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.

Opportunities for nurse involvement in surgical antimicrobial stewardship strategies: A qualitative study.

BACKGROUND: Multi-disciplinary antimicrobial stewardship teams are a common strategy employed to optimise antimicrobial prescribing. Nurses play a pivotal role in patient care and safety; however, their role and potential opportunities across surgical antimicrobial stewardship are not well-established. This study aims to highlight health professional perspectives of the nurse's role and relevant opportunities for nurses to engage in and lead surgical antimicrobial stewardship initiatives. METHODS: An exploratory, multi-site, collective qualitative case study. Transcribed audio-recordings of focus groups with health professionals underwent thematic analysis, with mapping to established frameworks. RESULTS: Four key themes were identified; surgical antimicrobial prophylaxis is not prioritised for quality improvement, but nurses perceive benefits from surgical antimicrobial prophylaxis education and training; professional hierarchy hinders nurse engagement and leadership in antimicrobial stewardship; nurses are consistently engaged with patient care throughout the surgical journey; and clarity of roles and accountability for surgical antimicrobial prophylaxis review and follow-up can bolster quality improvement initiatives. DISCUSSION: Many opportunities exist for nurse engagement in surgical antimicrobial stewardship. Identification of barriers and enablers support theoretically informed strategies i.e., education and guideline accessibility; multidisciplinary collaborations; executive support for nursing capacity building and the standardisation of surgical antimicrobial prophylaxis workflow and documentation. CONCLUSIONS: Nurses are critical to patient safety and to supporting antimicrobial stewardship, in the operating theatre, and throughout the patient's surgical journey. Applying theoretical frameworks to understand barriers and enablers to nurses' contribution to antimicrobial stewardship has given insights to inform interventions to support nurse engagement.  : Tweetable abstract: Nurses are critical for patient safety. Many opportunities exist to support them as surgical antimicrobial stewards.

The feasibility and generalizability of assessing the appropriateness of antimicrobial prescribing in hospitals: a review of the Australian National Antimicrobial Prescribing Survey.

The National Antimicrobial Prescribing Survey (NAPS) is a web-based qualitative auditing platform that provides a standardized and validated tool to assist hospitals in assessing the appropriateness of antimicrobial prescribing practices. Since its release in 2013, the NAPS has been adopted by all hospital types within Australia, including public and private facilities, and supports them in meeting the national standards for accreditation. Hospitals can generate real-time reports to assist with local antimicrobial stewardship (AMS) activities and interventions. De-identified aggregate data from the NAPS are also submitted to the Antimicrobial Use and Resistance in Australia surveillance system, for national reporting purposes, and to strengthen national AMS strategies. With the successful implementation of the programme within Australia, the NAPS has now been adopted by countries with both well-resourced and resource-limited healthcare systems. We provide here a narrative review describing the experience of users utilizing the NAPS programme in Canada, Malaysia and Bhutan. We highlight the key barriers and facilitators to implementation and demonstrate that the NAPS methodology is feasible, generalizable and translatable to various settings and able to assist in initiatives to optimize the use of antimicrobials.

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.

Knowledge, attitudes and practices of healthcare workers within an Australian tertiary hospital to managing high-consequence infectious diseases.

BACKGROUND: Adequate preparation and support for healthcare workers (HCWs) managing high-consequence infectious diseases (HCIDs) is critical to the overall clinical management of HCIDs. Qualitative studies examining how well prepared and supported HCWs feel are lacking despite their key role. This study investigated how prepared and supported front-line HCWs at an Australian tertiary hospital felt about managing HCIDs such as viral haemorrhagic fever (VHF). METHODS: A qualitative research approach was used to undertake interviews with 45 Royal Melbourne Hospital medical and nursing staff from emergency, intensive care and infectious diseases. Interview questions captured data on HCWs' role, familiarity with using protocols, psychological attributes and training for scenarios related to VHF patient management. Interviews were recorded and transcribed. Categorical responses were analysed quantitatively and open-ended responses were analysed thematically. RESULTS: Ninety-eight percent of participants indicated feeling capable of undertaking their role in managing VHF patients; 77% felt supported through personnel/resources. However, 69% indicated barriers to managing these patients effectively; and 68% felt anxious at the prospect of managing VHF patients. Themes emerging from participants' observations included concerns about training frequency, miscommunication, difficulty with uncertainty, feeling underprepared, and fear of transmitting infection to others. CONCLUSION: Although the majority of HCWs feel confident about their ability to care for VHF patients, they also have a moderately-high degree of anxiety. Perceptions of interviewed staff have fed into recommendations to increase HCW preparedness and reduce anxiety, which include investigating support services, and exploring training options that create multi-departmental groups of highly specialised medical officers and nurses.

Case for antimicrobial stewardship pharmacy technicians in Australian hospitals.

The pharmacist's role in hospital antimicrobial stewardship (AMS) programs is known to improve patient safety and the quality of care. Despite this, many Australian hospitals struggle to provide adequate pharmacy AMS program resourcing and need to explore newer models of care. The Pharmacy Board of Australia's Guidelines for Dispensing Medicines permit suitably qualified, competent and experienced pharmacy technicians to assist pharmacists in 'tasks in a pharmacy department'. The pharmacy technician workforce is expanding, and there is growing interest in career advancement and expansion of the pharmacy technician role. We propose that the pharmacy technician, a well-integrated member of many Australian hospital pharmacy departments, can play an important role in hospital AMS programs. To bolster AMS initiatives in Australian hospitals, this paper explores the existing evidence for pharmacy technicians in AMS programs and describes how this role may be better supported in Australia.

Assessing patient understanding of their antimicrobial treatment: How are we doing and how might we improve?

BACKGROUND: The Antimicrobial Stewardship Clinical Care Standard states that patients should receive certain information about their antimicrobial therapy. How well the patient communication recommendations of the standard are followed in clinical practice is not well established. The aim of this pilot quality improvement study was to assess current practices around communication with hospitalised patients about their antimicrobial therapy, to determine compliance with current recommendations, and develop and implement quality improvement actions focused on patient communication for antimicrobial stewardship in Australia. METHODS: Adult inpatients receiving one or more antimicrobials for greater than 72 h were recruited. A survey was conducted to assess rates of compliance with requirements to inform patients about the indication, duration and potential side effects of current antimicrobial therapy; modes of delivery of information; and rates of patient satisfaction with the information provided. A paper-based survey was conducted on the general medical, infectious diseases, geriatric evaluation and management, and rehabilitation wards in a 500-bed tertiary Australian hospital. A sample size of 50 was determined as adequate for a baseline analysis of patient communication practices and the development of quality improvement resources and actions. Responses to categorical questions were analysed quantitatively, with additional feedback from patients was collated and analysed qualitatively. RESULTS: A total of 54 patients were surveyed. A majority (83%) of patients had been informed that they were taking antimicrobials, and, of these, 96% said they knew the indication, 18% were informed of potential side effects, and 36% knew the duration. Only 22% were informed of the review plan and 27% knew if antimicrobials would be continued on discharge. Written information was given to 11% of patients. Over half (62%) of patients either wanted more information or had concerns about their antimicrobial therapy. Patients reported difficulty in obtaining information. Fifty-eight percent of patients received antimicrobial information from doctors, 13% from nurses and 12% from pharmacists. CONCLUSIONS: This study identified gaps in communication with patients regarding in-hospital antimicrobial therapy, and highlighted the need for development and delivery of local quality improvement activities to address this gap.

Antibiotic prescribing in surgery: A clinically and socially complex problem in Australia.

Surgical prophylaxis is a common indication for antimicrobial use in Australian hospitals with demonstrated poor rates of appropriateness. Ongoing analysis of the Surgical National Antimicrobial Prescribing Survey and exploration of influences on antimicrobial prescribing decisions can help identify clinical and behavioural issues that contribute to problematic antimicrobial use. Triangulation of quantitative and qualitiatve data supports the development of surgical antimicrobial stewardship, i.e., quality improvement initiatives for the optimisation of surgical antimicrobial prophylaxis. Such initiatives should be developed and implemented at both local and national levels to ensure that they remain effective and sustainable.

The role of nurses in antimicrobial stewardship near the end of life in aged-care homes: A qualitative study.

BACKGROUND: The excessive use of antimicrobials in aged-care homes is a widely recognised phenomenon. This is problematic because it can harm residents, and is detrimental to public health. Residents in the final month of life are increasingly likely to be prescribed an antimicrobial, commonly without having signs and symptoms of infection that support antimicrobial use. OBJECTIVES: We aimed to describe the perspectives of health professionals on antimicrobial use near the end of life in aged-care homes and investigate the potential opportunities for nurses to undertake antimicrobial stewardship activities near the end of life in aged-care homes. DESIGN: One-on-one, semi-structured, qualitative interviews. SETTINGS AND PARTICIPANTS: Twelve nurses, six general practitioners and two pharmacists providing routine care to residents of aged-care homes in Victoria, Australia were interviewed. Diversity in terms of years of experience, aged-care funding type (government, private-for-profits and not-for-profits) and location (metropolitan and regional) were sought. METHODS: Interviews were transcribed and open coded in a descriptive manner using validated frameworks for understanding behaviour change. The descriptive code was then used to build an interpretive code structure based on questions founded in grounded theory. RESULTS: Thematic saturation was reached after fourteen interviews, and an additional six interviews were conducted to ensure emergent themes were consistent and definitive. There are opportunities for aged-care home nurses to undertake antimicrobial stewardship activities near the end of life in the provision of routine care. Aged-care home nurses are influential in antimicrobial decisions near the end of life in routine care because of their leadership in advance care planning, care co-ordination and care provision in an environment with stopgap and visiting medical resources. Nurses also have social influence among residents, families and medical professionals during critical conversations near the end of life. Past negative social interactions within the aged-care home environment between nurses and families can result in 'fear-based' social influences on antimicrobial prescribing. CONCLUSIONS: The work of facilitating advance care planning, care coordination, care delivery, and communicating with families and medical professionals provide important opportunities for aged-care home nurses to lead appropriate antimicrobial stewardship activities near the end of life.

Measuring antimicrobial prescribing quality in outpatient parenteral antimicrobial therapy (OPAT) services: development and evaluation of a dedicated national antimicrobial prescribing survey.

BACKGROUND: Antimicrobial stewardship programmes are important in driving safety and quality of antimicrobial prescribing. The National Antimicrobial Prescribing Survey (NAPS) is a point-prevalence audit of inpatient antimicrobial prescribing in Australian hospitals. OBJECTIVES: To design and adapt the NAPS tool for use in the outpatient parenteral antimicrobial therapy (OPAT) and hospital-in-the-home (HITH) setting. METHODS: An inter-disciplinary working group with expertise in OPAT and HITH services was established to adapt the NAPS template for use in the OPAT setting-called HITH-NAPS. This was initially trialled in 5 HITH services, subsequently adapted following participant feedback, then offered nationally to 50 services in 2017. RESULTS: There were 1154 prescriptions for 715 patients audited via the HITH-NAPS. The most common antimicrobials prescribed were cefazolin (22%), flucloxacillin (12%), piperacillin/tazobactam (10%) and ceftriaxone (10%). The most common infections treated were cellulitis (30%) and respiratory tract infections (14%). Eighty-seven percent of prescriptions were assessed as appropriate, 11% inappropriate and 2% not assessable. Prolonged durations of antimicrobials and unnecessarily broad-spectrum antibiotics were used in 9% of prescriptions. CONCLUSIONS: The HITH-NAPS pilot project revealed that auditing of this type is feasible in HITH. It showed that antibiotic use in these HITH services was generally appropriate, but there are some areas for improvement. A national OPAT/HITH-NAPS can facilitate benchmarking between services, identify potentially inappropriate prescribing and help guide quality improvement.

Antimicrobial stewardship near the end of life in aged care homes.

BACKGROUND: The objective of this study was to understand how aged care home health professionals perceive antimicrobial use near the end of life and how they perceive potential antimicrobial stewardship activities near the end of life in aged care homes. METHODS: Qualitative semi-structured interviews were undertaken with general practitioners, nurses, and pharmacists who provide routine care in aged care homes in Victoria, Australia. Interviews were coded using frameworks for understanding behavior change. RESULTS: Themes were established within 14 interviews, and an additional 6 interviews were undertaken to ensure thematic saturation. Two major themes emerged: (i) Antimicrobial stewardship activities near the end of life in aged care homes need to enable aged care home nurses to make decisions substantiated by evidence-based clinical knowledge. Antimicrobial stewardship should clearly be part of an aged care home nurse's role, and accreditation standards provide powerful motivation for behavior change. (ii) Antimicrobial stewardship activities near the end of life in aged care homes must address family confidence in resident wellbeing. Antimicrobial stewardship activities should be inclusive of family involvement, and messages should highlight the point that antimicrobial stewardship improves care. CONCLUSIONS: Antimicrobial stewardship activities that reinforce evidence-based clinical decision-making by aged care home nurses and address family confidence in resident wellbeing are required near the end of life in aged care homes. Accreditation standards are important motivators for behavior change in aged care homes.

Influences on surgical antimicrobial prophylaxis decision making by surgical craft groups, anaesthetists, pharmacists and nurses in public and private hospitals.

BACKGROUND: Surgical antimicrobial prophylaxis (SAP) is a leading indication for antibiotic use in the hospital setting, with demonstrated high rates of inappropriateness. Decision-making for SAP is complex and multifactorial. A greater understanding of these factors is needed to inform the design of targeted antimicrobial stewardship interventions and strategies to support the optimization of SAP and its impacts on patient care. METHODS: A qualitative case study exploring the phenomenon of SAP decision-making. Focus groups were conducted with surgeons, anaesthetists, theatre nurses and pharmacists across one private and two public hospitals in Australia. Thematic analysis was guided by the Theoretical Domains Framework (TDF) and the Capabilities, Opportunities, Motivators-Behaviour (COM-B) model. RESULTS: Fourteen focus groups and one paired interview were completed. Ten of the fourteen TDF domains were identified as relevant. Thematic analysis revealed six significant themes mapped to the COM-B model, and subthemes mapped to the relevant TDF domains in a combined framework. Key themes identified were: 1) Low priority for surgical antimicrobial prophylaxis prescribing skills; 2) Prescriber autonomy takes precedence over guideline compliance; 3) Social codes of prescribing reinforce established practices; 4) Need for improved communication, documentation and collection of data for action; 5) Fears and perceptions of risk hinder appropriate SAP prescribing; and 6) Lack of clarity regarding roles and accountability. CONCLUSIONS: SAP prescribing is a complex process that involves multiple professions across the pre-, intra- and post-operative surgical settings. The utilisation of behaviour change frameworks to identify barriers and enablers to optimal SAP prescribing supports future development of theory-informed antimicrobial stewardship interventions. Interventions should aim to increase surgeon engagement, enhance the prioritisation of and accountability for SAP, and address the underlying social factors involved in SAP decision-making, such as professional hierarchy and varied perceptions or risks and fears.

The 2018 Aged Care National Antimicrobial Prescribing Survey: results show room for improvement.

The annual Aged Care National Antimicrobial Prescribing Survey aims to identify local and national prescribing issues and guide antimicrobial stewardship goals In the 2018 point prevalence survey, medication charts of over 20,000 residents were reviewed from 407 participating facilities across Australia On the day of the survey, almost 10% of residents were prescribed an antimicrobial Nearly two-thirds of recently prescribed antimicrobials were for residents who had no documented signs or symptoms of infection Over a quarter of antimicrobials had been prescribed for longer than six months Incomplete documentation was a prominent barrier to proper review of antimicrobial therapy, with the indication, review date or stop date not documented for many prescriptions Recommendations include using appropriate microbiological testing to guide prescribing, following national antimicrobial prescribing guidelines, documenting the indication for the antimicrobial, and its start, stop and review dates, and monitoring and re-evaluating long-term antimicrobial use

Surgical antibiotic prophylaxis - The evidence and understanding its impact on consensus guidelines.

BACKGROUND: Surgical site infections are complications of surgical care that may be prevented with appropriate surgical antibiotic prophylaxis (SAP). SAP is the most common indication for antimicrobial use in Australian hospitals; however, it is associated with high rates of inappropriate use. Inappropriate SAP is associated with adverse consequences for both the patient and the community. The underlying reasons for inappropriate use, however, are not well delineated. Potential factors include the quality of the evidence base regarding SAP use and available guidelines. METHODS: The literature review focused on research classified as having Level 1 evidence according to the National Health and Medical Research Council (NHMRC) evidence hierarchy. Findings were then compared to the current Australian recommended guidelines (Therapeutic Guideline: Antibiotic Surgical Prophylaxis). RESULTS: Overall, 50 systematic reviews (SR) and meta-analysis (MAs) were identified for the review. The evidence examined highlights that first-generation cephalosporins are the antimicrobial agents of choice and single-dose prophylaxis is effective for the majority of surgical procedures included in this review. There is limited evidence pertaining to a specific optimal antimicrobial, dosing and timing. Thus, there is no overarching Level 1 evidence combining all elements for an optimal SAP regimen (i.e., choice of agent, dose, route and duration) to support individual Therapeutic Guideline: Antibiotic recommendations, although there may be Level 1 evidence for the individual elements. CONCLUSIONS: Considerable evidence supports the use of SAP; however, there are gaps in the evidence behind recommendations for the most appropriate SAP regimen for different surgical procedures. Expert consensus guideline development aims to narrow these gaps, but guideline implementability and uptake are influenced by multiple factors including the comprehensiveness of the evidence. Further research is warranted to examine guideline implementability and uptake, and to identify problematic areas surrounding surgical prophylaxis prescribing.