Transforming routinely collected residential aged care provider data into timely information: Current and future directions

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.

The relationship between participation in leisure activities and incidence of falls in residential aged care

BACKGROUND

Active engagement in leisure activities has positive effects on individuals' health outcomes and social functioning; however, there is limited understanding of the link between participation in leisure activities, particularly non-exercise activities, and falls in older adults. This study aimed to determine the relationship between participation in leisure activities and the incidence of falls, and the variation of this relationship by dementia status in residential aged care facilities (RACFs).

METHODS

A retrospective longitudinal cohort study utilising routinely collected data (January 2021-August 2022) from 25 RACFs in Sydney, Australia, was conducted. The cohort included 3,024 older permanent residents (1,493 with dementia and 1,531 without) aged ≥65 and with a stay of ≥1 week. The level of participation in leisure activities was measured using the number of leisure activities per 1,000 resident days and divided into quartiles. Outcome measures were the incidence rate of all falls and injurious falls (i.e., number of falls per 1,000 resident days). We used multilevel negative binary regression to examine the relationship between leisure participation and fall incidence.

RESULTS

For the whole sample, leisure participation was significantly inversely associated with the incidence rate of all falls and injurious falls. For example, residents in the high leisure participation group were 26% less likely to experience a fall compared to those in the low leisure participation group after controlling for confounders (incidence rate ratio = 0.74, 95% confidence interval = 0.60, 0.91). Such inverse relationship was observed in both exercise and non-exercise activities and was stronger among residents without dementia.

CONCLUSIONS

Leisure participation is associated with a lower rate of falls, a key quality indicator by which RACFs are benchmarked and funded in Australia and many other countries. More recognition and attention are needed for the currently underfunded leisure activities in RACFs in future funding arrangement.

Development and internal validation of a dynamic fall risk prediction and monitoring tool in aged care using routinely collected electronic health data: a landmarking approach

OBJECTIVES

Falls pose a significant challenge in residential aged care facilities (RACFs). Existing falls prediction tools perform poorly and fail to capture evolving risk factors. We aimed to develop and internally validate dynamic fall risk prediction models and create point-based scoring systems for residents with and without dementia.

MATERIALS AND METHODS

A longitudinal cohort study using electronic data from 27 RACFs in Sydney, Australia. The study included 5492 permanent residents, with a 70%-30% split for training and validation. The outcome measure was the incidence of falls. We tracked residents for 60 months, using monthly landmarks with 1-month prediction windows. We employed landmarking dynamic prediction for model development, a time-dependent area under receiver operating characteristics curve (AUROCC) for model evaluations, and a regression coefficient approach to create point-based scoring systems.

RESULTS

The model identified 15 independent predictors of falls in dementia and 12 in nondementia cohorts. Falls history was the key predictor of subsequent falls in both dementia (HR 4.75, 95% CI, 4.45-5.06) and nondementia cohorts (HR 4.20, 95% CI, 3.87-4.57). The AUROCC across landmarks ranged from 0.67 to 0.87 for dementia and from 0.66 to 0.86 for nondementia cohorts but generally remained between 0.75 and 0.85 in both cohorts. The total point risk score ranged from -2 to 57 for dementia and 0 to 52 for nondementia cohorts.

DISCUSSION

Our novel risk prediction models and scoring systems provide timely person-centered information for continuous monitoring of fall risk in RACFs.

CONCLUSION

Embedding these tools within electronic health records could facilitate the implementation of targeted proactive interventions to prevent falls.

Factors impacting clinical data and documentation quality in Australian aged care and disability services: a user-centred perspective

BACKGROUND

Research has highlighted a need to improve the quality of clinical documentation and data within aged care and disability services in Australia to support improved regulatory reporting and ensure quality and safety of services. However, the specific causes of data quality issues within aged care and disability services and solutions for optimisation are not well understood.

OBJECTIVES

This study explored aged care and disability workforce (referred to as 'data-users') experiences and perceived root causes of clinical data quality issues at a large aged care and disability services provider in Western Australia, to inform optimisation solutions.

METHODS

A purposive sample of n = 135 aged care and disability staff (including community-based and residential-based) in clinical, care, administrative and/or management roles participated in semi-structured interviews and web-based surveys. Data were analysed using an inductive thematic analysis method, where themes and subthemes were derived.

RESULTS

Eight overarching causes of data and documentation quality issues were identified: (1) staff-related challenges, (2) education and training, (3) external barriers, (4) operational guidelines and procedures, (5) organisational practices and culture, (6) technological infrastructure, (7) systems design limitations, and (8) systems configuration-related challenges.

CONCLUSION

The quality of clinical data and documentation within aged care and disability services is influenced by a complex interplay of internal and external factors. Coordinated and collaborative effort is required between service providers and the wider sector to identify behavioural and technical optimisation solutions to support safe and high-quality care and improved regulatory reporting.

Adverse impacts in residential aged care facilities: The resident perspective

OBJECTIVES

Inclusion of consumer perspectives is a key component to person-centred health-care approaches. While current residential aged care systems focus on recording adverse events to meet the requirements of regulatory reporting, little is known about the views of residents. The aim of this research was to explore residents' responses on the types of incidents that have an adverse impact on them and how they are affected by these incidents.

METHODS

The study used a qualitative, inductive approach to derive themes from interviews with 20 permanent residents of aged care facilities in New South Wales and the Australian Capital Territory.

RESULTS

Four main themes surrounding adverse incidents emerged: (i) social relationships and the adverse impacts of lack of meaningful interactions, (ii) adjustment to life in the residential aged care facility and the loss of residents' former life and self-determination, (iii) the impact of COVID-19 lockdowns which meant that residents were not able to go out or interact with others and (iv) acceptance, resignation and resilience in coping with adverse incidents.

CONCLUSIONS

This research highlights the difference between health-care definition, used for incident management reporting and quality indicators, and the way residents respond when asked to describe an incident that has affected them. Resident responses discuss situations having an adverse effect on them in contrast to the way adverse events and incidents are reported and monitored. The findings suggest that within adverse event and incident management systems and resident governance systems, there is scope for incorporating periods of transitions and well-being measures that capture elements that matter to older people.

Quality and safety in residential aged care: an evaluation of a national quality indicator programme

BACKGROUND

In Australia, 243 000 individuals live in approximately 2700 residential aged care facilities yearly. In 2019, a National Aged Care Mandatory Quality Indicator programme (QI programme) was implemented to monitor the quality and safety of care in facilities.

AIM

To examine the validity of the QI programme indicators using explicit measure review criteria.

METHODS

The QI programme manual and reports were reviewed. A modified American College of Physicians Measure Review Criteria was employed to examine the QI programme's eight indicators. Five authors rated each indicator on importance, appropriateness, clinical evidence, specifications and feasibility using a nine-point scale. A median score of 1-3 was considered to not meet criteria, 4-6 to meet some criteria and 7-9 to meet criteria.

RESULTS

All indicators, except polypharmacy, met criteria (median scores = 7-9) for importance, appropriateness and clinical evidence. Polypharmacy met some criteria for importance (median = 6, range 2-8), appropriateness (median = 5, range 2-8) and clinical evidence (median = 6, range 3-8). Pressure injury, physical restraints, significant unplanned weight loss, consecutive unplanned weight loss, falls and polypharmacy indicators met some criteria for specifications validity (all median scores = 5) and feasibility and applicability (median scores = 4 to 6). Antipsychotic use and falls resulting in major injury met some criteria for specifications (median = 6-7, range 4-8) and met criteria for feasibility and applicability (median = 7, range 4-8).

CONCLUSIONS

Australia's National QI programme is a major stride towards a culture of quality promotion, improvement and transparency. Measures' specifications, feasibility and applicability could be improved to ensure the programme delivers on its intended purposes.

Usability and Acceptability of Clinical Dashboards in Aged Care: Systematic Review

BACKGROUND

The use of clinical dashboards in aged care systems to support performance review and improve outcomes for older adults receiving care is increasing.

OBJECTIVE

Our aim was to explore evidence from studies of the acceptability and usability of clinical dashboards including their visual features and functionalities in aged care settings.

METHODS

A systematic review was conducted using 5 databases (MEDLINE, Embase, PsycINFO, Cochrane Library, and CINAHL) from inception to April 2022. Studies were included in the review if they were conducted in aged care environments (home-based community care, retirement villages, and long-term care) and reported a usability or acceptability evaluation of a clinical dashboard for use in aged care environments, including specific dashboard visual features (eg, a qualitative summary of individual user experience or metrics from a usability scale). Two researchers independently reviewed the articles and extracted the data. Data synthesis was performed via narrative review, and the risk of bias was measured using the Mixed Methods Appraisal Tool.

RESULTS

In total, 14 articles reporting on 12 dashboards were included. The quality of the articles varied. There was considerable heterogeneity in implementation setting (home care 8/14, 57%), dashboard user groups (health professionals 9/14, 64%), and sample size (range 3-292). Dashboard features included a visual representation of information (eg, medical condition prevalence), analytic capability (eg, predictive), and others (eg, stakeholder communication). Dashboard usability was mixed (4 dashboards rated as high), and dashboard acceptability was high for 9 dashboards. Most users considered dashboards to be informative, relevant, and functional, highlighting the use and intention of using this resource in the future. Dashboards that had the presence of one or more of these features (bar charts, radio buttons, checkboxes or other symbols, interactive displays, and reporting capabilities) were found to be highly acceptable.

CONCLUSIONS

A comprehensive summary of clinical dashboards used in aged care is provided to inform future dashboard development, testing, and implementation. Further research is required to optimize visualization features, usability, and acceptability of dashboards in aged care.

The relationship between fall incidents and place of birth in residential aged care facilities: a retrospective longitudinal cohort study

BACKGROUND

Older populations in residential aged care facilities (RACFs) in many immigrant-receiving countries are now being increasingly culturally and linguistically diverse (CALD). CALD populations require tailored social and health services to support their needs and improve health outcomes. Falls among the elderly are common and can have significant health and psychosocial consequences. There is some evidence to suggest that country of birth may influence risk of falls among older people, but such evidence has been scarce. This study aimed to determine the association between place of birth and the incidence of falls in RACFs.

METHODS

Routinely collected incident data relating to 5,628 residents aged ≥ 65 years in 25 RACFs in Sydney, New South Wales, Australia were used. RACF residents were classified into two groups, Australia-born (N = 4,086) and overseas-born (N = 1,542). Overseas-born RACF residents were further categorised into two subgroups: overseas-English-speaking-country (N = 743) and overseas-non-English-speaking-country (N = 799). Outcomes measures were rate of all falls, injurious falls and falls requiring hospitalisation. Multilevel binary negative regression was used to examine the relationship between fall risk and place of birth.

RESULTS

Incidence rates of all falls, injurious falls and falls requiring hospitalisation were 8.62, 3.72 and 1.07 incidents per 1,000 resident days, respectively, among the Australia-born RACF residents, but were higher at 11.02, 4.13 and 1.65, respectively, among the overseas-born RACF residents. Within those born overseas, fall rates were higher among the overseas-non-English-speaking-country-born residents (11.32, 4.29 and 2.22, respectively) than those overseas-English-speaking-country-born (10.70, 3.96 and 1.05, respectively). After controlling for confounders, the overseas-born RACF residents overall experienced a higher risk of all three types of falls (incidence rate ratios: [IRR] = 1.278, 95% confidence interval [CI] = 1.131, 1.443; injurious falls: IRR = 1.164 [95% CI = 1.013, 1.338]; falls requiring hospitalisation: IRR = 1.460 [95% CI = 1.199, 1.777]) than the Australia-born RACF residents. Among the overseas-born RACF residents, males, respite residents and those overseas-non-English-speaking-country-born experienced higher rates of falls.

CONCLUSIONS

Fall incidence in RACFs varies significantly by place of birth. With increasingly diverse RACF populations, fall intervention and prevention programs should consider cultural and linguistical backgrounds of RACF residents. Greater attention to understand the mechanisms for the differences by place of birth in risk profiles is warranted.

Allied health in residential aged care: Using routinely collected data to improve funding opportunities

Consumers and providers have long been advocating for increased access to and delivery of allied health services in Australian residential aged care (RAC). There is significant evidence that allied health interventions are effective; however, there is limited evidence on the benefit of routine day-to-day allied health service delivery in RAC. This information is critical to effectively inform funders and policy advisors of the necessity of allied health in RAC. To improve arguments for future funding opportunities, providers, facilities and consumers need to partner together to use routinely collected, yet disparate, data, in electronic health and billing records, to improve data collection practices and evidence generation on allied health in aged care.

Optimising the quality of clinical data in an Australian aged care and disability service to improve care delivery and clinical outcomes (OPTIMISE): Protocol for an Agile Lean Six Sigma study

BACKGROUND

In Australia, aged care and disability service providers are legally required to maintain comprehensive and accurate clinical documentation to meet regulatory and funding requirements and to support safe and high quality care provision. However, evidence suggests poor quality clinical data and documentation is widespread across the sector and can significantly affect clinical decision-making and care delivery and increase business costs.

OBJECTIVE

The OPTIMISE study uses an Agile Lean Six Sigma framework to: 1) identify opportunities for optimisation of clinical documentation processes and clinical information systems, 2) implement and test optimisation solutions, and 3) evaluate outcomes post-optimisation, in a large post-acute community-based health service providing aged care and disability services in Western Australia.

METHODS

A three-stage prospective optimisation study will be undertaken. Stage 1 (Baseline) will measure existing clinical data quality, identify root causes of data quality issues across services, and generate optimisation solutions. Stage 2 (Optimisation) will implement and test changes to clinical documentation processes and information systems using incremental Agile sprints, and Stage 3 (Evaluation) will evaluate change in primary and secondary outcomes from baseline to 12 months post-optimisation. The primary outcome is data quality measured in terms of Defects Per Unit (DPU), Defects Per Million Opportunities (DPMO) and Sigma level. Secondary outcomes are care delivery (direct care time), clinical incidents, business outcomes (cost of quality, workforce productivity), and user satisfaction. Case studies will be analysed to understand impacts of optimisation on clinical outcomes and business processes.

RESULTS

As of 1 June 2022, Stage 1 commenced with baseline data quality audits conducted to measure current data quality. Baseline data quality audits will be followed by user consultations to identify root causes of data quality issues. Optimisation solutions will be developed by January 2023 to inform optimisation (Stage 2) and evaluation (Stage 3).

CONCLUSIONS

Study findings will be of interest to individuals and organisations in the healthcare sector seeking novel solutions to improve the quality of clinical data and support high quality care delivery and reduce business costs.

CLINICALTRIAL

N/A.

Quality indicators for home- and community-based aged care: A critical literature review to inform policy directions

OBJECTIVES

Australia is lagging behind other countries in implementing quality indicators (QIs) in home- and community-based aged care. This research aimed to identify and appraise home care QI sets used internationally for older adults, to inform the future development and utilisation of QIs in the Australian context.

METHODS

A systematic search of eligible studies outlining the development and validation of home care QI sets for older adults was undertaken. QIs were categorised using the Donabedian model to identify potential gaps in coverage of key areas of care quality. Each QI was classified as potentially "derivable" or not from existing national routinely collected datasets. Methodological quality was determined using the Appraisal of Indicators through Research and Evaluation instrument.

RESULTS

Three sets of home care QIs developed and used internationally for older adults were identified. Two of the QI sets focused predominantly on clinical and functional aspects of care. Of 45 unique QIs, the majority were outcome measures (93%), with only three QIs measuring care processes (7%), and zero indicators measuring quality in terms of the structure of care (e.g., waiting time to access services). Nearly half of the individual indicators identified would require Australian home care providers to undertake additional data collection. There were significant methodological limitations in the development of QI sets, particularly in the scientific evidence domain.

CONCLUSIONS

This review identified important gaps in existing QI sets, which should be considered by policymakers, researchers, and other stakeholders when developing and applying QIs in the Australian setting.

Epidemiology of Falls in 25 Australian Residential Aged Care Facilities: A Retrospective Longitudinal Cohort Study Using Routinely Collected Data

BACKGROUND

Falls are frequent among older adults and have significant health and economic consequences. There have been few studies on the epidemiology of falls in residential aged care facilities (RACFs). This study aimed to determine the incidence of falls in RACFs using longitudinal routinely collected incident data over five years (Jul 2014-Dec 2019).

METHODS

A retrospective cohort study using fall incident data from 25 RACFs in Sydney, NSW, Australia. Incidents relating to a population of 6,163 aged care residents aged ≥65 years were included. Outcome measures were incidents of all falls; injurious falls, and requiring hospitalisation. Risk-adjusted incidence rate (IR) for each outcome indicator for each of the 25 facilities was calculated.

RESULTS

A total of 27,878 falls were reported over 3,906,772 resident days (a crude rate of 7.14/1000 resident days; 95% confidence interval (CI) 6.81-7.48). Of these, 10,365 (37.2%) were injurious and 2,733 (9.8%) required hospitalisation. The crude IR for injurious falls was 2.65/1000 resident days (95% CI 2.53-2.78) and 0.70 (95% CI 0.66-0.74) for falls requiring hospitalisation. The incidence of falls was significantly higher in respite compared to permanent residents for all falls (adjusted incident rate ratio (aIRR) 1.33; 95% CI 1.18-1.51) and injurious falls (aIRR 1.30; 95% CI 1.14-1.48) and for men compared to women for all outcomes (all falls aIRR 1.69; 95% CI 1.54-1.86; injurious falls aIRR 1.87; 95% CI 1.71-2.04 and falls requiring hospitalisation aIRR 1.29; 95% CI 1.12-1.48). The risk-adjusted IRs per 1000 resident days between facilities varied substantially (all falls 0.57-12.93 falls; injurious falls 0.25-4.47 and falls requiring hospitalisation 0.10-1.70).

CONCLUSION

Falls are frequent in RACFs, often resulting in injury and hospitalisation. The study provides robust and comprehensive information that may help inform future initiatives to minimise the incidence of falls in RACFs.

A systematic review of opioid prevalence in Australian residential aged care facilities

OBJECTIVE

To systematically review the prevalence of opioid prescribing, dispensing and administration in Australian residential aged care facilities (RACFs).

METHODS

MEDLINE, Embase, CINAHL, AgeLine, Web of Science Core Collection, InformIT and International Pharmaceutical Abstracts (inception to September 2021) were searched for studies reporting opioid prevalence in Australian RACFs. Regular and as-required (i.e. pro re nata, PRN) opioid uses were considered. Screening, data extraction and quality assessment were performed independently by two review authors.

RESULTS

Twenty-three studies (n = 286,141 residents) reported opioid prevalence, of which 16 provided overall regular or PRN prescribing, dispensing or administration data. Five studies reported 28%-34% of residents were prescribed regular opioids over assessment periods ranging from one week to one month. Five studies reported 11%-42% of residents were prescribed PRN opioids over assessment periods ranging from one week to 30 months. Three studies reported 27%-50% of residents were dispensed an opioid over 12 months. Five studies reported 21%-29% were administered both regular and PRN opioids over 24 hours. Two studies reported 22%-42% of residents were administered PRN opioids over 1 week to 12 months. Two studies reported 6%-13% of residents were using doses >100 mg oral morphine equivalents/day.

CONCLUSIONS

Up to half of the residents were dispensed opioids over 12 months. The prevalence of opioid prescribing, dispensing and administration was highly variable, suggesting the potential value of opioid quality indicators and analgesic stewardship interventions to ensure opioid appropriateness.

The use and predictive performance of the Peninsula Health Falls Risk Assessment Tool (PH-FRAT) in 25 residential aged care facilities: a retrospective cohort study using routinely collected data

BACKGROUND

The Peninsula Health Falls Risk Assessment Tool (PH-FRAT) is a validated and widely applied tool in residential aged care facilities (RACFs) in Australia. However, research regarding its use and predictive performance is limited. This study aimed to determine the use and performance of PH-FRAT in predicting falls in RACF residents.

METHODS

A retrospective cohort study using routinely-collected data from 25 RACFs in metropolitan Sydney, Australia from Jul 2014-Dec 2019. A total of 5888 residents aged ≥65 years who were assessed at least once using the PH-FRAT were included in the study. The PH-FRAT risk score ranges from 5 to 20 with a score > 14 indicating fallers and ≤ 14 non-fallers. The predictive performance of PH-FRAT was determined using metrics including area under receiver operating characteristics curve (AUROC), sensitivity, specificity, sensitivity_{Event Rate(ER)} and specificity_ER.

RESULTS

A total of 27,696 falls were reported over 3,689,561 resident days (a crude incident rate of 7.5 falls /1000 resident days). A total of 38,931 PH-FRAT assessments were conducted with a median of 4 assessments per resident, a median of 43.8 days between assessments, and an overall median fall risk score of 14. Residents with multiple assessments had increased risk scores over time. The baseline PH-FRAT demonstrated a low AUROC of 0.57, sensitivity of 26.0% (sensitivity_ER 33.6%) and specificity of 88.8% (specificity_ER 82.0%). The follow-up PH-FRAT assessments increased sensitivity_ER values although the specificity_ER decreased. The performance of PH-FRAT improved using a lower risk score cut-off of 10 with AUROC of 0.61, sensitivity of 67.5% (sensitivity_ER 74.4%) and specificity of 55.2% (specificity_ER 45.6%).

CONCLUSIONS

Although PH-FRAT is frequently used in RACFs, it demonstrated poor predictive performance raising concerns about its value. Introducing a lower PH-FRAT cut-off score of 10 marginally enhanced its predictive performance. Future research should focus on understanding the feasibility and accuracy of dynamic fall risk predictive tools, which may serve to better identify residents at risk of falls.