Australian Health Care Facilities Research Articles

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

We explored the utility of the standardized infection ratio (SIR) for surgical site infection (SSI) reporting in an Australian jurisdiction. Retrospective chart review. Statewide SSI surveillance data from 2013 to 2019. Individuals who had cardiac bypass surgery (CABG), colorectal surgery (COLO), cesarean section (CSEC), hip prosthesis (HPRO), or knee prosthesis (KPRO) procedures. 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. 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. 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.

Ophthalmic Antimicrobial Prescribing in Australian Healthcare Facilities.

The National Antimicrobial Prescribing Survey (NAPS) is a web-based, standardized tool, widely adopted in Australian healthcare facilities to assess the reasons for, the quantity of, and the quality of antimicrobial prescribing. It consists of multiple modules tailored towards the needs of a variety of healthcare facilities. Data regarding ophthalmological antimicrobial use from Hospital NAPS, Surgical NAPS, and Aged Care NAPS were analysed. In Hospital NAPS, the most common reasons for inappropriate prescribing were incorrect dose or frequency and incorrect duration. Prolonged duration was also common in Aged Care prescribing: about one quarter of all antimicrobials had been prescribed for greater than 6 months. All three modules found chloramphenicol to be the most prescribed antimicrobial with a high rate of inappropriate prescribing, usually for conjunctivitis.

“It’s only the skin colour, otherwise we are all people”: the changing face of the Australian nurse

Objective: The aim of this paper is to report on the experience of racial discrimination by black sub-Saharan overseas qualified nurses working in rural Australia. Background: The arrival of black African people as skilled professional migrants is relatively new in rural Australia. The presence of black sub-Saharan African nurses in Australian healthcare facilities is changing the face of the Australian nurse. Australia, like other developed countries, has been receiving migrant nurses from the African continent in a bid to reverse its critical nurse shortage. Literature has shown that globally, overseas qualified nurses of colour have encountered work challenges that have included racial discrimination. Study design and methods: A qualitative hermeneutical phenomenological approach was used. Eighteen nurses were purposively selected using personal invite and a snowballing technique. Data collection involved individual face to face interviews and a focus group discussion. Results: The exploration of experiences revealed issues of race and colour among colleagues and between patients and overseas qualified nurses. Overseas qualified nurses experienced incidents of discrimination based on race and skin colour from their colleagues and patients. They felt unwelcome, not trusted and undervalued. They adopted various coping strategies to adjust to being seen differently. Discussion: The literature suggests that overseas qualified nurses tend to be discriminated against in their destination countries. In this paper the migration experience of black sub-Saharan African overseas qualified nurses has shown the power of welcoming people to their new country, the existence of discrimination by race at their healthcare facilities as well as showing the importance of trust and teamwork at the workplace. The study has also shown the resilience of black sub-Saharan African overseas qualified nurses in their time of adversity. Conclusion: There are pockets of racial discrimination that need to be checked within the Australian healthcare system. These undermine the confidence of overseas qualified nurses in their professional practice. Implications for research, policy and practice: The results provided insight into the existence of racism within the workplace. Black African nurses need to feel safe in their workplace and need more support to facilitate their integration. Nurse managers need to be more vigilant in monitoring staff interactions in their Units. Understanding and support for diversity at the workplace by all nurses will improve patient and staff safety. What is already known about the topic? There is a global shortage of nurses. Nurse migration between countries has been taking place for a long time, and the trend will continue. Discrimination against migrant nurses of colour has been identified in various destination countries. What this paper adds: Findings from this study suggest existence of racism against black sub-Saharan African nurses in rural Australian workplaces. Black sub-Saharan African nurses need more support from nurse managers. They may get this through close monitoring of staff interactions in the workplace and intervention when racism is noted. Black sub-Saharan African nurses showed resilience in overcoming adversity in their workplace.

Healthcare practitioner perspectives and experiences regarding vascular access device data: An exploratory study

ABSTRACT Background: A vascular access registry is a key strategy proposed to improve patient safety and quality, but its impact will be shaped by the attitudes, experience and resources of end-user stakeholders. This study aimed to examine stakeholders’ perspectives and experiences regarding the feasibility and utility of a standardized platform to collect vascular access data and to identify potential barriers and facilitators of a vascular access clinical quality registry. Methods: Individual (n = 17) and group (n = 1) semi-structured interviews were conducted between October–December 2018 with directors from various healthcare disciplines and policy makers in Australian healthcare facilities. Interviews were recorded, transcribed and analysed using inductive thematic analysis. Results: Overall, participants supported the idea of a standardized platform to capture vascular access data. Three main themes were identified: (1) data challenges (sub themes: standardized data capture, data quality and data sharing); (2) staff capability (lack of resources and feeling unsupported); and (3) logistics (resource capacity and implementation challenges). Conclusion: Stakeholder engagement and universal agreement on standardized vocabulary and data items are vital to registry development, implementation and sustainability. Continuous iterative cycles will be required to reflect upon, review and improve the processes around vascular access data collection using a standardized registry software platform.

Statistical Process Control Charts for Monitoring Staphylococcus aureus Bloodstream Infections in Australian Health Care Facilities.

Staphylococcus aureus bloodstream infection (SAB) in health care settings contributes significantly to mortality, and improved processes are associated with reduced burden of infection. In Australia, health care-associated SAB (HA-SAB) rates are reported as a health care performance indicator, but standardized methods for analyzing longitudinal data are not applied. Our objective was to evaluate the utility of statistical process control chart methodology for reporting HA-SAB and flagging higher than expected rates. A real-world test data set was defined as HA-SAB surveillance data collected by 155 Australian health care facilities between June 1, 2015, and June 30, 2017. This included 788 HA-SAB events, corresponding to an overall rate of 0.7 HA-SAB events per 10 000 occupied bed-days. The u-chart was selected as an appropriate tool, given the need for reporting natural units (HA-SAB rates) to a range of stakeholders. Facility-level data were plotted as u-charts, applying warning and control limits (2- and 3-SD thresholds, respectively). Sixty-eight of the 155 participating facilities (43.9%) observed at least 1 HA-SAB event during the studied period. Using the traditional method of Poisson modeling, 56 of these 68 facilities demonstrated overdispersion with variance-to-mean ratio spanning 1.03 to 42.82. Modeling by negative binomial (NB) distribution was therefore applied to enhance functionality. The u-chart is an accessible method for monitoring HA-SAB, interpretable by a range of stakeholders. We demonstrate the benefit of NB modeling to account for overdispersion, providing an effective tool to avoid inappropriate flags while maintaining early detection of out-of-control systems throughout a wide range of health care settings.

Epidemiology of Clostridium difficile infections in Australia: enhanced surveillance to evaluate time trends and severity of illness in Victoria, 2010–2014

With epidemic strains of Clostridium difficile posing a substantial healthcare burden internationally, there is a need for longitudinal evaluation of Clostridium difficile infection (CDI) events in Australia. To evaluate time trends and severity of illness for CDI events in Australian healthcare facilities. All CDI events in patients admitted to Victorian public hospitals between 1(st) October 2010 and 31(st) December 2014 were reported to the Victorian Healthcare Associated Infection Surveillance System. CDI was defined as the isolation of a toxin-producing C.difficile organism in a diarrhoeal specimen, and classified as community-associated (CA-CDI) or healthcare-associated (HA-CDI). Severe disease was defined as admission to an intensive care unit, requirement for surgery and/or death due to infection. Time trends were examined using a mixed-effects Poisson regression model, and the Walter and Edward test of seasonality was applied to evaluate potential cyclical patterns. In total, 6736 CDI events were reported across 89 healthcare facilities. Of these, 4826 (71.6%) were HA-CDI, corresponding to a rate of 2.49/10,000 occupied bed days (OBDs). The incidence of HA-CDI was highest in the fifth quarter of surveillance (3.6/10,000 OBDs), followed by a reduction. Severe disease was reported in 1.66% of events, with the proportion being significantly higher for CA-CDI compared with HA-CDI (2.21 vs 1.45%, P=0.03). The highest and lowest incidence of HA-CDI occurred in March and October, respectively. A low incidence of HA-CDI was reported in Victoria compared with US/European surveillance reports. Seasonality was evident, together with diminishing HA-CDI rates in 2012-2014. Severe infections were more common in CA-CDI, supporting future enhanced surveillance in community settings.

The use of MALDI-TOF MS in infection control

The spectrum and burden of multi-resistant organisms (MROs) in Australian health care facilities continues to rise despite efforts to control them. A number of interventions have been scaled up in recent times in an attempt to address this, including the widespread roll out of robust antimicrobial stewardship programs, however additional interventions are still required. Another tool that is likely to aid in the reduction of the spread of MROs in the healthcare setting is more rapid diagnostic tests. The benefits of more rapid diagnosis of organisms to species level has already been seen in the majority of health care facilities with the introduction of MALDI-TOF MS. While a rapid, accurate and cost effect method of organism identification, the ability of this technology to aid in the detection of antibiotic resistance is still generally considered novel. We have reported on the use of MALDI-TOF MS to identify vancomycin resistant enterococci (VRE) and the implementation of this method in the routine clinical microbiology laboratory. In this presentation this work will be reviewed in addition to recent advances in use of MALDI-TOF MS to identify other forms of antimicrobial resistance and hence contribute to infection control.

A mixed methods study of the barriers and enablers in implementing antimicrobial stewardship programmes in Australian regional and rural hospitals.

The Australian Commission on Safety and Quality in Health Care released recommendations for antimicrobial stewardship programmes to be established within all Australian healthcare facilities. However, implementation practices are not well defined. The aim of this study was to gain an understanding of factors affecting implementation of antimicrobial stewardship programmes within Australian regional and rural hospitals. This study was designed whereby a preliminary quantitative process was used to contribute to a principally qualitative study. Site visits to regional and rural hospitals in Queensland, New South Wales, Victoria and South Australia were planned to assess factors impacting on implementation of antimicrobial stewardship. Subsequently researchers identified issues requiring further exploration with specific key informant interviews and focus group discussions. Data were collected between May and October 2012 and entered into Nvivo10, openly coded and analysed according to mixed methods data analysis principles. Regional and rural hospitals were not conducting many of the recommended activities and seven major themes emerged. The key barriers were perceived to be lack of access to education, resources and specialist support. The enablers were a flatter governance structure, greater sense of pride, desire for success and good internet and tele-health access. This study helps us to identify where efforts should be focused to facilitate the establishment of antimicrobial stewardship programmes in regional and rural hospitals, by describing the gaps and limitations of current programmes and the major issues currently being faced, providing recommendations to better guide activities that support regional and rural hospitals.

Diminishing surgical site infections in Australia: time trends in infection rates, pathogens and antimicrobial resistance using a comprehensive Victorian surveillance program, 2002-2013.

To evaluate time trends in surgical site infection (SSI) rates and SSI pathogens in Australia. Prospective multicenter observational cohort study. A group of 81 Australian healthcare facilities participating in the Victorian Healthcare Associated Infection Surveillance System (VICNISS). All patients underwent surgeries performed between October 1, 2002, and June 30, 2013. National Healthcare Safety Network SSI surveillance methods were employed by the infection prevention staff at the participating hospitals. Procedure-specific risk-adjusted SSI rates were calculated. Pathogen-specific and antimicrobial-resistant (AMR) infections were modeled using multilevel mixed-effects Poisson regression. A total of 183,625 procedures were monitored, and 5,123 SSIs were reported. Each year of observation was associated with 11% risk reduction for superficial SSI (risk ratio [RR], 0.89; 95% confidence interval [CI], 0.88-0.90), 9% risk reduction for deep SSI (RR, 0.91; 95% CI, 0.90-0.93), and 5% risk reduction for organ/space SSI (RR, 0.95; 95% CI, 0.93-0.97). Overall, 3,318 microbiologically confirmed SSIs were reported. Of these SSIs, 1,174 (35.4%) were associated with orthopedic surgery, 827 (24.9%) with coronary artery bypass surgery, 490 (14.8%) with Caesarean sections, and 414 (12.5%) with colorectal procedures. Staphylococcus aureus was the most frequently identified pathogen, and a statistically significant increase in infections due to ceftriaxone-resistant Escherichia coli was observed (RR, 1.37; 95% CI, 1.10-1.70). Standardized SSI surveillance methods have been implemented in Victoria, Australia. Over an 11-year period, diminishing rates of SSIs have been observed, although AMR infections increased significantly. Our findings facilitate the refinement of recommended surgical antibiotic prophylaxis regimens and highlight the need for a more expansive national surveillance strategy to identify changes in epidemiology.

A survey of thickened fluid prescribing and monitoring practices of Australian health professionals.

This study aimed to describe (1) how thickened fluids are supplied to clients with dysphagia; (2) how clients' consumption of thickened fluids and hydration status is monitored; and (3) the impact of institutional factors on thickened fluid intake and hydration in Australian health care settings. Speech pathologists, dietitians and nurses working in Australian health care settings were asked to voluntarily participate in an online survey that was advertised through their respective professional associations. The questions required a self-report of their practice with respect to thickened fluids. Few health care facilities (17%) monitored thickened fluid consumption routinely even though, in the opinion of 51% the respondents, clients on thickened fluids at their facility do not drink enough. Palatability of the thickened fluid products and patients' dependence on others for drinking were thought to have a major impact on fluid intake. Respondents also highlighted institutional factors such as inadequate assistance from staff and inconsistent systems for monitoring fluid intake and signs of dehydration. The most common way to address inadequate intake was for nurses to 'push fluids' (87%). Free water protocols were used only 14% of the time and setting small oral fluid targets throughout the day was the least common strategy (11%). There is a need for Australian health care facilities to educate all clinical staff about the risks of dehydration and develop clinical pathways for clients with dysphagia, which include routine monitoring of oral fluid consumption and dehydration and timely intervention.

Development of a standardised approach to observing hand hygiene compliance in Australia

Abstract Background Evidence indicates that improved hand hygiene compliance can lead to reductions in healthcare associated infection. However, there are few papers that clearly document the observation method used to collect the hand hygiene compliance data. This article describes the Hand Hygiene Australia 5 Moments for Hand Hygiene observation method in detail. Methods The Australian Commission for Safety and Quality in Health Care funded Hand Hygiene Australia (HHA) to implement the National Hand Hygiene Initiative (NHHI) to improve hand hygiene compliance (HHC) and establish a national validated system of HHC auditing. Based on the World Health Organisation (WHO) World Alliance for Patient Safety campaign ‘Clean Care is Safer Care', HHA adapted the WHO hand hygiene compliance data collection form to suit Australian healthcare facilities. Results Hand Hygiene Australia developed a standardised approach to direct observation of HHC of healthcare workers by developing a uniform suite of tools and a data management system for accurate data collection and report generation. Conclusion Implementation of the HHA 5 Moments HHC audit method has facilitated standardised, reliable and meaningful collection of hand hygiene compliance data that is driving HHC improvement across many different healthcare settings around Australia.

Nutrition screening practices in Australian healthcare facilities: A decade later

AbstractAim: Nutrition screening can identify patients at risk for malnutrition so that early nutrition intervention can be initiated. The aim of this descriptive study was to compare nutrition screening practices in Australian hospitals in 2008 with those in 1995.Methods: A survey on nutrition screening practices in Australian healthcare institutions was sent to members of the Dietitians Association of Australia in 1995 and a similar survey in 2008.Results: Sixty‐eight hospitals responded to the 2008 survey and 124 hospitals to the 1995 survey. The number of hospitals reporting the conduct of nutrition screening has increased since 1995 (78% vs 23%). The number of patients being screened has also increased (all admissions 54% vs 35%) and the time taken to screen a patient has decreased (0–5 minutes 64% vs 13%). The Malnutrition Screening Tool was the most frequently reported screening tool used in 2008 (67%). The use of albumin as a nutrition screening parameter (which was the second most commonly used screening indicator after weight loss in 1995) has appropriately decreased (9% vs 65%). There is still some confusion among dietitians as to the definition of screening, with nutrition assessment tools such as Subjective Global Assessment and Mini‐Nutritional Assessment being used during the nutrition screening process (16% in 2008). Insufficient time and staff are still the top two barriers to nutrition screening implementation. Staff training was the most frequently cited strategy to assist with successful implementation of nutrition screening.Conclusion: There has been a significant increase in malnutrition screening over the past decade despite ongoing barriers to implementation.

Malnutrition and pressure ulcer risk in adults in Australian health care facilities

Objective To determine the effect of nutritional status on the presence and severity of pressure ulcer. Methods A multicenter, cross-sectional audit of nutritional status of a convenience sample of subjects was carried out as part of a large audit of pressure ulcers in a sample of Queensland, Australia, public healthcare facilities in 2002 and 2003. Dietitians in 20 hospitals and 6 residential aged care facilities conducted single-day nutritional status audits of 2208 acute and 839 aged care subjects using the Subjective Global Assessment. The effect of nutritional status on the presence and severity (highest stage and number of pressure ulcers) was determined by logistic regression in a model controlling for age, gender, medical specialty, and facility location. The potential clustering effect of facility was accounted for in the model using an analysis of correlated data approach. Results Subjects with malnutrition had adjusted odds ratios of 2.6 (95% confidence interval 1.8–3.5, P < 0.001) of having a pressure ulcer in acute care facilities and 2.0 (95% confidence interval 1.5–2.7, P < 0.001) for residential aged care facilities. There was also increased odds ratio of having a pressure ulcer, and having a more severe pressure ulcer (higher stage pressure ulcer and/or a higher number) with increased severity of malnutrition. Conclusion Malnutrition was associated with at least twice the odds ratio of having a pressure ulcer of in public health care facilities in Queensland. Action must be taken to identify, prevent, and treat malnutrition, especially in patients at risk of pressure ulcer.

ASID (HICSIG) position statement: infection control guidelines for patients with influenza‐like illnesses, including pandemic (H1N1) influenza 2009, in Australian health care facilities

ASID (HICSIG) position statement: infection control guidelines for patients with influenza‐like illnesses, including pandemic (H1N1) influenza 2009, in Australian health care facilities

Specifications for temperature and humidity in sterile storage environments – Where's the evidence?

The concept of event-related sterility for storage of medical devices is widely applied in Australian healthcare facilities. This paper reviews available literature, international standards and guidance documents with respect to the concept of event-related sterility in order to determine: (i) why commercially produced sterile medical devices may withstand adverse temperature and humidity conditions better than items produced in a Sterile Services Department; (ii) what effects temperature and humidity have on maintenance of sterility; and (iii) whether temperature and humidity conditions specified in AS/NZS4187:2003 are evidence-based and whether changes to these could be made in any future revisions. The literature review revealed that manufacturers of commercially available sterile medical devices are subject to stringent medical device regulations that require them to ensure that the devices remain both fit for purpose and sterile until use. This necessitates that manufacturers conduct accelerated ageing and environmental challenge tests to establish and justify the expiry dates given on the package label. The review also found a variety of specifications for temperature and humidity and the guidance documents gave no indication of evidence used as a basis for these requirements. In addition, it was apparent that many published studies on event-related sterility did not include consideration of the effect of temperature and humidity on the duration of sterility. After examination of a range of published material, it was concluded that the specifications in any future edition of AS/NZS4187 could be expanded to a temperature range of 16–25°C and a relative humidity range of 30–75%.

ASID (HICSIG) position statement: infection control guidelines for patients with influenza‐like illnesses, including pandemic (H1N1) influenza 2009, in Australian health care facilities

Standard and Droplet Precautions are considered adequate to control the transmission of influenza in most health care situations. Vaccination of health care staff, carers and vulnerable patients against seasonal and, eventually, pandemic influenza strains is an essential protective strategy. Management principles include: performance of hand hygiene before and after every patient contact or contact with the patient environment, in accord with the national 5 Moments for Hand Hygiene Standard; disinfection of the patient environment; early identification and isolation of patients with suspected or proven influenza; adoption of a greater minimum distance of patient separation (2 metres) than previously recommended; use of a surgical mask and eye protection for personal protection on entry to infectious areas or within 2 metres of an infectious patient; contact tracing for patient and health care staff and restriction of prophylactic antivirals mainly to those at high risk of severe disease; in high aerosol-risk settings, use of particulate mask, eye protection, impervious long-sleeved gown, and gloves donned in that sequence and removed in reverse sequence, avoiding self-contamination; exclusion of symptomatic staff from the workplace until criteria for non-infectious status are met; reserving negative-pressure ventilation rooms (if available) for intensive care patients, especially those receiving non-invasive ventilation; ensuring that infectious postpartum women wear surgical masks when caring for their newborn infants and practise strict hand hygiene; and implementation of special arrangements for potentially infected newborns who require nursery or intensive care.

Postgraduate courses in quality improvement: achievements and future directions.

Since 1996, the Centre for Clinical Epidemiology and Biostatistics at the University of Newcastle has offered courses in Quality Improvement in Health Care. The courses are offered at Graduate Certificate, Graduate Diploma and Masters levels, principally by distance learning. They offer training in research methods as well as the concepts and application of quality improvement. Feedback from students, many of whom are quality coordinators in Australian health care facilities, has been positive. Enrolments are taken mid-year as well as at the beginning of the academic year.

Quality assurance and clinical indicators in emergency medicine

Quality assurance and clinical indicators in emergency medicine