Assessing infection prevention and control programs in residential aged care in Australia: A multi-methods cross-sectional study.

AIM: To assess infection prevention and control programs in residential aged care facilities. METHODS: A cross-sectional survey and structured interviews from 10 residential aged care facilities in Victoria, Australia, were used. Infection prevention and control nurse leads from each facility completed a purpose-built survey based on best practice infection prevention control program core components, including staff training, policies and procedures, governance, and surveillance. Follow-up interviews with residential aged care staff, residents and family visitors were carried out to elaborate and verify survey data. RESULTS: Surveys from all 10 facilities were received and 75 interviews carried out. All facilities had an infection prevention and control lead nurse who had undergone additional training, and 60% of facilities had an infection prevention and control lead position description. All facilities had a committee to oversee their infection prevention and control program, and all had policies and procedures for standard and transmission-based precautions. One facility did not have a policy on healthcare-associated infection surveillance, and two facilities did not have an antimicrobial stewardship policy. All facilities provided staff training in hand hygiene and personal protective equipment use, but not all routinely assessed competency in these. CONCLUSIONS: The residential aged care facilities' infection prevention and control programs were generally in a strong position, although there were some areas that require improvement. Further assessment of the quality of infection prevention and control program components, such as content of education and training, and policies and procedures, and ongoing evaluation of programs is recommended. Geriatr Gerontol Int 2024; 24: 358-363.

Evaluation of an Infection surveillance program in residential aged care facilities in Victoria, Australia.

BACKGROUND: Infection surveillance is a key element of infection prevention and control activities in the aged care sector. In 2017, a standardised infection surveillance program was established for public residential aged care services in Victoria, Australia. This program will soon be expanded to a national level for all Australian residential aged care facilities. It has not been evaluated since its inception. METHODS: The current study aimed to evaluate the Victorian Healthcare Associated Infection Surveillance System (VICNISS) Coordinating Centre Aged Care Infection Indicator Program (ACIIP), to understand its performance and functionality. A mixed methods evaluation was performed using the Updated Guidelines for Evaluating Public Health Surveillance Systems developed by the United States Centers for Disease Control and Prevention as a framework. VICNISS staff who coordinate and manage the ACIIP were invited to participate in interviews. Residential aged care staff who use the program were invited to participate in a survey. Document analysis was also performed. RESULTS: Four VICNISS staff participated in the interviews and 38 aged care staff participated in the survey. The ACIIP is stable and able to be adapted quickly to changing definitions for infections. Users found the system relatively easy to use but have difficulties after the long intervals between data entry year on year. VICNISS staff provide expert guidance which benefits users. Users appreciated the benefit of participating and many use the data for improving local practice. CONCLUSIONS: The ACIIP is a usessful state-wide infection surveillance program for aged care. Further development of data validation, IT system capacity and models for education and user support will be required to support future scalability.

Identifying barriers and enablers to participation in infection surveillance in Australian residential aged care facilities.

BACKGROUND: Infection surveillance is a vital part of infection prevention and control activities for the aged care sector. In Australia there are two currently available infection and antimicrobial use surveillance programs for residential aged care facilities. These programs are not mandated nor available to all facilities. Development of a new surveillance program will provide standardised surveillance for all facilities in Australia. METHODS: This study aimed to assess barriers and enablers to participation in the two existing infection and antimicrobial use surveillance programs, to improve development and implementation of a new program. A mixed-methods study was performed. Aged Care staff involved in infection surveillance were invited to participate in focus groups and complete an online survey comprising 17 items. Interviews were transcribed and analysed using the COM-B framework. RESULTS: Twenty-nine staff took part in the focus groups and two hundred took part in the survey. Barriers to participating in aged care infection surveillance programs were the time needed to collect and enter data, competing priority tasks, limited understanding of surveillance from some staff, difficulty engaging clinicians, and staff fatigue after the COVID-19 pandemic. Factors that enabled participation were previous experience with surveillance, and sharing responsibilities, educational materials and using data for benchmarking and to improve practice. CONCLUSION: Streamlined and simple data entry methods will reduce the burden of surveillance on staff. Education materials will be vital for the implementation of a new surveillance program. These materials must be tailored to different aged care workers, specific to the aged care context and provide guidance on how to use surveillance results to improve practice.

Communities of practice in residential aged care: A rapid review.

BACKGROUND: Communities of practice (CoPs) have the potential to help address the residential aged care system's need for continuing education and quality improvement. CoPs have been used in healthcare to improve clinical practice; however, little is known about their application to the unique residential aged care context. OBJECTIVES: This rapid review of CoPs for residential aged care was conducted to summarise the features of CoPs, how they are developed and maintained, and assess their effectiveness. METHODS: MEDLINE and CINAHL databases were searched for studies published from January 1991 to November 2022 about CoPs in residential aged care. Data were extracted regarding the CoPs' three key features of 'domain', 'community' and 'practice' as described by Wenger and colleagues. Kirkpatrick's four levels of evaluation (members' reactions, learning, behaviour and results) was used to examine studies on the effectiveness of CoPs. The Mixed Methods Appraisal Tool was used for quality appraisal. RESULTS: Nineteen articles reported on 13 residential aged care CoPs. Most CoPs aimed to improve care quality (n = 9, 69%) while others aimed to educate members (n = 3, 23%). Membership was often multidisciplinary (n = 8, 62%), and interactions were in-person (n = 6, 46%), online (n = 3, 23%) or both (n = 4, 31%). Some CoPs were developed with the aid of a planning group (n = 4, 31%) or as part of a larger collaborative (n = 4, 31%), and were maintained using a facilitator (n = 7, 54%) or adapted to member feedback (n = 2, 15%). Thirteen (81%) studies evaluated members' reactions, and three (24%) studies assessed members' behaviour. The heterogeneity of studies and levels of reporting made it difficult to synthesise findings. CONCLUSIONS: This review revealed the variation in why, and how, CoPs have been used in residential aged care, which is consistent with previous reviews of CoPs in healthcare. While these findings can inform the development of CoPs in this context, further research is needed to understand how CoPs, including the membership makeup, delivery mode, facilitator type and frequency of meetings, impact quality of care.

An evaluation of influenza, pneumococcal and herpes zoster vaccination coverage in Australian aged care residents, 2018 to 2022.

BACKGROUND: For older persons, vaccination mitigates the harmful impact of vaccine preventable infections. Our study objectives were to evaluate in the Victorian public sector residential aged care services (PSRACS) (1) the existence of local vaccination policies and admission assessment practices, (2) the current documented status of resident influenza, pneumococcal and herpes zoster vaccination uptake and (3) changes in documented resident vaccination uptake over time. METHODS: Standardised data were annually reported by all PSRACS between 2018 and 2022. The influenza, pneumococcal and herpes zoster vaccination status of each resident was classified as vaccinated, declined, contraindicated or unknown. Annual trends in vaccination status were assessed using Spearman's correlation. RESULTS: In 2022, most PSRACS reported an influenza immunisation policy existed (87.1%) and new residents were assessed for their influenza vaccination status (97.2%); fewer PSRACS reported the same for pneumococcal disease (73.1% and 78.9%) and herpes zoster (69.3% and 75.6%). The median resident influenza, pneumococcal and herpes zoster (70-79 years old) vaccination uptake was 86.8%, 32.8% and 19.3% respectively. The median unknown status was 6.9%, 63.0% and 76.0% respectively. Statistical evidence of an increase in annual uptake was observed for the herpes zoster (all resident) surveillance module (rs = 0.900, p = 0.037). CONCLUSIONS: Our study showed local influenza vaccination policies and practices exist and influenza vaccination uptake was consistently high. Pneumococcal and herpes zoster vaccination uptake were lower. Quality improvement strategies that at least determine the status of those residents classified as unknown are required.

Hepatitis B immune status of staff in smaller acute healthcare facilities.

Objective To determine the proportion of staff employed in smaller Victorian public acute healthcare facilities with evidence of immunity to hepatitis B. Methods For optimal long-term immunity, a completed hepatitis B vaccination course and post vaccination hepatitis B surface antibody (anti-HBs) level ≥10 mIU/mL is desirable for all high-risk staff employed in healthcare facilities. For the financial years 2016/17-2019/20, a standardised surveillance module developed by the Victorian Healthcare Associated Infection Surveillance System (VICNISS) Coordinating Centre was completed by the smaller Victorian public acute healthcare facilities (individual hospitals with Results A total of 88 healthcare facilities reported hepatitis B immunity status of high-risk (Category A) staff (n = 29 920) at least once over 5 years; 55 healthcare facilities reported more than once. The aggregate proportion with evidence of optimal immunity was 66.3%. Healthcare facilities with 100-199 Category A staff employed reported the lowest evidence of optimal immunity (59.6%). Of all Category A staff with no evidence of optimal immunity, the majority had 'unknown' status (19.8%), with only 0.6% overall who declined vaccination. Conclusions Our study found evidence of optimal staff hepatitis B immunity in only two-thirds of Category A staff working in surveyed healthcare facilities.

IMpleMenting Effective infection prevention and control in ReSidential aged carE (IMMERSE): protocol for a multi-level mixed methods implementation study.

BACKGROUND: Older people living in residential aged care facilities are at high risk of acquiring infections such as influenza, gastroenteritis, and more recently COVID-19. These infections are a major cause of morbidity and mortality among this cohort. Quality infection prevention and control practice in residential aged care is therefore imperative. Although appointment of a dedicated infection prevention and control (IPC) lead in every Australian residential aged care facility is now mandated, all people working in this setting have a role to play in IPC. The COVID-19 pandemic revealed inadequacies in IPC in this sector and highlighted the need for interventions to improve implementation of best practice. METHODS: Using mixed methods, this four-phase implementation study will use theory-informed approaches to: (1) assess residential aged care facilities' readiness for IPC practice change, (2) explore current practice using scenario-based assessments, (3) investigate barriers to best practice IPC, and (4) determine and evaluate feasible and locally tailored solutions to overcome the identified barriers. IPC leads will be upskilled and supported to operationalise the selected solutions. Staff working in residential aged care facilities, residents and their families will be recruited for participation in surveys and semi-structured interviews. Data will be analysed and triangulated at each phase, with findings informing the subsequent phases. Stakeholder groups at each facility and the IMMERSE project's Reference Group will contribute to the interpretation of findings at each phase of the project. DISCUSSION: This multi-site study will comprehensively explore infection prevention and control practices in residential aged care. It will inform and support locally appropriate evidence-based strategies for enhancing infection prevention and control practice.

The same but different: a comparison of Staphylococcus aureus bloodstream infections in metropolitan and non-metropolitan hospitals (2010-2020).

BACKGROUND: Variation of infection rates between hospitals must be identified; differences may highlight opportunities for quality improvement in healthcare delivery to specific hospitals groups. AIMS: To analyse burden, time trends and risks of healthcare-associated (HA) Staphylococcus aureus bloodstream infections (SABSI) in patients admitted to Victorian metropolitan and non-metropolitan public acute care hospitals. METHODS: SABSI surveillance data submitted between 1 July 2010 and 30 June 2020 by all 118 Victorian public acute care hospitals were analysed. Aligned with the Australian Statistical Geography Standard Remoteness Structure, these hospitals were classified as metropolitan (major cities) or non-metropolitan (inner regional, outer regional, remote or very remote). RESULTS: Most SABSI were community associated: 66.9% and 75.0% of metropolitan (n = 9441) and non-metropolitan (n = 2756) hospital SABSI respectively. The overall HA-SABSI rate was statistically higher in metropolitan hospitals (1.13 per 10 000 occupied bed days (OBD)) compared with non-metropolitan hospitals (0.82 per 10 000 OBD; P < 0.001). In metropolitan and non-metropolitan hospitals, there was a statistically significant decline in the overall HA-SABSI rate (incidence rate ratio = 0.96; 95% confidence interval: 0.95-0.97; P < 0.001; and incidence rate ratio = 0.98; 95% confidence interval: 0.97-1.00; P = 0.044, respectively). In metropolitan and non-metropolitan hospitals, HA-SABSI were frequently associated with central venous (52.8%) and peripheral intravenous (62.2%) catheter use respectively. CONCLUSION: To reduce risks for SABSI and improve patient outcomes, hospital infection prevention and control programmes should be tailored according to local epidemiology. In common geographic locations, networking of hospitals should be considered as a means of strengthening delivery of these programmes.

Prophylactic Antimicrobial Prescribing in Australian Residential Aged-Care Facilities: Improvement is Required.

BACKGROUND AND OBJECTIVE: Inappropriate antimicrobial use can lead to adverse consequences, including antimicrobial resistance. The objective of our study was to describe patterns of prophylactic antimicrobial prescribing in Australian residential aged-care facilities and thereby provide insight into antimicrobial stewardship strategies that might be required. METHODS: Annual point prevalence data submitted by participating residential aged-care facilities as part of the Aged Care National Antimicrobial Prescribing Survey between 2016 and 2020 were extracted. All antimicrobials except anti-virals were counted; methenamine hippurate was classified as an antibacterial agent. RESULTS: The overall prevalence of residents prescribed one or more prophylactic antimicrobial on the survey day was 3.7% (n = 4643, 95% confidence interval 3.6-3.8). Of all prescribed antimicrobials (n = 15,831), 27.1% (n = 4871) were for prophylactic use. Of these prophylactic antimicrobials, 87.8% were anti-bacterials and 11.4% antifungals; most frequently, cefalexin (28.7%), methenamine hippurate (20.1%) and clotrimazole (8.8%). When compared with prescribing of all antimicrobial agents, prophylactic antimicrobials were less commonly prescribed for pro re nata administration (7.0% vs 20.3%) and more commonly prescribed greater than 6 months (52.9% vs 34.1%). The indication and review or stop date was less frequently documented (67.5% vs 73.8% and 20.9% vs 40.7%, respectively). The most common body system for which a prophylactic antimicrobial was prescribed was the urinary tract (54.3%). Of all urinary tract indications (n = 2575), about two thirds (n = 1681, 65.3%) were for cystitis and 10.6% were for asymptomatic bacteriuria. CONCLUSIONS: Our results clearly identified immediate antimicrobial stewardship strategies that aim to improve prophylactic antimicrobial prescribing in Australian residential-aged care facilities are required.

Improving management of urinary tract infections in residential aged care facilities.

BACKGROUND: Antimicrobial resistance rates are higher in Australian residential aged care facilities (RACFs) than other community or hospital settings. This is driven by antibiotic overuse and misuse. Urinary tract infection (UTI) is consistently the most common infection treated with antibiotics in Australian RACFs. OBJECTIVE: The aim of this article is to provide an overview of how general practitioners (GPs) can support appropriate UTI management in RACFs following antimicrobial stewardship (AMS) principles. DISCUSSION: GPs are well placed to improve UTI management in RACFs. In this article, criteria for suspected, proven, recurrent and relapsed UTI are outlined, in addition to key AMS practices for the assessment, prevention, treatment and review of UTIs. Included are recommendations for the judicious use of urine dipstick testing, a widespread and longstanding practice in RACFs, and first-line empirical antibiotic prescribing for suspected UTIs.

Ophthalmic Antimicrobial Prescribing in Australian Healthcare Facilities.

The National Antimicrobial Prescribing Survey (NAPS) is a web-based, standardized tool, widely adopted in Australian healthcare facilities to assess the reasons for, the quantity of, and the quality of antimicrobial prescribing. It consists of multiple modules tailored towards the needs of a variety of healthcare facilities. Data regarding ophthalmological antimicrobial use from Hospital NAPS, Surgical NAPS, and Aged Care NAPS were analysed. In Hospital NAPS, the most common reasons for inappropriate prescribing were incorrect dose or frequency and incorrect duration. Prolonged duration was also common in Aged Care prescribing: about one quarter of all antimicrobials had been prescribed for greater than 6 months. All three modules found chloramphenicol to be the most prescribed antimicrobial with a high rate of inappropriate prescribing, usually for conjunctivitis.

Evaluating peripheral intravascular catheter insertion, maintenance and removal practices in small hospitals using a standardized audit tool.

AIM: The aim of this study was to evaluate clinical practice about peripheral intravenous catheter (PIVC) insertion, maintenance and removal in a cohort of Victorian hospitals. DESIGN: A standardized PIVC audit tool was developed, and results from point prevalent surveys were conducted. METHODS: Hospitalized patients requiring a PIVC insertion were eligible for audit. Audit data submitted between 2015 and 2019 were extracted for the current study. RESULTS: 3566 PIVC insertions in 15 Victorian public hospitals were evaluated. 57.6% of PIVCs were inserted in wards, 18.7% in operating theatres and 11.6% in Emergency Departments (ED). 45.2% were inserted by nurses and 38.2% by medical staff. The preferred site for insertion was the dorsum of the hand and forearm (58.8%). 22.6% did not report a visual infusion phlebitis score at least daily, and 48% did not document a daily dressing assessment. Reasons for PIVC removal included no longer required (63%) and phlebitis (4.8%). No bloodstream infections were reported.

Antimicrobial stewardship in Australia: the role of qualitative research in programme development.

Antimicrobial stewardship (AMS) in Australia is supported by a number of factors, including enabling national policies, sectoral clinical governance frameworks and surveillance programmes, clinician-led educational initiatives and health services research. A One Health research programme undertaken by the National Centre for Antimicrobial Stewardship (NCAS) in Australia has combined antimicrobial prescribing surveillance with qualitative research focused on developing antimicrobial use-related situational analyses and scoping AMS implementation options across healthcare settings, including metropolitan hospitals, regional and rural hospitals, aged care homes, general practice clinics and companion animal and agricultural veterinary practices. Qualitative research involving clinicians across these diverse settings in Australia has contributed to improved understanding of contextual factors that influence antimicrobial prescribing, and barriers and facilitators of AMS implementation. This body of research has been underpinned by a commitment to supplementing 'big data' on antimicrobial prescribing practices, where available, with knowledge of the sociocultural, technical, environmental and other factors that shape prescribing behaviours. NCAS provided a unique opportunity for exchange and cross-pollination across the human and animal health programme domains. It has facilitated synergistic approaches to AMS research and education, and implementation of resources and stewardship activities. The NCAS programme aimed to synergistically combine quantitative and qualitative approaches to AMS research. In this article, we describe the qualitative findings of the first 5 years.

Topical antimicrobial prescribing patterns in residents of Australian aged-care facilities: use of a national point prevalence survey to identify opportunities for quality improvement.

BACKGROUND: Australian residential aged care facilities (RACFs) are encouraged to participate in an annual Aged Care National Antimicrobial Prescribing Survey. This data source was analysed to describe patterns of topical antimicrobial prescribing and thereby provide insight into antimicrobial stewardship (AMS) changes that might be required. METHODS: 2018 and 2019 survey data was analysed. RESULTS: The overall prevalence of the 52,431 audited residents (629 facilities) who were prescribed 1 or more topical antimicrobials was 2.9%. Of all prescribed antimicrobials (n=4899), 33.0% were for topical application. Most frequently prescribed topical antifungals were clotrimazole (85.3%) and miconazole (9.1%), and antibacterials chloramphenicol (64.1%) and mupirocin (21.8%). Tinea (38.3%) and conjunctivitis (23.8%) were the 2 most common indications. Topical antimicrobials were sometimes prescribed for pro re nata administration (38.8%) and greater than 6 months (11.3%). The review or stop date was not always documented (38.7%). CONCLUSIONS: To reduce the possibility of adverse consequences associated with antimicrobial use, antimicrobial stewardship programs in Australian residential aged care facilities should at least ensure mupirocin is appropriately used, first line antimicrobial therapy is prescribed for tinea, chloramphenicol is prescribed for conjunctivitis only if necessary, pro re nata orders for prescriptions are discouraged and to avoid prolonged duration of prescriptions, review or stop dates are always documented.

Measles immunisation status of healthcare workers in smaller Victorian hospitals: can we do better?

OBJECTIVE: To determine the proportion of healthcare workers (HCWs) in smaller Victorian public healthcare facilities with documented evidence of measles immunity. METHODS: A cross-sectional survey, developed by the Victorian Healthcare Associated Surveillance System Coordinating Centre, was completed by all eligible facilities. HCWs were reported as having evidence or no evidence of measles immunity. Those without evidence of immunity were sub-classified as incomplete, declined or unknown status. RESULTS: Seventy-five facilities reported measles immunity status of 17,522 employed HCWs. Of these, 11,751 (67.1%) had documented evidence of immunity. The proportion with evidence of immunity was lowest (45.6%) in facilities with ≤50 HCWs. The majority of HCWs without evidence of immunity (88.2%) had 'unknown' status. Declination or incomplete status comprised very low overall proportions (0.3% and 3.6%, respectively). CONCLUSIONS: Reported evidence of HCW measles immunity was moderate in surveyed facilities, with a large proportion having unknown status. HCW immunisation programs in some facilities require refinement to appropriately support public health responses to measles cases and prevention of occupational acquisition of measles. Implications for public health: Non-immune HCWs are at increased risk for acquiring and transmitting measles. Timely access to accurate HCW immunisation records is required to ensure that public health responses are effective.

Burden of antibiotic allergy labels in Australian aged care residents: Findings from a national point-prevalence survey.

OBJECTIVE: To determine the prevalence of antibiotic allergy labels (AALs) in Australian aged care residents and to describe the impact of labels on antibiotic prescribing practices. DESIGN: Point-prevalence survey. SETTING: Australian residential aged care facilities. PARTICIPANTS: We surveyed 1,489 residents in 407 aged care facilities. METHODS: Standardized data were collected on a single day between June 1 and August 31, 2018, for residents prescribed an antibiotic. An AAL was reported if it was documented in the resident's health record. Resident-level data were used to calculate overall prevalence, and antibiotic-level data were used to report relative frequency of AALs for individual antibiotics and classes. RESULTS: Among 1,489 residents, 356 (24%) had 1 or more documented AALs. The AALs for penicillin (28.3%), amoxicillin or amoxicillin/clavulanic acid (10.5%), cefalexin (7.2%), and trimethoprim (7.0%) were most commonly reported. The presence of an AAL was associated with significantly less prescribing of penicillins (OR, 0.43; 95% CI, 0.31-0.62; P < .001) and significantly more prescribing of lincosamides (OR, 4.81; P < .001), macrolides (OR, 2.03; P = .007), and tetracyclines (OR, 1.54; P = .033). Of residents with AALs, 7 residents (1.9%) were prescribed an antibiotic that was listed on the allergy section of their health record. CONCLUSIONS: A high prevalence of AALs was observed among residents of Australian aged care facilities, comparable to the prevalence of AALs in high-risk hospitalized patients. Significant increases in prescribing of lincosamide, macrolide, and tetracycline agents poses a potential risk to aged populations, and future studies must evaluate the benefits of AAL delabelling programs tailored for aged care settings.

Urinary tract infections in Australian aged care homes: Antibiotic prescribing practices and concordance to national guidelines.

BACKGROUND: Since 2015 the Aged Care National Antimicrobial Prescribing Survey has collected and reported data on antibiotic use in Australian aged care homes (ACHs) as part of the Australian Commission on Safety and Quality in Health Care's Antimicrobial Use and Resistance in Australia project. The objective of this study was to analyze this data source with regards to prescribing for urinary tract infections (UTIs) to improve the use of antibiotics. METHODS: This cross-sectional study analyzed the 2016 and 2017 survey data. Antibiotic prescribing for urinary tract indications was compared with national guideline recommendations. RESULTS: A total of 662 antibiotic prescriptions from 247 ACHs were analyzed. For all prophylactic antibiotics for UTI, 51.8% were prescribed for longer than 6 months, contrary to the guideline recommendation. Most antibiotics prescribed for treatment (71.6%) were for cystitis. Cefalexin was most frequently selected for treatment of cystitis, with 10.4% of these prescriptions being concordant with the recommendations. Prescribing additional daily doses of cefalexin occurred in 63.2% of prescriptions. CONCLUSIONS: Antimicrobial stewardship activities targeting UTI prophylaxis for durations longer than 6 months, and excessive daily doses of cefalexin to treat cystitis could yield significant reductions in unnecessary antibiotic consumption among Australian residents of ACHs.