Antibiotic prescribing practice in residential aged care facilities--health care providers' perspectives.

OBJECTIVE: To explore organisational workflow and workplace culture influencing antibiotic prescribing behaviour from the perspective of key health care providers working in residential aged care facilities (RACFs). DESIGN, SETTING AND PARTICIPANTS: Qualitative approach using semistructured interviews, focus groups and onsite observation between 8 January 2013 and 2 July 2013. Nursing staff, general practitioners and pharmacists servicing residents at 12 high-level care RACFs in Victoria were recruited. MAIN OUTCOME MEASURES: Emergent themes on antibiotic prescribing practices in RACFs. RESULTS: Sixty-one participants (40 nurses, 15 GPs and six pharmacists) participated. Factors influencing antibiotic prescribing practice have been divided into workflow-related and culture-related factors. Five major themes emerged among workflow-related factors: logistical challenges with provision of medical care, pharmacy support, nurse-driven infection management, institutional policies and guidelines, and external expertise and diagnostic facilities. Lack of onsite medical and pharmacy staff led to nursing staff adopting significant roles in infection management. However, numerous barriers hindered optimal antibiotic prescribing, especially inexperienced staff, lack of training of nurses in antibiotic use and lack of institutional infection management guidelines. With regard to culture-related factors, pressure from family to prescribe and institutional use of advance care directives were identified as important influences on antibiotic prescribing practices. CONCLUSIONS: Workflow- and culture-related barriers to optimal antibiotic prescribing were identified. This study has provided important insights to guide antimicrobial stewardship interventions in the RACF setting, particularly highlighting the role of nurses.

Quality of data reported to a smaller-hospital pilot surveillance program.

This data quality study assessed the accuracy of data collected as part of a pilot smaller-hospital surveillance program for methicillin-resistant Staphylococcus aureus (MRSA) infection and bloodstream infection (BSI). For reported MRSA infection, estimated values were as follows: sensitivity, 40%; specificity, 99.9%; and positive predictive value, 33.3%. For reported BSI, estimated values were as follows: sensitivity, 42.9%; specificity, 99.8%; and positive predictive value, 37.5%.

Implementation of a pilot surveillance program for smaller acute care hospitals.

BACKGROUND: An infection control (IC) surveillance program for smaller (<100 acute beds) hospitals was piloted for 18 weeks in 14 hospitals. The aim of the pilot stage was to test a theoretical program in the context in which it was to be implemented. METHOD: An evaluation framework was developed, outlining the program's intended activities for data collection, management, analysis, reporting, and use. This framework was used as a reference to interview each of the 12 IC nurses participating in the pilot stage. RESULTS: The preferred case finding methodologies were not uniformly applied. Management, analysis, and reporting of data were delayed because of infrequent and irregular IC hours and laboratory reporting. Reports were not always distributed to key persons. Specific action was only taken in response to the process (and not outcome) module reports. CONCLUSION: Discrepancies between the theoretical and actual implementation of a surveillance program for smaller hospitals were highlighted. The program will need to be revised before it is rolled out to all 89 eligible hospitals across Victoria.

Surgical antibiotic prophylaxis in smaller hospitals.

BACKGROUND: In 2004, The Victorian Hospital Acquired Infection Surveillance System Coordinating Centre established a smaller hospital (<100 beds) surveillance programme that included an optional 'surgical antibiotic prophylaxis' (SAP) module. Appropriate SAP is believed to be one of the most effective strategies to reduce surgical site infections after certain surgical procedures. METHODS: Trained infection control nurses in the participating hospitals were asked to collect SAP data for the first 50 consecutive procedures that could be classified into 1 of 12 surgical groups. The choice, timing and duration of antibiotics were compared against the Australian Therapeutic Antibiotic version 12 Guidelines and the US National Surgical Infection Prevention Project Advisory Statement. RESULTS: Fifty-one of the 87 smaller hospitals that participated in the surveillance programme of The Victorian Hospital Acquired Infection Surveillance System Coordinating Centre carried out surgery. Over 20 months, 25 of these hospitals contributed data on 1872 procedures. Antibiotic choice, timing and duration were 52.6, 54.7 and 76.1%, respectively, concordant with published recommendations. For antibiotic choice in five surgical groups (appendectomy, colon surgery, gastric surgery and abdominal and vaginal hysterectomies), less than half of the procedures were concordant with the Australian Therapeutic Antibiotic Guidelines. CONCLUSIONS: Substantial opportunities exist in smaller hospitals to improve compliance with published SAP recommendations. Further studies are required to determine the reasons for poor compliance with these recommendations.

Infections in Australian Aged-Care Facilities: Evaluating the Impact of Revised McGeer Criteria for Surveillance of Urinary Tract Infections.

Our survey of 112 Australian aged-care facilities demonstrated the prevalence of healthcare-associated infections to be 2.9%. Urinary tract infections (UTIs) defined by McGeer criteria comprised 35% of all clinically defined UTIs. To estimate the infection burden in these facilities where microbiologic testing is not routine, modified surveillance criteria for UTIs are necessary.

A user assessment of a smaller hospital surveillance program.

Forty-five infection control nurses responded to a survey that assessed a smaller hospital (<100 acute care beds) surveillance program. Most respondents (96.6%) agreed that participation in the program was useful. Only a few program elements that need further development were identified. Approximately half (52.3%) of the respondents agreed that the surveillance reports were easy to understand. The most frequent (72.9%) use of these reports was to present information to accreditation organizations. Approximately half (46.2% and 50%, respectively) of the respondents disagreed that the Web-based education package or the workplace visits by "educators" were useful.

MRSA infections in smaller hospitals, Victoria, Australia.

BACKGROUND: Infections caused by methicillin-resistant Staphylococcus aureus (MRSA) cause significant morbidity, mortality, and associated costs. METHODS: Trained infection control (IC) nurses in 84 smaller (<100 acute beds) hospitals during a 20-month period collected data on MRSA infections. RESULTS: The aggregate rate for all MRSA infections confirmed by the Victorian Hospital Acquired Infection Surveillance System Coordinating Centre IC nurse was 1.5 per 10,000 acute care occupied bed days (OBDs) (95% CI: 1.2-1.8). MRSA infections of 0.5 per 10,000 OBDs were detected >48 hours after admission (95% CI: 0.3-0.7). The aggregate rate for MRSA infections in sterile sites was 0.2 per 10,000 OBDs (95% CI: 0.0-0.4) and in nonsterile sites was 1.3 per 10,000 OBDs (95% CI: 1.0-1.6). CONCLUSION: The results suggested that serious MRSA infections in Victoria's smaller hospitals are an infrequent event. Most are "inherited" either from the community or other health care facilities.