CSIRO PUBLISHING Research

www.publish.csiro.au/journals/hi Healthcare Infection, 2011, 16, 108–114

A 9-year infection-control surveillance program

in Sydney-based residential aged-care facilities

Judith Forrest1,4 RN, CIC Syd. Hosp., Grad. Cert. Communicable Diseases UWS, FCN
Anne Tucker2
Alan J. M. Brnabic3 MA, BA, DipEd
1
Bug Control Infection Control Advisory Service, PO Box 406, Gordon, NSW 2072, Australia.
2
Columbia Aged Care Services, 64–70 Albert Road, Strathfield, NSW 2135, Australia.
3
ABC Consulting, 48 Badminton Road, Croydon, NSW 2132, Australia.
4
Corresponding author. Email: judy@bugcontrol.com.au

Abstract. Objective: There are very limited Australian data on the incidence of infections in the residential aged-care
setting. The objective of this study was to undertake a program of surveillance to establish a baseline rate of infection
within the high-care residential facilities of the Columbia Aged Care Services Group in Sydney, Australia. Further, this
baseline rate would be used as a benchmark to prompt subsequent process monitoring for infection control with the aim
of decreasing infection rates.
Methods: Data were collected using a surveillance form compliant with the internationally recognised McGeer
(1991) definitions for infection surveillance in long-term care facilities. The data were initially collected across five
facilities from March 2001 to December 2005 and the data were reviewed during this period. The audit continued from
January 2006 to December 2009 to monitor the success of ongoing surveillance and best-practice interventions.
Results: The rate of infection calculated over the first 5-year period established the baseline at 3.1 infections per
1000 occupied-bed days (95% CI, 3.0–3.3). For respiratory infections and for all facilities, a monthly seasonal trend
was detected using time series analysis, with the majority of infections occurring during the months of May to
September and peaking in July. After intervention, the July peak diminished during the second period, although it still
exceeded the baseline rate. Infection rates were relatively constant over time for most facilities throughout the
surveillance period. Control chart analysis identified several spikes in infection rates that were recorded as a result of
outbreaks.
Conclusion: This comprehensive long-term surveillance program has provided a valuable baseline rate of infection
for comparison. It has also facilitated a proactive approach to infection prevention and control, such that problem areas
and ‘high-risk’ periods can now be identified and managed. The application of this approach should be considered in
other high-care residential settings – perhaps nationally, given the absence of uniform systematic surveillance systems
in any Australian state or territory. However, there is a need to review and validate the 20-year-old American definitions
of McGeer et al. for the contemporary Australian context.

Introduction among this population can cause considerable morbidity and

As Australia’s population ages, the wellbeing of a
dramatically increasing number of older people will become
the responsibility of residential aged-care facilities. Between
2010 and 2050, the number of older people (aged 65–84) in
Australia will more than double, while the number of very old
people (aged 85 and over) will more than quadruple.1
Those among these groups who become residents of
high-care nursing facilities are, for a variety of reasons,
more susceptible to infections than non-residents.2 The
substantially increased incidence and severity of infections
mortality.3
This is recognised by the Aged Care Standards and
Accreditation Agency Ltd, through Accreditation Standard
4.7, which requires residential care facilities to have an
effective infection control program that includes a
surveillance system incorporating collection and analysis of
resident infection data.4
Despite this, there is no uniform systematic surveillance
system for infection in residential care facilities in any
Australian state or territory,2 and many facilities continue to

 Australian Infection Control Association 2011 10.1071/HI11014 1835-5617/11/030108

Infection-control surveillance program in residential aged-care facilities
satisfy Standard 4.7’s requirement for infection surveillance
using the prescription of antibiotics as the only criteria for
recording infections.
Further, there are no definitive longitudinal Australian data
on the incidence of infection in residential aged care. A 1999
point prevalence survey examined 19 residential care facilities
(3290 beds in rehabilitation and nursing home settings) in
metropolitan Melbourne and country Victoria. Overall
infection rates were 5.2/1000 beds (95% CI, 3.7–7.0) for
rehabilitation settings and 6.0/1000 beds (95% CI, 5.1–7.0) in
nursing homes.2
A report on infection surveillance data prospectively
collected over 1 year in 10 accredited residential care facilities
in Perth, Western Australia, reported an overall infection
incidence of 4.6/1000 resident days, with rates ranging from
1.9 to 9.0 in individual facilities. The most common sites of
infection were the respiratory tract, urinary tract, skin and soft
tissue.5
Most recently, a point prevalence survey reported
surveillance program data collected from 31 residential aged-
care facilities in the Grampians region of Victoria during June,
2010. For the 26 facilities (total occupied-bed days: 20 402)
that submitted data before the preliminary report, 52 infections
were reported by 21 facilities, with an overall infection rate
of 2.6/1000 occupied-bed days (95% CI, 1.9–3.3).6
Internationally, studies in the United States have reported
incidences of infection ranging from 1.8 to 9.4/1000
resident days, with urinary tract and lower respiratory
infections the most common.3 Studies from Germany,7 Italy8
and Norway9 reported infection rates of 6.0, 11.8 and 5.2/1000
resident days, respectively.
The objective of this study was to establish a baseline rate
of infection within the high-care residential facilities of the
Columbia Aged Care Services Group in Sydney, and to then
use this baseline as a ‘benchmark’ to identify unusual infection
activity and initiate immediate response, with subsequent
improvement of ongoing process monitoring for infection
prevention and control.
Methods
This was a comprehensive and systematic surveillance of
all urban-based facilities of the Columbia Aged Care Services
Group in Sydney, Australia. Data were collected from March
2001 to December 2009 across five facilities.
For reasons of privacy, the names and locations of specific
facilities will not be included in this report. The total approved
places for each of the sites is as follows: Facility 1–60 beds
(with an average of 18 749 occupied bed days per year
during the course of the surveillance); Facility 2–104 beds
(32 872 occupied bed days per year); Facility 3–146 beds
(46 550 occupied bed days per year); Facility 4–40 beds (9 924
occupied bed days per year); and Facility 5–90 beds (17 200
occupied bed days per year).
No data was collected for Facility 4 in 2001 or 2002 as the
site was only purchased by Columbia in 2003. No data was
Healthcare Infection 109
collected at Facility 5 in 2005 or 2006 due to closure of the site
for renovation.
All persons residing at these facilities, which exclusively
house high-care residents, were included in the review. At the
study’s conclusion, the proportion of residents aged under
65 years ranged from 2.4% (Facilities 1 and 2) to 3.3%
(Facility 3), while the proportion above 85 years ranged from
43.3% (Facility 3) to 63.8% (Facility 5). Across all facilities,
2.7% were aged under 65 years, 40.7% between 65 and
84 years and 56.6% over 85 years.
The surveillance form was designed to comply with the
McGeer definitions for infection surveillance in long-term
care facilities,10 in line with the then Australian Government
Department of Health and Ageing (AGDHA) infection
control guidelines.11 These definitions, which are the most
widely accepted definitions internationally, were applied as
documented without modification.
The surveillance form recorded: the resident’s admission
date; date the infection was first observed; type of infection
(eye, ear, nose or throat (EENT) infections; gastrointestinal
infections; respiratory infections; systemic infections; urinary
tract infections (UTIs); and wound/skin infections); signs
and symptoms of infection; pathology specimen results; and
interventions. Training in the use of the surveillance form was
conducted for staff across all centres to ensure standardisation
of the tool’s administration and to allow for uniform infection
identification and data collection. The deputy director of
nursing at each facility was responsible for regular checks
of surveillance data throughout the month, assessing data
integrity, acting on any immediate concerns and contacting
infection control consultants engaged for the project should
any indications of an outbreak emerge.
Data quality and control was further monitored by monthly
inspection of all reporting. The qualified infection control
consultants analysed surveillance reports and provided a
Quality Project Report each month outlining key outcomes,
such as: recorded infections and noted trends; action required,
such as resident care interventions and preventative measures,
pathology processes; and a project evaluation highlighting
any data quality control issues, any need for additional work or
any implications for future action and interventions moving
forward. Quarterly infection control committee meetings were
conducted by Columbia Aged Care Services representatives
from each site, together with the infection prevention and
control consultants, to further review and discuss the data and
outcomes.
Surveillance processes were designed to be as easy as
possible to implement and complete, in recognition of the time
constraints on key personnel of residential aged-care facilities,
who are often managing a range of portfolios, including
infection prevention and control.13
Data were initially collected over a 5-year period from
March 2001 to December 2005 in order to establish a baseline
rate of infection across the Columbia facilities. Data collection
subsequently continued from January 2006 to December
2009, with the intention of monitoring the success of best-
110 Healthcare Infection J. Forrest et al.

practice interventions, improving procedures and reducing the lowest observed rate of 2.4/1000 occupied-bed days in 2003.
rate of infection. After a rise in infections in 2004 (detailed below), the infection
Best-practice interventions were guided by comprehensive rate was then constant for most facilities for the remainder of
and infection-specific infection surveillance responses the surveillance period.
recommended and fully documented by the infection For the 4-year period from January 2006 to December
prevention and control consultants. These included, for 2009, a steady yearly rate of infections was observed through
example, the identification of peak infection periods – that is, to 2008, before an increase to 4.2/1000 occupied-bed days was
winter – and implementation of targeted education and recorded in 2009. A total of 3588 infections were recorded
influenza vaccination programs to all staff and residents ahead over the full 9-year span of the study, which equates to an
of these periods, to reduce the risks of infection transmission. overall rate of 3.2/1000 occupied-bed days.
A control chart displaying the rate of infection over the
Statistical analysis duration of the study is shown in Fig. 1. This figure illustrates a
Data were analysed using SAS® Version 9.2 for Windows constant overall rate of infections, with a few spikes, over the
(SAS Institute, Cary, NC, USA). Confidence intervals for duration of the surveillance period. The first notable spike in
the rates were calculated using the exact Poisson confidence infections beyond the initial months of the study occurred in
limits according to Leslie Daly (1992).12 Control charts 2004, and closer investigation revealed that this was related
were constructed using PROC SHEWART. Time series to an outbreak of gastrointestinal infections between May
forecasting models were fitted to the data and selected based and July of 2004 (Fig. 2). The spike reflected consecutive
on the goodness-of-fit assessed using the lowest Akaike outbreaks at three different facilities: 24 cases were recorded at
information criteria (AIC). The seasonal exponential Facility 5 in May (returning to zero in the following month); 18
smoothing model was chosen based on this criteria and cases were recorded at Facility 2 in June (returning to only one
implemented using PROC ESM. Seasonality was assessed case the following month and zero thereafter); and 34 cases at
using both frequency and time domain analysis. The Facility 3 in July (returning to zero the following month).
Bartlett’s Kolmogorov–Smirnov statistic was used via PROC The 3-month gastrointestinal outbreak contributed to a
SPECTRA with small P-values indicating that the null- higher overall rate of infection in 2004 (3.3/1000 occupied
hypothesis that the normalised periodogram is white noise, bed days), before falling again in 2005 (2.5/1000 occupied
cannot be accepted. PROC X11 was also implemented which bed days). A steady rate was subsequently maintained for
conducts a combined test of identifiable seasonality. The test much of the remainder of the observation period.
for identifiable seasonality is performed by combining the The spike in infections in 2009, shown in Fig. 1 reflects
F tests for stable and moving seasonality, along with a separate outbreaks of both gastrointestinal (Fig. 2) and
Kruskal–Wallis test for stable seasonality. respiratory infections (Fig. 3) during 2009. Specifically, an
outbreak of gastrointestinal infections occurred at Facility 5
Results in January (n = 18) and February (n = 10) 2009, and a spike
Table 1 presents the total number of infections and infection in respiratory infections (n = 47) was recorded in October
rates for the combined Columbia facilities in the period from 2009, primarily at Facilities 2 (n = 14) and 3 (n = 19). By
March 2001 to December 2009. The total number of infections March 2009 the incidence of gastrointestinal infections had
for the first 5-year period (March 2001 to December 2006) was returned to zero, where it stayed for the remainder of the year
1995, and the rate of infection calculated over the 5 years was across all facilities. Similarly, respiratory infection rates
3.13 per 1000 occupied-bed days (95% CI, 3.0–3.3). The returned to previous levels immediately subsequent to the
overall yearly infection rate decreased over the first 3 years of October outbreak.
the study, from 4.9/1000 occupied-bed days in 2001 to the Seasonality was assessed for all infections combined as
well as each infection type separately. Significant monthly
Table 1. Overall number of infections and infection rates with 95% seasonality was detected using spectral analysis for all
CIs, March 2001–December 2009 infections as well as respiratory, gastrointestinal and UTIs
Year Occupied n (%) Rate (per 1000 occupied-bed days)
(P < 0.001). Sensitivity analysis was conducted using the
bed days Rate 95% CI 95% CI identifiable seasonality test, which only confirmed seasonality
lower upper for all infections and possible trends for respiratory and UTIs
based on the Stable Seasonality F-test (P < 0.001). Fig. 4
2001 110 946 548 (27.5) 4.9 4.5 5.4
2002 129 989 368 (18.4) 2.8 2.6 3.1
presents respiratory infection rates by month for all facilities
2003 142 050 337 (16.9) 2.4 2.1 2.6 combined for the period 2001–2009. A seasonal exponential
2004 135 446 449 (22.5) 3.3 3.0 3.6 smoothing time series forecasting model was fitted to the data
2005 119 468 293 (14.7) 2.5 2.2 2.8 (shown as ‘predicted’), illustrating a clear seasonal trend
2006 111 032 328 (20.6) 3.0 2.6 3.3 validated by the spectral analysis (Bartlett’s Kolmogorov–
2007 126 783 366 (23.0) 2.9 2.6 3.2 Smirnov statistic, P < 0.001). The forecast of infections
2008 126 587 379 (23.8) 3.0 2.7 3.3
displays a projected stabilising of the rate. The majority of
2009 125 351 520 (32.6) 4.2 3.8 4.5
respiratory infections occurred during the months of May to
Infection-control surveillance program in residential aged-care facilities Healthcare Infection 111

10

8
No. Infections per 1000 bed days

5
UCL

3 U = 3.2

2
LCL
1

0
Year
2001 2002 2003 2004 2005 2006 2007 2008 2009
Month
3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12

Subgroup sizes: Min n = 8.516 Max n = 12.249

Fig. 1. Control chart displaying overall rate of infection, March 2001–December 2009.

4
No. Infections per 1000 bed days

UCL

U = .1
0
LCL
Year
2001 2002 2003 2004 2005 2006 2007 2008 2009
Month
3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 1112 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12

Subgroup sizes: Min n = 8.516 Max n = 12.249

Fig. 2. Control chart displaying rate of gastrointestinal infections, March 2001–December 2009.

September, peaking in July. This trend was more evident in the reported over the period. This trend was similar for each
March 2001 to December 2006 period. facility. For EENT, infection rates were either stabilising or
From 2001 to 2009, the most frequently occurring decreasing for all but one of the facilities. Respiratory
infections overall were respiratory (n = 1433) followed by infections were increasing over time for all facilities. Rates of
wound/skin (874) and UTIs (856). There were 276 EENT UTI were relatively stable for all facilities up until 2008; in
infections, 135 gastrointestinal and 14 systemic infections 2009, these rates increased for three of the facilities. Finally,
112 Healthcare Infection J. Forrest et al.

4
No. Infections per 1000 bed days

UCL
2

U = 1.3
1

LCL
0
Year
2001 2002 2003 2004 2005 2006 2007 2008 2009
Month
3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 1011 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 1112 1 2 3 4 5 6 7 8 9 10 11 12

Subgroup sizes: Min n = 8.516 Max n = 12.249

Fig. 3. Control chart displaying rate of respiratory infections, March 2001–December 2009.

Forecasts for ratio

4
#Infections per 1000 bed days

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Year/Month
Actual Predicted 95% Confidence band Start of multi–step forecasts

Fig. 4. Respiratory infection rates by month for all facilities combined, with seasonal exponential
smoothing model, 2001–2009.

wound/skin infection rates were relatively stable apart from a this threshold. However, two facilities exceed the threshold:
slight increase in 2009 for all but one of the facilities. 4.8/1000 occupied-bed days (95% CI: 4.4–5.3) and 4.3/1000
Figure 5 illustrates the range of rates of infection between occupied-bed days (95% CI: 4.0–4.7).
the five facilities. The dotted horizontal line represents the
overall infection rate for all centres combined for all years
(3.2/1000 occupied-bed days), with the lines either side Discussion
showing the lower and upper 95% confidence limits around This comprehensive, long-term audit of infection surveillance
this rate (3.1–3.3). Clearly, three of the facilities have in these aged-care facilities was the first of its kind to be
comparable rates (2.6–3.1/1000 occupied-bed days) below conducted in Australia. Having established a baseline rate of
Infection-control surveillance program in residential aged-care facilities
Infection rate per 1000 bed days
5
(+95% Confidence limit)
4
0
*Some centres do not have data for all years
Facility 1
Fig. 5. Overall rate of infection, by facility, with 95% upper confidence limit (March 2001–December
2009).
infection (3.1/1000 occupied-bed days) across its high-care
residential facilities, the Columbia Group’s focus has been
to apply this information in the clinical environment: any
recorded rate of infection that exceeded the lower 95%
confidence interval beneath the baseline rate would prompt
investigation and immediate action to prevent the spread of
further infections.
The baseline rate of infection determined in the course of
this study could be applied in a similar way to other Australian
high-care residential settings. However, the characteristics
of the residents – for example, stratification of low- and
high-care residents in other centres, or the involvement of
residents from a dementia-specific unit – need to be considered
if the baseline is to be confirmed as applicable. In these
areas, residents’ acuity can differ substantially from high-care
residents.
The confirmation of a seasonal trend in infections also
allows for the targeting of these ‘high-risk months’ through
better infection control practice, including: hand-hygiene
compliance and device-related care; vaccination for both
residents and staff (particularly influenza vaccination, in light
of the upward trend noted for respiratory infections across all
facilities); and a general heightened awareness facilitating the
ongoing refinement and improvement of procedures.
The significantly higher rate of infection recorded at two
of the five facilities (Fig. 5) required further investigation.
Possible factors that could have explained the difference in
rates include: socio-demographic and disease status of
residents; staffing levels (although it should be noted that
Columbia maintains a standard staff : resident ratio at each
facility) and training; the prevalence of dementia; and the
proportion and manner in which the beds in each facility are
divided between single-bed rooms versus multiple-bed wards.
Future plans of risk mitigation should incorporate a detailed
list of these potential risk factors that could be collected and
monitored to ensure that these two facilities will be able to
Healthcare Infection 113
Facility 2 Facility 3 Facility 4 Facility 5
achieve the same level of improvements observed at the other
facilities.
While the outbreaks noted in 2004 and 2009 were
significant, they also demonstrated the value of surveillance in
that strategies were acted upon immediately to reduce further
infections.
The gastrointestinal spike in 2004 was a direct reflection of
a state-wide outbreak; 58 outbreaks of gastroenteritis occurred
in institutional settings in NSW in May 2004, affecting more
than 1200 people. Of these outbreaks, 76% were reported
in aged-care facilities.14 While the outbreak during that
month at Facility 5 was followed by similar events at two
other facilities, the success in returning infections to zero in
the months immediately following outbreaks suggests that
intervention was efficient and effective; surveillance delivered
a swift response. Similar success was achieved with the
isolated gastrointestinal and respiratory outbreaks of 2009.
There are several barriers that commonly prevent the
effective implementation of surveillance systems in
residential-care facilities in Australia.2 This report presents
a model for a surveillance system aimed at the identification
of infections and early recognition of infectious disease
outbreaks. Further discussions should consider the application
of this approach on a national basis, especially in light of the
absence of a uniform systematic surveillance system in any
Australian state or territory.
While this is the case, part of the study’s strength lies in its
rigid adherence to the recommended definitions compiled by
McGeer et al. in 1991. Although these definitions are widely
accepted, they occasionally lack specificity, do not allow for
risk stratification, have not been rigorously validated, have not
been updated in almost two decades and were developed in
the USA. It is clear that these definitions need to be reviewed
and validated in the contemporary Australian context, as
outlined for the Australian Commission on Safety and Quality
in Health Care (2008).2
114 Healthcare Infection
Moreover, in moving beyond the scope of this study, the
goal must become the prevention of infections before
they occur, through the monitoring of infection prevention
processes rather than the collection of data after the fact.
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Manuscript received 24 March 2011, accepted 21 July 2011