Health Protection Scotland (HPS) Dr Christopher Sullivan Epidemiologist

SURGICAL SITE INFECTION (SSI) PROGRAMME Health Protection Scotland (HPS) Dr Christopher Sullivan Epidemiologist

Surgical site infection (SSI) is one of the most common healthcare associated infections (HAI) estimated to account for 15.9% 1 of inpatient HAI SSI cause: - excess morbidity and mortality, - on average to double the cost of treatment, - increase in length of stay 2. SSI is the most preventable of all HAI 1,3 1.Health Protection Scotland. NHS Scotland National HAI Prevalence Survey. Final Report 2007;Health Protection Scotland [Report]. 2.Broex EC, van Asselt AD, Bruggeman CA, van Tiel FH. Surgical site infections: how high are the costs? J Hosp Infect 2009 Jul;72(3):193-201. 3.Harbarth S, Sax H, Gastmeier P. The preventable proportion of nosocomial infections: an overview of published reports. J Hosp Infect 2003;54:258-66.

Aims of SSI Surveillance Collect surveillance data on SSIs to permit estimation of the magnitude of SSI risks in hospitalised patients. Analyse and report SSI surveillance data and describe trends in infection rates. Provide timely feedback of SSI rates to assist surgical units in minimising the occurrence of SSIs.

Role of HPS To co-ordinate, facilitate and support the implementation of SSI surveillance To prepare Protocols To prepare data collection tools To support on-going data management and ensure quality data To collate and report the national data set

Mandatory requirements for SSI surveillance In 2001, the Scottish Executive established the requirement for all NHS boards to participate in inpatient SSI surveillance of at least two procedures from a list of ten in the Health Department Letter HDL(2001)57 Prospective readmission surveillance for hip arthroplasty and PDS for caesarean section procedures for 30 post operative days was made a mandatory requirement in January 2007 through the release of HDL(2006)38 The period of post discharge surveillance (PDS) for caesarean sections was reduced to ten post operative days from April 2009 by Chief Executive Letter CEL 11 (2009)

Surveillance data

In this eighth year of surveillance (2010) a total of 15 NHS boards, 14 territorial and one special NHS board, participated in the mandatory programme of SSI surveillance The SSI rates for hip arthroplasty and caesarean section have decreased since 2003 but have remained relatively stable over the last three years of reporting, 2008-2010

Rate of inpatient SSI per 100 procedures for caesarean section and hip arthroplasty procedures in Scotland, 2003 to 2010 2.5% 2.0% SSI rate (%) 1.5% 1.0% 0.5% 0.0% 2003 2004 2005 2006 2007 2008 2009 2010 Year Caesarean section Hip arthroplasty

Rate of inpatient and PDS to day 10 SSI per 100 procedures for caesarean section and inpatient and readmission to day 30 SSI for hip arthroplasty procedures per quarter, 2007 to 2010 6.0% 5.0% SSI rate (%) 4.0% 3.0% 2.0% 1.0% 0.0% Jan-Mar 07 Apr- Jun 07 Jul-Sep 07 Oct -Dec 07 Jan-Mar 08 Apr-Jun 08 Jul-Sep 08 Oct -Dec 08 Jan-Mar 09 Apr-Jun 09 Jul- Sep 09 Oct -Dec 09 Jan- Mar 10 Apr- Jun 10 Jul- Sep 10 Oct -Dec 10 Quart er Caesarean section Hip arthroplasty

SSI rate by hip arthroplasty procedure January to December 2010 Procedure Primary total hip replacement Primary hip hemi arthroplasty Revision of total hip replacement Revision of hip hemi arthroplasty Repair of neck of femur* Number of procedures Inpatient Number of SSI Readmission to day 30 Total Total SSI Rate % 6166 15 22 37 0.6% 239 1 0 1 0.4% 660 4 4 8 1.2% 22 1 0 1 4.5% 2152 35 20 55 2.6% Not recorded 67 1 1 2 3.0% Total 9306 57 47 104 1.1% *This only includes procedures which were previously categorised as primary hip hemi arthroplasty

SSI rate for both inpatient and readmission to day 30 by hip arthroplasty procedure January to December 2010 5.0% 4.5% 4.0% 3.5% 3.0% SSI rate (%) 2.5% 2.0% 4.5% 0.9% 1.5% 1.5% 1.0% 0.6% 1.6% 1.5% 0.5% 0.5% 0.0% 0.4% 0.2% Primary total hip replacement (n=6166) 0.4% Primary hip hemi arthroplasty (n=239) 0.6% Revision of total hip replacement (n=660) Revision of hip hemi arthroplasty (n=22) Repair of neck of femur (n=2152) Not recorded (n=67) 0.6% Total (n=9306) Procedure category Inpatient Readmission to day 30

SSI rate by caesarean section procedure January to December 2010 Procedure Number of procedures Number of SSI Total SSI Rate % Caesarean section (elective) Inpatient PDS to day Total 10 6456 15 140 155 2.4% Caesarean section (non elective) 8770 37 237 274 3.1% Not recorded 3 0 0 0 0.0% Total 15229 52 377 429 2.8%

SSI rate for both inpatient and PDS to day 10 by caesarean section procedure January to December 2010 3.5% 3.0% 2.5% SSI rate (%) 2.0% 1.5% 2.2% 2.7% 2.5% 1.0% 0.5% 0.0% 0.2% 0.4% 0.3% Caesarean section elective (n=6456) Caesarean section (non-elective) (n=8770) Total (n=15229) Procedure category Inpatient PDS to day 10

Proportion of SSI involving superficial incisions or deep and organ space, January 2007 to December 2010, for hip arthroplasty (inpatient and readmission to day 30) and caesarean section (inpatient and PDS to day 10) 100% 90% 16.9% 6.9% 3.7% SSI types as proportion of total SSI types 80% 70% 60% 50% 40% 30% 20% 10% 36.9% 56.6% 51.3% 30.6% 89.6% 94.1% Not recorded Organ/Space Deep Superficial 0% Hip arthroplasty inpatient (n=274) Hip arthroplasty readmission to day 30 (n=160) Caesarean section inpatient (n=289) Caesarean section PDS to day 10 (n=1550) 2007-2010

More details The Annual Surveillance of Healthcare Associated Infections Report January - December 2010 http://www.documents.hps.scot.nhs.uk/hai/annualreport/annual-surveillance-hai-report-2010.pdf

Developments

OPCS4 codes HPS has reviewed the OPCS4 codes included in the surveillance to allow greater comparability with results produced by the Health Protection Agency (HPA) The list of OPCS4 codes which are included from July 2010 can be found within the SSHAIP standardised national protocol: http://www.hps.scot.nhs.uk/haiic/sshaip/guidelinedetail.aspx?id=31554

SAPG quarterly reporting This report has been developed in collaboration with SAPG and data for Q4 2010 was the first to be reported. It contains information on caesarean section and hip arthroplasty surgery compliance. This includes: the number of prophylactic antibiotics used the doses of prophylactic antibiotic given the last dose prophylactic antibiotic timing the timing of first dose antibiotics compliance with local guidelines antibiotic cement used for hip arthroplasty

Future developments

Light SSI Surveillance represents the minimal data to be collected by every surveillance unit is suited for continuous surveillance because of its limited workload

HPS has conducted a pilot on non-mandatory procedures within participating NHS boards during January to February 2011 A pilot on mandatory procedures within participating NHS boards will be conducted during July to December 2011

Advantages of light surveillance less resources than those needed for the standard surveillance this allows these resources to be used to tackle other areas of HAI

Disadvantages of light surveillance surveillance of SSI rates produced by the light methodology could only act as a method of highlighting possible areas for further investigation would result in an inability to routinely correct for case mix crude SSI cumulative incidence and incidence density rates would need to be used would limit the validity of comparisons between boards, which may have very different levels of patient vulnerability would impact on the SAPG collaboration

Colorectal surgery patients who undergo colorectal procedures have been found to be at high-risk of developing an SSI risk factors have been identified for developing a SSI after colorectal surgery risk factors could be addressed to help reduce SSI rates within colorectal procedures have a substantial impact on patient care in reducing costs associated with treating colorectal SSIs

Contact Details Dr Christopher Sullivan Epidemiologist Healthcare Associated Infection Group Health Protection Scotland (HPS) Cadogan Square 1 Cadogan Street Glasgow G2 7HF Email: NSS.HPSSSHAIP@nhs.net

We re moving From Monday 27 June, HPS contact details will be: NHS National Services Scotland Health Protection Scotland (HPS) 4th Floor Meridian Court 5 Cadogan Street Glasgow G2 6QE