Implementation of an intervention to reduce urine dipstick testing in aged care homes: a qualitative study of enablers and barriers, and strategies to enhance delivery.

OBJECTIVE: The 'To Dip or Not to Dip' (TDONTD) intervention aims to reduce antibiotic prescribing for urinary tract infection (UTI) by reducing low-value dipstick testing. The aims of this study were to use a qualitative approach to (1) evaluate potential influences on the delivery of the TDONTD intervention in Australian residential aged care homes (RACHs) by identifying perceived barriers and enablers to delivery and acceptance; and (2) propose intervention strategies to address barriers and enhance enablers. DESIGN: A qualitative before-after process evaluation of a multisite implementation study using interviews with nurse and pharmacist implementers. SETTING: This study was conducted in 12 Australian RACHs. PARTICIPANTS: Participants included 17 on-site nurse champions and 4 pharmacists (existing contracted providers). INTERVENTION: Resources from England's TDONTD intervention were adapted for an Australian context. Key resources delivered were case-based education, staff training video, clinical pathway and an audit tool. RESULTS: Key barriers to TDONTD were beliefs about nursing capabilities in diagnosing infection, beliefs about consequences (fear of missing infection) and social influences (pressure from family, doctors and hospitals). Key enablers were perceived increased nurse and carer knowledge (around UTI and asymptomatic bacteriuria), resources from a credible source, empowerment of nurse champions to apply knowledge and skills in delivering operational change initiatives, pharmacist-delivered education and organisational policy or process change. Of TDONTD's key components, the clinical pathway substituted dipstick testing in diagnosing UTI, delivery of case-based education was enhanced by their attendance and support of the intervention and the antibiotic audit tool generated feedback that champions shared with staff. CONCLUSIONS: Our study confirms the core components of TDONTD and strategies to enhance delivery and overcome barriers. To further reduce barriers to TDONTD, broader advocacy work is required to raise awareness of dipstick testing as a low-value test in older persons and by linking it to healthcare professionals and consumer education.

Assessing infection prevention and control programs in residential aged care in Australia: A multi-methods cross-sectional study.

AIM: To assess infection prevention and control programs in residential aged care facilities. METHODS: A cross-sectional survey and structured interviews from 10 residential aged care facilities in Victoria, Australia, were used. Infection prevention and control nurse leads from each facility completed a purpose-built survey based on best practice infection prevention control program core components, including staff training, policies and procedures, governance, and surveillance. Follow-up interviews with residential aged care staff, residents and family visitors were carried out to elaborate and verify survey data. RESULTS: Surveys from all 10 facilities were received and 75 interviews carried out. All facilities had an infection prevention and control lead nurse who had undergone additional training, and 60% of facilities had an infection prevention and control lead position description. All facilities had a committee to oversee their infection prevention and control program, and all had policies and procedures for standard and transmission-based precautions. One facility did not have a policy on healthcare-associated infection surveillance, and two facilities did not have an antimicrobial stewardship policy. All facilities provided staff training in hand hygiene and personal protective equipment use, but not all routinely assessed competency in these. CONCLUSIONS: The residential aged care facilities' infection prevention and control programs were generally in a strong position, although there were some areas that require improvement. Further assessment of the quality of infection prevention and control program components, such as content of education and training, and policies and procedures, and ongoing evaluation of programs is recommended. Geriatr Gerontol Int 2024; 24: 358-363.

Applying the standardized infection ratio for reporting surgical site infections in Australian healthcare facilities.

Objective: We explored the utility of the standardized infection ratio (SIR) for surgical site infection (SSI) reporting in an Australian jurisdiction. Design: Retrospective chart review. Setting: Statewide SSI surveillance data from 2013 to 2019. Patients: Individuals who had cardiac bypass surgery (CABG), colorectal surgery (COLO), cesarean section (CSEC), hip prosthesis (HPRO), or knee prosthesis (KPRO) procedures. Methods: The SIR was calculated by dividing the number of observed infections by the number of predicted infections as determined using the National Healthcare Safety Network procedure-specific risk models. In line with a minimum precision criterion, an SIR was not calculated if the number of predicted infections was <1. Results: A SIR >0 (≥1 observed SSI, predicted number of SSI ≥1, no missing covariates) could be calculated for a median of 89.3% of reporting quarters for CABG, 75.0% for COLO, 69.0% for CSEC, 0% for HPRO, and 7.1% for KPRO. In total, 80.6% of the reporting quarters, when the SIR was not calculated, were due to no observed infections or predicted infections <1, and 19.4% were due to missing covariates alone. Within hospitals, the median percentage of quarters during which zero infections were observed was 8.9% for CABG, 20.0% for COLO, 25.4% for CSEC, 67.3% for HPRO, and 71.4% for KPRO. Conclusions: Calculating an SIR for SSIs is challenging for hospitals in our regional network, primarily because of low event numbers and many facilities with predicted infections <1. Our SSI reporting will continue to use risk-indexed rates, in tandem with SIR values when predicted number of SSI ≥1.

COVID-19 infection among patients with cancer in Australia from 2020 to 2022: a national multicentre cohort study.

Background: The global COVID-19 pandemic disproportionately affected certain populations and its management differed between countries. This national study describes characteristics and outcomes of COVID-19 in patients with cancer in Australia. Methods: We performed a multicentre cohort study of patients with cancer and COVID-19 from March 2020 to April 2022. Data were analysed to determine varying characteristics between cancer types and changes in outcomes over time. Multivariable analysis was performed to determine risk factors associated with oxygen requirement. Findings: 620 patients with cancer from 15 hospitals had confirmed COVID-19. There were 314/620 (50.6%) male patients, median age 63.5 years (IQR 50-72) and majority had solid organ tumours (392/620, 63.2%). The rate of COVID-19 vaccination (≥1 dose) was 73.4% (455/620). Time from symptom onset to diagnosis was median 1 day (IQR 0-3), patients with haematological malignancy had a longer duration of test positivity. Over the study period, there was a significant decline in COVID-19 severity. Risk factors associated with oxygen requirement included male sex (OR 2.34, 95% CI 1.30-4.20, p = 0.004), age (OR 1.03, 95% CI 1.01-1.06, p = 0.005); not receiving early outpatient therapy (OR 2.78, 95% CI 1.41-5.50, p = 0.003). Diagnosis during the omicron wave was associated with lower odds of oxygen requirement (OR 0.24, 95% CI 0.13-0.43, p < 0.0001). Interpretation: Outcomes from COVID-19 in patients with cancer in Australia over the pandemic have improved, potentially related to changing viral strain and outpatient therapies. Funding: This study was supported by research funding from MSD.

An evaluation of influenza, pneumococcal and herpes zoster vaccination coverage in Australian aged care residents, 2018 to 2022.

BACKGROUND: For older persons, vaccination mitigates the harmful impact of vaccine preventable infections. Our study objectives were to evaluate in the Victorian public sector residential aged care services (PSRACS) (1) the existence of local vaccination policies and admission assessment practices, (2) the current documented status of resident influenza, pneumococcal and herpes zoster vaccination uptake and (3) changes in documented resident vaccination uptake over time. METHODS: Standardised data were annually reported by all PSRACS between 2018 and 2022. The influenza, pneumococcal and herpes zoster vaccination status of each resident was classified as vaccinated, declined, contraindicated or unknown. Annual trends in vaccination status were assessed using Spearman's correlation. RESULTS: In 2022, most PSRACS reported an influenza immunisation policy existed (87.1%) and new residents were assessed for their influenza vaccination status (97.2%); fewer PSRACS reported the same for pneumococcal disease (73.1% and 78.9%) and herpes zoster (69.3% and 75.6%). The median resident influenza, pneumococcal and herpes zoster (70-79 years old) vaccination uptake was 86.8%, 32.8% and 19.3% respectively. The median unknown status was 6.9%, 63.0% and 76.0% respectively. Statistical evidence of an increase in annual uptake was observed for the herpes zoster (all resident) surveillance module (rs = 0.900, p = 0.037). CONCLUSIONS: Our study showed local influenza vaccination policies and practices exist and influenza vaccination uptake was consistently high. Pneumococcal and herpes zoster vaccination uptake were lower. Quality improvement strategies that at least determine the status of those residents classified as unknown are required.

IMpleMenting Effective infection prevention and control in ReSidential aged carE (IMMERSE): protocol for a multi-level mixed methods implementation study.

BACKGROUND: Older people living in residential aged care facilities are at high risk of acquiring infections such as influenza, gastroenteritis, and more recently COVID-19. These infections are a major cause of morbidity and mortality among this cohort. Quality infection prevention and control practice in residential aged care is therefore imperative. Although appointment of a dedicated infection prevention and control (IPC) lead in every Australian residential aged care facility is now mandated, all people working in this setting have a role to play in IPC. The COVID-19 pandemic revealed inadequacies in IPC in this sector and highlighted the need for interventions to improve implementation of best practice. METHODS: Using mixed methods, this four-phase implementation study will use theory-informed approaches to: (1) assess residential aged care facilities' readiness for IPC practice change, (2) explore current practice using scenario-based assessments, (3) investigate barriers to best practice IPC, and (4) determine and evaluate feasible and locally tailored solutions to overcome the identified barriers. IPC leads will be upskilled and supported to operationalise the selected solutions. Staff working in residential aged care facilities, residents and their families will be recruited for participation in surveys and semi-structured interviews. Data will be analysed and triangulated at each phase, with findings informing the subsequent phases. Stakeholder groups at each facility and the IMMERSE project's Reference Group will contribute to the interpretation of findings at each phase of the project. DISCUSSION: This multi-site study will comprehensively explore infection prevention and control practices in residential aged care. It will inform and support locally appropriate evidence-based strategies for enhancing infection prevention and control practice.

Successful expanded clinic network collaboration and patient tracing for retention in HIV care.

BACKGROUND: There are more than 7,800 people living with human immunodeficiency virus (HIV) in Victoria, Australia. Crucial in maximising the individual and population level benefits from antiretroviral therapy (ART) is understanding how to achieve patient retention in care and the factors that drive it. This study was an expansion of a 2015 assessment of HIV-care retention in Victoria, which sought out to determine whether the inclusion of a broader range of HIV-healthcare sites would yield more accurate estimates of retention in HIV-care. We aimed to improve our understanding of HIV-care retention in Victoria, Australia, identify people living with HIV (PLHIV) with unknown outcomes, and attempt to re-engage PLHIV in care. METHODS: A network of 15 HIV-care sites was established in Victoria, Australia across diverse care settings which ranged from low-caseload rural sites to high-caseload metropolitan GP clinics and hospitals. Individuals who had an HIV viral load (VL) performed in both calendar years of 2016 and 2017 were classified as retained in care. Individuals with a VL test in 2016 but not in 2017 were considered to potentially have unknown outcomes as they may have been receiving care elsewhere, have disengaged from care or died. For this group, an intervention of cross-referencing partially de-identified data between healthcare sites, and contact tracing individuals who still had unknown outcomes was performed. RESULTS: For 5223 individuals considered to be retained in care across 15 healthcare sites in the study period, 49 had unconfirmed transfers of care to an alternative provider and 79 had unknown outcomes. After the intervention, the number of unconfirmed care transfers was reduced to 17 and unknown outcomes reduced to 51. These changes were largely attributed to people being reclassified as confirmed transfers of care. Retention in care estimates that did not include the patient outcome of confirmed transfer of care ranged from 76.2 to 95.8% and did not alter with the intervention. However, retention in care estimates which considered confirmed transfers and those that re-entered care at a new site as retained in care significantly increased across five of the sites with estimates ranging from 80.9 to 98.3% pre-intervention to 83.3-100% post-intervention. Individuals whose outcomes remained unknown post-intervention were more often men who have sex with men (MSM) when compared to other categories (person who injects drugs (PWID), combined PWID/MSM, men who identify as heterosexual or unknown) (74.5% vs. 53.5%, [p = 0.06]) and receiving ART at their last HIV-care visit (84.3% vs. 67.8% [p = 0.09]). CONCLUSION: This study confirmed high retention in HIV-care and low numbers of people disengaged from HIV-care in Victoria. This was demonstrated across a larger number of sites with varying models of care than a prior assessment in 2015. These data align with national and state targets aiming for 95% of PLHIV retained in HIV-care.

Improving management of urinary tract infections in residential aged care facilities.

BACKGROUND: Antimicrobial resistance rates are higher in Australian residential aged care facilities (RACFs) than other community or hospital settings. This is driven by antibiotic overuse and misuse. Urinary tract infection (UTI) is consistently the most common infection treated with antibiotics in Australian RACFs. OBJECTIVE: The aim of this article is to provide an overview of how general practitioners (GPs) can support appropriate UTI management in RACFs following antimicrobial stewardship (AMS) principles. DISCUSSION: GPs are well placed to improve UTI management in RACFs. In this article, criteria for suspected, proven, recurrent and relapsed UTI are outlined, in addition to key AMS practices for the assessment, prevention, treatment and review of UTIs. Included are recommendations for the judicious use of urine dipstick testing, a widespread and longstanding practice in RACFs, and first-line empirical antibiotic prescribing for suspected UTIs.

Performance of hospital administrative data for detection of sepsis in Australia: The sepsis coding and documentation (SECOND) study.

BACKGROUND: Sepsis is the world's leading cause of death and its detection from a range of data and coding sources, consistent with consensus clinical definition, is desirable. OBJECTIVE: To evaluate the performance of three coding definitions (explicit, implicit, and newly proposed synchronous method) for sepsis derived from administrative data compared to a clinical reference standard. METHOD: Extraction of administrative coded data from Australian metropolitan teaching hospital with 25,000 annual overnight admissions compared to clinical review of medical records; 313 (27.9%) randomly selected adult multi-day stay hospital separations from 1,123 separations with acute infection during July 2019. Estimated prevalence and performance metrics, including positive (PPV) and negative predictive values (NPV), and area under the receiver operator characteristic curve (ROC). RESULTS: Clinical prevalence of sepsis was estimated at 10.7 (95% CI = 10.3-11.3) per 100 separations, and mortality rate of 11.6 (95% CI = 10.3-13.0) per 100 sepsis separations. Explicit method for case detection had high PPV (93.2%) but low NPV (55.8%) compared to the standard implicit method (74.1 and 66.3%, respectively) and proposed synchronous method (80.4% and 80.0%) compared to a standard clinical case definition. ROC for each method: 0.618 (95% CI = 0.538-0.654), 0.698 (95% CI = 0.648-0.748), and 0.802 (95% CI = 0.757-0.846), respectively. CONCLUSION: In hospitalised Australian patients with community-onset sepsis, the explicit method for sepsis case detection underestimated prevalence. Implicit methods were consistent with consensus definition for sepsis, and proposed synchronous method had better performance.

Complex conversations in a healthcare setting: experiences from an interprofessional workshop on clinician-patient communication skills.

BACKGROUND: Communication is pivotal to the effective care and treatment of patients in our health care systems. Despite this understanding, clinicians are not sufficiently educated to confidently conduct complex discussions with patients. Communication skills workshops have been shown to be an effective educational format to improve clinician skills. However, despite the increasing interprofessional focus within modern medicine, there have been few studies looking at interprofessional communication workshops. METHODS: A qualitative study was conducted to assess how an interprofessional communication skills workshop affected the communication skills of clinicians at a tertiary health service. Pre- and post-workshop surveys were undertaken by participants, followed by focus group interviews eight-weeks post workshop. RESULTS: Clinicians were able to incorporate learnt communication skills into their daily practice. This was associated with an improvement in confidence of clinicians in having complex discussions, in addition to a reduction in the burden of having complex discussions. Participants responded positively to the interdisciplinary format, reporting benefits from the learning experience that translated into daily practice. CONCLUSION: Clinicians' communication skills in conducting complex clinician-patient conversations can be improved by participation in interprofessional communication skills workshops. We identified that the interprofessional aspect of the workshops not only improved interprofessional understanding and relationships, but also developed increased self-awareness during complex discussions, and reduced the sense of burden felt by clinicians.

Hospital clinical practice around urinalysis is an important opportunity for antimicrobial stewardship improvement activities.

BACKGROUND: To identify nurses' knowledge, perception and practice around urinalysis and asymptomatic bacteriuria (ASB) and to determine drivers of inappropriate urinalysis practice in an Australian hospital setting. METHODS: Undertaken in eight geriatric wards over four hospitals, a questionnaire inviting voluntary, anonymous participation tested nursing staff knowledge on urinalysis, recognition of urinary tract infection (UTI) and perception of the utility of urinalysis as a routine test on all ward admissions. A retrospective one-month audit was performed on admissions to a 32-bed geriatric ward. RESULTS: 132 of 220 (60%) distributed surveys were completed. Performing urinalysis on all new admissions was identified as routine practice by 89%, and with indwelling catheter change by 35% of respondents. Over-three-quarters believed that routine urinalysis on admission was useful practice and up to one-third believed urinalysis abnormalities warranted antibiotic prescribing. Dark urine (57.6%), foamy urine (55.3%) and vaginal itch (34.5%) were identified as features suggestive of a UTI. In the ward audit, routine urinalysis on admission accounted for most urinalysis testing (59%, 24/41). Of occasions with clinical prompt, delirium accounted for 60% of urinalysis and urinary symptoms 33% however urine culture was undertaken on 53% of occasions. CONCLUSION: There was an overall lack of nursing knowledge regarding ASB, with a high perception that urinalysis abnormalities would be suspicious of a UTI irrespective of clinical findings and that routine urinalysis on ward admission was useful practice. In hospital settings, nursing stewardship can deliver strategies to increase knowledge, motivation and opportunity to improve appropriateness of UTI treatment and recognition of ASB.

Managing diabetic foot infections: a survey of Australasian infectious diseases clinicians.

BACKGROUND: Diabetic foot infections (DFI) present a major morbidity, mortality and economic challenge for the tertiary health sector. However, lack of high quality evidence for specific treatment regimens for patients with DFIs may result in inconsistent management. This study aimed to identify DFI caseload proportion and patterns of clinical practice of Infectious Diseases (ID) Physicians and Trainees within Australia and New Zealand. METHODS: A cross-sectional online survey of Australian and New Zealand ID Physicians and Trainees was undertaken, to estimate the overall ID caseload devoted to patients with DFIs and assess clinicians' management practices of patients with DFIs. RESULTS: Approximately 28% (142/499) of ID Physicians and Trainees from Australia and New Zealand responded to the survey. DFI made up 19.2% of all ID consultations. Involvement in multidisciplinary teams (MDT) was common as 77.5% (93/120) of those responding indicated their patients had access to an inpatient or outpatient MDT. Significant heterogeneity of antimicrobial treatments was reported, with 82 unique treatment regimens used by 102 respondents in one scenario and 76 unique treatment regimens used by 101 respondents in the second scenario. The duration of therapy and the choice of antibiotics for microorganisms isolated from superficial swabs also varied widely. CONCLUSIONS: Patients with DFIs represent a significant proportion of an ID clinician's caseload. This should be reflected in the ID training program. Large heterogeneity in practice between clinicians reflects a lack of evidence from well-designed clinical trials for patients with DFI and highlights the need for management guidelines informed by future trials.

Voriconazole associated torsades de pointes in two adult patients with haematological malignancies.

Voriconazole can prolong the QT interval contributing to life-threatening cardiac arrhythmia. Torsades de pointes is an uncommon but serious complication of voriconazole use which may be under-recognised. We present torsades de pointes in two patients with underlying haematological malignancy being treated for invasive fungal infection with voriconazole. Patients receiving voriconazole should be screened and monitored for evidence of QT prolongation, and if prolongation detected, consideration given to alternative treatments or more intensive cardiac monitoring.