Title: Care Home Evidence-based Interventions to Reduce Infection that are Sustainable and Holistic (CHERISH)
Funder: Department of Health and Social Care

Abstract: Research question: Can a care home research network and data platform enable implementation of effective interventions to reduce/prevent infection in care homes, and address evidence-gaps by facilitating the development and evaluation of new interventions?Background: Our ageing population has led to a focus on prevention to reduce the need for adult social care and support. Many infections could be prevented by implementing existing interventions e.g. vaccination and/or by generating new evidence where none currently exists. Aim: To transform the current reactive model for managing infection in care homes to a proactive, evidence-based approach, which facilitates effective public health intervention and quality improvement; and to demonstrate my approach by delivering exemplar studies on two leading causes of infection: influenza and urinary tract infection (UTI). Methods: The study builds on partnerships with providers and linked data infrastructure established through my VIVALDI (COVID-19 in care homes study) in >300 care homes. Objective 1: Development of a set of 'social care infection indicators' to capture the impact of infection and outbreaks in care homes from multiple perspectives (residents, families, staff, NHS, providers, purchasers). This will include a systematic review of care home surveillance approaches, qualitative interviews with stakeholders and coproduction. Indicators will be used as the basis for infection dashboards for providers and for intervention evaluation in all subsequent studies. Objective 2: Feasibility study to gain insight into whether a rapid diagnostic test for influenza can increase the proportion of influenza cases (residents) who receive antivirals within 48 hours (primary outcome). The intervention will be coproduced with stakeholders and the study will run in 10 care homes. We will undertake a mixed methods process evaluation (focus groups, semi-structured interviews with staff, longitudinal survey).Objective 3: Development and evaluation of interventions to reduce (antibiotic-resistant) UTI. I will link the VIVALDI dataset to national microbiology and prescribing datasets and use it to estimate rates of UTI and UTI-related (gram-negative) bloodstream infections in residents. This will inform the design of my cluster randomised trial of a hydration intervention to prevent UTI in residents, in partnership with NHS England. The primary outcome and evaluation design will be coproduced with stakeholders, informed by the social care infection indicators (Objective 1), and include a health economic analysis and mixed methods process evaluation. Timelines for delivery: Infection indicators in Years 1-2 and deployed the following year. Influenza and UTI studies in Years 2-5. By Year 5, I aim to have obtained further funding to evaluate the influenza intervention, and will partner with NHSE to implement the UTI intervention, if successful, nationally. Dissemination: Knowledge exchange events, conference presentations, journal articles, and infographics. Findings will be shared with policymakers e.g. UKHSA and NHSE. Impact: Infection indicators will support providers and policymakers to monitor infection, and enable targeted public health and quality improvement interventions, improving residents' health and wellbeing. The influenza study will support improved practice in relation to antivirals and influenza testing, reducing outbreaks. Reductions in UTI will benefit residents (wellbeing and health) and the NHS (fewer avoidable admissions and consultations).

Lay abstract: THE PROBLEM In England, around 410,000 people live in 11,000 care homes for older adults. By 2041, there will be 3.2 million people over the age of 85. Our need for high-quality adult social care will keep increasing. Care home residents are prone to all sorts of infections like flu, COVID-19, and urine infections. Infections and outbreaks affect residents and staff members' health and wellbeing, potentially leading to hospital admissions, prolonged illness, and in some cases death. Family members are not able to visit during outbreaks, so residents can become isolated leading to further decline. We are aware that many infections could be prevented by wearing masks, vaccination, hydration, hand-washing, and isolating infected people. However, most of these approaches have only been tested in hospitals. Care homes are very different, and what works in a hospital may not work in a care home. Many of these approaches interfere with residents' daily life and do not promote individualised, person-centred care. This should be considered when deciding which approach to use. Since May 2020, we have worked with care homes to produce research on COVID-19. Together, we have recently started thinking about what we could learn from the pandemic to reduce all types of infection in care homes. THE SOLUTION Some may say it's simple - vaccinate everyone. We know from the COVID-19 vaccination programme that not everyone can or wants to be vaccinated and vaccines do not offer 100% prevention for all types of infection. Our plan is to create a network of care-homes that are interested in research and to collect data that can be shared with other care-homes and researchers. The network and data will make it quicker, easier and cheaper to set-up research studies in care homes investigating different types of infections. We will start by studying two major causes of illness - flu and urine infections. Study 1: Measuring the impact of infection on care-home residents. Care-homes collect lots of data, but there is not much information about infections. Before we can start, we need to go back to basics. For instance, how can we measure how many infections there are in care-homes? How do infections affect residents and care homes? We will consider how infections affect residents' overall health and well-being, costs of care and delivery of care. Study 2: Flu in care-homes. Antiviral drugs can be used to prevent flu spreading between care-home residents. However, without a fast way of identifying who has flu their usefulness is often limited. Rapid flu tests might help, but they aren't widely used in care-homes. We will use rapid flu tests in 10 care-homes to see if they improve the use of antiviral drugs and reduce the spread of flu. If the rapid test looks promising, we will apply for funding to test it in a larger study.Study 3: Preventing urine infections Urine infections are very common in care-home residents. We know that improving residents' fluid-intake can help to prevent urine infections, but we don't know the best way to do this. With NHS England's help, we will identify a promising intervention to improve residents' fluid intake and test it in a care home study. If the intervention works, we will make it available to all care homes in England. We will involve residents, families and staff at all stages of the research. They will help us decide which data to collect, how to use it, and help us to improve the design of our studies. They will also help us to understand our research findings, share them and put them into practice.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING;4.2 EVALUATION OF MARKERS AND TECHNOLOGIES
Health categories: INFECTION