Changes in US Nursing Home Infection Prevention and Control Programs From 2014 to 2018

Rethinking Infection Control: Nursing Home Administrator Experiences during the COVID-19 Pandemic

OBJECTIVE

To examine nursing home administrator perspectives of infection control practices in nursing homes at the height of the COVID-19 pandemic and characterize lessons learned.

DESIGN

Descriptive qualitative study.

SETTING AND PARTICIPANTS

Administrators from 40 nursing homes across 8 diverse health care markets in the United States.

METHODS

Semistructured interviews were conducted via telephone or Zoom with nursing home administrators. Interviews were repeated at 3-month intervals, for a total of 4 interviews per participant between July 2020 and December 2021 (n = 156). Qualitative analysis of interview transcripts used modified grounded theory and thematic analysis to identify overarching themes.

RESULTS

Three major themes emerged reflecting administrator experiences managing infection control practices and nursing home operations at the height of the COVID-19 pandemic. First, administrators reported that the more stringent infection control protocols implemented to manage and mitigate COVID-19 at their facilities increased awareness and understanding of the importance of infection control; second, administrators reported incorporating higher standards of infection control practices into facility-level policies, emergency preparedness plans, and staff training; and third, administrators said they and their executive leadership were reevaluating and upgrading their facilities' physical structures and operational processes for better infection control infrastructure in preparation for future pandemics or other public health crises.

CONCLUSIONS AND IMPLICATIONS

Insights from this study's findings suggest important next steps for restructuring and improving nursing home infection control protocols and practices in preparation for future pandemics and public health emergencies. Nursing homes need comprehensive, standardized infection control training and upgrading of physical structures to improve ventilation and facilitate isolation practices when needed. Furthermore, nursing home emergency preparedness plans need better integration with local, state, and federal agencies to ensure effective communication, proper resource tracking and allocation, and coordinated, rapid response during future public health crises.

Long-Term Care and the COVID-19 Pandemic: Lessons Learned

US nursing homes and other long-term care (LTC) communities such as assisted living and adult day care services have been disproportionally affected by COVID-19. Nurses and health care workers provided care and services despite health concerns for themselves and family members. Nurses on the frontline were called to act with extraordinary tenacity, skill, flexibility, and creativity to prevent infection; prevent complications; and optimize function, health, and well-being. The purpose of this article is to provide an overview of the challenges posed by the COVID-19 pandemic and the strategies prioritized and implemented by nurse and interdisciplinary colleagues in LTC settings.

Reimagining Infection Control in U.S. Nursing Homes in the Era of COVID-19

Residents of nursing homes (NHs) are susceptible to infection, and these facilities, particularly those that provide post-acute care services, are high-risk settings for the rapid spread of communicable respiratory and gastrointestinal illnesses, as well as antibiotic-resistant bacteria. The complexity of medical care delivered in most NHs has increased dramatically over the past 2 decades; however, the structure and resources supporting the practice of infection prevention and control in these facilities has failed to keep pace. Rising numbers of infections caused by Clostridioides difficile and multidrug-resistant organisms, as well as the catastrophic effects of COVID-19 have pushed NH infection control resources to a breaking point. Recent changes to federal regulations require NHs to devote greater resources to the facility infection control program. However, additional changes are needed if sustained improvements in the prevention and control of infections and antibiotic resistance in NHs are to be achieved.

Urinary catheter policies in home healthcare agencies and hospital transfers due to urinary tract infection

BACKGROUND

Urinary tract infections (UTIs) are a frequent cause of hospital transfer for home healthcare (HHC) patients, particularly among patients with urinary catheters.

METHODS

We conducted a cross-sectional, nationally representative HHC agency-level survey (2018-2019) and combined it with patient-level data from the Outcome and Assessment Information Set (OASIS) and Medicare inpatient data (2016-2018) to evaluate the association between HHC agencies' urinary catheter policies and hospital transfers due to UTI. Our sample included 28,205 patients with urinary catheters who received HHC from 473 Medicare-certified agencies between 2016-2018. Our survey assessed whether agencies had written policies in place for (1) replacement of indwelling catheters at fixed intervals, and (2) emptying the drainage bag. We used adjusted logistic regression to estimate the association of these policies with probability of hospital transfer due to UTI during a 60-day HHC episode.

RESULTS

Probability of hospital transfer due to UTI during a HHC episode ranged from 5.62% among agencies with neither urinary catheter policy to 4.43% among agencies with both policies. Relative to agencies with neither policy, having both policies was associated with 21% lower probability of hospital transfer due to UTI (P < .05).

CONCLUSION

Our findings suggest implementation of policies in HHC to promote best practices for care of patients with urinary catheters may be an effective strategy to prevent hospital transfers due to UTI.

Nursing Staff's Role in Detecting Urinary Tract Infections in Nursing Homes: An Integrative Review

Despite evidence-based protocols, inappropriate antibiotic use still presents a systemic global threat to health care in nursing homes (NHs). Nursing staff are responsible for recognizing signs and symptoms that may indicate urinary tract infections (UTIs). The current integrative review was designed to examine the state of the literature related to the role of nursing staff in UTI identification and care in NHs. This review, which includes 19 articles published between 2011 and 2020, identified that, although prescribers are the experts in UTI management, nursing staff in NHs were the individuals who recognized changes and communicated residents' needs to prescribers. Further research is required to understand nursing staff's decision making and unique perspectives and determine if evidence-based protocols align with current practice in the NH setting. [Journal of Gerontological Nursing, 48(5), 43-50.].

Southeastern United States Predictors of COVID-19 in Nursing Homes

This study’s aim was to determine nursing home (NH) and county-level predictors of COVID-19 outbreaks in nursing homes (NHs) in the southeastern region of the United States across three time periods. NH-level data compiled from census data and from NH compare and NH COVID-19 infection datasets provided by the Center for Medicare and Medicaid Services cover 2951 NHs located in 836 counties in nine states. A generalized linear mixed-effect model with a random effect was applied to significant factors identified in the final stepwise regression. County-level COVID-19 estimates and NHs with more certified beds were predictors of COVID-19 outbreaks in NHs across all time periods. Predictors of NH cases varied across the time periods with fewer community and NH variables predicting COVID-19 in NH during the late period. Future research should investigate predictors of COVID-19 in NH in other regions of the US from the early periods through March 2021.

Remote Infection Control Assessments of U.S. Nursing Homes During the COVID-19 Pandemic, April to June 2020

Background

Nursing homes (NHs) provide care in a congregate setting for residents at high risk of severe outcomes from SARS-CoV-2 infection. In spring 2020, NHs were implementing new guidance to minimize SARS-CoV-2 spread among residents and staff.

Objective

To assess whether telephone and video-based infection control assessment and response (TeleICAR) strategies could efficiently assess NH preparedness and help resolve gaps.

Design

We incorporated Centers for Disease Control and Prevention COVID-19 guidance for NH into an assessment tool covering 6 domains: visitor restrictions; health care personnel COVID-19 training; resident education, monitoring, screening, and cohorting; personal protective equipment supply; core infection prevention and control (IPC); and communication to public health. We performed TeleICAR consultations on behalf of health departments. Adherence to each element was documented and recommendations provided to the facility.

Setting and Participants

Health department–referred NHs that agreed to TeleICAR consultation.

Methods

We assessed overall numbers and proportions of NH that had not implemented each infection control element (gap) and proportion of NH that reported making ≥1 change in practice following the assessment.

Results

During April 13 to June 12, 2020, we completed TeleICAR consultations in 629 NHs across 19 states. Overall, 524 (83%) had ≥1 implementation gap identified; the median number of gaps was 2 (interquartile range: 1-4). The domains with the greatest number of facilities with gaps were core IPC practices (428/625; 68%) and COVID-19 education, monitoring, screening, and cohorting of residents (291/620; 47%).

Conclusions and Implications

TeleICAR was an alternative to onsite infection control assessments that enabled public health to efficiently reach NHs across the United States early in the COVID-19 pandemic. Assessments identified widespread gaps in core IPC practices that put residents and staff at risk of infection. TeleICAR is an important strategy that leverages infection control expertise and can be useful in future efforts to improve NH IPC.

Nursing Home Antibiotic Stewardship Policy and Antibiotics Use: 2013-2017

OBJECTIVES

Reducing inappropriate nursing home (NH) antibiotic usage by implementing stewardship programs is a national priority. Our aim is to evaluate the influence of antibiotic stewardship programs on antibiotic use rates in NHs over time.

DESIGN

Retrospective, repeated cross-sectional analysis.

SETTING AND PARTICIPANTS

Long-term residents not receiving hospice care in freestanding NHs that participated in 1 or both surveys in 2013 and 2017.

METHODS

Survey data were merged with the Minimum Data Set and the Certification and Survey Provider Enhanced Reporting data. Our outcome was a binary indicator for antibiotic use. The main predictor was the NH antibiotic stewardship policy intensity. Using multivariate linear regression models adjusting for resident and facility characteristics that differed between the 2 years, we calculated antibiotic use rates in 2013 and 2017 for all residents, those with Alzheimer's disease, and those with any infection including urinary tract infections (UTIs).

RESULTS

Our sample included 317,003 resident assessments from 2013 and 267,537 assessments from 2017, residing in 953 and 872 NHs, respectively. NH antibiotic stewardship policy intensity increased from 2013 to 2017 (P < .01) and among all NH residents, including those with Alzheimer's disease, antibiotic use rate decreased (P < .05), with 45% of the decline attributable to strengthening stewardship programs. For most residents, policy intensity was associated with decreased usage in residents with UTI. However, among Alzheimer's disease residents with a UTI, this association did not persist.

CONCLUSIONS AND IMPLICATIONS

Although there was a decrease in antibiotic use in 2017, more time is needed to see the full impact of antibiotic stewardship policy into practice. Adjustments to programs that directly address barriers to implementation and appropriate UTI antibiotic use for residents with Alzheimer's disease are necessary to continue strengthening NH antibiotic stewardship and improve care.

Overdiagnosis of urinary tract infections by nursing home clinicians versus a clinical guideline

PURPOSE

To inform overprescribing and antibiotic stewardship in nursing homes (NHs), we examined the concordance between clinicians' (NH primary care providers and registered nurses) diagnosis of suspected UTI with a clinical guideline treated as the gold standard, and whether clinician characteristics were associated with diagnostic classification.

METHODS

We conducted a cross-sectional web-based survey of a U.S. national convenience sample of NH clinicians. The survey included a discrete choice experiment with 19 randomly selected clinical scenarios of NH residents with possible UTIs. For each scenario, participants were asked if they thought a UTI was likely. Responses were compared to the guideline to determine the sensitivity and specificity of clinician judgment and performance indicators. Multivariable logistic mixed effects regression analysis of demographic, work, personality, and UTI knowledge/attitudes characteristics was conducted.

RESULTS

One thousand seven hundred forty-eight NH clinicians responded to 33,212 discrete choice scenarios; 867 (50%) were NH primary care providers and 881 (50%) were NH registered nurses, 39% were male, and the mean age was 45 years. Participants were uncertain about diagnosis in 30% of scenarios. Correct classification occurred for 66% of all scenarios (providers: 70%; nurses: 62%). Respondent judgment had a sensitivity of 78% (providers: 81%; nurses: 74%) and specificity of 54% (providers: 59%; nurses: 49%) compared to the clinical guideline. Adjusting for covariates in multivariable models, being a nurse and having higher closemindedness were associated higher odds of false positive UTI (odds ratio [OR] 1.61, p < 0.001; and OR 1.09, p = 0.039, respectively), although higher UTI knowledge and conscientiousness were associated with lower odds of false positive UTI ratings (OR 0.80, p < 0.001; OR 0.90, p = 0.005, respectively).

CONCLUSIONS

Clinicians tend to over-diagnose urinary tract infections, necessitating systems-based interventions to augment clinical decision-making. Clinician type, UTI knowledge, and personality traits may also influence behavior and deserve further study.

Infection prevention and control in nursing homes during COVID-19: An environmental scan

To examine processes and programmatic elements of infection prevention and control (IPC) efforts and identify themes and promising approaches in nursing homes (NHs), an environmental scan was conducted. Data sources included a literature search, relevant listservs and websites, and expert consensus based on a virtual summit of leaders in IPC in long-term care settings. Three thematic areas emerged which have the potential to improve overall IPC practices in the long-term care setting: staffing and resource availability, training and knowledge of IPC practices, and organizational culture. If improved IPC practices and reduced cross-transmission of infections in NHs are to be sustained, both short-term and long-term changes in these areas are essential to fully engage staff, build trust, and enhance a 'just' organizational culture.

Infection preventionists' experiences during the first nine months of the COVID-19 pandemic: Findings from focus groups conducted with Association of Professionals in Infection Control & Epidemiology (APIC) members

INTRODUCTION

A novel human Coronavirus (SARS CoV-2) was identified in January, 2020 and developed into a pandemic by March, 2020. This rapid, enormous, and unanticipated event had major implications for healthcare. Infection preventionists (IP) have a critical role in worker and patient safety. IPs' lessons learned can guide future pandemic response.

METHODS

Seven focus groups were conducted with APIC members in September and October, 2020 via Zoom to elicit IPs' experiences during the COVID-19 pandemic. Sessions were recorded then transcribed verbatim. Major themes were identified through content analysis.

RESULTS

In total, 73 IPs participated (average of 10 IPs per focus group) and represented all geographical areas and work settings. Participating IPs described multiple challenges they have faced during the COVID-19 pandemic, including rapidly changing and conflicting guidance, a lack of infection prevention recommendations for nonacute care settings, insufficient personal protective equipment, healthcare personnel complacency with personal protective equipment and infection prevention protocols, and increases in healthcare associated infections and workload.

CONCLUSIONS

The identified gaps in pandemic response need to be addressed in order to minimize healthcare associated infections and occupational illness. In addition, the educational topics identified by the participating IPs should be developed into new educational programs and resources.

The Trial to Reduce Antimicrobial Use in Nursing Home Residents With Alzheimer Disease and Other Dementias (TRAIN-AD): A Cluster Randomized Clinical Trial

IMPORTANCE

Antimicrobials are extensively prescribed to nursing home residents with advanced dementia, often without evidence of infection or consideration of the goals of care.

OBJECTIVE

To test the effectiveness of a multicomponent intervention to improve the management of suspected urinary tract infections (UTIs) and lower respiratory infections (LRIs) for nursing home residents with advanced dementia.

DESIGN, SETTING, AND PARTICIPANTS

A cluster randomized clinical trial of 28 Boston-area nursing homes (14 per arm) and 426 residents with advanced dementia (intervention arm, 199 residents; control arm, 227 residents) was conducted from August 1, 2017, to April 30, 2020.

INTERVENTIONS

The intervention content integrated best practices from infectious diseases and palliative care for management of suspected UTIs and LRIs in residents with advanced dementia. Components targeting nursing home practitioners (physicians, physician assistants, nurse practitioners, and nurses) included an in-person seminar, an online course, management algorithms (posters, pocket cards), communication tips (pocket cards), and feedback reports on prescribing of antimicrobials. The residents' health care proxies received a booklet about infections in advanced dementia. Nursing homes in the control arm continued routine care.

MAIN OUTCOMES AND MEASURES

The primary outcome was antimicrobial treatment courses for suspected UTIs or LRIs per person-year. Outcomes were measured for as many as 12 months. Secondary outcomes were antimicrobial courses for suspected UTIs and LRIs when minimal criteria for treatment were absent per person-year and burdensome procedures used to manage these episodes (bladder catherization, chest radiography, venous blood sampling, or hospital transfer) per person-year.

RESULTS

The intervention arm had 199 residents (mean [SD] age, 87.7 [8.0] years; 163 [81.9%] women; 36 [18.1%] men), of which 163 (81.9%) were White and 27 (13.6%) were Black. The control arm had 227 residents (mean [SD] age, 85.3 [8.6] years; 190 [83.7%] women; 37 [16.3%] men), of which 200 (88.1%) were White and 22 (9.7%) were Black. There was a 33% (nonsignificant) reduction in antimicrobial treatment courses for suspected UTIs or LRIs per person-year in the intervention vs control arm (adjusted marginal rate difference, -0.27 [95% CI, -0.71 to 0.17]). This reduction was primarily attributable to reduced antimicrobial use for LRIs. The following secondary outcomes did not differ significantly between arms: antimicrobials initiated when minimal criteria were absent, bladder catheterizations, venous blood sampling, and hospital transfers. Chest radiography use was significantly lower in the intervention arm (adjusted marginal rate difference, -0.56 [95% CI, -1.10 to -0.03]). In-person or online training was completed by 88% of the targeted nursing home practitioners.

CONCLUSIONS AND RELEVANCE

This cluster randomized clinical trial found that despite high adherence to the training, a multicomponent intervention promoting goal-directed care for suspected UTIs and LRIs did not significantly reduce antimicrobial use among nursing home residents with advanced dementia.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03244917.

Rectal Colonization by Drug Resistant Bacteria in Nursing Home Residents in Crete, Greece

(1) Background: In an area with a high prevalence of multi-drug resistant Gram-negative bacteria (MDR-GNB), we investigated the colonization of nursing home residents by such organisms. (2) Methods: A point prevalence study was performed in six nursing homes of the Heraklion area on the island of Crete. A rectal swab was taken and cultured from each participant, while additional risk factors such as recent hospitalization or antimicrobial usage were recorded and evaluated. (3) Results: A total of 137 nursing home residents were included in the study. Their mean age was 82.1 years and 19.7% were males. In total, cultures yielded 255 GNB; E. coli, K. pneumoniae and P. aeruginosa were the most common. Among the microorganisms cultured, 17.6% had the extended-spectrum beta-lactamase phenotype, while 18% were MDR. A statistically significant association was found between recent antimicrobial use and colonization by MDR-GNB; (4) Conclusions: Colonization by MDR-GNB was found to be highly prevalent in nursing home residents. Recent antimicrobial use was associated with MDR-GNB carriage.

Facilitators and challenges experienced by nursing homes enrolling in the CDC national health care safety network

BACKGROUND

Standardized measurement of health care-associated infections is essential to improving nursing home (NH) resident safety, however voluntary enrollment of NHs in Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) requires several steps. We sought to prospectively identify NH structural, process or staff characteristics that affect enrollment and data submission among a cohort of NHs receiving facilitated implementation.

METHODS

The evaluation employed a mixed methods approach. The meta-theoretical Consolidated Framework for Implementation Research was used to analyze reported facilitators and challenges. Primary and secondary outcomes were time to NHSN enrollment and data submission, respectively.

RESULTS

Of 36 participating NHs, 27 (75%) completed NHSN enrollment and 21 (58%) submitted 1 or more months of infection data during the 8-month study period. Mean days to complete enrollment was 82 (standard deviation [SD] = 24, range = 51-139) and days to first data submission was 112 (SD = 45, range = 71-245). Characteristics of NH staff liaisons associated with shorter time to enrollment included infection prevention and control knowledge, personal confidence, and responsibility for infection prevention and control activities. Facility characteristics were not associated with outcomes.

DISCUSSION

Time to NHSN enrollment and submission related more to characteristics of the person leading the process than to characteristics of the NH.

CONCLUSIONS

External partnerships that provide real-time support and resources are important assets in promoting successful NH participation in NHSN.

Does Integration of Palliative Care and Infection Management Reduce Hospital Transfers among Nursing Home Residents?

Background: An estimated 50% of nursing home (NH) residents experience hospital transfers in their last year of life, often due to infections. Hospital transfers due to infection are often of little clinical benefit to residents with advanced illness, for whom aggressive treatments are often ineffective and inconsistent with goals of care. Integration of palliative care and infection management (i.e., merging the goals of palliative care and infection management at end of life) may reduce hospital transfers for residents with advanced illness. Objectives: Evaluate the association between integration and (1) all-cause hospital transfers and (2) hospital transfers due to infection. Design: Cross-sectional observational study. Setting/Subjects: 143,223 U.S. NH residents, including 42,761 residents in the advanced stages of dementia, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). Measurement: Cross-sectional, nationally representative NH survey data (2017-2018) were combined with resident data from the Minimum Data Set 3.0 and Medicare inpatient data (2016-2017). NH surveys measured integration of palliative care and infection management using an index of 0-100. Logistic regression models were used to estimate the relationships between integration intensity (i.e., the degree to which NHs follow best practices for integration) and all-cause hospital transfer and transfer due to infection. Results: Among residents with advanced dementia, integration intensity was inversely associated with all-cause hospital transfer and transfer due to infection (p < 0.001). Among residents with advanced COPD, integration intensity was inversely associated with all-cause hospital transfer (p < 0.05) but not transfers due to infection. Among residents with advanced CHF, integration intensity was not associated with either outcome. Conclusions: NH policies aimed to promote integration of palliative care and infection management may reduce burdensome hospital transfers for residents with advanced dementia. For residents with advanced CHF and COPD, alternative strategies may be needed to promote best practices for infection management at end of life.

Infection Control Citations in Nursing Homes: Compliance and Geographic Variability

Objectives

To report the initial compliance with new infection control regulations and geographic disparities in nursing homes (NHs) in the United States.

Design

Retrospective cohort study from November 27, 2017 to November 27, 2019.

Setting and Participants

In total, 14,894 NHs in the continental United States comprising 26,201 inspections and 176,841 deficiencies.

Methods

We measured the cumulative incidence of receiving F880: Infection Prevention and Control deficiencies, geographic variability of F880 citations across the United States, and the scope and severity of the infection control deficiencies.

Results

A total of 6164 NHs (41%) in the continental United States received 1 deficiency for F880, and 2300 NHs (15%) were cited more than once during the 2-year period. Geographic variation was evident for F880 deficiencies, ranging from 20% of NHs in North Carolina to 79% of NHs in West Virginia. Between 0% (Vermont) and 33% (Michigan) of states’ NHs were cited multiple times over 2 years. Facilities receiving 2 or more F880 deficiencies were more reliant on Medicaid, for-profit, and served more acute residents. Infection Prevention and Control deficiencies were of similar severity but of greater scope in NHs that were cited multiple times.

Conclusions and Implications

As the coronavirus disease 2019 pandemic challenges hospitals with an increased surge of patients from the community, NHs will be asked to accept convalescing patients who were previously infected with the virus. NHs will need to rely on infection control practices to mitigate the effects of the virus in their facilities. Particular attention to NHs that have fared poorly with repeat infection control practices deficiencies might be a good first step to improving care overall and preventing downstream morbidity and mortality among the highest-risk patients.

Factors Associated With Antimicrobial Use in Nursing Home Residents With Advanced Dementia

OBJECTIVES

Widespread antimicrobial misuse among nursing home (NH) residents with advanced dementia raises concerns regarding the emergence of multidrug-resistant organisms and avoidable treatment burden in this vulnerable population. The objective of this report was to identify facility and resident level characteristics associated with receipt of antimicrobials in this population.

DESIGN

Cross-sectional analysis of baseline data from the Trial to Reduce Antimicrobial use in Nursing home residents with Alzheimer's disease and other Dementias (TRAIN-AD).

SETTING AND PARTICIPANTS

Twenty-eight Boston area NHs, 430 long stay NH residents with advanced dementia.

MEASURES

The outcome was the proportion of residents who received any antimicrobials during the 2 months prior to the start of TRAIN-AD determined by chart review. Multivariable logistic regression was used to identify resident and facility characteristics associated with this outcome.

RESULTS

A total of 13.7% of NH residents with advanced dementia received antimicrobials in the 2 months prior to the start of TRAIN-AD. Residents in facilities with the following characteristics were significantly more likely to receive antimicrobials: having a full time nurse practitioner/physician assistant on staff [adjusted odds ratio (aOR) 3.02; 95% confidence interval (CI), 1.54, 5.94], fewer existing infectious disease practices (eg, antimicrobial stewardship programs, established algorithms for infection management) (aOR, 2.35; 95% CI 1.14, 4.84), and having fewer residents with severely cognitively impaired residents (aOR 1.96; 95% CI 1.12, 3.40). No resident characteristics were independently associated with receipt of antimicrobials.

CONCLUSIONS AND IMPLICATIONS

Facility-level characteristics are associated with the receipt of antimicrobials among residents with advanced dementia. Implementation of more intense infectious disease practices and targeting the prescribing practices of nurse practitioners/physician assistants may be critical targets for interventions aimed at reducing antimicrobial use in this population.

Root Cause Analysis to Identify Medication and Non-Medication Strategies to Prevent Infection-Related Hospitalizations from Australian Residential Aged Care Services

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 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.