Infection prevention quality indicators in aged care: ready for a national approach

Additional keywords: aged care, infection prevention, surveillance.

Accreditation standards for Australian aged care homes (ACHs) include the requirement for programs to ensure infections are effectively controlled.¹ Recent outbreaks have highlighted the risks associated with congruent living and the need for robust infection prevention programs that support residents to remain well and live meaningful lives.²

Effective infection prevention programs are underpinned by relevant surveillance data providing the impetus for quality improvement and facilitating evaluation of interventions.³ There is currently no coordinated national approach to continuously collect and analyse infection surveillance data in Australian ACHs.

In healthcare, the development of standardised quality indicators enables monitoring of performance over time and benchmarking. In hospital settings, these activities are an important element for ensuring that clinical care is aligned with best practice and supported by allocated resources and infrastructure.

Aged care settings are distinct from hospital environments for several reasons, including the provision of a ‘home-like’ environment for residents and unique workforce skills. Notwithstanding these differences, the use of quality indicators in aged care would be likely to provide many benefits: quantifiable measures of performance, clinician feedback for improvement and education and transparency for residents and carers.⁴ Outside Australia, quality indicators for elderly populations have been developed to monitor infections and antimicrobial use, and these are frequently used in a multimodal manner, comprising both process and outcome measures.^5,6 Infection prevention quality indicators are an important element of the potential suite of measures reflecting complex care needs of Australian aged care residents.^7,8

In 2016, infection control professionals (ICPs) employed in Victorian public-sector residential aged care services (PSRACS) were invited to complete a survey examining their infection prevention programs and available resources. Overall, 164 services participated (90% response rate). The facilities surveyed had a median capacity of 28 residents, with medical review provided by a mean of 6.5 general practitioners per facility. Survey findings are summarised in Table 1. Notably, 84% believed they would have or probably would have the support of their executive team to commence an infection surveillance program, mean allocation to infection prevention activities was 12 staff hours per fortnight per service, 80% reported access to laboratory results for all residents and current surveillance activities included infections and antimicrobial use (90%), influenza vaccination compliance for staff (96%) and residents (76%) and monitoring of significant organisms (84%).

Table 1.  Infection prevention and surveillance programs, Victorian aged care facilities (2016)
GPs, general practitioners. Ranges shown are minimum–maximum

These findings support the fact that infection prevention and control programs and surveillance activities are generally supported and implemented at the facility level. Appreciating that surveillance activities may be strengthened further by a coordinated strategy, ICPs and clinical nurses in PSRACS commenced collection and submission of data to the Victorian Healthcare Associated Infection Surveillance System (VICNISS) Coordinating Centre in 2017, thereby ensuring uniform data submission and support for participating facilities.

Eight indicators have been developed and implemented (Table 2), incorporating process (influenza, pneumococcal and zoster vaccination uptake among residents; influenza vaccination uptake among staff; antimicrobial prescribing practices) and outcome measures (infections due to methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus and Clostridium difficile). VICNISS provides data reports to participating PSRACS and the Victorian Department of Health and Human Services using standardised data metrics, electronic data handling and a secure online portal. Further, expert infection control and infectious diseases advice is available to PSRACS, ensuring uniformity of surveillance methods and implementation of best-practice interventions. This model ensures data quality and contributes to staff knowledge, both of which are essential for quality improvement activities at the service level.

Table 2.  Infection quality indicators for aged care

Looking ahead, targets and triggers for change will be developed to ensure early detection of potential opportunities for improved performance. VICNISS has successfully developed and implemented comparable infection surveillance modules throughout Victorian acute care hospitals that are associated with the PSRACS.⁹ For example, annual staff influenza vaccination uptake in acute care services is currently monitored. A state-wide target of 75% was set in 2014, and this is now met by most participants.¹⁰ In ACHs, a similar process would reduce the risk of influenza transmission, encompassing both staff and residents.¹¹

From a national perspective, we note increasing involvement of ACHs in all states using the national tool for auditing infections and antimicrobial prescribing,¹² suggesting that ACHs outside Victoria now seek standardised monitoring of infection and prescribing practices and the capacity for benchmarking using a quantitative framework. The recent national review of infection prevention activities in ACHs in Australia¹³ will be an important step in understanding the need for developing standardised infection prevention quality indicators nationally.

In summary, we have identified support for infection prevention programs and surveillance activities at the service level in Victoria. Surveyed Victorian PSRACS demonstrate a range of infection surveillance activities to be appropriately supported by existing resources. In addition, we have successfully applied a networked model to strengthen monitoring activities, using a coordinated state-wide approach with an emphasis on quality improvement. We suggest that a national focus could strengthen this process further, ensuring a uniform strategy with enhanced benchmarking capacity. This calls for stakeholder engagement and refinement of appropriate indicators for monitoring quality improvement in public, not-for-profit and private sectors within aged care.

None of the authors has any conflicts of interest to declare.