PRE PLANNING SURVEY RESULTS

RESIDENTAL AGED CARE INFECTION SURVEILLANCE PROGRAM A PILOT PROJECT PRE PLANNING SURVEY RESULTS March 2010 Grampians Region Infection Control

Table of Contents A) Executive Summary... 3 B) Introduction... 4 C) Methodology... 4 D) Grampians Region Demographics... 5 E) Residential Aged Care Facility Details... 7 F) Current Infection Control Structure... 8 G) Current Surveillance Activities... 9 H) Pathology Service... 12 I) Where to From Here?... 13 Appendix 1 Members of Steering Committee... 14 References:... 15 Acknowledgements The author wishes to thank the Infection Control Professionals that completed the pre planning survey. The author wishes to acknowledge Bernadette Kennedy (Department of Health) and Pauline Woodburn, (Lodden Mallee Region Infection Resource Centre) for their participation in the Steering committee, Noleen Bennett and Dr Ann Bull (VICNISS Coordinating Centre) and Suranganie Wijesundara (University of Melbourne) for their participation in the Steering committee and for their assistance in developing the planning survey and writing this report. The author also wishes to acknowledge the assistance of Bruce Fowkes and Sue Daly (Department of Health Grampians Region) in developing the pilot project brief and review of this report. Correspondence Mary Smith Grampians Region Infection Control Consultant Department of Health PO Box 633 Horsham Victoria 3402 mary.smith@health.vic.au 29/05/2010 Page 2 of 15

A) Executive Summary This report summarises the results from a survey of 30 public residential aged care facilities (RACFs), located in the Grampians rural region in Victoria. The intent of the survey was to gather relevant information that would assist with the planning of a pilot healthcare infection surveillance program in this region. The RACFs are part of 12 health services. The survey was completed by Infection Control (IC) professionals employed at these health services. All 12 health services have agreed to participate in the pilot program. All 30 RACFs have high care (HC) beds; some also have low care (LC) beds. Eleven of the 30 facilities have HC and LC beds under one roof; the remainder are stand alone HC facilities. Sixteen of the facilities are colocated with an acute care hospital. All 12 health services have access to qualified IC professionals (ICPs), supported by two regional ICPs working out of the Grampians Region Department of Health. Only three health services have designated IC hours for aged care, although all health services indicated that some time is allocated for IC in aged care. Overall, there is one ICP for every 334 beds in the region (including acute and aged care beds). Of the total 5.95 EFT for the 12 health services, 5.52 is designated to acute care (656 beds) and 0.43 is formally designated to aged care (1334 beds). Hospital acquired infections (HAI) are increasingly being recognized as a problem in RACFs, however the resources available to address this problem do not seem to reflect this. Twentysix of the facilities utilise an IC liaison or link program where care staff take on an IC role within their facility this is usually a voluntary role with no additional remuneration or time attached. All 30 RACFs are currently conducting some form of infection surveillance, and all are using the same definitions for infections. All facilities collect data about urinary tract, respiratory and gastrointestinal infections, and almost all collect data about skin and eye and ear, nose and throat infections. Twentytwo collect data on systemic infections. The time periods for data collation vary and there is no standardization of what is reported and who receives the reports. In addition, there are four different pathology providers in the region and there is no consistency or standardized reporting. Some facilities receive no summary reports from pathology providers and others receive these in a less than useful format, for example grouped by requesting doctor. Problems with inconsistency in reporting from pathology providers is a universal problem at present, although it is likely that it will be addressed as pathology results are increasingly being used for electronic surveillance and imported into various hospital databases. These important issues will take some time to resolve. In summary, there was a positive response from the 30 surveyed RACFs when it was requested that they be involved in a pilot program to standardize infection surveillance and reporting. All facilities are currently carrying out some surveillance however programs are under resourced and relying on the goodwill of ICPs and care staff for their continuation. Surveillance is hindered at some facilities by a lack of consistent and useful reporting of pathology results. 29/05/2010 Page 3 of 15

B) Introduction Surveillance of infections in RACFs in Victoria is required under standard 4.7 of the Commonwealth Aged Care Accreditation Standards 1, although the requirements are not expressed in detail. Coordinated surveillance does not exist for all facilities in Victoria, although the Rural Infection Control Practice Group (RICPRAC) carry out annual point prevalence surveys which collate data from facilities in all five Department of Health Rural Regions 2. These surveys utilize the McGeer definitions for infections in long term care. 3 Overall, there is very little published in Australia on infections in RACFs. Results of the point prevalence surveys have shown that the majority of infections in long term care are symptomatic urinary tract infections and cellulitis/soft tissue/wound infections. There are also significant numbers of cases of conjunctivitis and respiratory tract infections. With the ageing population and recent shifts in the focus and delivery of health care and aged care services have come new challenges in the interactions between acute care and aged care. In many health services aged and acute care patients are under the same roof, and even where facilities are separated aged care patients are often transferred to acute care for short term treatment. This facilitates transfer of pathogens between these facilities and there is a need for more information regarding infections in aged care. Standardized surveillance has been in operation for Victorian acute care hospitals since 2003 4. With the aim of expanding and building on existing surveillance activities, the Grampians region are planning to undertake a pilot program which involves continuous surveillance of selected infections. Prior to the commencement of the surveillance, a survey was issued to public RACFs within the region to gather relevant preplanning information such as demographics, IC structure, current surveillance activities and pathology reporting. This report details the results of the survey. The pilot surveillance program is scheduled to commence on 1 June 2010. C) Methodology Late 2009, a Steering committee of interested parties (Appendix 1) was formed to investigate the possibility of commencing a continuous standardised infection surveillance program for HC RACFs. Public health services located in the Grampians region were purposely targeted for a pilot project. These health services were chosen on the basis that they have all had some experience with surveillance activities. All had participated in the annual RICPRAC point prevalence surveys 2 and Victorian Healthcare Infection Surveillance System (VICNISS) acute care surveillance program 4. A project brief was developed by the Regional Infection Control Consultants and was signed off by the Manager of Acute and Aged Care. A letter was sent to the Chief Executive Officers (CEO) of the health services under the Manager of Acute and Aged Care s signature, inviting them to participate in the RACF infection surveillance pilot project. The project brief was attached to the letter. The CEOs were advised that if they agreed to participate, the ICP employed at their health service would be requested to complete a planning survey. In the letter, it was noted that any data collected would be deidentified. At the Grampians IC regional meeting (February 2010), the planning survey was distributed to the ICPs. The ICPs were asked to complete the survey for each of their RACF and return it to the Steering committee within two weeks. All incomplete and obviously incorrect data was followed up. Aside from the planning survey, additional data was sourced from the agency annual reports for 20082009 5. 29/05/2010 Page 4 of 15

D) Grampians Region Demographics Grampians region has the smallest population base of all rural regions, but the region is large with some of the most sparsely populated areas of Victoria where providing health services provides a significant challenge. The region covers an area of 47,980 square kilometres and extends approximately 360 km from Bacchus Marsh in the east to the South Australian border in the west, and from Woomelang in the north to Inverleigh in the south (Diagrams 1 and 2). Diagram 1: Victoria rural health regions Diagram 2: Grampians rural health region 29/05/2010 Page 5 of 15

The 12 public health services in the region consist of one regional health service, one subregional health service and 10 local health services (Table 1) 6. They provide a comprehensive range of services across primary, community, acute, sub acute, mental health and residential aged care. There are 51 RACFs that provide LC and/or HC services. 7 Table 1: Grampians region health services Regional health service Ballarat Health Services Subregional health services Wimmera Health Care Group (Horsham) Local health services Beaufort & Skipton Health Service (Beaufort and Skipton) Djerriwarrh Health Services (Bacchus Marsh and Melton) Dunmunkle Health Services (Rupanyup, Minyip and Murtoa) East Grampians Health Service (Ararat and Willaura) East Wimmera Health Service (St Arnaud, Charlton, Donald, Wycheproof and Birchip) Edenhope & District Memorial Hospital Hepburn Health Service (Daylesford, Creswick and Trentham) Rural Northwest Health (Warracknabeal, Hopetoun and Beulah) Stawell Regional Health West Wimmera Health Service (Nhill, Jeparit, Kaniva, Rainbow, Natimuk and Goroke) Wimmera Health Care Group (Dimboola) 29/05/2010 Page 6 of 15

E) Residential Aged Care Facility Details All 12 health services (30 RACFs with HC beds) have agreed to participate in the pilot project (Table 2.1). One small RACF with only two HC beds has elected not to be involved. Across the 12 health services, there are a total of 1334 aged care beds 542 LC beds and 792 HC beds (Table 2.2 and 2.3). Eleven of the 30 participating RACFs have both LC and HC beds under the one roof. The other 19 are standalone HC RACFs. Sixteen (53%) RACFs are colocated with an acute care facility. There are 656 acute beds in the Grampians region (Table 2.4). 5 Thirteen RACFs (43%) provide Hospital in the Home (HITH) capacity. For residents, HITH is the provision of hospital care in their RAC bed. Patients receive the same treatment that they would receive if they were in an acute inpatient hospital bed. The most common conditions and treatments delivered by HITH are intravenous antibiotic therapy for cellulitis, genitourinary tract or respiratory tract infection, anticoagulant therapy and chemotherapy. 8 The 30 participating RACFs are affiliated with four different Divisions of General Practice Western Victoria, Ballarat, Central Highland and Murray Plains Division of General Practice (Table 2.5) Table 2 Participating Residential Aged Care Facilities (RACF) Measurement unless other stated, in participating RACF(s) No. % 2.1 Health service participation No. of health services that have nominated 1 participating RACF No. of health services that have nominated 2 participating RACFs No. of health services that have nominated 3 participating RACFs No. of health services that have nominated >4 participating RACFs 2.2 Low care (LC) beds Total no. of LC beds across the RACFs No. of RACFs that have both LC and HC beds Maximum no. of LC beds per RACF Minimum no. of LC beds per RACF Average no. of LC beds per RACF Total no.* of LC beds across the 12 health services 5 3 1 3 148 11 30 5 5 542 42% 25% 8% 25% 33% 2.3 High care (HC) beds Total no. of HC beds across the RACFs Maximum no. of HC beds per RACF Minimum no. of HC beds per RACF Average no. of HC beds in RACFs Average no. of HC beds per health service 2.4 Acute care beds No. of RACFs colocated with acute care facilities. Total no. of aged care beds colocated with acute beds Maximum no. of acute beds per RACF Minimum no. of acute beds per RACF Average no. of acute beds per RACF Total no. of acute beds across the12 health services 6 2.5 General Practice Divisions (GPD) No. of RACFs affiliated with West Victoria GPD No. of RACFs affiliated with Ballarat GPD No. of RACFs affiliated with Central Highland GPD No. of RACFs affiliated with Murray Plains GPD No. of RACFs affiliated with Ballarat and West Vic GPD 792 70 10 26 66 16 196 43 2 12 656 17 6 4 2 1 53% 57% 20% 13% 7% 3% * Colocated and stand alone RACFs 29/05/2010 Page 7 of 15

F) Current Infection Control Structure All 12 health services have a qualified ICP. Ten health services have designated IC hours. (To be designated, the RACF employee must be allocated IC equivalent full time (EFT)). The other two health services have ICPs who carry out IC duties on an as needed basis. The total IC designated EFT allocated for the 12 health services is 5.95 EFT (Table 3.1). 5.52 EFT is designated to acute care. Whilst all 12 health services indicate they allocate some time for IC in aged care, 0.43 EFT only is formally designated across three health services. Given the number of acute and aged care beds, this equates to one IC designated EFT for 334 acute and aged care beds, one IC designated EFT for 119 acute beds and one IC designated EFT for 3102 aged care beds across the 12 health services. The allocated time for aged care IC activities ranges from 30 minutes up to 4 hours per week. Fourteen RACFs did not nominate a specific time range but reported that the time spent varies, is ad hoc, limited or as required (Table 3.2). Twentysix of the 30 RACFs (87%) have an IC liaison or link nurse program (ICLN) where care staff take on an IC role. This is usually a voluntary portfolio without additional remuneration or time attached to the role. All but one of the RACF with an ICLN program has at least one trained ICLN (Table 3.3). Two regional ICPs operate out of the Grampians Region Department of Health to provide support and advice to the health service ICPs. Table 3 Current Infection Control Structure Measurement No. % 3.1 Infection control (IC) equivalent full time (EFT) Total EFT for acute and aged care beds Average EFT for acute and aged care beds per health service Average EFT for acute care beds only per health service Maximum IC EFT acute and aged care Maximum IC EFT acute only Minimum IC EFT acute only 3.2 Actual hours per week per RACF 30 minutes 1 hour 2 hours 2 to 4 hours Other 3.3 Qualified* infection control liaison nurses (ICLN) per RACF No qualified ICLNs 1 qualified ICLN 1 or 2 qualified ICLNs (varies at different times) 2 qualified ICLN s 5.95 0.50 0.46 2.4 2.0 0 1 4 4 7 14 1/26 13/26 6/26 6/26 3% 13% 13% 23% 47% 4% 50% 23% 23% *To be qualified, the person must have attended an official training day 29/05/2010 Page 8 of 15

G) Current Surveillance Activities All 30 participating RACFs are currently conducting some form of infection, staff health immunization status and resident immunization status surveillance program. At all RACFs, McGeer 3 definitions (or modules) for infections in longterm care are being used (Table 4.1). The urinary tract infection module is considered the most useful (Table 4.2). The person responsible for collecting the infection surveillance data is usually someone other than the IC designate. Two RACFs reported both the IC designate and ICLN collect data. In most RACFs, staff health immunization data is collected by the IC designate. Resident immunisation data is collected by a range of different personnel (Table 4.34.5). Table 4 Current surveillance activities Data collection Measurement No. RACFs % 4.1 Current infection surveillance modules Respiratory tract infections Urinary tract infections Skin infections Gastrointestinal infections Eye, ear, nose & mouth infections Systemic infections 4.2 Useful infection surveillance modules Respiratory tract infections Urinary tract infections Skin infections Gastrointestinal infections Eye, ear, nose & mouth infections Systemic infections 4.3 Person responsible for infection data collection IC designate IC liaison/link nurses (ICLN) Other Care staff Div 1 & 2 nurses Division 1 nurses Registered nurses 4.4 Person responsible for staff health immunisation status data collection IC designate Staff health department 4.5 Person responsible for resident immunisation status data collection IC designate Nursing Unit Manager Nursing Unit Manager and IC designate Nursing home staff/ward staff 30/30 30/30 29/30 30/30 29/30 22/30 27/30 30/30 22/30 27/30 22/30 14/30 9/30 7/30 16/30 5/30 6/30 4/30 1/30 28/30 2/30 11/30 8/30 3/30 8/30 100% 100% 97% 100% 97% 73% 90% 100% 73% 90% 73% 46% 30% 23% 53% 17% 20% 13% 3% 93% 7% 36% 27% 10% 27% A range of methods are used to collect and record infection data (Table 5.1). Seventeen of the 30 RACFs (57%) use an electronic system specific for infection surveillance. There is no standard system across the 12 health services with four different programs in use (Table 5.2). The majority (77%) of RACFs compile their infection data monthly (Table 5.3). Twentysix (87%) RACFs have a system of verifying that the infection reported meets the standard definition. For five RACFs this includes infrequent spot audits. The persons responsible for verifying the infections is most commonly the designated ICP (31%) (Table 5.4). 29/05/2010 Page 9 of 15

Table 5 Current surveillance activities Data management 5.1 Method used to collect/record infection data Spreadsheet Data base Paperbased system Spreadsheet and paperbased Database and paperbased 5.2 Electronic systems Aged Care Quality Association (ACQA) ICare Lee Total Care Riskman 5.3 Compilation of data Monthly Bi monthly Quarterly 5.4 Person responsible for data verification IC designate ICLN only Other Nurse Unit Manager IC Designate and IC RAC IC Designate and ICLN 5/30 14/30 17/30 5/30 1/30 5/17 5/17 1/17 6/17 23/30 1/30 6/30 8/26 5/26 6/26 6/26 1/26 17% 47% 57% 17% 3% 29% 29% 6% 36% 77% 3% 20% 31% 19% 23% 23% 4% The infection surveillance reports are distributed to a wide range of committees with a different reporting structure in each health service (Table 6). Reporting ranges from a simple structure where reports are tabled at the IC or quality committee meetings only, to a complex structure where the results of infection surveillance are reported to several committees, the medical director and are a key performance indicator for the Board of Management. Table 6 Current surveillance activities Data reporting 1 2 3 4 5 6 7 8 9 10 11 12 Description Infection Control committee (ICC) Infection Control Liaison Nurses, ICC, Patient Care Committee, Staff Nurse Unit Managers (NUM), Occupational Health & Safety meeting (Infection Control) (OHS) Staff meetings, ICC, Campus manager, IC Report IC/OHS meeting, senior staff, board ICC OHS meeting Medical director, aged care forum, ICC, Quality committee, Key Performance Indicator to Board of Management Unit Manager (UM) at staff meeting, used to be tabled at clinical risk meeting but new Chief Executive Officer is restructuring meeting schedule so unsure at this stage NUM, Theatre/ICC which goes to Quality Assurance committee and Board of Governance Residential Services Quality Management Meeting, Unit Director of Nursing who report back to unit level Unit Quality Meeting 29/05/2010 Page 10 of 15

The estimated time spent on surveillance activities per week is varied (Table 7). The ICPs in answering this survey question may have combined the time spent on surveillance activities in both their acute and aged care facilities. If this is the case, then as the results suggest their actual hours per week per RACF (See Table 3.2) would not be entirely taken up with surveillance activities. Table 7 Current surveillance activities Estimated time 7.1 Estimated time spent on surveillance activities per week Less than 30 minutes 30 minutes 1 hour 1 hour 2 hours 2 hours 3 hours 5/30 3/30 10/30 12/30 17% 10% 33% 40% Eight respondents (67%) highlighted there were specific issues in relation to data collection, analysis and/or reporting (Table 8). Table 8 Current surveillance activities Issues Comments: 1. Accuracy of reporting, items reported, items followed up, verification sometimes unable to be done. 2. Ad hoc method which is not based on definitions nor does it have a good process for collecting or a very good process for reporting data back to staff 3. Timely reporting, verifying data due to delay in receipt of results, time constraints, time allocation 4. Limited designated hours 5. The resident vaccination history is confined to influenza and pneumococcal immunisation. Lack of time, lack of ICLN staff. Lack of simple system to collect and record data 6. Staff health has few problems apart from staff presenting for immunisation. The resident vaccination history is confined to influenza and pneumococcal immunisation, time constraints 7. Have to look up pathology online for results so is time consuming. Also need to know who to look up, so have to rely on Aged Care doing their job properly, (i.e. reporting the infection in the first place). 8. Available time!! Facility managers and staff indicate that they often do not see these reports. IC is an agenda item at facility meetings. 29/05/2010 Page 11 of 15

H) Pathology Service There are four different pathology providers servicing the Grampians region. One health service with multiple campuses has two pathology providers for the one health service. There is a range of reporting methods and reporting frequencies, even from within the one Pathology service (Table 9). Table 9 Pathology Services Pathology provider Bendigo Dorevitch Gribbles St John of God No. of RACFs using pathology provider 1/30 6/30 1/30 22/30 Routine distribution of pathology reports to IC designate Daily reports Hard & electronic copies 0/1 6/6 1/1 19/22 Hard copy only (4 RACFs) Monthly reports Hard copy only Hard & electronic copy (2 RACFs) Daily & monthly reports Hard copy only (6 RACFs) Electronic copy (4 RACFs). Informal discussions with some health service ICPs indicate that a recent change of Pathology provider has changed the method of reporting pathology results. The previous pathology service provided monthly summaries of all microbiology results by department, including individual aged care facilities. They also included a separate report of blood cultures. These reports were considered very useful and made monitoring infections at an acute and aged care level efficient and easy. The departmental summaries were used to cross check reported infections in acute and aged care, assist with verifying infections and to alert ICP to possible missed infections at the unit level. The stand alone blood culture report was considered important for highlighting serious infections rapidly. It would appear from the data and from informal discussions with the ICPs that one pathology service in particular has a number of different reporting methods and frequencies. They do not always provide separate data for aged care, other than online, where the ICP has go into the program and retrieve information on the resident concerned. This is possible if the unit has reported an infection but will not allow ICP to check for missed reporting of infections by unit staff. It has been described as being much more time consuming, less efficient and could lead to missed infections. Further discussions with the health service ICPs regarding issues with pathology reporting have taken place since the pre planning surveys have been returned. A number of ICPs have indicated that it is possible to get the required reports from the provider concerned by negotiating with particular personnel. It was agreed that the health service ICPs involved will approach the Pathology provider again to seek more suitable reporting for both acute and aged care. 29/05/2010 Page 12 of 15

I) Where to From Here? Based on discussions with the Grampians Region IC Group (GRICG) and the results of this survey, the Grampians region will expand and build on existing surveillance activities to conduct continuous surveillance of selected infections over a three month trial period. The infections selected for continuous surveillance are urinary tract infections, skin infections, conjunctivitis and bronchitis. These infections are currently monitored by the majority of participating RACFs and are the four most common infections identified in the 2009 RICPRAC point prevalence survey 2. The definitions that will be used for the study are the McGeer 3 definitions for infections in aged care. The McGeer definitions are currently used by all 30 RACFs and are used for the RICPRAC point prevalence survey. All ICPs are familiar with these definitions. A formal invitation to participate in the survey has been signed off by the Chief Executive Officer of each health service. The pilot project will be promoted at a series of regional meetings for the managers of the aged care facilities in the Grampians region prior to the start of the project. Emphasis will be placed on the importance of accurate identification of infections using the McGeer definitions and subsequent verification of data. A final prepilot project workshop will be held at the April GRICG meeting with a representative from VICNISS present to discuss possible issues and to emphasize importance of data accuracy and verification. The project will also be described and promoted at the Rural Health Conference 2010 to be held on 22 April 2010 in Ballarat. To further assist with data quality, infection surveillance information kits will be given to the health service IC staff for distribution to all participating facilities. The kits will include a copy of the McGeer article describing the infection definitions for long term care, a laminated sheet listing the McGeer definitions for the selected infections, a surveillance checklist (developed with the assistance of VICNISS) and a copy of the GRICG IS IT BACTERIURIA Yes, but is it a Symptomatic UTI? booklet 9. The aim of this kit is to assist agencies submit accurate, verified data. The pilot surveillance program is scheduled to commence on 1 June 2010. 29/05/2010 Page 13 of 15

Appendix 1 Members of Steering Committee Member Representing Mr Bruce Fowkes Mrs Mary Smith Ms Pauline Woodburn Ms Bernadette Kennedy Dr Ann Bull Ms Noleen Bennett Ms Suranganie Wijesundara Grampians Region Infection Control, Department of Health Grampians Region Infection Control, Department of Health Loddon Mallee Quality, Safety and Patient Experience, Department of Health VICNISS Coordinating Centre VICNISS Coordinating Centre University of Melbourne 29/05/2010 Page 14 of 15

References: 1 2 3 4 5 Aged Care Standards and Accreditation Agency Ltd www.accreditation.org.au/site/uploads/accreditation%20standards%20factsheet.pdf Accessed April 2010 RICPRAC Residential Aged Care Facility Point Prevalence Surveillance Infection and Device use. 2009 (Unpublished) McGeer A, Campbell B, Emori T.G., Hierholzer W.J, Jackson M.M et al Definitions of infection for surveillance in longterm care facilities Am J Infect Control 19(1):17, 1991 VICNISS Coordinating Centre www.vicniss.org.au Accessed April 2010 State Government of Victoria, Department of Health, Grampians Region Agency Annual Reports 20082009 6 State Government of Victoria, Department of Health Rural directions for a stronger healthier Victoria 2009 www.health.vic.gov.au/ruralhealth Accessed April 2010 7 8 9 State Government of Victoria, Department of Health, Health Data Development Unit Agency Information Management System (AIMS) S5129 data collection Grampians region data Accessed April 2010. State Government of Victoria, Department of Health www.health.vic.gov.au/hith/ Accessed April 2010 Fowkes, B and Smith, M. Is it bacteruria Yes, but is it a symptomatic UTI? Grampians Region Infection Control Group (GRICG) 2010 http://www.grhc.org.au/ Accessed April 2010 29/05/2010 Page 15 of 15