mission hospital

- Also participates in WHO African

Partnerships for Patient Safety (APPS)

INTERVENTION MEASURES

15

2123

26

44

30

47

59

52

8

16

26

29

23

18

15

21

8

0

10

20

30

40

50

60

70

1 2 3 4 5 6 7 8 9

Num

ber

of

op

era

tions

Month of 2014

Pre op patient bath

yes

no

Start of intervention

0

20

40

60

80

100

120

1 2 3 4 5 6 7 8 9

% p

art

icip

ants

Hair removal

clipper

not done

razor

1 2 3 4 5 6 7 8 9

Yes 13 41 8.2 0 4.5 47.9 100 94.9 100

No 87 59 91.8 100 95.5 52.1 0 5.1 0

0

20

40

60

80

100

120

% a

llow

ed to

dry

Patient skin prep allowed to dry

0

10

20

30

40

50

60

70

80

1 2 3 4 5 6 7 8 9

Num

ber

of

opera

tion

s

Pre-operative antibiotic prophylaxis administration

yes

no

5. Challenges of SSI surveillance?

our SUSP experience41

Data quality

Missing or inconsistent data ?

Incomplete follow-up ?

Data management

Epi-Info analysis issues …

Data sharing + back-up via

Staff issues

$ for extra staff = 1 new nurse / site

Intensive+repetitive work

Limiting to approx 50 surveillance ops / month

Hasn’t been a problem in

SUSP – but had intensive

training + support

42

Kenya

AIC Kijabe Hospital, Nairobi

Jack Barasa, Carol Mwangi,

Peter N’thumba…

Uganda

1. Kisiizi Hospital, Kisiizi

Gabriel Okumu, Robert

Mugrobe, Agnes Katwsigye…

2. Mulago Hospital, Kampala

Peter Ongom, Alex Elobu,

Dorah Nakamwa…

Zimbabwe

Parirenyatwa Hospital, Harare

Sheba Chuma, Matthew Wazara,

Salome Biri…

Zambia

Ndola Central Hospital, Ndola

Joseph Musowoya, Margaret

Kasepa, Mayaba Maimbo…

Benedetta Allegranzi

Zeynep Kubilay

Joyce Hightower

Sean Berenholtz

Kathryn Taylor

And many, many others

Many thanks to all my colleagues in SUSP

Questions?