Survey highlights gaps in infection control practice and policy

The aged care accreditation standards need to be more explicit on infection prevention and control strategies and should be more closely aligned with the national standards governing the acute sector, a new study concludes.

The research also calls for a new national database of infection control policies and procedures that all aged care facilities can access, and for enhanced immunisation of aged care workers and residents.

Antimicrobial guidelines, which outline the appropriate use of antibiotics, also need to be developed for common infections in aged care so as to better support GPs, according to the research to be published in the Internal Medicine Journal.

The survey of infection control and antimicrobial stewardship practices in aged care, conducted in 2013 and early 2014, was led by Dr Rhonda Stuart, an infectious disease physician with Monash Health and Adjunct Clinical Associate Professor with Monash University.

The research noted:

• older people have a three-fold increased risk of pneumonia and a 20-fold increased risk of urinary tract infection
• each resident develops between one and three infections a year on average
• infection is the most common cause of hospital admission – accounting for between 26 and 50 per cent of resident transfers to acute facilities.

Dr Stuart told Australian Ageing Agenda that there were numerous challenges in providing robust infection control and prevention practices including limited resources, the differences between aged care and acute in service delivery and governance, and a lack of data.

Antimicrobial stewardship was becoming increasingly important in the acute care sector due to increasing bacterial resistance, “but it hasn’t really been looked at in residential aged care” because of challenges including the number of providers and difficulties getting pathology results, she said.

“We decided to start at the beginning and look at what was available in residential aged care facilities around Australia, in terms of guidelines, resources, vaccination programs, and infection control resources,” said Dr Stuart of the background to the research.

The survey was completed by 265 facilities nationally, representing 22,350 aged care beds (70 per cent high care). The facilities ranged in size from 50 to 250 beds.

Mixed findings

While the survey found that 91 per cent of facilities had a staff member dedicated to infection control, only 31 per cent of them had any certification or training in infection control.

“The majority of facilities, 81 per cent, had an infection control committee overseeing infection control, but again we don’t really know what sort of governance and how much push they actually had,” said Dr Stuart.

The survey found positive results on hand hygiene, which Dr Stuart said remained a big issue in infection control, with alcohol-based hand rub (ABHR) accessible in 95 per cent of the aged care facilities; although it was available in resident bedrooms in just 28 per cent of facilities.

“Nearly 2 per cent didn’t have any ABHR, so that’s an area that surprised us; people not using alcohol-based hand rubs.”

With regards to antibiotic prescribing, the survey found that policies governing antibiotic use were available in only 40 per cent of facilities. Further, just 14 per cent of facilities reported there were any restrictions to antibiotic prescribing. Dr Stuart said:

“GPs could basically prescribe whatever they wanted. That’s a concern for us if they’re using antibiotics without some guidance on what should be required.”

Many GPs are not aware of the emerging situation where patients are getting infections that cannot be treated with antibiotics, she said. “We’ve got to be really careful the way we use antibiotics.”

Vaccination of staff and residents was another area highlighted by the study as requiring attention.

While influenza vaccination of residents was high at 96 per cent, only 14 per cent of the facilities had high vaccination rates for their staff (greater than 75 per cent of workers). A quarter of facilities had 50 to 75 per cent of staff vaccinated for influenza, while 60 per cent of sites had less than half their staff vaccinated.

While Dr Stuart acknowledged that achieving high staff vaccination rates was also a challenge across the acute sector, she added that “the literature is really saying that the most evidence for workers being vaccinated lies in the residential aged care setting.”

While influenza vaccination rates for residents were high, 45 per cent of facilities did not know if their residents had received the pneumococcal vaccination. Only 20 per cent reported vaccination rates greater than 75 per cent.

Resources for workers, GPs needed

Based on the survey results, the researchers make a number of recommendations for both policy and practice changes within aged care.

Dr Stuart said policy makers needed to think about aligning accreditation of residential aged care with the national standards that govern the acute sector.

The aged care accreditation standards were too general, whereas the national standards governing the acute sector were specific, she said. “They are clear that you must audit all these things, you must have an antimicrobial stewardship program, you must have a vaccination program.”

In addition to changes to accreditation, the researchers are calling for a new database of policies and procedures for aged care facilities to access. “Although a lot of places have [policies], some of them didn’t and if there were standard procedures and policies around the way we should be managing NRSA or VRE, for example, it might make it easier for the smaller places that don’t have personnel to produce these procedures,” said Dr Stuart.

Addressing the gap in protocols around the use of antibiotics, the researchers have recommended the development of antimicrobial guidelines for common infections in residential aged care. This could support GPs in their decision not to prescribe antibiotics, said Dr Stuart: “I think a lot of the time there might be a push from relatives, family members or nursing staff, but it may be beneficial for GPs to actually not prescribe them.”

The research also recommends enhanced immunisations for workers and residents, specifically to address the low rates in areas such as pneumococcal.

Discussing future research in the area, Dr Stuart said that a recent grant from the National Health and Medication Research Council (NHMRC) would fund a new study on antimicrobial stewardship, one of the components of which will be in residential aged care.