International Journal of

Environmental Research
and Public Health

Article
Root Cause Analysis to Identify Medication and
Non-Medication Strategies to Prevent Infection-
Related Hospitalizations from Australian Residential
Aged Care Services
Janet K. Sluggett 1,2,3,* , Samanta Lalic 1,4, Sarah M. Hosking 1,5, Brett Ritchie 6,
Jennifer McLoughlin 7, Terry Shortt 7, Leonie Robson 7, Tina Cooper 7, Kelly A. Cairns 8,
Jenni Ilomäki 1,9, Renuka Visvanathan 5,10,11 and J. Simon Bell 1,3,5,9
1 Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash
University, Parkville, VIC 3052, Australia; [email protected] (S.L.); [email protected]
(S.M.H.); [email protected] (J.I.); [email protected] (J.S.B.)
2 University of South Australia, Adelaide 5001, Australia
3 NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Hornsby 2077, Australia
4 Pharmacy Department, Monash Health, Melbourne 3168, Australia
5 National Health and Medical Research Council of Australia Centre of Research Excellence in Frailty
and Healthy Aging, Adelaide 5005, Australia; [email protected]
6 Infectious Diseases Department, Women’s and Children’s Hospital, Adelaide 5006, Australia;
[email protected]
7 Resthaven Incorporated, Adelaide 5034, Australia; [email protected] (J.M.);
[email protected] (T.S.); [email protected] (L.R.); [email protected] (T.C.)
8 Pharmacy Department, The Alfred, Alfred Health, Melbourne, VIC 3181, Australia; [email protected]
9 Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004,
Australia
10 School of Medicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide 5005,
Australia
11 Aged and Extended Care Services, The Queen Elizabeth Hospital, Central Adelaide Local Health
Network, SA Health, Adelaide 5011, Australia
* Correspondence: [email protected]; Tel.: +61-8812-849-99
check Eor
updates
Received: 1 April 2020; Accepted: 5 May 2020; Published: 8 May 2020

Abstract: Infections are leading causes of hospitalizations from residential aged care services
(RACS), which provide supported accommodation for people with care needs that can no longer
be met at home. Preventing infections and early and effective management are important to avoid
unnecessary hospital transfers, particularly in the Australian setting where new quality standards
require RACS to minimize infection-related risks. The objective of this study was to examine root
causes of infection-related hospitalizations from RACS and identify strategies to limit infections
and avoid unnecessary hospitalizations. An aggregate root cause analysis (RCA) was undertaken
using a structured local framework. A clinical nurse auditor and clinical pharmacist undertook a
comprehensive review of 49 consecutive infection-related hospitalizations from 6 RACS. Data were
collected from nursing progress notes, medical records, medication charts, hospital summaries,
and incident reports using a purpose-built collection tool. The research team then utilized a
structured classification system to guide the identification of root causes of hospital transfers. A
multidisciplinary clinical panel assessed the root causes and formulated strategies to limit
infections and hospitalizations. Overall, 59.2% of hospitalizations were for respiratory, 28.6% for
urinary, and 10.2% for skin infections. Potential root causes of infections included medications that
may increase infection risk and resident vaccination status. Potential contributors to hospital
transfers included possible suboptimal selection of empirical antimicrobial therapy, inability of
RACS staff to establish on-site intravenous access for antimicrobial administration, and the need to
access subsidized medical services not provided in the RACS (e.g., radiology and pathology).
Strategies identified by the panel included medication

Int. J. Environ. Res. Public Health 2020, 17, 3282; doi:10.3390/ijerph17093282 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2020, 17, 3282 2 of

review, targeted bundles of care, additional antimicrobial stewardship initiatives, earlier

identification of infection, and models of care that facilitate timely access to medical services. The
RCA and clinical panel findings provide a roadmap to assist targeting services to prevent infection
and limit unnecessary hospital transfers from RACS.

Keywords: infection; residential aged care; long-term care; hospitalization; root cause analysis;
antimicrobial stewardship; medication review; Australia

1. Introduction
Residents of aged care services often live in close proximity to one another, have comorbid
conditions, and have unavoidable contact with health care workers. These conditions are conducive
to rapid infection transmission and increase the risk of morbidity and mortality from infectious
diseases [1]. Infections are one of the leading causes of hospitalization from residential aged care
services (RACS) [1–5]. RACS are synonymous with “nursing homes” and “long-term care facilities”
and provide supported accommodation for people with care needs that can no longer be met in
their own homes [4,6]. Australian and European studies have found that up to 25% of all
hospitalizations from RACS are for infection [3,4], most commonly for respiratory, urinary tract,
gastrointestinal, and skin infections [2,5,7,8]. One study in the United States (US) found that
potentially preventable hospitalizations accounted for 23% (USD 223.8 million) of the total cost of
hospitalizations from RACS in 2004 [9]. Heterogeneity in RACS settings and different definitions of
“preventable” means that the proportion of hospitalizations deemed potentially preventable varies
[2]. However, previous research suggests that 13%–67% of infection-related hospitalizations are
potentially preventable [2,5,10], and therefore preventing unnecessary hospitalizations is a priority
for RACS providers.
Broad strategies for preventing infection-related hospitalization may aim to prevent an
infection occurring (e.g., vaccinations) or to better manage an infection in the RACS to avoid
hospitalization (e.g., early detection and administering appropriate antimicrobials). Prevention of
infection in RACS is important as there is increasing concern regarding antimicrobial resistance [11].
Antimicrobial resistance is associated with increased hospital costs and length of stay and death
[12]. Antimicrobial stewardship, outbreak control and initiatives to prevent urinary tract infections
(UTIs) have strengthened in the US RACS from 2013 to 2018 [13]. A recent systematic review
found high-quality evidence to suggest that vaccinating residents against influenza reduces
hospitalizations from RACS [14]. Strategies to prevent infections include general infection control
procedures, such as promoting hand hygiene [8,15]. Other strategies include ongoing staff
education in infection control [8], effective communication between staff and with external
healthcare providers [8], environmental cleaning, and use of personal protective equipment such as
gloves and gowns [16]. These are the same key principles of infection prevention and control
outlined by the Australian Government for RACS providers [17]. Hospitalizations for infectious
diseases may be reduced if advance care directives are put in place on admission to RACS and
reviewed when a resident’s condition changes and/or deterioration in resident condition suggestive
of infection is identified earlier [5]. Hospitalizations may also be reduced with effective
communication among staff, and/or the management of infection at the RACS with the resources
available, or with new models of care that facilitate provision of medical services that are not
routinely available in Australian RACS [2,10,18].
Several strategies have been developed and trialed to prevent specific types of infection in
RACS [16], although evidence regarding effectiveness of these strategies has been mixed [19].
These include protocols to reduce the number of catheter-associated UTIs [20], clinical care
standards on infection [21], toolkits and protocols for preventing and managing gastroenteritis
outbreaks [22], and protocols for effective monitoring and care of wounds including diabetic ulcers,
pressure injuries, surgical wounds, and other injuries [16]. Adequate oral care for residents
[23], identification of
 dysphagia and aspiration risk protocols [24], and pneumococcal [25] and influenza vaccination
among residents [14,25] and RACS staff [26] have been recommended for prevention of respiratory
infections. A root cause analysis (RCA) is a process undertaken in healthcare settings to
understand the underlying factors that led to a specific event of interest and develop strategies to
help avoid similar occurrences in the future [27,28]. Previous research from the US has shown that
an aggregate RCA process, which investigates a group of similar events, can be used to identify and
develop strategies to prevent hospitalizations from skilled nursing facilities [18]. However, this
strategy has yet to be
applied in an Australian setting in the investigation of infection-related hospitalizations specifically.
In Australia, the formal, subsidized interdisciplinary antimicrobial stewardship programs that
exist within the hospital setting are not routinely available in Australian RACS. However, new
national Aged Care Quality Standards that apply from July 2019 outline the need for RACS
provider organizations to implement antimicrobial stewardship policies and activities [29]. One
quarter of all hospitalizations from South Australian RACS are for infections [4]. An improved
understanding of strategies that could be applied to reduce infection risk and hospital transfers
locally could assist stakeholders to enhance resident quality of care. The objective of this study was
to examine root causes of infection-related hospitalizations from RACS and identify strategies to
limit infections and avoid unnecessary hospitalizations among residents of aged care services.

2. Materials and Methods

2.1. Design and Setting

This study was an aggregate RCA that utilized the South Australia Health (SA Health) process
for RCA as a framework [28]. SA Health is a government-funded entity that maintains public health
services such as hospitals and ambulance services across country and metropolitan South Australia
and contributes to research and policy development. The purpose of an RCA, as defined by SA
Health, is to identify system issues that contribute to an incident and recommend strategies to
prevent or minimize the risk of recurrence [28]. The approach focuses on learning from an incident
to improve processes or systems used in care delivery. Using an interdisciplinary approach, we
followed the first 4 steps of the SA Health RCA process: identification of events, data collection, root
cause identification, and recommendation generation [28]. This process was similar to previous
aggregate RCAs undertaken in the US, in which hospitalizations from RACS were reviewed, and a
previous RCA that examined root causes of falls-related hospitalizations from RACS [30,31].
However, the current study focused specifically on infection-related hospitalizations from an
Australian RACS setting.

2.2. Identification of Events

This RCA reviewed 49 infection-related hospitalizations among 41 residents of 6 RACS in
South Australia. These infection-related hospitalizations were identified from a previous
prospective cohort study that has been described elsewhere [4,32]. Briefly, the previous cohort study
followed 383 residents aged ≥ 65 years over 12 months who were recruited from a group of 6 RACS
in South Australia. The 383 residents who participated in the previous cohort study were
representative of all residents of the 6 RACSs in terms of age, sex, and diagnosed dementia. For the
383 residents participating in the previous cohort study, details of all overnight hospitalizations (e.g.,
admission date, discharge date, and reason for hospitalization) during follow-up were extracted
from RACS records. Hospital transfers that did not result in an overnight stay (e.g., emergency
department visits, same day admissions, and outpatient appointments) were not captured. The
reasons for all overnight hospitalizations were coded independently by two clinicians according to
the World Health Organization International Statistical Classification of Diseases and Related Health
Problems, 10th Revision (ICD-10). Infection-related hospitalizations were identified by the following
ICD-10 codes: A00-B99, N12, N13.6, N39.0, J09–J18, J22, J44.0, J69.0, L03, and T84.7 [4]. Of the 51
infection-related hospitalizations recorded during the 12 months follow-up, records were available
for 49 hospitalizations for inclusion in the present RCA.
2.3. Data Collection
The RCA was conducted using a purpose-built tool, developed with input from a
multidisciplinary expert panel. The panel consisted of a geriatrician, general medical practitioner
(GP), infectious disease physician, 4 pharmacists (infectious diseases pharmacist, geriatrics specialist
pharmacist, ambulance service pharmacist, and a community pharmacist who provided
collaborative medication reviews in RACS), a consumer representative, and 4 registered nurses. A
complete list of panel members appears in the acknowledgments section. The panel included staff
from within the RACS provider as well as external experts. Development of this tool was also
informed by a review of published literature and the INTERACT Quality Improvement Tool for
Review of Acute Care Transfers [30]. The tool was tailored for use in an Australian RACS setting
and focused specifically on infection-related hospitalizations. It was designed to capture
information about resident characteristics, risk factors, medication use, vaccination status, details of
the hospital transfer, actions taken prior to hospital transfer, infection-specific vital signs and
symptoms, pathology and other test results, and discharge information provided post-
hospitalization. The tool was reviewed for face and content validity by an infectious diseases
physician, a pharmacist, and 3 registered nurses.
Using the purpose-built tool described above, a clinical audit nurse extracted data on resident
risk factors for infection, changes in resident condition leading up to the hospitalization, and
management of risk factors in the RACS. Data were extracted from RACS nursing progress notes,
medical records, medication charts, hospital discharge notes, and incident reports for each resident.
A pharmacist also reviewed each resident’s medication administration chart to identify medications
taken in the month prior to hospitalization that are associated with an increased risk of infection,
including oral corticosteroids [33], oxybutynin [34,35], etanercept [36], methotrexate [37], and
proton pump inhibitors [38]. Data were collected and managed using the Research Electronic Data
Capture (REDCap) web-based tool hosted by Monash University [39].

2.4. Root Cause Identification

Data extracted for each resident by the clinical audit nurse and pharmacist using the purpose-
built tool were reviewed by the research team and an infectious disease physician. The research
team were cognizant that clinical staff at the RACS are trained to use a charting by exception
approach when documenting information in resident case notes. Factor identification for each case
was guided by the SA Health Contributing Factors classification tool, which provides 9 broad factor
categories ranging from proximal factors, such as patient assessment, to distal factors, such as
facility policies and procedures [28]. For each factor, the research team were asked to apply the 5
why’s technique to ensure the factor represented a root cause rather than a symptom [40,41]. The 5
why’s technique is common approach for conducting RCA in patient safety, and involves the
investigator exploring incidents in increasing depth (through continually asking why) until the
underlying root cause is identified [31,40–42]. An example of using the 5 why’s technique is
provided in Table 1. The research team considered events leading up to the hospital transfer and
content in the hospital discharge letter, and repeatedly asked “why” when reviewing each key event
until the root causes were identified [40–42]. The root cause findings were then collated into root
cause statements that were grouped according the themes outlined in the SA Health Contributing
Factors tool [28]. The root cause statements were tabulated for presentation to the multidisciplinary
expert panel.

Table 1. Example of using the 5 why’s technique.

• The resident showed signs of deterioration after a recent hospitalization for infection—why?
• Because the resident did not receive an antibiotic—why?
• Because the antibiotic was not commenced on return to the residential aged care service as recommended in the hospital
discharge letter—why?
• Because the resident’s usual general medical practitioner did not initiate the antibiotic on return to the residential aged
care service—why?
• Because the actions to take post-discharge were not clearly outlined in the hospital discharge letter
2.5. Recommendation Generation
The same multidisciplinary expert panel that developed the purpose-built tool was reconvened
to review all factors that may have contributed to each infection-related hospitalization. For each
root cause, panel members were asked to brainstorm potential medication and non-medication
interventions that may help to prevent future infection-related hospitalizations. Finally, panel
members were asked to review interventions and discuss whether the interventions may be feasible
and consider any potential unintended consequences of implementation.

2.6. Data Analysis

Descriptive statistics were used to describe the infection, the processes prior to hospitalization,
and the resident characteristics at the time of the infection-related hospitalization. The root cause
statements and final recommendations of the panel were tabulated according the themes outlined in
the SA Health Contributing Factors tool [28].

2.7. Ethical Considerations

Ethical approval for this study was obtained from the Monash University Human Research
Ethics Committee on November 9, 2017 (application ID 11418). Written informed consent for
resident participation in the original cohort study was obtained previously. Panel members
provided written informed consent to participate in the RCA. We confirm that the investigations
were carried out following the rules of the Declaration of Helsinki of 1975, revised in 2013.

3. Results
Among the infection-related hospitalizations reviewed in this study, the median age for
residents hospitalized for infection was 86 years (interquartile range 82–92) and 65.3% were female
(Table 2). Heart failure (38.8%), chronic obstructive pulmonary disorders (COPD) (34.7%), and
diabetes (32.7%) were the most common medical conditions among residents hospitalized for
infection. Among residents hospitalized with infection, 12.2% had an indwelling urinary catheter
and 20% were taking medications in the month prior to hospitalization that may increase infection
risk.

Table 2. Resident characteristics at the time of the infection-related hospitalization (n = 49 hospitalizations).

Characteristic N (%) or Median (Interquartile Range)

Age (Years) 86 (82–92)
Female 32 (65.3)
Medical conditions
Dementia 10 (20.4)
Diabetes 16 (32.7)
Asthma 8 (16.3)
Chronic obstructive pulmonary disease 17 (34.7)
Ischemic heart disease 16 (32.7)
Heart failure 19 (38.8)
Prior stroke 7 (14.3)
Current smoker 2 (4.1)
Indwelling catheter 6 (12.2)
History of infection in the previous 6 months 15 (30.6)
Advance care directive in place prior to hospitalization 34 (69.4)
 Table 2. Cont.
Characteristic N (%) or Median (Interquartile Range)
Medication use a
Polypharmacy (≥9 regular medications) b 32 (71.1)
Charted regular medications that may increase infection risk b 9 (20.0)
Influenza vaccination prescribed by GP on the RACS
medication chart and documented as administered c 11 (24.4)
Abbreviations: GP, general medical practitioner; RACS, residential aged care service. a Medication chart for
the 2 weeks prior to hospitalization was not available on four occasions. b Assessed in the 2 weeks prior to the
hospitalization. c Assessed in the 12 months prior to hospitalization. It is noted that influenza vaccinations may
sometimes be recorded by GPs as administered in the progress notes only.

In total, 59.2% of infection-related hospitalizations were for respiratory infections, followed by

urinary (28.6%), and skin infections (10.2%) (Table 3). Urinalysis or urinary dipstick testing was
undertaken prior to 26.5% of hospital transfers for infection and 17% of residents had blood tests. At
the time the infection was suspected and prior to hospital transfer, vital signs were monitored in
81.6% of residents and medications that may increase infection risk were charted in the previous
fortnight in 20% of residents. Just over one-third of residents (37.8%) received antimicrobial therapy
prior hospital transfer. In four out of five cases (81.6%), the resident’s usual GP, a GP from same
practice, or a locum GP had evaluated the resident prior to hospital transfer. Almost three-quarters
of hospital transfers for infection occurred on a weekday. Figure 1 shows the time and day of week
when each resident was transferred to hospital.

Table 3. Characteristics of the infection and resulting infection-related hospital transfer.

N (%)
Characteristic
(n = 49)
Infection type
Respiratory infection 29 (59.2)
Pneumonia 12 (24.5)
Exacerbation of chronic obstructive pulmonary disease 5 (10.2)
Urinary infection 14 (28.6)
Urinary tract infection 7 (14.3)
Urosepsis 6 (12.2)
Hospitalizations for urinary infection where an indwelling catheter was present 2 (4.1)
Skin infection 5 (10.2)
Cellulitis 3 (6.1)
Other 4 (8.2)
New or worsening signs or symptoms in the 2 weeks prior to hospital transfer
Feeling unwell 15 (30.6)
Altered mental status or changes in behavior 7 (14.3)
Malaise, lethargy, drowsiness, or refusal to get out of bed 13 (26.5)
Functional decline 9 (18.4)
Fall 7 (14.3)
New or worsening pain 17 (34.7)
Fever, chills, or rigors 7 (14.3)
Decreased oral intake 10 (20.4)
Nausea or vomiting 13 (26.5)
New/increasing abdominal pain or diarrhea 8 (17.0)
Testing undertaken within the RACS in the 2 weeks prior to hospital transfer a
Blood test 8 (17.0)
Urinary dipstick or urinalysis 13 (26.5)
Other 3 (6.4)
Radiology 0 (0.0)
No testing undertaken 29 (61.7)
 Table 3. Cont.
N (%)
Characteristic
(n = 49)
Interventions undertaken within the RACS from the time the condition was first suspected until
hospital transfer
Monitor vital signs 40 (81.6)
New or change in medication(s) 27 (55.1)
Oxygen 22 (44.9)
Physiotherapy review/treatment 3 (6.1)
Other 5 (10.2)
None required 3 (6.1)
External provider evaluation of the resident
Usual GP or GP from same practice 27 (55.1)
Locum GP 13 (26.5)
Nurse Practitioner 1 (2.0)
Extended care paramedic 5 (10.2)
Resident’s condition discussed with GP or locum via telephone 5 (10.2)
Nil documented 6 (12.2)
Antimicrobial use in the 2 weeks prior to hospital transfer b 17 (37.8)
Penicillin 9 (20.0)
Cephalosporin 5 (11.1)
Macrolide 5 (11.1)
Trimethoprim or nitrofurantoin 4 (8.9)
Oseltamivir 2 (4.4)
Person authorizing hospital transfer
Usual GP or GP from same practice 13 (26.5)
Locum GP 8 (16.3)
Nurse practitioner 2 (4.1)
Registered nurse 19 (38.8)
Resident or family member 4 (8.2)
Extended care paramedic 3 (6.1)
Day of hospital transfer
Weekday (Monday–Friday) 36 (73.5)
Weekend (Saturday–Sunday) 13 (26.5)
Time of hospital transfer
Between 07:00 and 14:59 24 (49.0)
Between 15:00 and 22:59 13 (26.5)
Between 23:00 and 06:59 12 (24.5)
Abbreviations: GP, general medical practitioner; RACS, residential aged care service. a Information was available
for n = 47 events. b Medication administration charts for the 2 weeks prior to hospitalization were available for
n = 45 events.

Table 4 lists the factors contributing to infection-related hospitalizations identified in the

aggregate RCA. Factors identified include administration of medications that increase the risk of
infection. Possible suboptimal selection of empirical antimicrobial therapy and access to medical
services including intravenous access, radiology, and pathology were also identified as potential
contributors to infection-related hospitalizations. Table 4 also outlines potential strategies to mitigate
risk of infection-related hospitalizations as identified by the expert panel. These include strategies
such as targeted bundles of care, medication review, antimicrobial stewardship, earlier
identification of infection, and models of care that facilitate timely access to medical services.
Int. J. Environ. Res. Public Health 2020, 17, 3282 8 of

Table 4. Factors contributing to infection-related hospitalizations identified through the root cause analysis and potential strategies to mitigate the risk of
hospitalization that were identified by panel members.

Factors Contributing to Infection-Related Hospitalizations

Domain Identified through the Root Cause Analysis Potential Strategies to Mitigate Risk of Infection-Related Hospitalizations

• Consider implementation of a screening tool to identify residents who are at high risk
of infection
• Increase awareness and access to evidence-based resources and guidelines for management
of common infections and increase on-site and electronic availability
• (e.g., Therapeutic Guidelines)
• Administration of medications that increase the risk of Embed flags and decision support tools relating to identification of medication use that may
infection (e.g., corticosteroids) or contribute to urinary increase infection risk, identify residents at risk of adrenal insufficiency during acute
retention (e.g., medications with anticholinergic properties) infection, and support optimal empirical antimicrobial selection into electronic RACS
Resident
• medication management systems, where available in the RACS
assessment Possible suboptimal management of adrenal insufficiency • Increase awareness and access to tools to facilitate regular review of skin care in residents at
during acute infection
high risk of skin infections (e.g., those with diabetes or using topical corticosteroids for
• Possible suboptimal selection of empirical extended periods)
antimicrobial therapy
• Increase awareness and access to tools to monitor fluid balance
• Implement a subsidized RACS antimicrobial stewardship program that is adequately
resourced to bring together GPs, facility staff, pharmacists, and external infectious disease
physician expertise
• Clinical pharmacist or nurse employed within the RACS as part of a subsidized program to
undertake antimicrobial stewardship
• Earlier identification and response to signs and symptoms
• Implement a structured checklist and training package to support clinical staff to identify
of confusion, delirium, infection, and sepsis
• signs and symptoms of dehydration, infection, and sepsis
Earlier recognition and response to signs and symptoms of
• Develop and implement a clinical pathway to assist staff to respond to suspected infections
reduced oral intake and dehydration as early signs
• Implement a subsidized “diagnostic stewardship” program that is adequately resourced to
of infection
Staff training and • engage GPs and clinical RACS staff
Possible deficits in knowledge and practices relating to
resident factors specimen collection • Increase awareness and access to existing chronic obstructive pulmonary disease and asthma
• action plans
Possible inconsistent documentation of observations where
indicated (e.g., documented in the progress notes and/or • Involve pharmacists in the review of inhaler technique, training for staff/residents and
observation chart) provision of chronic obstructive pulmonary disease and asthma action plans
• Inhaler technique may not be regularly checked or corrected • Increased access to “hospital in the home” or similar external service to support parenteral
by a health professional rehydration in residents with limited oral intake and dehydration
 Table 4. Cont.

Factors Contributing to Infection-Related Hospitalizations

Domain Potential Strategies to Mitigate Risk of Infection-Related Hospitalizations
Identified through the Root Cause Analysis

• Increase access to mobile or on-site pathology and radiology services that are subsidized
for residents
• Utilize telehealth services to facilitate review and inform the decision to initiate a
• Problems with timely access to subsidized medical, hospital transfer
Equipment and radiology, and pathology services • Develop and implement subsidized models of care that support proactive on-site
work environment • RACS clinical staff unable to establish intravenous access multidisciplinary care from GPs and geriatricians
and administer parenteral antimicrobials at the RACS • Increased access to “hospital in the home” or external OPAT services to support parenteral
antimicrobial administration in RACS to support hospital avoidance or early discharge
• Models that support input from infectious diseases physicians during infectious disease
outbreaks that may occur within RACS
• A specific procedure to support documentation of resident’s wishes (e.g., advance care
• The resident and/or family member’s wishes regarding directives) in a clear and consistent manner to inform decision-making regarding a hospital
hospital transfers may be unknown transfer for infection
• Influenza vaccinations were not always prescribed and/or • Nurse practitioners or advance care directive “champions” within a RACS could assist with
there may be difficulty in determining current vaccination documentation of advanced care directives (implemented since completion of study)
Information, status. Pneumococcal vaccination status was difficult to • Support health professionals to reference existing and emerging tools (e.g., electronic health
policies, and determine as residents may have been immunized many records such as Australia’s My Health Record or immunization registers such as the
procedures years prior to admission to the RACS but documentation Australian Immunization Register) to record vaccines given to residents
regarding administration may not have been received from • Embed flags to highlight future immunization dates into electronic RACS medication
the previous GP and/or the resident or family may not be management systems where available and in use
able to provide vaccination history when the resident first • Robust procedures in place to ensure immunizations are administered and this is
enters the RACS
documented for RACS staff to view
• Challenges with timely communication between health
professionals and staff at RACS when changes occur in
resident behavior, cognition, physical status, • Facilitate timely communication of changes in resident behavior, cognition, and medication
and medications use to all persons involved in the resident’s care
Communication
• Delays in reviewing pathology test results received post- • Implement a standardized format for transfer of information, e.g., ISBAR
and coordination
initiation of empirical antimicrobial therapy Suboptimal • Facilitate timely access to review of empirical therapy through mechanisms such as
• communication of results of pathology tests antimicrobial stewardship programs
undertaken in hospital and ongoing antimicrobial therapy
plan after hospital discharge
Abbreviations: GP, general medical practitioner; ISBAR, Introduction, Situation, Background, Assessment, Recommendation; OPAT, outpatient antimicrobial therapy; RACS, residential
aged care service.
Int. J. Environ. Res. Public Health 2020, 17, 3282 10 of

Figure 1. Time and day of hospital transfer among residents hospitalized for infection (n = 49).

4. Discussion
This was the first Australian aggregate RCA to investigate hospitalizations for infectious
diseases from RACS. Factors identified that potentially contributed to infection-related
hospitalizations include the use of medications that may increase the risk of infection, selection of
empirical antimicrobial therapy, and timely access to subsidized medical, radiology, and pathology
services.
Medications that may increase the risk of infection were administered to one in five residents
who were hospitalized for infection. It may not be possible to avoid administration of some of these
medications, and therefore, prevention and careful monitoring for infection, and early intervention
when an infection is present in these “higher risk” residents is important. Potential strategies
suggested by the expert panel included medication reviews, implementation of screening tools to
identify residents at high risk of infection, embedding flags and decision support tools for high-risk
medication use, and education/support for staff.
Respiratory infections and UTIs were identified as the two most common reasons for
hospitalization due to infection in our RCA. This is consistent with other studies in the RACS
setting [2,5,7,8]. Prevention of respiratory tract infections, in particular pneumonia, is a priority
among RACS providers due to associated high rates of morbidity and mortality including
hospitalization [43,44]. Prevention strategies include influenza and pneumococcal vaccinations [25].
An infection quality indicator program that includes four indicators pertaining to resident and staff
vaccination was recently implemented in public-sector RACS in Victoria, Australia [45]. A recent
Cochrane review noted that further research is required to determine whether professional oral care
reduces the incidence of pneumonia in comparison to usual oral care [44]. Similarly, prevention of
UTIs is important to minimize hospital transfer. A recent systematic review provided a
comprehensive list of interventions for prevention of UTIs among residents with and without a
urinary catheter [20]. In the present study, only two of the six hospitalizations where an indwelling
catheter was present were for UTIs. This may be because
the organization involved in this project has implemented a range of strategies to manage residents
with urinary catheters including organizational protocols, incontinence nurse reviews, staff
training programs, and skills assessments.
An Australian RACS study found that one-third of residents were colonized with at least
one antimicrobial-resistant pathogen, including either methicillin-resistant Staphylococcus aureus,
vancomycin-resistant enterococci, or multidrug-resistant Gram-negative bacilli [12]. The prevalence
of multidrug-resistant organisms (MDROs) in RACS is increasing worldwide, with evidence
suggesting that some MDROs are more prevalent in RACSs than in acute hospitalized patients
[46,47].
A German study reported an average annual cost of €50,306 (USD $56,349) per resident due to
antimicrobial-resistant pathogens [48]. Strategies for preventing antimicrobial resistance include
monitoring antimicrobial use with a focus on appropriateness [8,49], hand hygiene [13,49], and
avoiding unnecessary hospitalization [49]. Infection quality indicators to monitor for three
significant organisms (methicillin-resistant Staphylococcus aureus and vancomycin-resistant
Enterococcus and Clostridium difficile) have recently been implemented in Victorian public-sector
RACS [45].
Selection of suboptimal empirical antimicrobial therapy was identified as a potential factor
contributing to infection-related hospitalization. Inappropriate antimicrobial use increases the risk
of treatment failure, drug interactions, adverse events, and treatment-related problems such as
Clostridium difficile infection and contributes to antimicrobial resistance [50]. One of the potential
strategies suggested by the expert panel was to optimize antimicrobial use by implementing an
interdisciplinary antimicrobial stewardship program. Australian antimicrobial stewardship
programs have predominantly focused on the hospital setting, although new Aged Care Quality
Standards that apply from July 2019 outline the need for RACS to show evidence of policies and
activities to minimize infection-related risks [29]. Since November 2017, multidisciplinary
antimicrobial stewardship programs are mandated in all RACS in the US [51]. These programs were
introduced to minimize inappropriate antimicrobial use and antimicrobial resistance. An
Australian national
survey [52] showed that 55.2% of the antimicrobial prescriptions were for residents with no signs and/or
symptoms of infection in the week prior to the start date and, of these, only 18.4% met the
internationally recognized McGeer et al. [53] infection definitions. Peron et al. found that in the US,
43% of all days of antimicrobial therapy in RACS were unnecessary based on guideline-
recommendations [54]. Increased awareness and access to evidence-based resources and guidelines
for the management of common infections for health professionals at the RACS was identified by
the expert panel as another potential strategy to mitigate risk of hospitalizations due to suboptimal
antimicrobial choice. This includes increased on-site and electronic availability to infectious diseases
clinical practice guidelines for GPs, locums, other prescribers, and health professionals.
Necessary equipment, appropriately trained staff, and access to external healthcare provider
support are required to treat infection within the RACS. These were identified by the expert panel as
factors that may contribute to infection-related hospitalizations. Australian RACS provide nursing
support rather than acute medical services. Therefore, there is limited capacity for RACS nursing
staff to establish intravenous access and administer parenteral antimicrobials [6]. Increasing access
to “hospital in the home” or outpatient antimicrobial therapy (OPAT) services to support parenteral
antimicrobial administration in RACSs would likely improve resident satisfaction and comfort,
minimize length of hospital stay, or avoid the need for hospitalization entirely. Two studies in
Australia showed that a “hospital in the home” program could be effective in reducing hospital
admissions from RACS residents [55,56]. As part of the RCA, data on the day and time of hospital
transfer were recorded because there may be different access to staff and medical services at
different times of the day. The availability of staff, equipment, clinical governance, and external
clinical support, particularly after hours, have been identified in previous research as barriers to
treatment within RACSs [2,18]. This indicates an opportunity that exists to reduce hospital transfers
from RACSs by ensuring equipment and expertise are available. One potential solution is presented
in a recent evaluation of a “Geriatric Flying Squad” (GFS) model [57]. The team of healthcare
providers (the GFS) included a geriatrician, nurse practitioners/nurse practitioner candidates, and
clinical nurse consultant who provided a 7-day service. This model involves RACSs referring
acutely deteriorating residents to the GP or directly to the GFS if the GP is not contactable. The GFS
visit the RACS and provide additional diagnostic and management support not available within the
facility. The evaluation indicated that the GFS were able to manage 90.3% of cases within the facility,
preventing 578 hospitalizations from RACSs over 18 months. Similarly, a collaborative approach, led
by an advanced practice nurse with aged care skills, found that residents receiving this intervention
were 41% less likely to be admitted to hospital [58]. Another potential solution may be to better
equip primary care practitioners to better manage residents
to minimize hospital transfer. This may include providing professional support and education for
RACS staff on quality indicators, functional decline, and hospital transfers of residents [59]. Rolland
et al. found that this intervention had a significant positive effect on the prevalence of assessment of
pressure injury risk, depression, pain, and prevalence of hospital transfers [59].
Another factor identified as potentially contributing to hospitalization with infectious diseases
was that the resident and/or family member’s wishes regarding hospital transfers may be unknown.
Additionally, some advanced care directives may be difficult to interpret and may lack specific
information about specific treatments or hospitalizations. In Canada, 21.7% (n = 80,413) of residents
had “do-not-hospitalize” directives documented between 2009–2010 and 2011–2012, and of these,
7.2% were hospitalized [60]. Among residents who were hospitalized and had a do-not-hospitalize
directive, almost half (46.3%) of the hospitalizations were deemed potentially preventable [60]. A
potential strategy suggested by the expert panel to mitigate the risk of hospitalization was
employing nurse practitioners or training advance care directive “champions” in RACS. This could
assist with documentation and interpretation of advanced care directives. A standardized approach
to documentation of advanced care directives and specific examples may be important in
preventing hospitalizations for infection.

Strengths and Limitations

This aggregate RCA recruited residents from six facilities in both metropolitan and rural areas
of South Australia. However, the data for the RCA were retrospectively collected from a modest
sample of residents, and the residents were recruited from six RACS maintained by one aged care
provider organization, and therefore, generalizability may be limited. However, the 383 residents
included in the original cohort study from which this aggregate RCA was derived were
representative of all residents of the 6 RACS in terms of age, sex, and diagnosed dementia.
Although the sample size is small compared to epidemiological studies, our study is based on a
comprehensive and in-depth review of nursing progress notes, medical records, medication charts,
hospital summaries, and incident reports for each of the participating residents. These data were
reviewed independently by the research nurse, an infectious diseases physician, and an infectious
diseases pharmacist. Additionally, the expert panel was composed of members internal and external
to the RACS provider ensuring that reviews were well informed and independent. A lack of
independence has previously been a criticism of RCA [61]. The purpose-specific data collection tool
was based on the SA Health RCA tool. The tool was developed by the expert panel ensuring that all
relevant information was captured to inform the RCA. While single incident analysis may lead to
prioritizing actions and resources to a rare event, an aggregate RCA identifies recurring events
allowing for consideration of system and human factors contributing to hospitalizations [61]. A
limitation of our approach is that by only assessing infection-related hospitalizations, we were
unable to ascertain whether factors perceived to contribute to infection-related hospitalizations were
different to those which may contribute to hospitalizations for other health conditions. However,
this is an important issue to examine because 25% of hospitalizations from RACS are for infection
[4].

5. Conclusions
This aggregate RCA identified medication and non-medication opportunities that exist to
prevent infection-related hospitalizations through targeted medication review, antimicrobial
stewardship, earlier identification of infection, and models of care that facilitate timely and
extended access to medical services. RACS provider organizations, clinicians, policy makers, and
other stakeholders can use these findings to review current strategies in place and inform next steps
to limit infections and associated hospital transfers from RACS. Future studies could explore factors
associated with successful implementation and associated outcomes for residents and other
stakeholders.
Author Contributions: Conceptualization, J.K.S. and J.S.B.; data curation, J.K.S., S.M.H., J.M., T.S., and K.A.C.;
formal analysis, J.K.S.; funding acquisition, J.K.S., J.I., R.V., and J.S.B.; investigation, J.K.S., S.M.H., B.R., J.M.,
T.S.,
L.R., T.C., K.A.C., and J.S.B.; methodology, J.K.S., B.R., J.I., and J.S.B.; project administration, J.K.S., S.L., and
S.M.H.; resources, J.K.S., L.R., T.C., and J.S.B.; software, S.H.; supervision, J.S.B.; visualization, S.L.; writing—
original draft, S.L.; and writing—review and editing, J.K.S., S.H., B.R., J.M., T.S., L.R., T.C., K.A.C., J.I., R.V., and
J.S.B. All authors have read and agreed to the published version of the manuscript.
Funding: This study was funded by a grant from Resthaven Inc. and the Centre for Research Excellence in
Frailty and Healthy Ageing (grant no. GNT1102208). Employees of Resthaven Incorporated were involved
as study authors, participated in the collection of data and discussion and interpretation of the results, and
critically revised the manuscript for intellectual content. All authors had final responsibility for the decision to
submit for publication. JKS was supported by a National Health and Medical Research Council (NHMRC)
Early Career Fellowship (APP1156439). JSB was supported by an NHMRC Boosting Dementia Research
Leadership Scheme Fellowship.
Acknowledgments: The authors acknowledge the contributions of the following expert panel members:
Peter Hayball, Solomon Yu, Jasmin MacIntyre, Terry Shortt, Belinda Willshire, Eleanor Van Dyk, Kelly A
Cairns, Leonie Robson, Jenny McLoughlin, Brett Ritchie, Bryan Burnett, Georgina A Hughes, and Greg Scarlett.
We also gratefully acknowledge Ms Choon Ean Ooi for assistance with manuscript formatting.
Conflicts of Interest: L.R., T.C., T.S., and J.M. are employed by Resthaven Incorporated. R.V. is a Board Director
of Resthaven Incorporated. S.M.H. is supported by a Deakin University Dean’s Research Postdoctoral
Fellowship.
J.K.S. is employed part-time by CPIE Pharmacy Services, an aseptic compounding pharmacy, and is a
shareholder in Infusion Innovations Pty Ltd. Infusion Innovations Pty Ltd. was established to conduct research
and development to support safety and efficacy of Hospital in the home services and has filed several infusion
device patent applications. Neither CPIE Pharmacy Services nor Infusion Innovations Pty Ltd. were involved
in this research project.

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