Annual Infection Prevention & Control Report

2018 - 2019

Infection Prevention and Control CommitteeJuly 2019

Executive Summary 1 Surveillance and HCAI Reduction Targets 2 Surveillance of Infection within the Critical Care Unit 5

Caesarean Section Wound Infection Surveillance 6

Orthopaedic Wound Infection Surveillance 7

Tuberculosis (TB) Working Group 7 Outbreaks and increased incidents of infection 8 Improvement initiatives to reduce HCAI 9

Involving the Public / Patients and Users 10

Patient Experience Services 12

IPCT Improvement Plan 16

Antimicrobial Management 19

Electronic surveillance software systems 22

IPC Service Controls Assurance Accreditation 18 -19 23

Guidelines and Policies 23

IPCC Plans for 2019-2020 24

ContentsPage

Executive Summary This report has been produced by our Infection Prevention & Control Committee (IPCC). It provides an overview of the work streams outlined in the IPCC Annual Action plan 2018-2019 which is taken from themes within the Trust Infection Prevention and Control Strategy 2015-2018.

The membership of the IPCC represents Directorates across the acute and community settings of the Trust and the Corporate Directorates who support them. There is a strong commitment to preventing all avoidable healthcare-associated infection and this remains a high priority for the Trust.

This year, we did not meet the Department of Health/ Public Health Agency targets for MRSA blood stream infection. However the majority (67%), of cases were identified from patients attending the Emergency Department for treatment of their infection and therefore not attributable to their inpatient stay. Whilst the Clostridium difficile infection target was not met, none of the cases were judged to be attributed to transmission within our hospitals. This year, targets were introduced to reduce gram-negative blood stream infections and antimicrobial use and plans are being implemented to review trends and make improvements.

The IPCC members continue to work to commission the acute services ward block on the Ulster Hospital site in May 2020. There are also exciting plans to improve the environment for outpatients living with cancer. This will involve renovation of part of the elderly care building at the Ulster Hospital to create a purpose built unit. Work continues to advance construction of the new primary care centre on the Lagan Valley Hospital site.

I would like to express thanks to all who have contributed to this important work which is core to delivering high quality care and ensuring a safe and positive experience for all of those patients and carers who use our services.

Nicki PattersonDirector of Primary Care Older People & NursingLead Director for Infection Prevention & Control

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Surveillance and Healthcare-associated Infection (HCAI) reduction targets Meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia and Clostridium difficile infections (CDI).

The annual target set by the Northern Ireland Department of Health (DOH), for 2018-2019, was to have no more than five MRSA bloodstream infections in inpatients and 55 Clostridium difficile infections reported across the Trust acute care facilities.

In relation to MRSA bloodstream infection a total of 12 was reported. The majority, (67%) of cases were identified from patients attending the Emergency Department(s) for treatment of infection. A timely post-infection review was carried out for all MRSA bloodstream infections and these case reviews have helped identify and share learning and improve the management of patients with invasive devices in place as part of their care.

Figure 1: South Eastern HSC Trust’s MRSA Bloodstream Infections 1 April 2007- 31 March 2019

In relation to Clostridium difficile infection (CDI) the number reported was 66% over the target set. A review was undertaken of each case and none were linked to transmission within our healthcare facilities. Case reviews have provided assurance that there is a high level of compliance with the Trust’s first line empirical antibiotic prescribing guidelines and IPC related practice when managing patients in hospital who present with diarrhoea. There is more work planned for 2019-2022 in respect of reducing antimicrobial use which reflects the DoH plans to reduce antimicrobial consumption and tackle antimicrobial resistance.

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Figure 2: Clostridium difficile infections reported across the Trust from 2007 to the 31 March 2019.

Gram-negative bloodstream infectionsThe Department of Health (NI) aims to reduce healthcare-associated gram-negative bacteraemia by 50% by 2021. As of the 1st April 2018, all cases of E.coli. Pseudomonas aeruginosa and Klebsiella species (gram-negative bloodstream infections), were reported to Public Health Agency using a live electronic web system known as HI-Surv. This also included the collection of a data set of risk factor information for gram-negative bloodstream infections. The majority of these infections usually develop in the community, however with the development of resistant strains learning and understanding of such trends is important.

E. coli urinary tract infection is more common within community settings, work commenced this year with the PHA to scope the feasibility of introducing a urinary tract infection checklist (for the over 65 years) into our residential care facilities. This tool can help with the risk assessment diagnosis and management of older people presenting with symptoms of which a urinary infection maybe the cause. Further work has commenced to improve the care management of patients with long term urinary catheters.

Figure 3: Gram-negative bloodstream infections August 2018

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Glycopeptide-resistant enterococci (GRE)Enterococci are bacteria found in the faeces of most humans and many animals. More than a dozen species of Enterococcus are currently recognized, and of these, two species, E.faecalis and E.faecium, are the most important causes of enterococcal infections in humans.

Resistance to the glycopeptide group of antibiotics including vancomycin and teicoplanin is an emerging problem in some countries. The trend within the Trust is that most of clinical isolates of Enterococcus species, whether glycopeptide-susceptible or resistant, represent colonisation rather than infection, which is typically endogenous. This year a very small number, (<5) reported to the infection prevention and control team), contributed to bloodstream infection. All measures were taken to ensure that relevant infection prevention and control precautions were in place and the patients were treated appropriately.

Carbapenamase- producing enterobacteriaceae (CPE)Enterobacteriaceae refers to a group of bacteria which usually live harmlessly in the bowel, but can cause urinary tract infections or pneumonia. When such organisms develop this extreme resistance to antibiotics, infections caused by these bacteria are difficult to treat.

This year a very resistant strain Carbapenamase-producing enterobacteriaceae (CPE) was identified as part of routine screening of patients in accordance with National guidelines. A follow up exercise of patients being managed in the same area was undertaken and no transmission was identified. Work will continue with the Public Health Agency and other Trusts to keep this emerging resistance under close review. CPE have resulted in outbreaks of infection in the Republic of Ireland and other parts of the United Kingdom and this is a worrying trend.

Group A Beta-haemolytic Streptococcal infectionsThis bacterium can be found on the skin and throat without causing any problems. In some instances the bacteria can cause throat and mild to severe skin and soft tissue infection and scarlet fever.

Over the year around 30% of infections reported to the infection prevention and control team were treated as invasive infections. This has increased since the previous year of 7%. A small number namely 12% were isolated from throat swabs. All of the cases were considered to be community-acquired and there were no cases linked to transmission within the Trust hospitals. Public Health England has reported an exceptionally high trend of invasive group A beta-haemolytic streptococcal infections occurring in 2018-2019.

Surveillance of infection within the Critical Care Unit (CCU)The CCU contributes to a regional surveillance programme which was introduced in June 2011. This includes the monitoring of central venous catheter-associated blood stream infection, urinary catheter-associated blood stream infection and ventilator-associated pneumonia. The information is sent to the Public Health Agency for collation enabling the unit to benchmark against other centres in the province.

Trust CCU reported infections from April 2018 - March 2019 compared to the overall rate reported from other CCUs in Northern Ireland are outlined in Figure 4-9.

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Figure 4: N.I. Urinary catheter- associated

infections.

Figure 5: SET - CCU Urinary catheter-associated

infections.

Figure 4 (N.I. aggregate rate = 0.41%). Figure 5 Urinary catheter-associated infections = 0. There have been none reported since surveillance commenced in 2011.

Figure 6: Central line-associated bloodstream

infections CCUs N.I.

Figure 7: Central line-associated bloodstream

infections CCUs Ulster Hospital

Figure 7: Central venous catheter-related blood stream infections = 0.4% per 1000 central venous catheter days), (unit rolling average rate). Figure 6 shows the N.I. aggregate rate for the same period = 0.4%.

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Figure 8: Ventilator-associated pneumonia CCUs N.I.

Figure 9: Ventilator-associated pneumonia CCUs Ulster Hospital

Ventilator-associated pneumonia = 1.45%, rolling average rate per 1000 ventilator days. N.I. aggregate rate = 1.26%. (Rolling average is the mean of the previous month’s results (based on a 12-month cycle).

Caesarean Section Wound Infection SurveillanceFrom 1 January 2018 - 31 December 2018 the number of caesarean section wound infections occurring during inpatient stay and within the community post-discharge is detailed in Table 1. This compares infections occurring in the previous calendar year. Overall infection rates have risen slightly and on review there has been underlying complex risk factors which have contributed to this increase.

Table 1: C-section wound infection prevalence in 2017 and 2018 Trust and Northern Ireland (NI) average

An information leaflet has been produced for mothers to provide advice on how to manage a caesarean section wound.

The Trust has been scoping the feasibility of collecting the information electronically in conjunction with PHA. This would reduce the workload for clinical teams as the current method used for reporting infection is a paper form. This will be taken forward in 2019-20.

Calendar Year

Average Trust C-section

wound infection occurring during

inpatient stay

Average Trust Post-discharge

infection

Average C-section

wound infection occurring during

inpatient stay across Northern

Ireland

Average C-section post-

discharge infection across Northern Ireland

2017 0.2% 5.5% 0.2% 5.4%

2018 0.4% 6.0% 0.2% 6.0%

Orthopaedic Wound Infection SurveillanceWound infection rates following orthopaedic surgery remains low. In reviewing trends from previous years an increase was noted towards the end of 2015 into the first quarter of 2016 and at the beginning of 2017. Investigations were undertaken at the time and there were no links thought to be attributed to hospital transmission. From January 2018 - the last quarter of 2018 = 0.16%. Overall, this compares favourably with the NI average = 0.26%. Thanks to PHA colleagues for producing Figures 10 and 11 below.

Figure 10: Trust Quarterly Orthopaedic wound infection rates 2014 - 3rd Quarter 2018

Figure 11: Trust Annual orthopaedic infection rates 2014- 3rd quarter 2018

Tuberculosis (TB) Working Group The Trust continues to progress an annual plan of TB and Latent TB related work. The key work strands for TB across the Trust include:

a. TB case management

b. TB vaccination

c. Latent TB Screening of high /at risk groups in community

d. Latent TB screening in Northern Ireland Prisons.

TB vaccination and case management continued as set out by best practice and Trust policy.

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The Trust aims to appoint a band 7 Public Health - TB Prevention Nurse to implement and manage a clear patient management pathway for latent TB screening across the Trust’s community catchment area. Referrals from GPs and other agencies in the community for those at risk of Latent TB including immigrants and the homeless will be screened and treated as required for latent TB.

Follow up of TB cases identified and treated in 2018-19, and regionally has shown appropriate individualised management and this has facilitated a process of continuous improvement in practice.Resources were obtained to undertake a programme of Latent TB Screening within the Northern Ireland prison population from August to November 2018. A total of 104 people were screened of which 7% were identified and offered Latent TB treatment.

Outbreaks and increased incidents of infectionNorovirus (viral gastroenteritis)The Trust reported all increased incidents of infection (as is usual practice) to the PHA duty room over the year. The number of Trust facilities closed or partially closed due to norovirus/vomiting and diarrhoea outbreaks was greater than the previous year. Two incidents were caused by influenza. In over half of the outbreaks heightened infection control measures were put in place which successfully prevented complete closure of the facilities. The additional method introduced within the Ulster hospital laboratory to undertake rapid testing for Norovirus in addition to the new inpatient ward block with extra isolation facilities has helped with the management of these incidents.

Table 2: Outbreaks of vomiting and diarrhoea across Trust facilities from1 April 2018 - 31 March 2019

Influenza and Flu-like illnessesA review of Trust influenza plans was undertaken to prepare for winter pressures associated with influenza.

An increased incidence in patients being admitted with influenza and flu-like symptoms commenced towards the end of November 2018 and peaked in February 2019. The predominant circulating strain was Flu A (Figure 12). Although this was less than the previous year this occurred during a period of increasing bed pressures. Some wards within the Trust hospitals had to initiate flu cohort areas to manage patients with influenza. A number of private care homes across the Trust catchment area were also affected.

Hospital / Community facilities

Number of wards / areas affected Causative organism Identified

Residential care facilities 1 None

Ulster Hospital 13 Norovirus (7 incidents)Influenza A strain (two incidents)

Lagan Valley Hospital 2 Norovirus (one incident)Community Hospitals 1 None

Information on influenza cases was submitted to the Public Health Agency/Health & Social Care Board as part of the annual regional seasonal influenza surveillance programme.

Funding was obtained to allow patient samples (sent from our hospital facilities), to be tested quickly by the Ulster Hospital laboratory using the in-house influenza polymerase-chain reaction (PCR) test. This new system quickly identifies the presence of influenza from swabs (taken from patients) and allows for early decision making in relation to patient placement/isolation. This has been a very useful given the persistent bed pressures across Trust hospitals and in particular the emergency department(s).

An article was also produced for the Trust Facebook page during the flu season to give the public general advice about flu and what to do if symptoms developed.

Figure 12: Annual Influenza trend across the Trust Hospitals April 2017- March 2019

Improvement initiatives to reduce HCAIEach year the IPC team undertake a number of initiatives to support and monitor the application of device care across wards and services. The most common device used in the care of our patients is venous access devices. This year the Trust is leading a regional initiative to develop a number of short training videos for staff as reminders and to update staff on best practice and ensure an aseptic approach to the care of venous lines.

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Involving the Public / Patients and UsersInternational Infection Prevention & Control week Opportunity is taken each year to involve our patients, public and staff in national international events which raise awareness of pertinent infection prevention & control measures which when implemented can reduce infection.

International Infection Prevention & Control Week took place in October 2018 with the theme of “Protecting People Everywhere”. A number of posters were published to provide information on the standard measures that all Healthcare staff should take no matter where they are providing care. This also included advice for public on how they could protect themselves. The information was displayed in various locations throughout the Trust hospitals and some community facilities.

Initiatives were introduced this year to maintain awareness of the importance of hand hygiene and the correct technique. Staff in one ward implemented a “Clamp Down on Hand Hygiene” week. This focused on using methods to raise awareness of following the correct hand hygiene procedure at the right time. Posters were displayed in the ward to publicise the event. The ultra-violet light box was also used in areas of the Trust to promote the correct hand hygiene technique

5 May World Hand Hygiene DayEach year World Hand Hygiene Day is celebrated on 5 May and this year the theme and slogan for the day was “it’s in your hands - prevent sepsis in health care”. Sepsis is known to affect more than 30 million patients every year in the world.

On 4 May 2018 the Infection Prevention & Control (IPC) Lead Nurses from both PHA and South Eastern Health & Social Care Trust (SET) held a joint event in the Downe Hospital to mark Global Hand Hygiene Day. Care Home managers attended the event where the focus was on Hand Hygiene and the use of the ‘Urinary Tract Infection Decision Aid’ in Care Homes.

The Public Health Agency has published this aid to help nurses and carers who work with older people in care homes promptly identify and manage a resident

with a possible (UTI), and when to contact a doctor. By utilising the UTI decision aid the aim is to ensure that the patient is managed appropriately and that action can be taken when there are early signs of deterioration (suspected sepsis).

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A review of public awareness surrounding Infection Prevention & Control measures in hospital, antibiotic use and resistanceA survey was carried out over a three week period in May 2018 in the Ulster, Lagan Valley and Downe Hospitals to identify the local population’s knowledge, concerns and opinions on infection prevention and control issues. This survey gathered both quantitative and qualitative data and the age range of the participants. We investigated public understanding of antibiotic use, along with the accompanying emergence in bacterial resistance.

Questionnaires were placed in a number of frequently used public settings such as, reception areas, outpatient clinics and departments. Visitors were asked to complete these anonymously and return the completed form to a designated box for collection and a total of 70 questionnaires were returned for analysis.

The IPC team had previously researched public awareness of infection prevention and control issues in hospital during 2011 and the recent findings were compared with this survey. Some of the outcomes included:

• Less concern about picking up an infection than before - 40% compared to 60% in 2011

• Opinions gathered on preferred methods of information delivery was dependent of age range of the recipient – younger age range (up to 35) preferred to get IPC updates using “modern” media such as the Trust website and Facebook whereas the older population still favoured signage, notices, posters and leaflets

• 10% increase in recognition that antibiotics are not effective against flu viruses since 2011

• 69% of recipients displayed good understanding of antibiotic resistance. The majority did not understand it is not the individual’s body becoming resistant but the bacterium attaining mechanisms of resistance to the drug – leads many to believe therefore that they are not at risk.

It was positive to note improvements in knowledge but the survey also highlighted gaps which can then be used by the IPC team to inform and shape their future planning and effective methods to deliver advice.Resistance to antibiotics is a global concern; surveying the knowledge surrounding antibiotic usage and resistance is crucial and if public opinion cannot be altered there are far reaching implications for all.

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Midwifery Careers Day 20th November 2018The Infection Prevention and Control Team (IPCT) took part in a Midwifery Careers Day on 20th November 2018. This day was to encourage local secondary school children to consider Midwifery as a future career. This gave the IPCT opportunity to engage with future potential healthcare staff.

The groups were told how Infection prevention and control practitioners work across the whole health and care system and play a key role working collaboratively to improve the safety and quality of care delivered to all patients. The pupils were informed of the methods used to advise and support healthcare workers to prevent and control the spread of healthcare-associated infection.

The participants took part in a short Hand Hygiene facts quiz and were then invited to check their handwashing skills using the ultra violet light box.

A variety of posters and information leaflets were on display to demonstrate the information available for patients, staff and the public.

Sepsis InformationThe Trust had developed a sepsis information leaflet for the public to help in the recognition of sepsis. This was taken to the PHA Regional sepsis working group and from this further work was undertaken to revise and publish the information. This leaflet has been issued to GP health centres, GP out of hours across the Trust catchment area and our outpatients and emergency departments.

Patient Experience Services Table 3: Environmental Cleanliness

All facilities across the Trust undergo regular environmental cleanliness audits to measure compliance with Regional standards.

These are carried out by the Trust’s Patient Experience Quality Monitoring Team and the relevant Patient Experience Supervisor for the area.

All locations within the healthcare environment are classified into the following relevant risk categories:

• Very High

• High

• Moderate.

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It is against these categories that individual schedules of cleaning are established and monitored. This helps ensure the allocation of adequate numbers of cleaning staff and resources in each of the areas.

The Policy for The Provision and Management of Cleaning Services issued by the Department of Health Northern Ireland ( in January 2015), stipulated that Very High Risk and High Risk Areas’ Scores were to be reported against the standards set for cleaning duties undertaken by support services staff and the nursing (clinical) teams.Audit scores for both cleaning and Multi-Disciplinary audits are now displayed on the Trust iconnect site which allows Ward/Department Managers to easily find the audit scores for their area, this also give the audit scores from the current financial year which is used to gauge trends and dips in performance.

The Patient Experience Management team have also developed a set of internal special measures for those Wards/Departments which are consistently not achieving the target of 90% pass (Trigger is three audit failures in a row or two if both scores are below 80%, in high and very high risk areas). These Special Measures focus on increased Supervision, review of current Work Schedules, Review of equipment needs and Senior Management Walkabouts of Ward areas to help drive improvement.

In December 2018 changes were made to Discharge cleans on the Ulster Hospital Site. The Patient Experience Discharge Team now complete decontamination of the entire Patient’s bed (including mattress) for all isolation cleans following discharge or transfer of a Patient with a known infection. Previously Nursing staff completed the cleaning of the mattress; therefore this new method of working is saving Nursing time. This will be rolled out to Lagan Valley & Downe Hospitals in the 2019/2020 financial year.

A new version of the electronic monitoring system was introduced across the Trust to aid monitoring of Environmental Cleanliness. This enables the Quality, Performance & Training Team to carry out audits electronically on a hand held device. This system has the facility to allow the auditor to add additional commentary and photographs which helps to highlight excellent practices and cleaning standards and those which require improvement. A timely report is generated and sent directly to the Manager with an action plan of issues identified for these to be addressed. This is being rolled out throughout all Trust’s in the region which will allow for benchmarking between Trusts.

Food SafetyFood safety and hygiene practices continue to remain a high priority. The Trust is regularly inspected by the local Councils’ Environmental Health Officers and internal audits are also undertaken (Table 4). Our facilities have achieved a food hygiene practice rating of 4 or 5. A rolling programme of training is in place for all food handlers including nursing and ward/department domestic staff. Work continues to progress to open the new purpose built kitchen and restaurant in the Acute Services ward block Ulster Hospital in May 2020.

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Table 4: Food Hygiene and Safety

TITLE TARGET NARRATIVE

PROGRESSQ1

18/19

Q2

18/19

Q3

18/19

Q4

18/19

Cat

erin

g R

esul

ts To at least meet the regional

cleanliness target score of 92%

Catering Results for Acute & Community Catering Facilities

Acute

93%

Acute

92%

Acute

92%

Acute

93%

Community

94%

Community

94%

Community

93%

Community

95%

Central Sterile Supplies Department (CSSD) CSSD continued to provide a medical device and flexible endoscope decontamination service for the Trust, Community facilities and external Private clinics.

A considerable number of quality improvement projects have been completed within the department to provide a decontamination service to our service users which follows best practice, regulatory guidance and legislation.

CSSD underwent a 3 year strategic review in March 2019 by a microbiologist representing the notified body Medicines & Healthcare Products Regulation Agency (MHRA) and retained the accreditation to quality management standard for medical devices ISO 13485:2016.The department also achieved substantial compliance to the Controls Assurance for the Decontamination of Reusable Medical devices which will be replaced by Decontamination Assurance Framework in April 2019.

CSSD were proud to have been finalists for the ‘Ensure Safety, Improve Quality and Test Experience’ section of the Chairman’s Award 2018

Laundry Despite the age of the laundry equipment the laundry staff continued to provide an excellent linen decontamination service for the Trust, Community facilities and external Private clinics.

The Laundry service underwent a 3 year strategic review in February 2019 and retained accreditation to the ISO 9001:2015. The service was nominated as finalists in the 2018 LCN awards for the ‘Best on-premises’ laundry category.

The new laundry is on its way! The equipment tender was awarded to a contractor in March 2019 and building work will commence in September 2019 with the new Laundry scheduled to open in July 2020.

EstatesVentilation is used extensively in healthcare premises for both the comfort of occupants in buildings and to closely control the environment and air movement of the space that it serves, in order to contain, control and reduce hazards to patients and staff from airborne contaminants, dust and harmful bacteria. The Estate Services Department continue to manage the maintenance of all

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ventilation systems via the management software system Zetasafe™. This ensures compliance with relevant legislation and best practice guidance. A new regional ventilation contract is now in place which will further assist with the service, maintenance, validation and verification of critical and non-critical ventilation systems within the estate. There are plans to upgrade some of the ventilation systems in Downe and Lagan Valley Hospitals in 2019.

Pest ControlSatisfactory standards of pest control in both clinical and non-clinical areas are an integral part of providing an optimum environment for the delivery of good quality patient care. The Estate Services Department continue to manage the pest control contract via their compliance management system software Zetasafe™. This allows live online reporting of pest control compliance check’s and any subsequent remedial actions.

Water Safety Committee The Water Safety Group continue to manage the safety of all water used by patients/residents, staff and visitors, and to minimise the risk of infection associated with waterborne pathogens. There has been a significant amount of work carried out by the Water Safety Group to raise awareness of the key role all staff play in the management of domestic water systems including their responsibility to identify infrequently used outlets and carrying out the necessary flushing to keep water moving.

A new Water Safety Plan and Written Control Scheme were made operational in January 2019. This policy provides clear guidance for staff across the Trust regarding the requirements and processes set in place for the safe and effective management and maintenance of domestic water systems within our facilities.

From this an annual programme of work was implemented this year which included a review of risk assessments and water sampling to test for the presence of Legionella and Pseudomonas aeruginosa. An independent water safety expert was commissioned to undertake an annual inspection of the initiatives being undertaken. Recommendations have been actioned and/or included in the Water Safety group annual programme of work. Systems have been put in place to ensure that the water outlets within the new inpatient ward block are being managed in accordance with best practice guidelines. Remedial works have been undertaken within some of the Trust residential facilities, Lagan Valley and the Ulster Hospital sites to improve pipe work and maintain a safe supply of water.

The committee are actively involved in the water safety commissioning of the new acute services ward block on the Ulster hospital site. It is envisaged that the building will be handed over to the Trust in November 2019. A programme of water sampling will be undertaken in advance of the move of wards and services from the old inpatient ward block in May 2020. This will firm up plans to address redundant water outlets within vacant wards in the old building. Work continues to be undertaken to improve water systems on Lagan Valley Hospital site in preparation for the construction of the new health centre. Some of the Committee members will undertake a Water Safety training course in April 2019.

Capital DevelopmentThe Infection Prevention and Control Committee continue to work with Capital Development Team.Since the opening of the Inpatient Ward Block (IWB) in April 2017, a small number of issues have been identified and addressed. Overall feedback from staff regarding working in the building itself is very good.

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The Cardiac Catheterisation Service became operational within the new building in August 2018.

Construction is well advanced in the second building, the Acute Services Block (ASB). The building will provide an enhanced caring environment, to provide high quality care. Services include a new Emergency, Radiology Department(s), and Inpatient wards, Mortuary, Kitchen and a Restaurant.It is anticipated that the building will be handed over in November 2019 and the doors open to patients in May 2020. The Infection Prevention and Control Committee will continue to assist with the commissioning of this building.

On the Lagan Valley site, enabling works have begun for the Lisburn Primary and Community Care Centre. It is anticipated that this building will be open to patients and clients June 2021.

IPCT Improvement Plan The Infection Prevention and Control Team (IPCT) implemented an improvement plan which included monitoring the adherence to policies and guidelines. The audits and outcomes are detailed in the table below:

Table 5: IPC Audits undertaken in 2018-2019

Audit Type/Date Aim Outcome/Action

Review of MRSA screening programme of all patients admitted for Plastic surgery.

April 2018 (1 week)

November 2018

(1 week)

95 % compliance with screening.

To measure the value of targeted screening in this client group long term. (Incidence of MRSA infection in this client group).

Screening occurred in over 30% of all patients. Following feedback this increased to 69% compliance. (Some patients would have had day procedure surgery).No cases of MRSA infections were reported in the study period.

Recommendations: review the benefits of screening in this population group and Trust MRSA Screening Guidelines.

Undertake a Public Survey regarding awareness of Healthcare- associated infection and Antibiotic awareness. May 2018.

Gain awareness of public perception of healthcare-associated infection.Review information available and accessibility to patients, public and visitors seeking to rectify gaps in knowledge.

Public knowledge was of HCAI and Antimicrobial usage was generally good. Multiple methods of sharing the information with the public in place and opportunities for continued engagement on HCAI issues continue (see Pages 14-15).

Admission IPC Risk Assessment in four Medical Wards. June 2018.

(a) Identify % of patients admitted to medical wards who had an Infection control risk assessment completed. (b) Those identified with risks will have a care plan completed

95% compliance with the completion of risk assessments and relevant documentation.

Support staff as required toward improved compliance.

93% (overall average compliance) had a risk assessment completed. A number of wards achieved 100% compliance.

Of the patients identified as having an alert organism, 44% had documented plan of care for the respective organism. One area audited demonstrated 100% compliance with care plans.

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Audit Type/Date Aim Outcome/Action

Undertake four Multidisciplinary team Environmental Cleanliness audits with Estates and Patient Experience.

Compliance with Trust and DoH standards of cleanliness. Ensure any estate issues are highlighted and resources for repairs prioritised.Address any equipment cleanliness issues with relevant staff.

Where cleanliness scores did not meet expected standards, following remedial action a re-audited demonstrated improvement.

Any estates issues highlighted through audit where identified to the Estates team as a priority.

Retrospective comparative study of outbreaks of increased incidences of diarrhoea & vomiting in 2017/18 as compared with 2016/17 in Trust inpatient areas. Undertaken June 2018.

To measure the impact of single room inpatient areas in the new inpatient ward block (IPWB), as compared to open bay wards in Ulster Hospital main ward block.

From comparison in 2016-17, prior to opening the IPWB and the first year of opening there was a marked reduction in gastrointestinal outbreaks/ increased incidences.

In the year April 17- March 18 there were no outbreaks recorded on the Ulster site.

A comparison of only two years is not enough to draw definitive conclusions. This review will continue over the next 2-3 years.

Audit of peripheral venous cannula (PVC) care management in medical wards Ulster Hospital.

December 2018.

No patients will have a PVC infection.

Less than 5% will have a phlebitis score at the cannula site of 2 or more.

2.8% of patients who had PVC were identified as having a Phlebitis score of 2 or more.

Of the 2.8% identified, 1.7% equated to phlebitis likely caused by chemical interaction. There were no PVC infections identified.

Review of MRSA screening programme of all patients admitted to two care of the elderly wards.

To identify the value of screening in this client group long term.

This study has been useful in identifying colonised patients who would not have otherwise been screened. Going forward the plan will be to continue screening in this patient population

Evaluation of an electronic non-touch thermometer; combined with Assessment in use and management of a tympanic thermometer in 4 adult wards

June – October 2018.

Establish the benefits of an electronic non-touch thermometer from an IPC and staff perspective.

Review the management of the current tympanic thermometer used in the wards

Staff feedback on the non-touch thermometer was very positive.

Some practices in the management of the current tympanic thermometer were identified and remedial action introduced. The report was shared across all wards.

Evaluate a combined peripheral cannula with extension set in Emergency Department. March 2019

Establish the benefits of this device from staff and IPC perspective.

The results from this audit returned mixed reviews. Staff will continue to select peripheral cannula devices on an individual basis depending on patient presentation & clinical need.

Regional audit to establish the IPC training provision for domiciliary support workers/Agency Nurses. (HSC and Independent providers). October 2018-Marh 2019

To scope the IPC training provision for Primary Care & Community domiciliary support workers in conjunction with NICE guidelines and produce an options appraisal.

Findings are currently being analysed and a regional report is being produced and will be issued through RQIA later in 2019.

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IPC Training/Education ProgrammesThis year the IPCT increased their input into the education of International nurses undertaking OSCE’s (Objective Structured Clinical Examinations). This took place at local level on the Ulster site in collaboration with Clinical Educators and the Nursing Workforce Development Team and at regional level alongside Nurse Education Consultants at the HSC Clinical Education Centres.The development of a regional tiered IPC e-learning option accessible for Trust staff is nearing completion. This will allow staff with direct care responsibilities to engage in a scenario based follow-up session on completion of e-learning basic course. It will also give healthcare staff more options to access IPC training. Figure 13 would suggest that eLearning has become more popular over the last two years.

In the interim face-to-face sessions with all the acute and community multidisciplinary staff continued over the year resulting in high numbers of staff trained and good networking opportunities.

Table 6: Number of staff attending IPC Training 1 April 2018 - 31 March 2019

Figure 13: Uptake of IPC Training 1 April 2014 - 31 March 2019

Visit by European Centre for Disease Control (ECDC)The Trust’s Medical Director and IPC team hosted a visit from a team of colleagues from the European Centre for Disease Control. This was arranged by the Public Health Agency and Department of Health (DoH). The purpose was to discuss the organisational approach to infection prevention and control, antimicrobial resistance and antimicrobial usage. The links to the Public Health Agency and DoH were also explored. ECDC colleagues visited the Critical Care Unit and the inpatient ward block in the Ulster hospital and had opportunity to speak to clinical staff. Overall they were very impressed with the facilities and the structures in place to tackle antimicrobial resistance.

PERIOD

STAFF ATTENDANCE AT IPC TRAINING/AWARENESS UPDATES in 2018- 2019

(includes eLearning and adhoc training provided for other providers and managers)

April 2018 – March 2019 2254 and 1152 e learning

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Antimicrobial ManagementThe Trust continues to promote prudent antimicrobial prescribing through an antimicrobial improvement plan overseen by the Antimicrobial Stewardship Group.

The Trust Microguide app which allows staff direct access to Trust antimicrobial guidelines via their mobile devices has been updated with a revised section which gives guidance on the treatment of Sepsis.

For the first time the DOH in Northern Ireland introduced targets for the reduction of antibiotic consumption in both primary and secondary care with the aim of reducing total antibiotic prescribing in Northern Ireland by 10% by 31 March 2021.

Targets are:

• Trusts should have 55% of their antibiotic usage from the WHO-access list measured as DDD/1000 admissions

• If unlikely to meet this target as considerably below 55% baseline then alternative target is to increase use of WHO-access list antibiotics by 3%/year in first year.

• Primary Care: to achieve a 2% reduction in total antibiotic prescribing by end of March 2019 taking 2017/2018 as baseline

• Secondary Care to achieve a 1% reduction in total antibiotic prescribing(DDD/1000 admissions) by end of March 2019 taking 2017/2018 as baseline

• Secondary Care to achieve a 3% reduction in pip/taz prescribing(DDD/1000 admissions) by end of March 2019 taking 2017/2018 as baseline

• Secondary Care to achieve a 3% reduction in Carbapenem prescribing(DDD/1000 admissions) by end of March 2019 taking 2017/2018 as baseline.

In order to meet these targets the main body of antimicrobial stewardship work in the Trust this year has centred on the South Eastern HSC Trust participation in the Antibiotic Review Kit (ARK - hospital) research study. This study is a UK-wide evaluation of an intervention to support the DOH tool-kit Start Smart then Focus. This involves a time-limited 3 day initial antibiotic prescription as part of a multifaceted strategy including prescriber education, audit and feedback.

Figure 14: Initial results from the ARK 3 month implementation phase

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Carbapenem SurveillanceOver the last three years the Trust has been operating a surveillance programme for all patients prescribed carbapenems in the Ulster Hospital. This intervention has been successful at reducing carbapenem consumption. In March 2019 this surveillance programme was extended to Lagan Valley and Downe hospital sites.

Outpatient Antimicrobial Therapy ServiceThe Trust was successful in gaining additional regional funding to employ an Outpatient Parenteral Antibiotic Therapy (OPAT) Pharmacy team to support the implementation of the Best Practice Guidelines for OPAT. The key objective of an OPAT service is to safely and effectively manage patients with infections as outpatients, ensuring that their treatment is optimised, appropriately delivered and supervised and that risks are minimised.

OPAT allows patients who are medically stable and whose only reason for admission to / or remaining in hospital is the requirement for IV antibiotic therapy, which could be treated in an outpatient setting. The initial phase of the new OPAT service is the appointment of two OPAT pharmacists to ensure appropriate and robust governance and stewardship at the point of prescription. Additional input from a Consultant Microbiologist in the coming year will facilitate more time to provide expert advice on drug choices and access to the service; offer alternatives to proposed treatment when required and contribute to weekly multidisciplinary virtual ward rounds.

Newly appointed OPAT pharmacists

OPAT pharmacists will:Provide expert advice on drug choices and compatibilities; advice and training on therapeutic drug monitoring:

• Provide advice on alternatives to proposed treatment in liaison with the Consultant Microbiologist;

• Lead on dispensary, procurement and regulatory issues relating to OPAT; oversee dispensary pharmacist, pharmacy technician and dispensary staff training to facilitate OPAT

• Have input into guidance and OPAT drug formulary,

• Have input at weekly multidisciplinary virtual ward round

• Contribute to audit and quality improvement activity.

Working with community nursing teams to provide this service will facilitate earlier discharge for patients who can get their treatment at home. A reduction in the number of IV antibiotics prescribed or suggesting alternatives that may require less frequent administration has the potential to free up nursing care.

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Table 7: Microguide App Usage figures to date

Guide Guide Accesses All Guidance 44,425Microguide App User Category Number of Registered Microguide App users Medicine 913 Pharmacy 174 Dentistry 6 Podiatry 7 Physiotherapy 13 Healthcare Manager 7 Physicians Associates or Equivalent 4 Other 46 Nurse 141 Biomedical Scientist 1 Clinical Scientist 0 Paramedic 1 Overall Total 1313

Antimicrobial Training / Education ProgrammesComprehensive Antimicrobial stewardship training is a priority. This year the Antimicrobial pharmacy team increased their input into the education of nurses, nurse assistants and all grades of pharmacy staff. The number of staff undertaking antimicrobial stewardship training including on-line ARK stewardship training more than doubled to just over one thousand.

The antimicrobial pharmacy team coordinated the review of QUB Advanced pharmacy practice diploma workbook and examinations.

Table 8: Number of staff attending Antimicrobial Stewardship sessions

PERIOD STAFF ATTENDANCE ANTIMICROBIAL STEWARDSHIP TRAINING/ in 2018- 2019

April 2018 – March 2019 768

April 2018 – March 2019 270 completed Antibiotic Review Kit (ARK) on-line training

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Audit Overview / Outcome Action

Antibiotic Review Kit (ARK) research study

May-July 2018

The new ARK medication kardex is to continue to be used and its use extended to all adult medical and surgical wards across the Trust.

A re-audit of systems for ordering and supply of restricted antimicrobials in the Ulster hospital, October 2018

All supplies of restricted antimicrobials in October 2018 in the Ulster hospital were audited for compliance with Trust guidance for ordering and supply of restricted antibiotics.

256 orders were supplied over 1 month period.

Of the 167(65%) orders with patient details available 104 were inputted onto JAC with the patient details.

Review of wards holding restricted antimicrobials as a stock item identified only three wards not authorised to hold restricted antimicrobials. A total of 12 unauthorised stock orders were received.

These results represent a substantial improvement compared to the previous audit in October 2015.

Improvement plan was developed:

1. Review the list of wards authorised to hold restricted antimicrobials as stock on a three monthly basis

2. Training for all Trust staff on the storage, ordering, supply and return of restricted antimicrobials to be scheduled on a regular three monthly basis.

Table 9: Antimicrobial Improvement, Audit and Research Activity 2018-2019

Electronic surveillance software systemsMuch work has been undertaken in order to improve systems which can alert staff if a patient has a history of an infectious condition or who is colonised with a bacterium known to cause outbreaks of infection. This has included collaboration with colleagues across the region to establish local requirements and identify the resources required to introduce a regional system so that patients can be cared for appropriately. Within the Trust hospitals the IPCT have worked with the Informatics Communication & Technology (ICT) teams to develop an alert on the e-whiteboards in wards. This system ensures that staff are aware of patients with infection and they can be isolated and managed promptly as required.

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IPC Service Controls Assurance Accreditation 2018 -2019Controls Assurance Standards are no longer used to benchmark IPC governance arrangements within healthcare Trusts in Northern Ireland. Some proposals have been issued by the DoH but no overall replacement has been agreed.

For some years the Trust has implemented IPC best practice standards published by the National Institute of Clinical Excellence (NICE), (the latter are used during RQIA inspections). A recent review has been undertaken and this has identified that a high level of compliance and governance arrangements are in place.

Guidelines and PoliciesInfection Prevention and Control guidelines and policies undergo a review process in accordance with Trust protocols. This year work has been undertaken in conjunction with other Trusts and the Public Health Agency to update the Northern Ireland Regional Infection Control Manual web-site. This work will continue this year.

There are a total of 35 South Eastern HSC Trust policies and guidelines relating to infection prevention and control and aspects of antimicrobial prescribing. The IPC team continue where possible to summarise policies and guidelines on a page to enable staff and clinical teams to have easy reference material highlighting key aspects and clear standards of practice.

IPCC Plans for 2019-2020 To prioritise and monitor the implementation of initiatives from the Trust’s Infection Prevention & Control Strategy 2019 - 2022.

• Continue to reduce avoidable healthcare–associated infections and antimicrobial resistance

• Work with PHA to gain further understanding of gram-negative bacterial bloodstream infections (E. coli) and other surveillance initiatives

• To review the IPC Annual Training Programme and scope the feasibility of introducing a new elearning programme across the Trust to support mandatory IPC training

• To further develop the Trust’s Antimicrobial prescribing guidelines and work to embed Antimicrobial Stewardship by producing and implementing a five year antimicrobial improvement plan

• To develop the OPAT service to safely and effectively manage patients on IV antibiotics as outpatients, ensuring their treatment is optimised, appropriately delivered and supervised, and that risks are minimised

• To further develop the Trust’s Antimicrobial smart phone application Microguide® to expand the range of specialties and infections included infections in the prescribing guidelines

• To further embed the care management of vascular access and invasive devices and reduce the incidences of false-positive blood cultures

• To review the Trust’s MRSA screening guidelines following the issue of the DOH/PHA recommendations from recent regional audit

• To work with Capital development, Estates and Contractors in planning for the construction of new buildings and renovations across the Trust

• To work towards full implementation of the Trust’s TB Action Plan

• To ensure IPC Policies and Guidelines are reviewed and updated and work with the PHA to support review of the Northern Ireland Infection Control Manual

• To review the IPC Improvement programme in light of past findings and as part of continuous outcomes based improvement

• To contribute to the Trust’s Water Safety Programme

• Continue to support and influence the development and inclusion of IPC related information and triggers in Regional Electronic Surveillance systems

• Pilot the use of a urinary infection management checklist with the Trust’s Residential Care Homes and, seek to establish the benefits of a urinary catheter passport for patients with long term catheters.

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