- Email: [email protected]
Infection rates in residential aged care facilities, Grampians region, Victoria, Australia
Research
CSIRO PUBLISHING
www.publish.csiro.au/journals/hi
Healthcare Infection, 2011, 16, 116–120
Infection rates in residential aged care facilities, Grampians region, Victoria, Australia Mary Smith1,4 RN, Cert.Inf.Cont&Sterilisation Ann L. Bull2 B.Sc(Hons), MApEpid, PhD Michael Richards2 MBBS, FRACP, MD Pauline Woodburn3 RN, Cert.Inf.Cont&Sterilisation, Grad Dip Mgmt Noleen J. Bennett2 RN, MPH, PhD 1
Department of Health, Grampians Region, 21 McLachlan Street, Horsham, Victoria, 3400 Vic., Australia. Victorian Healthcare Associated Infection Surveillance System (VICNISS) Co-ordinating Centre, 10 Wreckyn St, North Melbourne, 3051, Vic., Australia. 3 Bendigo Health, 62 Lucan St, Bendigo, 3550 Vic., Australia. 4 Corresponding author. Email: [email protected] 2
Abstract. In 2010, 30 eligible residential aged care facilities (RACFs) in the Grampians region, Victoria, participated in a 6-month pilot healthcare-associated infection (HAI) surveillance program. The aims of the pilot program were to establish if there was a need for a program, and if yes, to determine if the program, as currently structured, was plausible. Data was continuously collected for five surveillance modules – ‘bronchitis and tracheobronchitis’, ‘cellulitis’, ‘conjunctivitis’, ‘gastroenteritis’ and ‘symptomatic urinary tract infections’. The overall confirmed and total (confirmed and excluded) infection rates were 2.2 and 3.6 infections per 1000 resident days, respectively. Infections reported by clinical staff employed at the RACFs had to be either confirmed or excluded by an infection control consultant. The main reason infections could not be confirmed was because supporting documentation was incomplete. Although the infection rates were lower or equivalent to those reported elsewhere, it was recommended that the implementation of an HAI surveillance program in the Grampians RACFs be considered. Some program elements, such as the supporting documentation and infection definitions, would need to be reviewed.
Introduction In an Australian residential aged care facility (RACF), personal and/or nursing care is provided to a person in addition to accommodation. In June 2008, there were 175 472 RACFs with an increase of 5401 facilities compared with June 2007. The current plan is to provide 88 places per 1000 persons aged 70 years and over by 2011. On June 30, 2008 over onehalf (55%) of the 160 250 residents were aged 85 years and over and one-quarter (27%) were aged 90 years and over.1 Residential aged care facility residents are highly susceptible to infections for a variety of reasons. For individual residents, these reasons may include advanced age, multiple chronic co-morbidities (eg., diabetes), functional disabilities (eg., faecal and urinary incontinence), immuno-suppression, increased antibiotic exposure which affects resistance to infection and the use of sometimes permanent invasive devices (eg., urinary tract catheters). 2–4 In addition, several factors promote the transmission of infectious agents in RACFs. The residents live in a home-like Australian Infection Control Association 2011
environment and have close contact with potentially infected or colonised residents and staff. Some too have multiple and often prolonged acute care hospitalisations.5–7 The literature does not extensively detail infection rates in Australian RACFs.8,9 However, numerous studies have shown infections are a common cause of acute care hospitalisation among RACF residents. In the most recent study, over 6 years, there were 3310 admissions from 147 South Australian RACFs.5–7,10,11 Infection was the primary diagnosis for 432 (13.1%) of the admissions. Pneumonia (5.6%) and urinary tract infections (UTI) (3.4%) were most commonly reported. In 2010, a pilot healthcare-associated infection (HAI) surveillance program was undertaken in RACFs based at the 12 hospital-associated health services located across the Grampians rural region, Victoria, Australia. There are five rural regions in the state of Victoria, as defined by the Department of Health. The focus of this pilot program was to gather information, further to that described above, that would 10.1071/HI11017
1835-5617/11/030116
Infection rates in residential aged care facilities
assist in making any decisions about future programs in these RACFs. The two main aims were to establish if there was a need for an ongoing HAI surveillance program, and if yes, to determine if the HAI surveillance program, as currently structured, was plausible. This paper outlines and discusses the results related to both the pilot program aims. The results related to the second aim are also further detailed in a future paper. It was agreed by the relevant stakeholders that if the pilot program demonstrated there was a relatively ‘average’ or ‘high’ infection rate in the Grampians RACFs then there would be a need for an ongoing HAI surveillance program. The intended outcome of an ongoing program would be to enhance continuous quality improvement efforts and reduce the infection rates. Methodology Data collection In the 30 participating RACFs (792 occupied beds), only high-care residents were included. High-care residents are assessed by an Australian Government Aged Care Assessment Team (ACAT), as those who require almost complete assistance with most daily living activities This includes accommodation, meals, laundry, room cleaning, personal hygiene care and if necessary, medical care.12 Data was continuously collected for 6 months (June to November, 2010) for four surveillance modules – ‘bronchitis and tracheo-bronchitis’, ‘cellulitis’, ‘conjunctivitis’ and ‘symptomatic UTI’. In addition, data was collected for 3 months (September to November) for the ‘gastroenteritis’ module. The first four modules were included in the pilot program because previous Rural Infection Control Practice Group annual surveys had indicated there was a high prevalence of bronchitis, trachea-bronchitis, cellulitis, conjunctivitis and symptomatic UTIs. Since 2007, all five rural regions in Victoria have annually participated in this prevalence survey. The gastroenteritis module was later included because at an Australian Commission in Safety and Quality in Healthcare workshop in August 2010, Clostridium difficile infection surveillance in aged care was recommended.13 Although pneumonia has been commonly reported in RACFs, a ‘pneumonia’ module was not included. It would have been difficult to confirm a pneumonia case because, as occurs elsewhere14,15, chest radiographs are infrequently performed in these RACFs. The five modules were based on the widely used McGeer et al.14 aged care infection definitions. These definitions outline criteria that have to be met before an infection is considered ‘true’ and were recommended for use in RACFs by the Australian Government Department of Health and Aging 2004 Infection Control guidelines.16 At each RACF, a clinical staff member or staff members were made responsible for, during their daily patient care activities, identifying residents with infections. Residents admitted or transferred to the facility during the 48 hours before identification of an infection were excluded. Identified infections were documented on a standard data collection
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form that was then forwarded to the health service infection control (HSIC) consultant. Data validation Each month, the HSIC consultant was asked to complete a monthly summary that recorded the number of ‘confirmed reported’, ‘excluded reported’ and ‘detected unreported’ infections. Total reported infections included both confirmed and excluded reported infections. All ‘infections’ reported by RACF staff members had to be confirmed or excluded by the HSIC consultant and/or treating doctor. The HSIC consultant was also asked to periodically check the microbiology reports for any infections not reported by RACF staff members. Completed data collection forms were forwarded to the one regional infection control coordinator who entered the data onto an Excel spreadsheet. Any missing data or obvious anomalies were followed up with the HSIC consultant. Data analysis Each month, a surveillance report was forwarded to the HSIC consultant. For each module, these cumulative reports listed the confirmed reported infection rates for their RACF(s) and for benchmarking purposes, the confirmed reported infection rates of all the RACFs combined. Infection rates were expressed as the number of infections per 1000 resident days; 95% confidence intervals were calculated. In the final 6-month report, in addition to the confirmed reported infection rates, the equivalent total reported infection rates were calculated for each module. For the confirmed reported infections only, the frequency for each criterion reported was also calculated. Results During the surveillance period, the mean age of the residents for whom an infection was reported was 84.9. Most (68%) were females. Table 1 outlines the confirmed reported and total reported infection rates. The majority of RACFs reported at least one infection for most modules. For the two RACFs that equalled or exceeded the ‘all infections’ 95th percentile (6.2 infections per 1000 resident days), symptomatic UTIs were mostly reported. One of these RACFs (1469 resident days) reported 20 infections, including 10 UTIs. The other RACF (5336 resident days) reported 33 infections, including 15 UTIs. Eighteen (19%) of the residents for whom a UTI was reported had a urethral urinary catheter in situ. Eight infections were detected by the HSIC consultant after reviewing microbiology reports. These ‘detected unreported’ infections were reclassified as ‘confirmed reported’ infections. Forty-four percent of the 466 infections reported by RACF staff members were excluded by an HSIC consultant. This was because: the resident had been admitted or transferred to the RACF within 48 hours (3.4%), the infection did not meet the criteria (71.4%) or there was ‘another’ reason (26.3%). The HSIC consultants commonly noted there was insufficient documentation in the residents’
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Table 1. Six-month cumulative infection rates Modules No. of reporting RACFs Bronchitis and tracheo-bronchitis Cellulitis/soft tissue/wound infection Conjunctivitis Gastroenteritis Symptomatic urinary tract infection All infectionsA
All residential aged care facilities Confirmed infections Total reported infectionsC No. of Infection 95% CI No. of Infection 95% CI infections rateB infections rateB
24 25 24 2 28 30
91 59 48 4 95 293
0.7 0.4 0.4 0.1 0.7 2.2
0.5–0.8 0.3–0.6 0.3–0.5 0.0–0.2 0.6–0.9 1.9–2.4
155 113 56 9 170 494
1.1 0.8 0.4 0.1 1.3 3.6
1.0–1.3 0.7–1.0 0.3–0.5 0.1–0.3 1.1–1.5 3.3–4.0
A
Gastroenteritis infections are not included in the ALL infections total. Infection rate = number of infections per 1000 resident days. C Total reported infections = confirmed reported and excluded reported infections. RACF, residential aged care facility. B
medical records to retrospectively assess and support the infection criteria. Table 2, except for gastroenteritis, outlines the frequency of criteria reported for the confirmed reported infections. Discussion The pilot program confirmed reported and total reported infection rates were 2.2 and 3.6 infections per 1000 Table 2.
resident days, respectively. The marked difference between the two rates was because of the significant number (41%) of infections reported by RACF staff members that could not be confirmed by the HSIC consultants. It is probable that the difference would have been less if the HSIC consultants had always had sufficient documentation in the residents’ medical records to retrospectively assess the criteria. Incomplete documentation of clinical findings in RACF medical records has been noted elsewhere.17
Frequency of reported criteria
Modules and criteria
Reported criteria No. %
Bronchitis and tracheo-bronchitis. Residents had to meet at least three of the criteria 1. New or increased cough 2. Change in status or breathing difficulty, new/increased shortness of breath, respiratory rate >25 per minute and/or worsening mental or functional status 3. New or increased physical findings on chest examination. Rales, rhonchi, wheezes or bronchial breathing 4. New or increased sputum production 5. Fever (>38C) 6. Pleuritic chest pain
84/91 68/91
92.3 74.7
67/91 38/91 35/91 11/91
73.6 41.8 38.5 12.1
Cellulitis/soft tissue/wound infection. Residents had to meet either criteria 1 or 2. For criteria 2, residents had to have at least four of the signs and symptoms. The signs and symptoms 2b–2f had to be at the affected site and new or increasing 1. Pus present at a wound, skin or soft tissue site 2a. Redness 2b. Heat 2c. Swelling 2d. Tenderness and pain 2e. Serous drainage 2f. Fever (>38C) or worsening mental/ functional status
28/59 31/31 29/31 28/31 27/31 9/31 8/31
47.5 100 93.5 90.3 87.1 29.0 25.8
Conjunctivitis. Residents had to meet either criteria 1 or 2 1. Pus appearing from one or both eyes present for at least 24 hours 2. New or increased conjunctival redness with or without itching or pus present for at least 24 hours
37/48 11/48
77.1 22.9
Symptomatic urinary tract infection. Residents who did not have an indwelling urinary catheter had to have at least three of the criteria. Residents who had an indwelling urinary catheter had to have at least two of the criteria. Criteria 3 was not applicable if residents had an indwelling catheter in situ 1. Change in character of urine (clinical or laboratory) 2. Worsening of mental or functional status 3. New or increased burning pain on urinating, frequency or urgency 4. New flank or supra-pubic pain or tenderness 5. Fever (>38C) or chills
90/95 90/95 58/77 25/95 19/95
94.7 94.7 75.3 26.3 20.0
Infection rates in residential aged care facilities
Published infection rates in RACFs may vary due to methodological differences in regard to the population studied, definitions used and type and intensity of surveillance undertaken. Notwithstanding these differences, it was useful to compare the pilot program infection rates to previous studies and determine that these rates were relatively low or average. In six Sydney RACFs (total 450 beds), from 2001 to 2005, the mean infection rate was 3.2 per 1000 bed days.9 In 2001, in 10 Perth private RACFs (total 407 beds) the mean infection rate was 4.6 per 1000 resident days; rates in individual facilities ranged from 1.9 to 9.0.8 Internationally, the infection rate has ranged from 1.8 to 11.8 per 1000 resident days.18–20 Over the 6-month pilot program, the residents in the participating RACFs were especially at risk of developing bronchitis and trachea-bronchitis, and symptomatic UTI. This is similar to the two Australian studies referenced earlier. The most common infection sites in both the Sydney and Perth RACFs were respiratory tract, urinary tract and skin and soft tissue.8,9 Interestingly, 11 bloodstream infections were identified in the Sydney RACFs. Although bloodstream infections might be infrequent in Australian RACF residents, the impact of this infection type can be severe.21 It was anticipated that some residents for whom a UTI was reported would have a urinary catheter in situ. The use of catheters in RACFs is common22 and those residents with a catheter in situ are always bacteruric. The presence of a catheter bypasses normal host defences, allowing continuous access of organisms into the urinary bladder. Residents with catheters in situ have been shown to have increased morbidity from urinary infection compared with bacteruric residents without catheters.23 Bronchitis and tracheo-bronchitis may have been frequently reported because the surveillance period included the winter months. In a German study, there was marked seasonal variation for respiratory tract infections with mean rates of 0.63 and 4.40 per 1000 resident days for May to November and December to April, respectively (RR = 6.99; 95% CI 3.84–12.70; P < 0.001).19 In addition, some of the bronchitis and tracheo-bronchitis infections may have been more accurately classified as pneumonia if chest radiographs had been undertaken. It was not surprising that only four gastroenteritis infections were confirmed between September and November. In a recent systematic review,24 the mean incidence of gastroenteritis in long-term care facilities (LTCF) residents was found to be relatively low: ~0.40 (95% CI 0.27–0.56). The authors noted new studies are needed to better assess the incidence of gastroenteritis in LTCFs due to its ‘potential for serious clinical outcomes and propensity to cause outbreaks’. The pilot program demonstrated that clinical manifestations of infection can be subtle and/or atypical, which has been described elsewhere.25–27 Fever, sometimes referred to as the ‘cardinal sign of infection’,27 was infrequently reported. This may have been because a ‘classic’
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definition of fever (>38C) was used. The Infectious Diseases Society of America recommend for older adult residents that fever be defined as: 1. a single oral temperature >37.8C, or 2. repeated oral temperatures >37.2C or rectal temperatures >37.5C, or 3. an increase in temperature of >1.1C over the baseline temperature.26 ‘Worsening of mental or functional status’ was especially common (94.7%) for those residents with symptomatic UTI. This noteworthy percentage was similarly observed28 in a USA LTCF over 6 months. Infection was determined to be present in 77% of episodes of ‘decline in function’. Decline in function was defined as new or increasing confusion, incontinence, falling, deteriorating mobility or failure to cooperate with rehabilitation. The pilot program had limitations. First, the data collected on high-care residents was not risk-adjusted. An appropriate risk stratification would have included some of the reasons why residents are highly susceptible to infections.29 Second, the program did not measure the impact of reported infections. This information is useful to know when promoting the need for an effective IC program. Indices that may be used to measure the impact include the volume of antimicrobial agent use, frequency of transfer to acute care hospitals and infectionrelated mortality.15 Conclusion The pilot program improved knowledge about infections and HAI surveillance programs in Australian RACFs. The information gathered will assist in making any decisions about future HAI surveillance programs in the Grampians RACFs. There were numerous recommendations made following the completion of the pilot program. 1. The establishment of an HAI surveillance program in the Grampians RACFs should be considered. This is because the confirmed reported infection rate, if the excluded reported infections could have been confirmed, may have been classified as ‘average’. As previously stated, it was agreed by the relevant stakeholders before the commencement of the pilot program that an average or high infection rate would indicate there was a need for an ongoing program. 2. All infections that were monitored in the pilot program should be included in a Grampians RACF HAI surveillance program. This includes gastroenteritis because 3 months may not have been long enough to best assess the incidence of this infection in the RACFs. A ‘bloodstream infection’ module should also be considered. 3. The documentation of clinical findings in the Grampians RACF medical records should be reviewed and if necessary improved. 4. The McGeer et al.14 definitions should be reviewed. These definitions constitute a valuable data collection tool but
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some aspects, for example the fever criteria, need further evaluation. 5. Future HAI surveillance programs and associated evaluations in the Grampians RACFs should address the pilot program limitations.
15. 16.
17.
Acknowledgements Special gratitude is expressed to the IC consultants and staff employed at the participating RACFs. We also wish to acknowledge the support given by the Department of Health Grampians Region.
18.
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Australian Government. Residential aged care in Australia 2007–08. Canberra, Australian Government. 2009. Garibaldi RA. Residential care and the elderly: the burden of infection. J Hosp Infect 1999; 43: S9–18. doi:10.1016/S0195-6701(99)90061-0 Nicolle LE. Preventing infections in non-hospital settings: long-term care. Emerg Infect Dis 2001; 7: 205–7. doi:10.3201/eid0702.010210 Strausbaugh LJ, Joseph CL. The burden of infection in long-term care. Infect Control Hosp Epidemiol 2000; 21: 674–9. doi:10.1086/501712 Finn JC, Flicker L, Mackenzie E, Jacobs IG, Fatovich DM, Drummond S, et al. Interface between residential aged care facilities and a teaching hospital emergency department in Western Australia. Med J Aust 2006; 184: 432–5. Finucane PM, Wundke R, Whitehead C, Williamson L, Baggoley CJ. Profile of people referred to an emergency department from residential care. Aust N Z J Med 1999; 29: 494–9. doi:10.1111/j.1445-5994.1999. tb00749.x Hillen JC, Reed RL, Woodman RJ, Law D, Hakendorf PH, Fleming BJ. Hospital admissions from residential aged care facilities to a major public hospital in South Australia (1999). Australas J Ageing Epub ahead of print. doi:10.1111/j.1741-6612.2010.00479.x Reilly M. Infection surveillance in residential aged high care facilities in Western Australia. Griffith University, Brisbane, 2001. Forrest J. Bean Counting the Bugs: Evaluation of 5 years of infection surveillance data in 6 residential aged care facilities. Australian Infection Control Association, Sydney 2006. Calver J, Horner B, Boldy D, Bulsara M. The burden of infectious diseases in Western Australian residential aged care facilities: a population-based record linkage study. Australian Infection Control 2006; 11: 79–89. Karmel R, Gibson D, Lloyd J, Anderson P. Transitions from hospital to residential aged care in Australia. Australas J Ageing 2009; 28: 198– 205. doi:10.1111/j.1741-6612.2009.00376.x Australian Government Department of Health and Aging. http://www. agedcareaustralia.gov.au/internet/agedcare/publishing.nsf/Content/ Glossary+Index+H. Australian Commission on Safety and Quality in Healthcare. Report on National Clostridium difficile Infection Workshop, 2010, Commonwealth of Australia, Canberra. McGeer A, Campbell B, Emori TG, Hierholzer WJ, Jackson MM, Nicolle LE, et al. Definitions of infection for surveillance in long-term care facilities. Am J Infect Control 1991; 19: 1–7. doi:10.1016/01966553(91)90154-5
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Nicolle LE, Strausbaugh LJ, Garibaldi RA. Infections and antibiotic resistance in nursing homes. Clin Microbiol Rev 1996; 9: 1–17. Australian Government Department of Health and Aging. Infection Control Guidelines for the prevention of transmission of infectious diseases in the healthcare setting. Canberra, Australian Government Publishing Service 2004. Simor AE. The role of the laboratory in infection prevention and control programs in long-term-care facilities for the elderly. Infect Control Hosp Epidemiol 2001; 22: 459–63. doi:10.1086/501935 Brusaferro S, Regattin L, Silvestro A, Vidotto L. Incidence of hospital-acquired infections in Italian long-term-care facilities: a prospective six-month surveillance. J Hosp Infect 2006; 63: 211–5. doi:10.1016/j.jhin.2006.01.012 Engelhart ST, Hanses-Derendorf L, Exner M, Kramer MH. Prospective surveillance for healthcare-associated infections in German nursing home residents. J Hosp Infect 2005; 60: 46–50. doi:10.1016/j.jhin.2004.09.037 Eriksen HM, Koch AM, Elstrom P, Nilsen RM, Harthug S, Aavitsland P. Healthcare-associated infection among residents of long-term care facilities: a cohort and nested case-control study. J Hosp Infect 2007; 65: 334–40. doi:10.1016/j.jhin.2006.11.011 Collignon P, Dreimanis D, Feguson J, van Gessel H, Taylor P, Wilkinson I. et al. Bloodstream infection. In Cruickshank M, Ferguson J, eds. Reducing Harm to Patients from Health Care Associated Infections: The Role of Surveillance. Canberra, Commonwealth of Australia 2008. Woodburn P. Residential Aged Care Facility Point Prevalence Surveillance of Infection and Device use. 2010. Rural Infection Control Practice Group, Melbourne. Nicolle LE. The chronic indwelling catheter and urinary infection in long-term-care facility residents. Infect Control Hosp Epidemiol 2001; 22: 316–21. doi:10.1086/501908 Kirk MD, Hall GV, Veitch MG, Becker N. Assessing the incidence of gastroenteritis among elderly people living in long term care facilities. J Hosp Infect 2010; 76: 12–7. doi:10.1016/j.jhin.2010.04.009 Berman P, Hogan DB, Fox RA. The atypical presentation of infection in old age. Age Ageing 1987; 16: 201–7. doi:10.1093/ageing/16.4.201 High KP, Bradley SF, Gravenstein S, Mehr DR, Quagliarello VJ, Richards C, et al. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America. Clin Infect Dis 2009; 48: 149–71. doi:10.1086/595683 Norman DC. Fever in the elderly. Clin Infect Dis 2000; 31: 148–51. doi:10.1086/313896 Brooks S, Warshaw G, Hasse L, Kues JR. The physician decisionmaking process in transferring nursing home patients to the hospital. Arch Intern Med 1994; 154: 902–8. doi:10.1001/archinte.154.8.902 Golliot F, Astagneau P, Cassou B, Okra N, Rothan-Tondeur M, Brucker G. Nosocomial infections in geriatric long-term-care and rehabilitation facilities: exploration in the development of a risk index for epidemiological surveillance. Infect Control Hosp Epidemiol 2001; 22: 746–53. doi:10.1086/501865
Manuscript received 14 June 2011, accepted 12 August 2011
http://www.publish.csiro.au/journals/hi
CSIRO PUBLISHING
www.publish.csiro.au/journals/hi
Healthcare Infection, 2011, 16, 116–120
Infection rates in residential aged care facilities, Grampians region, Victoria, Australia Mary Smith1,4 RN, Cert.Inf.Cont&Sterilisation Ann L. Bull2 B.Sc(Hons), MApEpid, PhD Michael Richards2 MBBS, FRACP, MD Pauline Woodburn3 RN, Cert.Inf.Cont&Sterilisation, Grad Dip Mgmt Noleen J. Bennett2 RN, MPH, PhD 1
Department of Health, Grampians Region, 21 McLachlan Street, Horsham, Victoria, 3400 Vic., Australia. Victorian Healthcare Associated Infection Surveillance System (VICNISS) Co-ordinating Centre, 10 Wreckyn St, North Melbourne, 3051, Vic., Australia. 3 Bendigo Health, 62 Lucan St, Bendigo, 3550 Vic., Australia. 4 Corresponding author. Email: [email protected] 2
Abstract. In 2010, 30 eligible residential aged care facilities (RACFs) in the Grampians region, Victoria, participated in a 6-month pilot healthcare-associated infection (HAI) surveillance program. The aims of the pilot program were to establish if there was a need for a program, and if yes, to determine if the program, as currently structured, was plausible. Data was continuously collected for five surveillance modules – ‘bronchitis and tracheobronchitis’, ‘cellulitis’, ‘conjunctivitis’, ‘gastroenteritis’ and ‘symptomatic urinary tract infections’. The overall confirmed and total (confirmed and excluded) infection rates were 2.2 and 3.6 infections per 1000 resident days, respectively. Infections reported by clinical staff employed at the RACFs had to be either confirmed or excluded by an infection control consultant. The main reason infections could not be confirmed was because supporting documentation was incomplete. Although the infection rates were lower or equivalent to those reported elsewhere, it was recommended that the implementation of an HAI surveillance program in the Grampians RACFs be considered. Some program elements, such as the supporting documentation and infection definitions, would need to be reviewed.
Introduction In an Australian residential aged care facility (RACF), personal and/or nursing care is provided to a person in addition to accommodation. In June 2008, there were 175 472 RACFs with an increase of 5401 facilities compared with June 2007. The current plan is to provide 88 places per 1000 persons aged 70 years and over by 2011. On June 30, 2008 over onehalf (55%) of the 160 250 residents were aged 85 years and over and one-quarter (27%) were aged 90 years and over.1 Residential aged care facility residents are highly susceptible to infections for a variety of reasons. For individual residents, these reasons may include advanced age, multiple chronic co-morbidities (eg., diabetes), functional disabilities (eg., faecal and urinary incontinence), immuno-suppression, increased antibiotic exposure which affects resistance to infection and the use of sometimes permanent invasive devices (eg., urinary tract catheters). 2–4 In addition, several factors promote the transmission of infectious agents in RACFs. The residents live in a home-like Australian Infection Control Association 2011
environment and have close contact with potentially infected or colonised residents and staff. Some too have multiple and often prolonged acute care hospitalisations.5–7 The literature does not extensively detail infection rates in Australian RACFs.8,9 However, numerous studies have shown infections are a common cause of acute care hospitalisation among RACF residents. In the most recent study, over 6 years, there were 3310 admissions from 147 South Australian RACFs.5–7,10,11 Infection was the primary diagnosis for 432 (13.1%) of the admissions. Pneumonia (5.6%) and urinary tract infections (UTI) (3.4%) were most commonly reported. In 2010, a pilot healthcare-associated infection (HAI) surveillance program was undertaken in RACFs based at the 12 hospital-associated health services located across the Grampians rural region, Victoria, Australia. There are five rural regions in the state of Victoria, as defined by the Department of Health. The focus of this pilot program was to gather information, further to that described above, that would 10.1071/HI11017
1835-5617/11/030116
Infection rates in residential aged care facilities
assist in making any decisions about future programs in these RACFs. The two main aims were to establish if there was a need for an ongoing HAI surveillance program, and if yes, to determine if the HAI surveillance program, as currently structured, was plausible. This paper outlines and discusses the results related to both the pilot program aims. The results related to the second aim are also further detailed in a future paper. It was agreed by the relevant stakeholders that if the pilot program demonstrated there was a relatively ‘average’ or ‘high’ infection rate in the Grampians RACFs then there would be a need for an ongoing HAI surveillance program. The intended outcome of an ongoing program would be to enhance continuous quality improvement efforts and reduce the infection rates. Methodology Data collection In the 30 participating RACFs (792 occupied beds), only high-care residents were included. High-care residents are assessed by an Australian Government Aged Care Assessment Team (ACAT), as those who require almost complete assistance with most daily living activities This includes accommodation, meals, laundry, room cleaning, personal hygiene care and if necessary, medical care.12 Data was continuously collected for 6 months (June to November, 2010) for four surveillance modules – ‘bronchitis and tracheo-bronchitis’, ‘cellulitis’, ‘conjunctivitis’ and ‘symptomatic UTI’. In addition, data was collected for 3 months (September to November) for the ‘gastroenteritis’ module. The first four modules were included in the pilot program because previous Rural Infection Control Practice Group annual surveys had indicated there was a high prevalence of bronchitis, trachea-bronchitis, cellulitis, conjunctivitis and symptomatic UTIs. Since 2007, all five rural regions in Victoria have annually participated in this prevalence survey. The gastroenteritis module was later included because at an Australian Commission in Safety and Quality in Healthcare workshop in August 2010, Clostridium difficile infection surveillance in aged care was recommended.13 Although pneumonia has been commonly reported in RACFs, a ‘pneumonia’ module was not included. It would have been difficult to confirm a pneumonia case because, as occurs elsewhere14,15, chest radiographs are infrequently performed in these RACFs. The five modules were based on the widely used McGeer et al.14 aged care infection definitions. These definitions outline criteria that have to be met before an infection is considered ‘true’ and were recommended for use in RACFs by the Australian Government Department of Health and Aging 2004 Infection Control guidelines.16 At each RACF, a clinical staff member or staff members were made responsible for, during their daily patient care activities, identifying residents with infections. Residents admitted or transferred to the facility during the 48 hours before identification of an infection were excluded. Identified infections were documented on a standard data collection
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form that was then forwarded to the health service infection control (HSIC) consultant. Data validation Each month, the HSIC consultant was asked to complete a monthly summary that recorded the number of ‘confirmed reported’, ‘excluded reported’ and ‘detected unreported’ infections. Total reported infections included both confirmed and excluded reported infections. All ‘infections’ reported by RACF staff members had to be confirmed or excluded by the HSIC consultant and/or treating doctor. The HSIC consultant was also asked to periodically check the microbiology reports for any infections not reported by RACF staff members. Completed data collection forms were forwarded to the one regional infection control coordinator who entered the data onto an Excel spreadsheet. Any missing data or obvious anomalies were followed up with the HSIC consultant. Data analysis Each month, a surveillance report was forwarded to the HSIC consultant. For each module, these cumulative reports listed the confirmed reported infection rates for their RACF(s) and for benchmarking purposes, the confirmed reported infection rates of all the RACFs combined. Infection rates were expressed as the number of infections per 1000 resident days; 95% confidence intervals were calculated. In the final 6-month report, in addition to the confirmed reported infection rates, the equivalent total reported infection rates were calculated for each module. For the confirmed reported infections only, the frequency for each criterion reported was also calculated. Results During the surveillance period, the mean age of the residents for whom an infection was reported was 84.9. Most (68%) were females. Table 1 outlines the confirmed reported and total reported infection rates. The majority of RACFs reported at least one infection for most modules. For the two RACFs that equalled or exceeded the ‘all infections’ 95th percentile (6.2 infections per 1000 resident days), symptomatic UTIs were mostly reported. One of these RACFs (1469 resident days) reported 20 infections, including 10 UTIs. The other RACF (5336 resident days) reported 33 infections, including 15 UTIs. Eighteen (19%) of the residents for whom a UTI was reported had a urethral urinary catheter in situ. Eight infections were detected by the HSIC consultant after reviewing microbiology reports. These ‘detected unreported’ infections were reclassified as ‘confirmed reported’ infections. Forty-four percent of the 466 infections reported by RACF staff members were excluded by an HSIC consultant. This was because: the resident had been admitted or transferred to the RACF within 48 hours (3.4%), the infection did not meet the criteria (71.4%) or there was ‘another’ reason (26.3%). The HSIC consultants commonly noted there was insufficient documentation in the residents’
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Table 1. Six-month cumulative infection rates Modules No. of reporting RACFs Bronchitis and tracheo-bronchitis Cellulitis/soft tissue/wound infection Conjunctivitis Gastroenteritis Symptomatic urinary tract infection All infectionsA
All residential aged care facilities Confirmed infections Total reported infectionsC No. of Infection 95% CI No. of Infection 95% CI infections rateB infections rateB
24 25 24 2 28 30
91 59 48 4 95 293
0.7 0.4 0.4 0.1 0.7 2.2
0.5–0.8 0.3–0.6 0.3–0.5 0.0–0.2 0.6–0.9 1.9–2.4
155 113 56 9 170 494
1.1 0.8 0.4 0.1 1.3 3.6
1.0–1.3 0.7–1.0 0.3–0.5 0.1–0.3 1.1–1.5 3.3–4.0
A
Gastroenteritis infections are not included in the ALL infections total. Infection rate = number of infections per 1000 resident days. C Total reported infections = confirmed reported and excluded reported infections. RACF, residential aged care facility. B
medical records to retrospectively assess and support the infection criteria. Table 2, except for gastroenteritis, outlines the frequency of criteria reported for the confirmed reported infections. Discussion The pilot program confirmed reported and total reported infection rates were 2.2 and 3.6 infections per 1000 Table 2.
resident days, respectively. The marked difference between the two rates was because of the significant number (41%) of infections reported by RACF staff members that could not be confirmed by the HSIC consultants. It is probable that the difference would have been less if the HSIC consultants had always had sufficient documentation in the residents’ medical records to retrospectively assess the criteria. Incomplete documentation of clinical findings in RACF medical records has been noted elsewhere.17
Frequency of reported criteria
Modules and criteria
Reported criteria No. %
Bronchitis and tracheo-bronchitis. Residents had to meet at least three of the criteria 1. New or increased cough 2. Change in status or breathing difficulty, new/increased shortness of breath, respiratory rate >25 per minute and/or worsening mental or functional status 3. New or increased physical findings on chest examination. Rales, rhonchi, wheezes or bronchial breathing 4. New or increased sputum production 5. Fever (>38C) 6. Pleuritic chest pain
84/91 68/91
92.3 74.7
67/91 38/91 35/91 11/91
73.6 41.8 38.5 12.1
Cellulitis/soft tissue/wound infection. Residents had to meet either criteria 1 or 2. For criteria 2, residents had to have at least four of the signs and symptoms. The signs and symptoms 2b–2f had to be at the affected site and new or increasing 1. Pus present at a wound, skin or soft tissue site 2a. Redness 2b. Heat 2c. Swelling 2d. Tenderness and pain 2e. Serous drainage 2f. Fever (>38C) or worsening mental/ functional status
28/59 31/31 29/31 28/31 27/31 9/31 8/31
47.5 100 93.5 90.3 87.1 29.0 25.8
Conjunctivitis. Residents had to meet either criteria 1 or 2 1. Pus appearing from one or both eyes present for at least 24 hours 2. New or increased conjunctival redness with or without itching or pus present for at least 24 hours
37/48 11/48
77.1 22.9
Symptomatic urinary tract infection. Residents who did not have an indwelling urinary catheter had to have at least three of the criteria. Residents who had an indwelling urinary catheter had to have at least two of the criteria. Criteria 3 was not applicable if residents had an indwelling catheter in situ 1. Change in character of urine (clinical or laboratory) 2. Worsening of mental or functional status 3. New or increased burning pain on urinating, frequency or urgency 4. New flank or supra-pubic pain or tenderness 5. Fever (>38C) or chills
90/95 90/95 58/77 25/95 19/95
94.7 94.7 75.3 26.3 20.0
Infection rates in residential aged care facilities
Published infection rates in RACFs may vary due to methodological differences in regard to the population studied, definitions used and type and intensity of surveillance undertaken. Notwithstanding these differences, it was useful to compare the pilot program infection rates to previous studies and determine that these rates were relatively low or average. In six Sydney RACFs (total 450 beds), from 2001 to 2005, the mean infection rate was 3.2 per 1000 bed days.9 In 2001, in 10 Perth private RACFs (total 407 beds) the mean infection rate was 4.6 per 1000 resident days; rates in individual facilities ranged from 1.9 to 9.0.8 Internationally, the infection rate has ranged from 1.8 to 11.8 per 1000 resident days.18–20 Over the 6-month pilot program, the residents in the participating RACFs were especially at risk of developing bronchitis and trachea-bronchitis, and symptomatic UTI. This is similar to the two Australian studies referenced earlier. The most common infection sites in both the Sydney and Perth RACFs were respiratory tract, urinary tract and skin and soft tissue.8,9 Interestingly, 11 bloodstream infections were identified in the Sydney RACFs. Although bloodstream infections might be infrequent in Australian RACF residents, the impact of this infection type can be severe.21 It was anticipated that some residents for whom a UTI was reported would have a urinary catheter in situ. The use of catheters in RACFs is common22 and those residents with a catheter in situ are always bacteruric. The presence of a catheter bypasses normal host defences, allowing continuous access of organisms into the urinary bladder. Residents with catheters in situ have been shown to have increased morbidity from urinary infection compared with bacteruric residents without catheters.23 Bronchitis and tracheo-bronchitis may have been frequently reported because the surveillance period included the winter months. In a German study, there was marked seasonal variation for respiratory tract infections with mean rates of 0.63 and 4.40 per 1000 resident days for May to November and December to April, respectively (RR = 6.99; 95% CI 3.84–12.70; P < 0.001).19 In addition, some of the bronchitis and tracheo-bronchitis infections may have been more accurately classified as pneumonia if chest radiographs had been undertaken. It was not surprising that only four gastroenteritis infections were confirmed between September and November. In a recent systematic review,24 the mean incidence of gastroenteritis in long-term care facilities (LTCF) residents was found to be relatively low: ~0.40 (95% CI 0.27–0.56). The authors noted new studies are needed to better assess the incidence of gastroenteritis in LTCFs due to its ‘potential for serious clinical outcomes and propensity to cause outbreaks’. The pilot program demonstrated that clinical manifestations of infection can be subtle and/or atypical, which has been described elsewhere.25–27 Fever, sometimes referred to as the ‘cardinal sign of infection’,27 was infrequently reported. This may have been because a ‘classic’
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definition of fever (>38C) was used. The Infectious Diseases Society of America recommend for older adult residents that fever be defined as: 1. a single oral temperature >37.8C, or 2. repeated oral temperatures >37.2C or rectal temperatures >37.5C, or 3. an increase in temperature of >1.1C over the baseline temperature.26 ‘Worsening of mental or functional status’ was especially common (94.7%) for those residents with symptomatic UTI. This noteworthy percentage was similarly observed28 in a USA LTCF over 6 months. Infection was determined to be present in 77% of episodes of ‘decline in function’. Decline in function was defined as new or increasing confusion, incontinence, falling, deteriorating mobility or failure to cooperate with rehabilitation. The pilot program had limitations. First, the data collected on high-care residents was not risk-adjusted. An appropriate risk stratification would have included some of the reasons why residents are highly susceptible to infections.29 Second, the program did not measure the impact of reported infections. This information is useful to know when promoting the need for an effective IC program. Indices that may be used to measure the impact include the volume of antimicrobial agent use, frequency of transfer to acute care hospitals and infectionrelated mortality.15 Conclusion The pilot program improved knowledge about infections and HAI surveillance programs in Australian RACFs. The information gathered will assist in making any decisions about future HAI surveillance programs in the Grampians RACFs. There were numerous recommendations made following the completion of the pilot program. 1. The establishment of an HAI surveillance program in the Grampians RACFs should be considered. This is because the confirmed reported infection rate, if the excluded reported infections could have been confirmed, may have been classified as ‘average’. As previously stated, it was agreed by the relevant stakeholders before the commencement of the pilot program that an average or high infection rate would indicate there was a need for an ongoing program. 2. All infections that were monitored in the pilot program should be included in a Grampians RACF HAI surveillance program. This includes gastroenteritis because 3 months may not have been long enough to best assess the incidence of this infection in the RACFs. A ‘bloodstream infection’ module should also be considered. 3. The documentation of clinical findings in the Grampians RACF medical records should be reviewed and if necessary improved. 4. The McGeer et al.14 definitions should be reviewed. These definitions constitute a valuable data collection tool but
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some aspects, for example the fever criteria, need further evaluation. 5. Future HAI surveillance programs and associated evaluations in the Grampians RACFs should address the pilot program limitations.
15. 16.
17.
Acknowledgements Special gratitude is expressed to the IC consultants and staff employed at the participating RACFs. We also wish to acknowledge the support given by the Department of Health Grampians Region.
18.
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Manuscript received 14 June 2011, accepted 12 August 2011
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