Infection prevention

and control
Standardised care process

Objective Infection: ‘When an infectious agent enters the

body and multiplies to levels where it causes
To promote evidence-based practice in the
disease’ (National Health and Medical Research
prevention and control of infection for older people
Council (NHMRC) 2013, p. 2).
who live in residential aged care settings.
Infectious agents: Organisms that cause infection
Why the management of infection (bacteria, viruses, fungi and parasites) (NHMRC
2013, p. 2).
is important
Multi-resistant organism: ‘A type of infectious
Older adults with multiple comorbidities and high
agent that has become resistant to a number
care needs living in residential aged care facilities
of different antibiotics normally used in its
are at risk of acquiring infections because of close
treatment’. Examples include methicillin-resistant
living proximity and frequent contact between
Staphylococcus aureus, vancomycin-resistant
residents and staff and among residents (Lim et al.
enterococci and Clostridium difficile (NHMRC
2015; van Buul et al. 2012).
2013, p. 7).
The Aged Care Quality Standards identify that
Standardised care process (SCP): This has been
organisations must demonstrate the following:
developed for the department’s Strengthening Care
Minimisation of infection-related risks to Outcomes for Residents with Evidence (SCORE)
consumers, the workforce and the broader initiative through a comprehensive review of the
community through implementing: evidence and consultation with public sector
a) standard and transmission-based precautions to residential aged care stakeholders and experts to
prevent and control infection mitigate significant clinical risk in residential aged
b) practices to promote appropriate antibiotic care services.
prescribing and use to support optimal care
and reduce the risk of increasing resistance Transmission: ‘The spread of infectious agents from
to antibiotics (Aged Care Quality and Safety one person to another’ (NHMRC 2013, p. 2).
Commission, 2018).
Antimicrobial stewardship is an important Team
component of an infection prevention and Manager, registered nurses, enrolled nurses,
control program. This SCP should be read/used in personal care attendants, leisure and lifestyle,
conjunction with the Antimicrobial stewardship SCP. general practitioner (GP), infection control
professionals, residents and/or family/carers; and
Definitions access to a microbiologist, infectious disease
physician, continence advisor, wound consultant
Clinical risk: Where action or inaction on the part
and allied health professionals such as a
of the organisation results in a potential or actual
physiotherapist and occupational therapist.
adverse health outcome on consumers of health
care (Department of Health 2012, p. 5).
Acknowledgement
Colonisation: ‘When an infectious agent establishes
itself on, or in, the body but does not cause disease’ This SCP has been developed and reviewed by
(NHMRC 2013, p. 2). the Australian Centre for Evidence Based Care,
La Trobe University for the Department of Health
Contamination: ‘When infectious agents spread to
and Human Services based on the best available
a surface or item, creating risks for the spread of
evidence in 2018.
infection’ (NHMRC 2013, p. 2).
Brief standardised care process
Recognition and assessment Referral
Early detection of infection can help prevent • General practitioner
transmission to other residents, staff and visitors. • Microbiologist
When an infection is suspected, a diagnosis should • Public Health authority
be sought. • Pharmacist
• Infection control professional
Collect clinical and diagnostic evidence to confirm
the presence, source and type of infection. • Infectious disease physician
• Continence advisor/wound consultant
• Carry out a physical examination and collect
vital signs.
• Ask the resident about their symptoms.
Evaluation and reassessment
• Review the resident’s history for previous Maintain ongoing monitoring for:
infections, predisposing illness, vaccination • continuing compliance with recommended
status, medicines, lifestyle factors and previous interventions
living environment. • improvement in the clinical picture and
• Consider non-infective causes. resolution of symptoms
• Observe for new, rapidly increasing or atypical • evidence of a new infection
signs and symptoms of infection. • continuing compliance with the organisation’s
• If new or increasing signs or symptoms of infection prevention and control policy and
infection are present carry out diagnostic testing procedures by staff
and follow up results promptly – treatment is • factors that might increase the risk of infection.
based on these results.
• If there are no typical or atypical signs or Continue to document progress in the notes.
symptoms of infection there is no need for
microbiology or other tests. Resident involvement
Document and communicate any assessment Provide general education to residents and
findings, including signs and symptoms of infection, families on:
in a timely and effective manner to the appropriate • how to prevent the spread of infection through
members of the healthcare team and in the correct hand hygiene practices and cough
resident’s health record. etiquette
• the requirements for transmission-based
Interventions precautions
• the difference between bacterial and viral
Prevention strategies should be implemented to infections and the role of antimicrobials.
prevent infections in residential aged care. These
include:
Staff knowledge and education
• the exemplary practice of standard and
transmission-based precautions A member of the clinical team holds the portfolio for
• identifying residents who are susceptible to infection prevention and control.
infection The whole clinical care team receives education
• identifying and addressing the organisational on: recognising signs and symptoms of infection;
and staff risk factors for infection transmission recognising and acting on possible outbreak
• enhancing the resident’s ability to resist infections situations; infection prevention and control
• implementing a staff and resident immunisation interventions; and the importance of accurate and
program descriptive documentation.
• early identification of gastroenteritis and
respiratory outbreaks and implementing
outbreak management.

Infection prevention and control 2

Full standardised care process
Recognition Note signs and symptoms of infection may be slow-
onset, vague, masked or absent in older adults,
Early detection of infection can help prevent particularly where the resident has decreased
transmission to other residents, staff and visitors. immune function. Observe for atypical signs and
symptoms:
Assessment • low-grade fever or afebrile
When an infection is suspected, a diagnosis should • fever with lethargy
be sought. • fever in the absence of any other indications or
source
Collect clinical and diagnostic evidence to confirm
• subtle change in mental status and confusion
the presence, source and type of infection.
• behaviour change (for example, uncooperative,
• Carry out a physical examination and collect increased lethargy)
vital signs (temperature, pulse, blood pressure, • falls and functional decline
respiration rate, oxygen saturation).
• incontinence
• Ask the resident about their symptoms (although
• loss of appetite
caution should be taken for accuracy where
• vague systemic symptoms
there is a cognitive impairment, communication
• complicating comorbidities.
impairment or uncorrected hearing impairment).
• Review the resident’s history for previous If new or increasing signs or symptoms of infection
infections, predisposing illness, vaccination are present carry out diagnostic testing:
status, medicines, lifestyle factors and previous • Where bacterial or viral infection is suspected,
living environment. obtain appropriate microbiology specimens
• Consider non-infective causes (for example, before starting an antimicrobial.
underlying comorbidities or medication • Transfer microbiological specimens to
changes). laboratories in a timely manner to maintain
Observe for new or rapidly increasing signs and specimen quality. Check with your pathology
symptoms of infection, which include: provider for storage requirements and handling
of specimens.
• fever of single oral temperature ≥ 37.8°C, repeated
• Follow up diagnostic results promptly as
oral temperatures ≥ 37.2°C or rectal temp ≥ 37.5°C
treatment is based on these results.
or single temperature ≥ 1.1°C over baseline from
any site (oral, tympanic, axillary) • Refer to radiology (as required).
• acute change in mental status from baseline and If there are no typical or atypical signs or symptoms
delirium of infection there is no need for microbiology or
• acute functional decline other tests.
• malaise and loss of energy
In the case of a suspected urinary tract infection
• inflammation
(UTI), do not rely on microbiology results alone,
• pain
as diagnosis of a UTI is based on the presence
• increased respiratory rate (over 25 breaths per
of a typical clinical presentation. Screening for,
minute), oxygen saturation of 90 per cent or less
or treatment of, asymptomatic bacteriuria is not
• increased pulse
recommended. Urinary dipstick testing is only
• skin changes (rash, blisters)
‘necessary’ if there is a typical clinical presentation
• bodily fluids (amount, colour, turbidity, odour)
of UTI.
• elevation in white blood cell count (leucocytosis).
Document and communicate any assessment
findings, including signs and symptoms of infection
in a timely and effective manner to the appropriate
members of the healthcare team and in the
resident’s health record.

Infection prevention and control 3

Interventions • respiratory hygiene and cough etiquette
• aseptic non-touch technique for all clinical
Prevention procedures
A number of strategies can be implemented to • safe handling of waste and linen
prevent infections in residential aged care. These • providing alcohol-based hand sanitiser in
include identifying and minimising risk factors publicly accessible areas and resident bedrooms.
for transmission of infection and the exemplary Transmission-based precautions should be initiated
practice of standard and transmission-based in addition to standard precautions to prevent
precautions. transmission of significant pathogens to other
Residents who are susceptible to infection should residents, staff and visitors during an outbreak.
be identified. The risk factors include: This includes:
• compromised immune system • appropriate use of personal protective
• immunosuppression caused by medications and equipment by staff and visitors when in
health conditions direct contact with the resident or their care
environment
• multiple or prolonged recent hospitalisations
• the use of dedicated equipment for the resident
• prior exposure to (broad-spectrum)
antimicrobials • allocating single rooms or cohorting of residents
• a wound or pressure injury • enhanced cleaning and disinfection of
the resident’s environment – frequency of
• frailty, poor functional status or immobility
environmental cleaning and disinfection during
• urinary and faecal incontinence (increases the
an outbreak should be increased to at least twice
risk of UTI)
daily, particularly for frequently touched surfaces
• presence of indwelling devices (for example, such as overbed tables and door handles (use
urinary catheters, percutaneous feeding appropriate disinfectant as per dilution ratios in
tubes, central lines, peritoneal dialysis and departmental guidelines)
haemodialysis)
• restricting or safely transferring residents within
• social and lifestyle factors such as exposure and between facilities and other locations
to toxic substances, malnutrition, stressful life
• restricting movement of staff within, and
events.
between, facilities
Organisational risk factors for transmission of • encouraging immunisation of unvaccinated staff
infection should be identified and addressed. These and residents.
include: Staff infection control measures
• an inadequate infection prevention and control • Encourage staff to maintain the recommended
policy healthcare worker immunisations and yearly
• staffing deficits (high resident-to-staff ratio, influenza vaccinations and maintain a record of
frequent staff turnover and inadequate numbers staff vaccinations.
of clinical staff • Encourage staff to report if they are experiencing
• limited facilities for hand hygiene. symptoms related to possible infection
Standard precautions are practised at all times by (diarrhoea, vomiting, fever, sore throat or
all staff, for all work practices and following every jaundice) or infected skin lesions, and to take sick
leave as recommended by local infection control
contact with a resident. These include:
guidance or their GP.
• personal hygiene practices, particularly hand
• Minimise wearing of jewellery. False fingernails
hygiene
have been associated with infection transmission
• the use of personal protective equipment and should not be worn by clinical staff.
• safe handling and disposal of sharps • Manage work clothing if soiled with blood or body
• routine cleaning of the environment and fluids, and wash daily.
managing spills (blood and other body
substances)
• reprocessing (cleaning, disinfection, sterilisation)
of reusable instruments and equipment

Infection prevention and control 4

Minimise resident exposure to infection • Infection control professional
• Identify care-based interactions and resident • Infectious disease physician
risk factors that increase the transmission • Continence advisor/wound consultant
of infection including multidrug-resistant
organisms. Evaluation and reassessment
• Minimise the use of invasive devices where
• Monitor for continuing compliance with
possible (urinary catheters) and remove when no
recommended interventions.
longer required.
• Monitor for improvement in clinical picture and
• Ensure compliance with standard precautions.
resolution of symptoms.
Enhance the resident’s ability to resist infections • Monitor for evidence of a new infection in the
• Encourage recommended immunisation for older individual resident and in the general resident
adults such as seasonal influenza, herpes zoster population.
and pneumococcal. • Monitor staff for continuing compliance with the
• Optimise nutritional status and fluid intake. organisation’s infection prevention and control
• Manage stress. policy and procedures.
• Encourage mobility/exercise (according to the • Monitor and report any factors that might
resident’s capabilities). increase the risk of infection for individual
residents or the general resident population.
Outbreak management • Continue to document progress in the notes,
The most common outbreaks in the residential including signs and symptoms of infection.
aged care setting are gastroenteritis and
respiratory illness. Always access public health Resident involvement
guidelines to ensure adequate management of
Provide general education to residents and
outbreaks.
families on:
Respiratory outbreak management strategies • how to prevent the spread of infection
should be initiated when three or more residents in • correct hand hygiene practices and cough
a unit or facility are symptomatic within a three- etiquette
day period. • the requirements for transmission-based
precautions
Gastroenteritis outbreak management strategies
should be initiated when two or more residents or • the difference between bacterial and viral
infections and the role of antimicrobials
staff in a unit or facility are symptomatic within a
• expectations and goals of care.
two-day period.

The following outbreak management strategies Staff knowledge and education

should be swiftly instigated:
A member of the clinical team holds the portfolio for
• early identification and reporting of residents
who are unwell infection prevention and control with appropriate
training.
• follow the facility’s infection control procedures
• consult with public health authorities The whole clinical care team receives education on:
• post signage to alert visitors of the outbreak • recognising signs and symptoms of infection
• initiate transmission-based precautions in • recognising and acting on possible outbreak
addition to standard precautions. situations
• infection prevention and control interventions
Referral • the importance of accurate and descriptive
• General practitioner documentation.
• Microbiologist
• Public Health authority
• Pharmacist to ensure antimicrobial are
ordered and managed correctly and to review
microbiology data

Infection prevention and control 5

Evidence base for this
standardised care process
Aged Care Quality and Safety Commission 2018, Department of Health and Human Services 2018,
Aged Care Quality Standards and Guidance and Respiratory illness in residential and aged care
resources for providers to support the Aged Care facilities, viewed 3 December 2018, <https://www2.
Standards, Australian Government. health.vic.gov.au/public-health/infectious-diseases/
infection-control-guidelines/respiratory-illness-
Australian Commission on Safety and Quality
management-in-aged-care-facilities>.
in Health Care (ACSQHC) 2018, Antimicrobial
Stewardship in Australian Health Care, ACSQHC, Grampians Region Infection Control Group (GRIGG)
Sydney. and VICNISS 2017, UTI clinical pathway, viewed
12 April 2019, <https://www.vicniss.org.au/>.
Australian Medicines Handbook (AMH) 2006,
Australian medicines handbook drug choice Katz M, Roghmann M 2016, ‘Healthcare associated
companion: Aged care (2nd edition), Australian infections in the elderly: what’s new’, Current
Medicines Handbook Pty Ltd, Adelaide. Opinion Infectious Diseases, vol. 29, no. 4, pp.
388–393.
Centers for Disease Control and prevention (CDC)
2015, The core elements of antibiotic stewardship Lim CJ, Stuart RL, Kong DC 2015, ‘Antibiotic use in
for nursing homes, US Department of Health and residential aged care facilities’, Australian Family
Human Services, CDC, Atlanta, GA. Physician, vol. 44, no. 4, pp. 192–196.

Department of Health 2012, Strengthening care National Health and Medical Research Council
outcomes for residents with evidence (SCORE), (NHMRC) 2013, Prevention and control of infection
Ageing and Aged Care Branch, Victorian in residential and community aged care, Australian
Government, Melbourne. Government, Canberra.

Department of Health 2018, Australian Stone N, Ashraf M, Calder J, Crnich C, Crossley

Immunisation Handbook, viewed 3 December 2018, K, Drinka P, et al. 2012, ‘Surveillance definitions of
<https://immunisationhandbook.health.gov.au/ infections in long-term care facilities: revisiting the
resources/publications/catch-up-vaccination-for- McGeer Criteria’, Infection Control and Hospital
adolescents-and-adults>. Epidemiology, vol. 33, no. 10, pp. 965–977.

Department of Health and Human Services 2010, van Buul LW, van der Steen JT, Veenhuizen RB,
Guidelines for the investigation of gastroenteritis, Achterberg WP, Schellevis FG, Essink RT, van
viewed 3 December 2018, <https://www2.health.vic. Benthem HB, Natsch S, Hertogh CM 2012, ‘Antibiotic
gov.au/about/publications/researchandreports/ use and resistance in long term care facilities’,
Guidelines-for-the-investigation-of- JAMDA, vol. 13, 568.e1e568.e13.
gastroenteritis>.
Yaeger JJ 2015, ‘Infection’ in SE Meiner (ed),
Department of Health and Human Services 2014, Gerontologic nursing, 5th edition (chapter 15,
Vaccination for healthcare workers, viewed 3 pp. 270–280), Elsevier Mosby, Missouri.
December 2018, <https://www2.health.vic.gov.au/
public-health/immunisation/adults/vaccination-
workplace/vaccination-healthcare-workers>.

Infection prevention and control 6

 Important note: This SCP is a general resource only and should not be relied upon as an exhaustive or
determinative clinical decision-making tool. It is just one element of good clinical care decision making,
which also takes into account resident/patient preferences and values. All decisions in relation to resident/
patient care should be made by appropriately qualified personnel in each case. To the extent allowed by
law, the Department of Health and Human Services and the State of Victoria disclaim all liability for any
loss or damage that arises from any use of this SCP.

To receive this publication in an accessible format phone 9096 6963, using the
National Relay Service 13 36 77 if required, or email <[email protected]>.
Authorised and published by the Victorian Government, 1 Treasury Place, Melbourne.
© State of Victoria, Department of Health and Human Services, August 2019. (1908450)
ISBN 978-1-76069-020-5 (pdf)
Available from the department’s website at <www2.health.vic.gov.au/ageing-and-aged-care/residential-aged-
care/safety-and-quality/improving-resident-care/standardised-care-processes>.

Infection prevention and control 7