Contribution of facility level factors to variation in antibiotic use in long-term care facilities: a national cohort study

Antimicrobial stewardship in the community setting: a qualitative exploratory study

BACKGROUND

Existing evidence underscores inappropriate antimicrobial prescribing and use in the community setting. Increased and inappropriate antimicrobial use are major factors contributing to the emergence and transmission of antimicrobial resistance (AMR). Antimicrobial stewardship (AMS) programmes are critical for mitigating AMR, enhancing patient outcomes, and reducing healthcare costs. Despite the existing Australian National Action Plan on AMR, optimisation of antimicrobial use in the community setting remains inadequately investigated. This study explored health professionals' perspectives on community AMS practices and systems, identifying challenges and areas for improvement.

METHODS

This qualitative study utilised semi-structured interviews to explore the perspectives of 17 different health professionals from diverse community practice settings in South-East Queensland, Australia. Interviews were audio-recorded, anonymised, and transcribed verbatim. Data were thematically analysed, with NVivo 12 utilised for organisation and analysis. Data were then mapped and examined using the Elements of Medicines Stewardship (EMS), which aligns with United States Centers for Disease Control and Prevention- Core Elements of Antibiotic Stewardship. This was reported following the consolidated criteria for reporting qualitative research checklist.

RESULTS

Four main themes described the health professionals' insights on community AMS practices and systems. Thematic analysis from these findings reveals a state of ambiguity and fragmentation in the community AMS practices and systems. In comparison to the hospital-based AMS system, the Australian community AMS system appears to be in its nascent stages of development. Applying the EMS is essential for developing and implementing community AMS strategies to enhance practices and systems.

CONCLUSION

The study identified key health system factors that impact the implementation of community AMS programmes and highlighted the need for developing community-specific governance and frameworks that integrate multidisciplinary strategies to support effective implementation and enhance patient outcomes. This research will inform community AMS intervention strategies, influencing policy and practice to advance sustainable healthcare and address antimicrobial resistance.

Setting standards in residential aged care: identifying achievable benchmarks of care for long-term aged care services

BACKGROUND

Benchmark is an important aspect of quality measurement and evaluation of long-term care services (LTCS) performance. In this study, we aimed to estimate achievable benchmarks of care (ABC©) for 12 quality indicators used to monitor the quality of care in Australian LTCS and to identify LTCS characteristics associated with attaining the estimated ABC.

METHODS

A cross-sectional study was conducted using integrated population-based datasets from long-term care, health care, and social welfare sectors within the Registry of Senior Australians (ROSA) National Historical Cohort. All LTCS residents in 2019 were included. Twelve risk-adjusted quality indicators were examined. ABC were defined as the performance level of top-ranked LTCS, including those sequentially from rank 1 onward, until the combined number of residents included at least 10% of all residents nationally. Indicator-specific ABC for 2019 were estimated using Bayesian-adjusted performance fraction ranking. Logistic regressions estimated LTCS characteristics associated with ABC attainment.

RESULTS

2746 LTCS and 244 419 residents (≥65 years) between 1 January 2019 and 31 December 2019 were included. The cohort was mostly female (65%), with a median age of 86 years, and 56% had dementia. The ABC provide performance targets based on the observed levels of top-performing LTCS. The ABC for premature mortality (0.007%), weight loss hospitalizations (0.1%), pressure injuries (0.2%), delirium and dementia hospitalizations (0.2%), and medication-related adverse events (0.4%) were lower than 1% and attained by 17-59% of LTCS. The ABC for fractures (1.3%), falls (3.9%), and emergency department presentations (5.1%) were between 1 and 5% and attained by 7-11% of LTCS. The ABC for antipsychotic use (10.5%), chronic opioid use (12.6%), high sedative load exposure (26.8%), and antibiotic use (47.8%) were between 10 and 50% and met by 6-7% of LTCS. Smaller LTCS and government-owned LTCS were more likely to achieve the ABC compared to medium, larger, private, and not-for-profit LTCS.

CONCLUSION

This is the first national estimation of ABC for Australian LTCS, identifying real-world examples of LTCS with relatively better national performance. The ABC are realistic goals for LTCS improvement efforts. They can be leveraged as national standards in quality monitoring reports and incentive programs. Smaller and government LTCS were generally more likely to attain ABC.

Relationship between medication safety-related processes and medication use in residential aged care facilities

OBJECTIVE

To explore the association between the implementation of medication safety-related processes measured with the Medication Safety Self-Assessment for Long-Term Care (MSSA-LTC) tool and medication use in residential aged care facilities (RACFs).

METHODS

A descriptive cross-sectional study was conducted in Australian RACFs. Data on facility characteristics, aggregated medication use at the facility level for selected medications commonly associated with a high risk of harm and the MSSA-LTC were completed by clinical pharmacists providing clinical pharmacy services. The Spearman's correlation test was used to evaluate the association between the MSSA-LTC score and medication use. A scatter plot between the MSSA-LTC score and medication use data was generated, and a linear trend line was plotted using the least squares method.

RESULTS

Data were collected from 31 RACFs servicing 2986 residents. Most medication safety-related processes were implemented in Australian RACFs. A higher facility MSSA-LTC score was associated with a lower proportion of residents with polypharmacy (r = -.48, p = .01) and one or more benzodiazepines (r = -.41, p = .03). In addition, a negative linear trend was observed between the MSSA-LTC score and the average number of medications per resident, the proportion of residents with one or more anticonvulsants and the proportion of residents using one or more opioid analgesics.

CONCLUSIONS

This study indicates that implementing medication safety-related processes may improve medication use in RACFs.

Surveillance of Antimicrobial Use in Long-Term Care Facilities: An Antimicrobial Mapping Survey

OBJECTIVES

To explore antimicrobial management processes in Australian residential aged care facilities (RACFs), including antimicrobial prescribing, supply, administration, and documentation to inform surveillance activities.

DESIGN

Voluntary, online cross-sectional survey.

SETTING AND PARTICIPANTS

The survey was disseminated to all South Australian RACFs (n = 237) seeking participation from an infection prevention and control lead (preferred respondent), a nurse or senior RACF staff member, or an aged care pharmacist.

METHODS

The survey was open during May-June 2023. Questions aimed to understand clinical and medication management systems, sources of antimicrobial prescription and supply, management by external health care providers and documentation of antimicrobial administration. A process map of antimicrobial management in RACFs was developed.

RESULTS

Of the 54 RACFs included in the analysis (29.5% response rate), most used an electronic clinical documentation system (74.1%) or a hybrid electronic paper-based system (22.2%). Medication charts were either electronic (81.0%), hybrid (5.6%), or paper-based (13.0%). Antimicrobials were prescribed by the resident's usual general practitioner, but also by locums, hospital or specialist physicians, nurse practitioners, virtual care physicians, and dentists. Oral, topical, and inhaled antimicrobial formulations were usually supplied by community pharmacies, and intravenous formulations were predominately supplied by hospitals for administration by outreach nurses. Almost all RACFs (96.2%) had imprest stock of antimicrobials that included both oral and intravenous formulations. Antimicrobials were predominately administered by an enrolled nurse or a registered nurse.

CONCLUSIONS AND IMPLICATIONS

Antimicrobial management in RACFs is complex, particularly during care transitions. Multiple prescribers and sources of antimicrobials, use of different systems for clinical documentation, particularly by external health care providers, and clinical governance relating to imprest supplies were identified as key areas where medication management could be improved. Addressing these gaps will facilitate comprehensive, real-time antimicrobial surveillance in Australian RACFs.

Resident-, prescriber-, and facility-level factors associated with antibiotic use in long-term care facilities: a systematic review of quantitative studies

BACKGROUND

Antimicrobial stewardship programmes are needed in long-term care facilities (LTCFs) to tackle antimicrobial resistance. We aimed to identify factors associated with antibiotic use in LTCFs. Such information would be useful to guide antimicrobial stewardship programmes.

METHOD

We conducted a systematic review of studies retrieved from PubMed, Cochrane Library, Embase, APA PsycArticles, APA PsycINFO, APA PsycTherapy, ScienceDirect and Web of Science. We included quantitative studies that investigated factors associated with antibiotic use (i.e., antibiotic prescribing by health professionals, administration by LTCF staff, or use by residents). Participants were LTCF residents, their family, and/or carers. We performed a qualitative narrative synthesis of the findings.

RESULTS

Of the 7,591 screened records, we included 57 articles. Most studies used a longitudinal design (n = 34/57), investigated resident-level (n = 29/57) and/or facility-level factors (n = 32/57), and fewer prescriber-level ones (n = 8/57). Studies included two types of outcome: overall volume of antibiotic prescriptions (n = 45/57), inappropriate antibiotic prescription (n = 10/57); two included both types. Resident-level factors associated with a higher volume of antibiotic prescriptions included comorbidities (5 out of 8 studies which investigated this factor found a statistically significant association), history of infection (n = 5/6), potential signs of infection (e.g., fever, n = 4/6), positive urine culture/dipstick results (n = 3/4), indwelling urinary catheter (n = 12/14), and resident/family request for antibiotics (n = 1/1). At the facility-level, the volume of antibiotic prescriptions was positively associated with staff turnover (n = 1/1) and prevalence of after-hours medical practitioner visits (n = 1/1), and negatively associated with LTCF hiring an on-site coordinating physician (n = 1/1). At the prescriber-level, higher antibiotic prescribing was associated with high prescription rate for antibiotics in the previous year (n = 1/1).

CONCLUSIONS

Improving infection prevention and control, and diagnostic practices as part of antimicrobial stewardship programmes remain critical steps to reduce antibiotic prescribing in LTCFs. Once results confirmed by further studies, implementing institutional changes to limit staff turnover, ensure the presence of a professional accountable for the antimicrobial stewardship activities, and improve collaboration between LTCFs and external prescribers may contribute to reduce antibiotic prescribing.

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.

Primary, allied health, geriatric, pain and palliative healthcare service utilisation by aged care residents, 2012-2017

OBJECTIVES

To examine the incidence and trends in primary care, allied health, geriatric, pain and palliative care service use by permanent residential aged care (PRAC) residents and the older Australian population.

METHODS

Repeated cross-sectional analyses on PRAC residents (N = 318,484) and the older (≥65 years) Australian population (N ~ 3.5 million). Outcomes were Medicare Benefits Schedule (MBS) subsidised primary care, allied health, geriatric, pain and palliative services between 2012-13 and 2016-17. GEE Poisson models estimated incidence rates and incidence rate ratios (IRR).

RESULTS

In 2016-17, PRAC residents had a median of 13 (interquartile range [IQR] 5-19) regular general medical practitioner (GP) attendances, 3 (IQR 1-6) after-hours attendances and 5% saw a geriatrician. Highlights of utilisation changes from 2012-13 to 2016-17 include the following: GP attendances increased by 5%/year (IRR = 1.05, 95% confidence interval [CI] 1.05-1.05) for residents compared to 1%/year (IRR = 1.01, 95%CI 1.01-1.01) for the general population. GP after-hours attendances increased by 15%/year (IRR = 1.15, 95%CI 1.14-1.15) for residents and 9%/year (IRR = 1.08, 95%CI 1.07-1.20) for the general population. GP management plans increased by 12%/year (IRR = 1.12, 95%CI 1.11-1.12) for residents and 10%/year (IRR = 1.10, 95%CI 1.09-1.11) for the general population. Geriatrician consultations increased by 28%/year (IRR = 1.28, 95%CI 1.27-1.29) for residents compared to 14%/year (IRR = 1.14, 95%CI 1.14-1.15) in the general population.

CONCLUSIONS

The utilisation of most examined services increased in both cohorts over time. Preventive and management care, by primary care and allied health care providers, was low and likely influences the utilisation of other attendances. PRAC residents' access to pain, palliative and geriatric medicine services is low and may not address the residents' needs.

Registry of Senior Australians (ROSA): integrating cross-sectoral information to evaluate quality and safety of care provided to older people

PURPOSE

The Registry of Senior Australians (ROSA) was established to evaluate aged care experiences in Australia. In this manuscript, we describe the ROSA framework, the two ROSA cohorts, highlights from research findings, and future plans.

PARTICIPANTS

The South Australian ROSA Prospective Cohort (August 2018-June 2020) enrolled 26 605 participants, of which 59.2% (N=15 745) are women, with a median age of 83 (interquartile range (IQR) 77-88). The National ROSA Historical Cohort (January 2002-June 2020) includes 1 694 206 participants with an aged care eligibility assessment, of which 59.1% (N=1 001 705) are women and the median age is 78 (IQR 72-83).

FINDINGS TO DATE

Most research using the ROSA has focused on dementia, service accessibility, quality and safety of care, falls and injuries and quality use of medicines. The ROSA has also examined the experience of individuals with highly prevalent and understudied conditions in aged care settings (eg, eye and mental health) and aspects of services (eg, built environment) and innovation (eg, mobile radiological services) that can affect older people's health. Important learnings from the ROSA's development include the significant resources and multidisciplinary expertise required for establishing this platform. Between 2018 and 2022, 43 academic publications, eight reports of the Australian Government Royal Commission into Aged Care Quality and Safety, and several reports to state health authorities and professional societies have used the ROSA.

FUTURE PLANS

Our plans include to: (1) continue delivering high-quality evidence to support the improvement of ageing and aged care services; (2) influence and improve the quality of research in and for the aged care sector; (3) expand scope to facilitate examining aims in more depth; (4) include future aged care sector data collections within the ROSA; (5) inform best practices and innovate how consumer engagement occurs in research; (6) monitor and evaluate the impact of the 2021 Australian Aged Care Reforms.

A multimodal intervention to optimise antimicrobial use in residential aged care facilities (ENGAGEMENT): protocol for a stepped-wedge cluster randomised trial

BACKGROUND

Inappropriate antibiotic use can cause harm and promote antimicrobial resistance, which has been declared a major health challenge by the World Health Organization. In Australian residential aged care facilities (RACFs), the most common indications for antibiotic prescribing are for infections of the urinary tract, respiratory tract and skin and soft tissue. Studies indicate that a high proportion of these prescriptions are non-compliant with best prescribing guidelines. To date, a variety of interventions have been reported to address inappropriate prescribing and overuse of antibiotics but with mixed outcomes. This study aims to identify the impact of a set of sustainable, multimodal interventions in residential aged care targeting three common infection types.

METHODS

This protocol details a 20-month stepped-wedge cluster-randomised trial conducted across 18 RACFs (as 18 clusters). A multimodal multi-disciplinary set of interventions, the 'AMS ENGAGEMENT bundle', will be tailored to meet the identified needs of participating RACFs. The key elements of the intervention bundle include education for nurses and general practitioners, telehealth support and formation of an antimicrobial stewardship team in each facility. Prior to the randomised sequential introduction of the intervention, each site will act as its own control in relation to usual care processes for antibiotic use and stewardship. The primary outcome for this study will be antibiotic consumption measured using defined daily doses (DDDs). Cluster-level rates will be calculated using total occupied bed numbers within each RACF during the observation period as the denominator. Results will be expressed as rates per 1000 occupied bed days. An economic analysis will be conducted to compare the costs associated with the intervention to that of usual care. A comprehensive process evaluation will be conducted using the REAIM Framework, to enable learnings from the trial to inform sustainable improvements in this field.

DISCUSSION

A structured AMS model of care, incorporating targeted interventions to optimise antimicrobial use in the RACF setting, is urgently needed and will be delivered by our trial. The trial will aim to empower clinicians, residents and families by providing a robust AMS programme to improve antibiotic-related health outcomes.

TRIAL REGISTRATION

US National Library of Medicine Clinical Trials.gov ( NCT04705259 ). Prospectively registered in 12th of January 2021.

Temporal and regional trends of antibiotic use in long-term aged care facilities across 39 countries, 1985-2019: Systematic review and meta-analysis

BACKGROUND

Antibiotic misuse is a key contributor to antimicrobial resistance and a concern in long-term aged care facilities (LTCFs). Our objectives were to: i) summarise key indicators of systemic antibiotic use and appropriateness of use, and ii) examine temporal and regional variations in antibiotic use, in LTCFs (PROSPERO registration CRD42018107125).

METHODS & FINDINGS

Medline and EMBASE were searched for studies published between 1990-2021 reporting antibiotic use rates in LTCFs. Random effects meta-analysis provided pooled estimates of antibiotic use rates (percentage of residents on an antibiotic on a single day [point prevalence] and over 12 months [period prevalence]; percentage of appropriate prescriptions). Meta-regression examined associations between antibiotic use, year of measurement and region. A total of 90 articles representing 78 studies from 39 countries with data between 1985-2019 were included. Pooled estimates of point prevalence and 12-month period prevalence were 5.2% (95% CI: 3.3-7.9; n = 523,171) and 62.0% (95% CI: 54.0-69.3; n = 946,127), respectively. Point prevalence varied significantly between regions (Q = 224.1, df = 7, p<0.001), and ranged from 2.4% (95% CI: 1.9-2.7) in Eastern Europe to 9.0% in the British Isles (95% CI: 7.6-10.5) and Northern Europe (95% CI: 7.7-10.5). Twelve-month period prevalence varied significantly between regions (Q = 15.1, df = 3, p = 0.002) and ranged from 53.9% (95% CI: 48.3-59.4) in the British Isles to 68.3% (95% CI: 63.6-72.7) in Australia. Meta-regression found no association between year of measurement and antibiotic use prevalence. The pooled estimate of the percentage of appropriate antibiotic prescriptions was 28.5% (95% CI: 10.3-58.0; n = 17,245) as assessed by the McGeer criteria. Year of measurement was associated with decreasing appropriateness of antibiotic use over time (OR:0.78, 95% CI: 0.67-0.91). The most frequently used antibiotic classes were penicillins (n = 44 studies), cephalosporins (n = 36), sulphonamides/trimethoprim (n = 31), and quinolones (n = 28).

CONCLUSIONS

Coordinated efforts focusing on LTCFs are required to address antibiotic misuse in LTCFs. Our analysis provides overall baseline and regional estimates for future monitoring of antibiotic use in LTCFs.