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DIRECTOR OF INFECTION, PREVENTION AND CONTROL (D.I.P.C.)

ANNUAL REPORT

INFECTION, PREVENTION & CONTROL

2015/2016

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Contents Page

1.0 Executive Summary ………………………………………………………………………………. 4

2.0 Infection Prevention & Control Arrangements ………………………………………………. 5 2.1 Infection Prevention & Control Team (IPCT) ……………………………………………………. 5 2.2 Infection Prevention & Control and Environmental Hygiene Committee (IPCEHC) ………… 6 2.3 Reporting line to the Trust Board …………………………………………………………………. 6 3.0 Infection Prevention and Control Trust Stakeholders …………………………………….. 6 3.1 Environmental Hygiene and Food Safety Committee ………………………………………….. 6 3.2 Medical Devices and Decontamination Committee …………………………………………….. 8 3.3 Estates Services ……………………………………………………………………………………. 8 3.3.1 Control of Pseudomonas ………………………………………………………………………… 9 3.3.2 Control of Legionella ……………………………………………………………………………... 10

4.0 HCAI Targets ……………………………………………………………………………………….. 10 4.1 Clostridium difficile infections ……………………………………………………………………… 10 4.2 Meticillin Resistant Staphylococcus aureus (MRSA) Bacteraemia …………………………… 10 5.0 Healthcare Associated Infections ………………………………………………………………. 11 5.1 Meticillin Resistant Staphylococcus aureus (MRSA) ……………………………………………. 11 5.2 Meticillin Sensitive Staphylococcus aureus (MSSA) ……………………………………………... 12 5.3 Clostridium difficile………………………………………………………………………………….... 12 5.4 Pseudomonas aeruginosa ………………………………………………………………………….. 14 5.4.1 Microbiology monitoring of water outlets in Augmented Care areas and NNU …………….. 14 5.4.2 Patient screening for detection of Pseudomonas aeruginosa............................................... 14 5.5 Norovirus Outbreaks ………………………………………………………………………………… 14 6.0 Antimicrobial stewardship ……………………………………………………………………….. 15 6.1 Antibiotic Policy ……………………………………………………………………………………… 15 6.2 Multidisciplinary Antibiotic Stewardship Round…………………………………………………... 15 6.3 Usage of Antibiotic in NHSCT………………………………………………………………………. 15 6.4 Antimicrobial Audit results…………………………………………………………………………… 17 6.5 Publications and other activities ……………………………………………………………………. 19 7.0 Hand Hygiene ………………………………………………………………………………………. 21 7.1 Clean Your Hands Campaign ……………………………………………………………………… 21 7.2 Hand Hygiene Audits ……………………………………………………………………………….. 22 8.0 High Impact Interventions/Care Bundles ……………………………………………………… 22 9.0 Audit ………………………………………………………………………………………………….. 24 9.1 Regulation and Quality Improvement Authority (RQIA) Audits …………………………………. 24 9.2 Independent Audits on management of Clostridium difficile…………………………………….. 24 9.3 Commode/Mattress Audits ………………………………………………………………………….. 24

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Page

10.0 Policy Review …………………………………………………………………………………….. 25 11.0 Training & Education ……………………………………………………………………………. 25 12.0 Other Infection Prevention & Control Initiatives ……………………………………………. 27 12.1 Infection Control Fast Facts ………………………………………………………………………. 27 12.2 Infection Risk Assessment Tool (IRAT)………………………………………………………….. 28 12.3 Student Nurse Education and Placement ………………………………………………………. 28 12.4 Temporary IPC Secondment Post ……………………………………………………………….. 28 12.5 Augmented Care Focus Group …………………………………………………………………… 28 12.6 IPC & Corporate Communications Department ………………………………………………… 29 12.7 Infection Prevention and Control in the Built Environment ……………………………………. 29 12.8 On-Call service……………………………………………………………………………………… 29 13.0 Conclusion …………………………………………………………………………………………. 29

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1.0 Executive Summary This report outlines a summary of the key infection prevention and control initiatives and activities of the Trust for the year April 2015 to March 2016. It also provides an assessment of performance against regional targets for this year. Infection, Prevention and Control remains a Trust priority and the programme of activities developed to reduce infection rates has been implemented and maintained. Work has continued to achieve compliance with the following:

• The Quality Standards for Health & Social Care DHSS&PS 2006 • Saving Lives High Impact Interventions (DH, 2007) • Environmental Cleanliness Standards DHSS&PS 2005 • Controls Assurance Standard for Infection Control DHSS&PS 2009 • Changing the Culture, Strategic regional action plan for the prevention and control

of healthcare-associated infections in Northern Ireland, DHSSPS 2010. • Ten elements a short guide to Board - to - ward assurance on healthcare

associated infections (HCAIs) for members of HSC Trust Boards • NICE Clinical Guideline 139: Infection Prevention and Control of Healthcare

Associated Infections in Primary and Community Care. The Trust’s self assessment against the controls assurance standard for infection prevention and control was compliant at 97%. The Trust maintained a continuing high focus on reducing the incidence of Healthcare Associated Infections (HCAIs). However, despite this focus, the Trust was not able to meet its PFA target in relation to MRSA bacteraemia infection but it did achieve the PFA target for Clostridium difficle during 2015/16. It was extremely challenging for the Trust to attain the target set for C. difficile for 2015/2016. Considering the unprecedented rise in cases over the first half of the 15/16 year, this was a good achievement. In line with current NICE Guidance the Trust continues training and assessment of compliance with Aseptic Non Touch Technique in the management of peripheral lines and other indwelling medical devices. The Infection Prevention and Control Nurses continue to undertake validation audits of HCAI Care Bundles with respect to the Management of MRSA and Clostridium Difficile, Peripheral Line Management, Urinary Catheter Care and Hand Hygiene In overall terms the Trust has continued to make continued significant progress in Infection Prevention and Control during 2015/16 and remains fully committed to maintaining this progress during 2016/17.

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2.0 Infection Prevention & Control Structure and Arrangements The Northern Trust Infection Prevention and Control Strategy was formally launched and approved in Feb 2014 and is currently under for review for completion at the end of 2016. The Strategy was developed to ensure that the Trust has effective infection control arrangements in place to protect patients, visitors and staff. The Trust strategy is aligned with the core principles from the Regional Changing the Culture Strategy highlighting that infection prevention and control is an integral part of safe effective care and that infection prevention and control is everybody’s business (Department of Health, Social Services and Public Safety – DHSSPS 2010). This Strategy describes the key themes to support staff and the Trust in meeting the current and future demands for quality standards by minimising risk and integrating IPC into core business. This strategy continues to build on the work already achieved. The key themes identified in the Trust Strategy are as follows; 1. Patient Experience 2. Clean, Safe, Environment 3. Communication 4. Culture 5. Leadership 6. Workforce, Education and Learning 7. Assurance 8. Antimicrobial Stewardship The Trust Operational Directorates are responsible for delivery and implementation of the Trust IPC Strategy and Policies. They are also responsible for managing performance regarding infection control outcomes in their service areas through constant review of their delivery and performance plans at each Directorate Infection Control meeting. 2.1 Infection Prevention & Control Team (IPCT) The Infection Prevention and Control Team consists of:

1.0 WTE Infection Prevention & Control Lead Nurse

4.0 WTE Senior Infection Prevention & Control Nurses (Band 7)

4.52 WTE Infection Prevention & Control Nurses (Band 6)

1.0 Consultant Medical Microbiologist

0.3 Control of Infection Doctor

1.48 WTE Anti-Microbial Pharmacist The IPC team remains accountable to the Director of Infection Prevention and Control (DIPC) for the I.P.C. Service. The Infection Control Doctor leads the team and provides advice to the DIPC. The nurses report managerially to the Director of Nursing and the Infection Control Doctor reports into the laboratory management structure.

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2.2 Infection Prevention Control and Environmental Hygiene Committee (IPCEHC) The Trust’s Infection Prevention Control and Environmental Hygiene Committee (IPCEH) is responsible for developing a strategic and integrated approach to achieving high standards of infection prevention control and environmental cleanliness practice to reduce health care associated infections (HCAIs) where possible. 2.3 Reporting line to the Trust Board The Director of Infection Prevention & Control (DIPC) is an Executive Director of the Trust, member of the Senior Management Team, Governance Committee and Trust Board. The Trust Board is kept informed of the organisation’s performance in relation to Infection Prevention & Control by receiving:

Monthly HCAI performance dashboard

Annual reports

Infection Control Strategy

Trust Directorate Delivery Plans

3.0 Infection Prevention and Control Trust Stakeholders

3.1 Environmental Hygiene and Food Safety Committee The Trust recognises that hospital cleanliness is a vital component in the management of Health Care Associated Infections. To ensure cleaning standards are maintained, daily cleaning observational checks and environmental cleanliness audits are carried out in wards and departments. The target compliance scores for the audits changed in 2015, with scores for very high and high risk wards/departments increasing from 85% to 90% and medium to low risk departments remaining at 85%. Audits continue to be completed on a monthly basis for very high e.g. Emergency Departments, Intensive Care Units, Augmented Care Wards and high risk areas e.g. General Wards and every 3 months for medium to low risk areas e.g. Outpatients and Medical Records and high risk areas and every 3 months for medium to low risk areas. In addition to these audits and, as a means of verification of the departmental audits, Annual managerial audits are carried out by a team consisting of infection control, domestic services, nursing, and estates services personnel. The Regional Healthcare, Hygiene and Cleanliness Audit tool is used for these annual audits. Action plans and follow up visits/audits are also a fundamental part of the auditing process. Audit results are reported Senior Management Team and to the Infection Prevention Control and Environmental Hygiene committee with any deficiencies in standards being identified for improvement.

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A programme of Patient Environment Leadership Walkabouts is also in place and public representatives participate in the walkabouts, Ward Sisters/Charge Nurses and patient surveys are completed bi-annually. As a means of enhancing the daily ward cleaning process and accepted by the Infection Control Team as good practice in reducing HCAIs, a twice yearly intensive cleaning programme of wards exists in the Trust‘s hospitals. This programme is currently being achieved even though it is challenging due to clinical demands wards sometimes have to cancel and then have to be rescheduled. A multi-disciplinary approach to cleaning has been created whereby domestic services staff using specialist equipment, nursing and estates services staff work together to thoroughly clean ward areas after decant of patients. The Intensive Clean Protocol was re-launched at a meeting of the Nursing Executive Team on the 2nd of April 2015. Domestic services staff receive infection control training as part of their induction and existing staff receive refresher training at least once every two years. Domestic services management and the Infection Prevention and Control Team work in partnership to reduce the incidence of HCAIs in Trust Hospitals and facilities and are members of hospital cleaning focus groups. This ensures that patients are cared for in a safe and clean environment. The Environmental Cleanliness and Food Safety Committee met on the 8th April, 17th June, 2nd September and the 14th of December 2015. At each of the meetings the committee reviewed the results of the Cleanliness Matters Audits, Regional Healthcare, Hygiene and Cleanliness audits, RQIA Reports and Action Plans, Patient Environment Leadership Walkabout Action Plans Food Safety Audits, Controls Assurance Standards and survey results. The committee were also informed about the outcome of the unannounced Environmental Health Inspections, and it is positive to report that all Trust hospitals/facilities achieved a food hygiene rating of either 4 or 5, with 5 being the highest score achievable. There also continued to be a major focus on the “Dump the Junk” Initiative in place across the Trust. The committee also monitored the Estates planning programme in relation to the patient environment and highlighted areas where estates issues were impacting on the ward environment results in the RQIA reports. Food Hygiene and Ward Kitchen policies have been prepared and approved by the Trust’s Policy Committee and were reviewed by the committee as were the results of the daily Ward Kitchen Observational Audits. Staff Training and Development programmes for Support Services staff continue to be recommended. The Trust continues to be an accredited training centre for the British

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Institute of Cleaning Science training for Domestic Services staff and a number of Food Hygiene Courses are delivered for staff in-house. The committee continued to support the Food Safety Awareness training for non-catering staff which is now in place for both Acute and Community staff involved in handling patient/client food. 3.2 Medical Devices and Decontamination Committee The Medical Devices and Decontamination Committee oversees all aspects of use and decontamination of medical devices within the Trust with two sub-committees looking at disposable medical devices (the Clinical Procurement Advisory Group) and clinical capital purchases (the Medical Devices and Clinical Capital Scrutiny Group). In relation to the centralised decontamination of both community podiatry and dental instruments funding was made available during the year to purchase the requisite instruments for all of the podiatry needs and those for dental associated with Ballymena Health and Care Centre. The podiatry centralisation was completed in March 2106. In terms of Dental the remaining capital will be released by the Department in April 2016 and this will enable all of this work to be centralised by December 2016 with BHCC by June 2016. In addition a regional group has been set up to look at the decontamination of devices such as specialist cardiac diagnostic devices and the Trust is participating in this work. Further within the Trust, with SSU involvement work is taking place with regard to future arrangements and standards regarding both endoscopy and HSDU and how best to develop. In this regard a business case continues to be worked on with regard to the Phase 2 of building at Antrim Area Hospital which would include combined endoscopy and HSDU facilities. Additional scopes to increase the complement available within the Trust were purchased from the clinical capital allocation during the year. 3.3 Estate Services IPC QA Audits – Estates continue to work with ward managers and department heads to ensure that Estates actions are completed. Senior Estates staff attend all Patient Environment Leadership walkabouts with IPC, Nursing & Support Services staff. The IPC Team continue to provide input and expert advice into all new major and minor capital project planning. Estate Services is committed to improving the level of water safety compliance as set down in the Health and Safety Executive’s approved code of practice L8 and Health

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Technical Memorandum (HTM) 04-01. Annual Action Plans for Water have been in place since 2012. The Trust Water Safety Group which is chaired by the, Head of Engineering, acting on behalf of Assistant Director of Estates, continues to meet quarterly. The Terms of Reference of this group, which is a sub group of the Infection, Prevention, Control & Environmental Hygiene Committee (IPCEH) is attached. The HTM 04-01 Addendum: Pseudomonas aeruginosa – advice for augmented care areas which was published in England in March 2013 has been adopted by DHSSPS in February 2014. 3.3.1 Control of Pseudomonas aeruginosa Comprehensive water sampling and testing for Pseudomonas continues to be in place in all augmented care areas which represent a higher clinical risk as detailed in HTM04-01 Addendum. The Northern Health and Social Care Trust have defined the following areas as Inpatient Augmented Care Areas:

Neonatal Unit (including Special Care Baby Unit), Antrim Hospital

Intensive Care Unit, Antrim Hospital and Causeway Hospital

High Dependency Unit (theatre recovery), Antrim Hospital

Ward A4 inpatient dialysis and haemato-oncology, Antrim Hospital

Macmillan unit, Antrim Hospital All augmented care areas are on a 6 monthly testing schedule. The control measures in place are currently successful as a high percentage of these 6 monthly tests meet the stringent parameters of zero cfu /100 mls, without further remedial work and re-test, with the exception of C7. C7 24 bedroom ward, which was not specified as an augmented care area at tender stage, had 50% failure on the Pseudomonas test results on the hot & cold water outlets when the building was handed over. Remedial works and water testing has been carried out in C7 and the current situation is that 17 ensuite bedrooms meet the augmented care specification. Further work was carried out including the 6 monthly trialing of a biocide dosing system during November 2013- June 2014. Results taken during this time showed no impact in the Pseudomonas levels and the Trust did not proceed with biocide dosing in C7. The Annual independent Audit carried out in November 2016 made recommendations based on 2 options with regards the use of filters in C7. An options paper has been submitted by the Water Safety Manager to Assistant Director of Medical Services (Interim) and Professional lead for Nursing for C7, the options will be considered based on cost implications and long term benefits to Ward C7. An important element in the control of Pseudomonas aeruginosa is regular flushing of hot & cold water taps and showers. Corporate Support Services have a twice daily flushing and recording routine in augmented care areas. HTM04-01 Addendum (Northern Ireland Amendments Annex A), requested an independent validation and report relating to the establishment of systems and processes for water management relating to Pseudomonas aeruginosa. Three audits have since

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been conducted in 2013, 2014 & 2015. In most recent audit carried out in November 2015, the auditor noted in his assurance statement that the Trust’s management system for this risk is worthy of validation. The 2016 report is due and has been scheduled for December 2016. 3.3.2 Control of Legionella There is a programme in place for the control of Legionella on all Trust premises. This is managed using a risk based approach with the application of available resources in risk rank order. Risk assessments are carried out and are up to date for all Trust facilities. The £162, 000 MES funded work for the control of legionella in 2015/16 was completed. The quantum of remedial action depends on the level of water contamination, age and design of the systems. The more comprehensive regime of water sampling for Legionella, which was recommended by HSE, has been implemented. Random quarterly samples collected from showers and hot & cold water taps in Trust owned facilities are tested on a quarterly basis. Results are shared by Estates with the Trust Microbiologist and Infection Control. Where results are outside the specification, remedial action and retesting is required, this is implemented by Water Safety Manager and Estate Officers. This is escalation procedure is detailed in the Trust Water Safety Plan which is available on the staff intranet and due to be reviewed March 2017.

4.0 HCAI Targets 4.1 Clostridium difficile infections The Annual Target for Clostridium difficile in 2015/16 was 59 cases aged 2 years and over. The number of cases of C difficile reflects on the quality of environmental and equipment cleaning, the appropriate use of antibiotics and other infection control practices such as hand hygiene and appropriate patient placement. Despite an overall rise in the number of cases of C difficle in the province again this year, the Northern Trust achieved the required reduction in C difficile cases to attain the set target of 59 cases. Additionally, despite a significant rise in our inpatient activity, the Northern Trust was the only Trust to achieve the target set by the Department of Health for reduction of C diff numbers in NI. 4.2 Meticillin Resistant Staphylococcus aureus (MRSA) Bacteraemia The Annual Target for MRSA bacteraemia in 2015/16 was 10 cases. Despite previously reducing our numbers of MRSA bacteraemia last year, the Northern Trust is reporting an increase in cases and was unable to achieve a reduction of cases for 2015/16 where we identified 21 cases of MRSA bacteraemia. Not all cases of MRSA bacteraemia are preventable and a proportion of cases seen during 2015/16 have been acquired in the community. The IPC team are increasing efforts to work with community colleagues to target reduction of MRSA colonisation in patients receiving community care. The HCAI performance target for 2015/16 did not include MSSA bacteraemia. However, surveillance of MSSA bacteraemia remained mandatory during 2011/12 therefore all

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MSSA infections were continued to be recorded on the web based surveillance system and through laboratory reporting.

5.0 Healthcare Associated Infections The Trust reports the following Healthcare Associated Infection (HCAI) statistics to the Public Health Agency: Meticillin Resistant Staphylococcus aureus (MRSA) bacteraemia Clostridium difficile

Trust surveillance data on MRSA, MSSA and Clostridium difficile is reported to the Public Health Agency (PHA) through the HCAI web based surveillance system every month. The PHA issues the Trust with a monthly report showing the NI and NHSCT cumulative total against the monitoring trajectory for each organism. The Infection Prevention Control and Environmental Hygiene Committee receive monthly surveillance data at each meeting; this is presented as a performance table with data on compliance with High Impact Interventions and Environmental Cleanliness. The same information is presented to Trust Board monthly and non-executive Directors have the opportunity to question the Director of Infection Prevention and Control (D.I.P.C.) on performance. 5.1 Methicillin Resistant Staphylococcus aureus (MRSA) Mandatory surveillance of Staphylococcus aureus bacteraemia has been in place since March 2008. The Trust is required by the DHSSPS to report all MRSA positive blood cultures that have been identified by the Trust’s Microbiology Department. The following graph shows the cumulative monthly incidence of MRSA bacteraemia for year 2015/16

0

5

10

15

20

25

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-15

May

-15

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-15

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15

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-15

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MRSA bacteraemias 2015/16

Ant MRSA

Cau MRSA

Other MRSA

MRSA targ

Cumulative MRSA

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All cases of MRSA bacteraemia are investigated by a multi-disciplinary Post Infection

Review (PIR) process. These are undertaken within Directorates Clinical Teams with

support from the Infection Prevention and Control (IPC) team and any relevant supporting

services. The outcome of ward based PIR’s are reviewed by the Senior Director, Director

of Nursing and the Medical Director, and where themes and learning are identified, these

are shared throughout the organisation. These findings help to inform review of IPC and

other related policies and guidance. If the cases merits reflection of any community based

healthcare interventions then members of those teams are also included in the PIR

process to ensure local learning

5.2 Methicillin Sensitive Staphylococcus aureus (MSSA)

During 2015/2016 the Trust continued to monitor and report the number of bacteraemia cases caused by MSSA, which can be found commonly in the general population. 5.3 Clostridium difficile As previously mentioned, the Annual Target for 2015/2016 was 59 cases aged 2 years and over. The cumulative position as at 31st March 2015 was 59 episodes: the Trust was successful in meeting the PFA target and was able to demonstrate a reduction in the incidence of Clostridium difficile infections of over 7% in comparison to 2014/15. During 2015/16, the Trust, continued to work towards a reduction in the incidence of Clostridium difficle infections through active promotion of good infection control practices, early isolation of new cases, high standard of environmental cleanliness and careful use of antibiotics. This work is ongoing in 2016/2017. The following graph shows the cumulative monthly incidence of Clostridium difficile infections for years 2015/16.

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All cases of Clostridium difficle infections are investigated by a multi-disciplinary Post Infection Review team. The outcome of these Post Infection Reviews are reviewed by the Director of Nursing/Director of Infection Prevention and Control, Consultant Microbiologist/Infection Control Doctor and Infection Control Team in collaboration with clinical teams. Where themes and learning are identified, these are shared throughout the organisation. Throughout the Trust on-going interventions include;

Annual review of the antimicrobial policy is now undertaken and specialist services

have guidelines specific to their services

Antimicrobial rounding by microbiologists in liaison with Ward Consultants in medical

and augmented care areas

Continued active promotion of good infection control practices, early isolation of new

cases and maintenance of a high standard of environmental cleanliness.

A continuous programme of training for staff which includes risk assessment and

management of patients with diarrhoea using Infection Risk Assessment Tool (IRAT)

(developed by the IPC Team). This also involves daily liaison with Patient Flow Teams

Annual programme of monitoring of antimicrobial prescribing is undertaken including

use of high risk antibiotics

The Trust recognises that hospital cleanliness is a vital ingredient in the fight against

Health Care Associated Infections (HCAIs) including C Difficile. Results of

unannounced inspections by RQIA, show that the Northern Trust Hospital hygiene

standards are amongst the highest in the region

Domestic services management and the IPC team work in partnership to reduce the

incidence of HCAIs in Trust Hospitals and facilities and are members of hospital

cleaning focus groups. This ensures that patients are cared for in a safe and clean

environment.

Root cause analysis (RCA) of each case of C diff and MRSA by a multi-disciplinary team, to understand why and how the infection occurred.

Learning from audits and RCA outcomes is shared with staff across the Trust Rapid Response teams from Corporate Support Services promptly respond to full bay cleans undertaken after relocation of any identification of C Difficile or viral diarrhoea cases.

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5.4 Pseudomonas aeruginosa Following on from the publication of HSS (MD) 16/2012 and the HTM 04-01 addendum in March 2013, control of Pseudomonas aeruginosa in augmented care units and those units caring for level 1 to 3 babies has been incorporated into the Trust’s Water Safety Plan. Risk assessments have been completed on all augmented care areas and routine water testing carried out in accordance with the relevant guidance. Where Pseudomonas is found in the water supply appropriate remedial action is taken. In addition, Pseudomonas aeruginosa has been added to the list of alert organisms within the Trust and the microbiology service took an active role in the surveillance of clinical cases in both neonates and adults with PHA colleagues, including typing the isolates through the Regional Virus Laboratory in Belfast. During 2015/16 there were seven cases of bacteraemia in adult augmented care patients and a single case of colonisation of a neonate. Of these, none were linked to water from within the Trust or transmission from another patient within the Trust when analysed in accordance with guidance. 5.4.1 Microbiology monitoring of water outlets in augmented care areas and NNUs Microbiological monitoring continues in accordance with HSS (MD) 16/2012 and HTM 04-01a as overseen by the Trust Water Safety Group. Most areas have water testing on a maintenance basis every six months as they have been shown to be clear of colonisation repeatedly. Work has continued within Ward C7 to clear persistent colonisation with the result that only part of the ward can be used for augmented care patients. Whilst this is a new build, the complexity of the plumbing system continues to pose challenges to the remedial actions required. Currently the ward is subject to enhanced flushing regimes and point-of-use filters are used where Pseudomonas is detected to ensure microbiological quality of water. 5.4.2 Patient screening for detection of Pseudomonas aeruginosa Admission and weekly screening of all babies in the NNU for the detection of Pseudomonas aeruginosa continues in accordance with Regional guidance. 5.5 Norovirus Outbreaks All increased incidences of suspected Norovirus and confirmed outbreaks of Norovirus in Trust acute and community facilities are reported immediately to the Public Health Agency Duty Room, followed by daily update reports. There were no outbreaks of Norovirus in any acute ward settings or community settings during the period April 2015- March 2016.

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6.0 Antimicrobial Stewardship 6.1 Antibiotic Policy During 2009/2010 the Trust’s Consultant Microbiologists and Antimicrobial Pharmacists worked with a regional group to develop a revised regional anti-microbial prescribing framework. This policy sought to reduce the usage of co-amoxiclav across the region. It was introduced in the NHSCT in August 2010 and is reviewed and updated annually in accordance with local surveillance patterns and national/regional guidelines. Adherence to the antimicrobial policy is audited weekly via the antimicrobial stewardship audits. This data is used by the antimicrobial pharmacists to produce the following:

A monthly report of compliance to policy and review of therapy after 48 hours. This is sent to all consultants, ward managers and pharmacy staff. See details in section 6.4 below.

A quarterly report of compliance to policy which is tabled at the Antimicrobial Management Team (AMT) meeting and the Infection Prevention Control and Environmental Health Committee (IPCEHC) meeting to support directorates and monitor trends in antimicrobial prescribing.

6.2 Multidisciplinary Antibiotic Stewardship Round Weekly multidisciplinary stewardship rounds commenced in June 2012 on the Antrim site which at present take place on the respiratory wards. In the ward round all patients are reviewed by the multidisciplinary team to assess compliance with policy, suitability for IV to oral switch, appropriate durations, potential to rationales/tailor treatment etc. and recommendations documented in the medical notes. 6.3 Usage of Antibiotics in NHSCT in terms of DDD (Defined Daily Dose)/Occupied bed days The pharmacy computer system changed regionally from the PIL system to JAC in June 2012. Work is on-going on automating conversion of antibiotic usage into DDDs within JAC. Since June 2012 data has been collated manually on antibiotic use for Antrim hospital. The unit of measurement of antibiotic use is the Defined Daily Dose (DDD) which is the assumed average maintenance dose per day for a drug used for its main indication in adults. The DDD is a unit of measurement and does not necessarily reflect the recommended or prescribed daily dose. Drug consumption expressed in numbers of DDDs will only give a rough estimate of consumption and not an exact indication of drug use; however it does allow comparison of antibiotic use across Health and Social Care Trusts in Northern Ireland and the rest of the UK (WHO, 2011). In order to adjust for bed occupancy antibiotic use is expressed as the number of DDDs per 1000 occupied bed days. Bed occupancy data was obtained from the Corporate Information Department.

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The regional antimicrobial pharmacist group aim to share DDD data for agreed agents/groups in line with Start Smart then Focus (SSTF) annually from 2014 onwards. The agents advised in SSTF are broad-spectrum antibiotics such as cephalosporins, co-amoxiclav, piperacillin/tazobactam, fluoroquinolones and carbapenems. Below is the NHSCT data for 2015/16.

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Carbapenem and cephalosporin use remain at a stable low level. The increased use of quinolones was expected as a result of the cycling policy as these were advised first line for certain respiratory and GI indications and the trends experienced follow the advice of the empirical policy. Reassuringly there was no increase in hospital associated CDI cases associated with the increased use of quinolones. After the introduction of the cycling policy in September 2013 the use of co-amoxiclav, macrolides and piperacillin/tazobactam fluctuate according to the expected pattern of restriction and inclusion in the empirical policy.

6.4 Antimicrobial Audit Results and Appropriateness of Exempt Antibiotics On-going audits carried out across the NHSCT on antibiotic use include adherence to the empirical antibiotic guidelines for adults. This audit is carried out by pharmacy staff on a weekly basis where data is collected on a sample of five patients on antibiotics in each adult ward in Antrim, Mid-Ulster, Whiteabbey and Causeway Hospitals. This audit provides a snapshot of what antibiotics are prescribed across the NHSCT for various indications. In some cases antibiotic therapy is not empirical, whereby patients have had previous failed antibiotic courses both in hospital and in primary care and in other cases antibiotics are prescribed based on sensitivity results or as per microbiology advice. In these cases the use of antibiotics is classified as appropriate non-adherence and they are included in adherence figures. In some cases there is uncertainty over the diagnosis or there is insufficient information in the case notes to assess adherence, therefore these cases are classified as indeterminate. Below are the results from April 2015 to March 2016.

Adherence to NHSCT Empirical Antibiotic Guidelines (excludes indeterminate cases) from April 2015 to March 2016

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Average compliance for 15/16 was 90.9%.The target compliance is set at 90% and as illustrated previously this target was missed on three occasions during the year. The reason for the fall in adherence in 2016 is felt to be as a result of increased audits in non-acute sites and seems to be skewed by the frequent use of urinary prophylaxis for greater than the 6 months recommended. As part of the strategy to reduce the emergence of resistance and incidence of CDI the use of certain antimicrobials is restricted and consultant approval is required before they can be used. A NHSCT Exemption Form is required when these antimicrobials are prescribed in order to monitor the appropriateness of their use. All exemption forms received into pharmacy are assessed by the Antimicrobial Management Team for appropriateness of prescribing of restricted antimicrobials. These results are also fed back monthly to consultants, ward managers and pharmacy teams along with the adherence to policy results. Below are the results from April 2015 to March 2016. Use of Restricted Antimicrobials throughout NHSCT (excludes those lost to

follow-up) from April 2015 to March 2016

The target is set at 90% appropriateness and as demonstrated in figure 4 we are consistently falling below this goal. We feedback on a monthly basis the non-validated antibiotics directly to the consultants with an explanation as to why it was felt there was another more appropriate choice. The Trust is unable to benchmark as other Trusts in NI do not have this data.

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6.5 Publications and other activities Education and training given:

April 2015 – Fy0 training by antimicrobial pharmacist and microbiology consultant about treatment of common infections and antimicrobial stewardship

July 2015 – microbiology consultant presentation to clinical pharmacists on antimicrobial treatment and management of sepsis

August 2015 – Induction presentation from both antimicrobial pharmacy and microbiology on antimicrobial stewardship activities in the NHSCT to all grades of doctors

December 2015 – antimicrobial pharmacist presentation of gentamicin prescribing and monitoring to medical staff on the causeway site.

February 2016 - Induction presentation from both antimicrobial pharmacy and microbiology on antimicrobial stewardship activities in the NHSCT to all grades of doctors

March 2016 – microbiology associate specialist presentation to clinical pharmacists on interpretation of microbiological results

March 2016 - antimicrobial pharmacist presentation to level 4 undergraduates in Queens university on antimicrobial stewardship

Queens and UU student hospital placements:

April 2015 – Level 2 placement with specialist pharmacists

October/November 2016 – Level 4 placement for audit facilitation One of the NHSCT antimicrobial pharmacists facilitated the antimicrobial assessment day of the Advanced Pharmacy Practice programme for NICPLD in December 2015. Pre-registration Pharmacists:

May 2015, Dec 2015, March 2016 – 1 Day rotation of current pre-registration student through antimicrobials

Jan 2016 – 1 week rotation of current pre-registration student through antimicrobials

The following external visitors were hosted to demonstrate the current antimicrobial stewardship activities within the NHSCT:

March 2015 – Spanish pharmacist, half day.

October 2015 – Estonian and Swedish pharmacists, half day.

November 2015 – Dutch Pharmacist, half day.

Feb 2016 - Spanish pharmacist for 1 week. The pharmacist published the following in relation to her time in the NHSCT. “International Centres of Excellence in Hospital Pharmacy”; a SEFH new initiative; the role of the clinical pharmacist in the hospital antibiotic stewardship in Northern Ireland. Farm Hosp. 2016;40(4):233-236

The NHSCT lead antimicrobial pharmacist sat on the regional group for implementation of a Regional Medication Kardex which included a dedicated antimicrobial section. This was introduced in July 2015. A post implementation audit was carried out regionally which showed improvements in documentation and positive user feedback. This work was

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presented as a poster in May 2015 at the IDSI 8th Annual Scientific Meeting and was accepted for an oral presentation at the BSAC spring meeting in March 2016, presented by the antimicrobial pharmacist in the BHSCT on behalf of the regional group. The NHSCT Micro APP was launched in November 2015 on European Antibiotic Awareness Day. It contains the Empirical Antibiotic Policy and Surgical Prophylaxis Guidelines. The regional antimicrobial pharmacists group led by NHSCT undertook a Global PPS in March 2015. Data was uploaded and submitted in May 2015. Recent publications include:

Reduction in the incidence of hospital-acquired MRSA following the introduction of a chlorine dioxide 275 ppm based disinfecting agent in a district general hospital. Eur J Hosp Pharm doi:10 1136/ejhpharm-2014-000608. Published August 2015.

Tackling the problem of blood culture contamination in the intensive care unit using an educational intervention. Epidemiology and Infection / Volume 143 / Issue 09 / July 2015, pp 1964-1971

Are we measuring what we intend to measure? Implications for the management of healthcare-acquired infections. Letters to the Editor / Journal of Hospital Infection 92 (2016) 204-211. Published February 2016.

Conference Presentations

LAMPS (Live Automated Microbiology Pharmacy Surveillance System) was presented at the launch of the Medicine Optimisation and Innovation Centre in February 2016 to the health minister.

The LAMPS (Live Automated Microbiology Pharmacy Surveillance) System is being developed using a six phase approach. Phase one and two are now operational. The system receives live data-feeds from multiple existing healthcare databases which allow monitoring of antimicrobial use in relation to policy. Phase two of LAMPS focuses on additional microbiology surveillance data, further antimicrobial performance indicators and early-warnings in the form of automatic microorganism-specific ‘intelligent’ alerts. The NSCHT (Along with the rest of the region) submitted 2014 hospital antimicrobial consumption data to ESAC-net in June 2015.

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7.0 Hand Hygiene 7.1 Clean Your Hands Campaign Previous annual reports have described the Trust participation in the National Patient Safety Agency (NPSA) ‘Clean Your Hands’ Hand Hygiene Campaign which involved four main components:

• Point of care Alcohol hand sanitiser • Awareness posters and signage • Patient, visitors and staff involvement • Observational audit of clinical staff’s compliance with hand hygiene.

Although the national campaign no longer exists, this approach to hand hygiene is embedded and contributes to form a substantial portion of the local IPC work programme: Additionally, to mark the World Health Organisation (WHO) World Hand Hygiene Day in May 2016 the Infection Prevention and Control Nurses (IPCN’s) raised the profile of hand hygiene through promotional posters, staff photographs and awareness sessions throughout the trust hospitals. IPCN’s invited staff and visitors to watch a video clip which demonstrated the correct hand washing technique and take part in a simple hand washing test using ultra-violet light boxes. World Hand Hygiene Day is promoted by the Trust every year to underline the importance of hand hygiene in health care in helping to prevent the spread of infection and reduce an avoidable burden on healthcare systems. World Hand Hygiene Day ‘brings people together’ in support of hand hygiene improvement globally.

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7.2 Hand Hygiene Audits Hand hygiene training is mandatory across the Trust for all staff; the IPC Nursing Team continues to monitor compliance with hand hygiene along with the Department of Health (DH) initiative ‘Bare below the elbow’ with all staff working in clinical areas. The requirement for staff to be ‘bare below the elbow’ when in clinical areas or delivering hands on clinical care is reinforced at all training sessions and compliance is monitored during hand hygiene audits. The IPC Nursing Team continues to use a comprehensive Hand Hygiene Audit Tool across inpatient facilities. The observational elements of this audit tool include:

1. The WHO ‘ 5 Moments of Care’ 2. The 7 step hand decontamination technique 3. Bare below the elbow 4. The use of hand sanitisers after hand washing in Augmented Care settings

In addition, a specially adapted Hand Hygiene audit tool for community staff is used to audit compliance with hand hygiene in domiciliary care. Hand hygiene continues to be a key performance indicator for all wards and departments within the Acute Sector. The IPC nursing team complete independent validation hand hygiene audits on every acute inpatient ward area, at least twice yearly. These are undertaken as a rolling audit programme with the expectation that if an area fails to achieve compliance or there is a cluster of HCAI cases, then additional audits will be undertaken. Direct and immediate feedback is given to staff that are non-compliant to improve the overall safety culture of the organisation. When independent audits scores drop below the accepted level of compliance (90%), then the ward/department manager will be responsible for ‘weekly’ management-led, observed audits of practice for 3 consecutive months, these are known as special measures audits. The results of the independent IPCN audits and special measures audits are reported to the patient safety office for corporate reporting. These audits must also be discussed at Directorate IPC and Governance meetings. Additionally, all staff are encouraged to challenge poor practice when observed and escalate poor compliance to the DIPC, Clinical Director and/ or the Medical Director. The IPC Nursing Team continues to audit hand hygiene compliance weekly in Neo –natal unit (NNU) for assurance purposes in relation to the management of Pseudomonas aeruginosa in NNU.

8.0 High Impact Interventions DH ‘Saving Lives’ High Impact Interventions (HII) or care bundles have been identified as a simple evidence based tool that reinforces the measures that clinical staff need to undertake every time for key procedures in order to significantly reduce infection. Their aim is to increase the reliability of clinical processes and reduce unwarranted variations in care and practice.

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The IPC Nursing Team continues to educate, support and encourage clinical staff to implement these evidence based care bundles. As with hand hygiene audits, the IPC nursing team continue to perform independent clinical practice validation audits on every ward, at least twice yearly. These are undertaken as a rolling audit programme with the expectation that if there is non-compliance with best practice or there is a cluster of HCAI cases, then additional audits will be undertaken. Direct and immediate feedback is given to staff that are non-compliant to improve safe, quality care. If these independent validation audits find standards below the accepted level of compliance (90%), the ward/department manager is responsible for ‘weekly’ management-led, observed audits of practice for 3 consecutive months, these are again known as special measures audits. The results of the independent IPCN audits and special measures audits are reported to the patient safety office for corporate reporting. Furthermore, all staff are encouraged to challenge poor practice when observed and escalate poor compliance to the DIPC, Clinical Director and/ or the Medical Director. In addition, the IPC Nursing Team provided training to clinical staff on Aseptic Non Touch Technique (ANTT) to strengthen compliance with device related High Impact Intervention Care Bundles. ANTT is taught during induction and mandatory training sessions for nursing staff, medical staff and other clinical staff who perform invasive procedures as part of their role. ANTT is also demonstrated during blood culture competency training sessions. The Trust continues to strengthen accountability for High Impact Interventions including Peripheral Intravenous Care Bundle, Urinary Catheter Care Bundle, Central Venous Catheter Care Bundle, Surgical Site Infection, Renal Care Bundle, Ventilator Care Bundle and Management of Clostridium difficile. The Governance Department collates and presents audit compliance results in a monthly Corporate Performance report for Trust Board. The IPC Nursing Team continues to encourage staff to implement the evidence based guidelines for Infection Prevention and Control highlighted in ‘Epic 3’; including daily assessment and prompt removal of indwelling devices that are no longer clinically indicated.

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9.0 Audit 9.1 Regulation and Quality Improvement Authority (RQIA) Audits Between April 2015 and March 2016 RQIA inspected;

Date Hospital Wards Type of Inspection Announced/ Unannounced

June 2015 Antrim A2, B1, C3 Hygiene Inspection Unannounced

Aug 2015 Antrim Neo-Natal Unit Augmented Care Inspection Unannounced

Sept 2015 Causeway Coronary Care Unit, Rehab 1

Hygiene Inspection Unannounced

Oct 2015 Antrim B2, C6, ED Hospital Inspection (includes Hygiene and IPC)

Unannounced

Dec 2015 Causeway ICU Augmented Care Inspection Unannounced

Jan 2016 Antrim ICU Augmented care Inspection Unannounced

The standards of cleanliness and infection control practice were generally high. Where areas of improvement were required, action plans were developed and submitted from each inspection report. 9.2 Independent audits on Management of Clostridium difficile The IPC Nursing Team have also continued to monitor each identified case of Clostridium difficile in an acute clinical Trust setting by undertaking an independent audit to monitor compliance with all aspects of the management of Clostridium difficile. Feedback is provided during Post infection Review meetings and IPCEH Committee. It remains reassuring to note that the majority of Trust areas were found to be compliant with audit scores over 90% when audited. 9.3 Commode/Mattress Audits Commode audits are carried out weekly by ward/department staff; who inspect cleanliness, wear and tear. These audit results are returned to the Clinical Services Managers responsible for that clinical area. Any commodes identified by staff as being damaged, rendering them unable to be cleaned effectively are condemned and replaced. Spot checks are also undertaken by IPCN’s during their daily and weekly clinical visits. There is growing awareness that defective hospital mattresses may contribute to the spread of infections; the integrity and cleanliness of a mattress is essential to minimise this risk. Monthly mattress audits are carried out in all wards and departments; a leak-proof test is carried out on all mattresses to provide assurance that the mattress cover is intact and that the underlying sponge core has not become contaminated. Completed mattress audits are also returned to the Clinical Service Managers responsible for that clinical area. Any mattresses failing mattress audits/inspections are condemned and replaced.

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Infection Prevention and Control Nurses continue to spot check and validate commode and mattress audits during routine clinical visits and Cleanliness Audits. Timely identification and immediate action to `condemn and replace` unfit for purpose mattresses’ and commodes, ensures prompt removal of potentially high reservoirs of infection from clinical areas. The mattress decontamination suite has also contributed to safer decontamination and storage of mattresses. Collaborative work is on-going to develop a secure analytic tagging (SAT) system for traceability of beds and mattresses throughout the Trust.

10.0 Policy Review The Regional Infection Prevention and Control Manual is available for staff to view on the Trust Intranet (Staffnet). The IP&C Nursing team contribute towards policy formulation for the Regional IPC Manual along with Infection Control Teams in other Trusts. This manual is now under review by PHA in collaboration with all Trust IPC Teams. NHSCT Policies relating to IPC are formulated, reviewed and updated and made available on the Trust Intranet (Staffnet). THE IP&C Nursing team also provided evidenced based guidance to departments and facilities to support and assist with the formulation of many Standard Operative Procedures (SOP).

11.0 Training and Education Training requirements for IPC are outlined in the Trusts training needs analysis which forms part of the mandatory and statutory training programme. The IPC team deliver a wide range of evidence based training sessions in a range of formal and interactive formats; to ensure knowledge and awareness of risks relating to healthcare associated infections. Induction Infection Control training is provided to all new staff commencing employment within the Trust during corporate induction and additionally discipline specific inductions e.g., nursing, medical, support services and healthcare assistants. IPC is also included in the corporate induction programme. Update Mandatory Training: A rolling 3 year training strategy incorporates; 1. Three yearly Face to Face training sessions for Nursing delivered as part of mandatory nurse training through Clinical Education Centre. Aseptic Non Touch Technique (ANTT) training has now been incorporated into mandatory training for staff that have direct contact with indwelling medical devices. 2.Two IPC training DVD’s continue to be in use in both Acute and Community care settings, both DVDs are also available to view on Staffnet. The DVDs have Competency

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tools incorporated to be scored by their line manager. A score of 95% must be attained in the competency tool; if this is not successful, a face to face session is recommended. DVDs enable managers to meet their annual infection control training target as part of the IPC 3 year Training Strategy. 3. Face to Face tiered training for non-nursing and medical staff encompasses current issues in infection control e.g. Standard and transmission based Precautions, Root Cause Analysis, Outbreak Management, High Impact interventions including aseptic non-touch technique (ANTT). This year, the IPC team delivered 35 bespoke IPC tiered training sessions to 1258 staff from different staff groups including, Porters, Pharmacists, Chaplains, Catering, Estates, Clerical, Dieticians, Occupational Therapists, Mortuary, Volunteers, etc. Multidisciplinary training continues to be delivered to some groups of Community staff to facilitate community arrangements e.g. Closure days. The IPC team continue to provide formal and impromptu targeted training and information to staff at the clinical interface when required e.g. to action audit findings or address non-compliance with clinical practices. Additional education is provided on a one to one basis in response to patient specific clinical enquiries from wards and departments. Link Nurse and Link Support Worker Training An accredited module for Registered Nurses on the application/management of the Principles of IPC in Clinical Practice is available through CEC. The module is co-ordinated by both CEC staff and the IPC team who deliver theory/practical sessions and act as mentors for the participants of this module. The aim of this course is to enable the practitioner to develop their knowledge and practical skills to manage IPC in the patient/client environment. This practitioner should be allocated specific time for IPC duties, and to attend updates and study days, however fulfilling this commitment has been difficult. Equally a continuous development framework co-exists for health care assistants who wish to become IPC Link Support workers. This programme was conceived some years ago to address the problem of unclean equipment and low equipment audit scores in wards and departments. IPC Link Support workers support the IPC Link Nurses and the IPC team by demonstrating effective IPC practices, leading by example. Twice yearly updates and study days are provided for existing IPC link nurses and support workers. Various educational presentations from a variety of healthcare specialists are delivered to support their role. One of the challenges of this group is attendance from the acute wards, where shift patterns and annual leave inevitably have an impact. IPC Champion awards are presented to Link Staff who have been nominated for implementing initiatives or supporting IPC changes in their department, staff who are a good role model and visible advocate for IPC.

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ANTT Training The IPC Team have implemented the nationally-recognised ANTT (Aseptic Non Touch Technique) programme. The IPC Nursing Team continue to provide individual ANTT training at the clinical interface to strengthen compliance with device related High Impact Intervention Care Bundles, in particular insertion and on-going care of peripheral cannula, urinary catheters and Blood Culture collection and competency assessment. The IPC team was able to source funding to support the purchase of mannequins for ANTT training. Stoolsmart Training Additional focused IPC training is also delivered to address concerns with inappropriate faecal specimen collection in areas where this has been a concern. ‘Stoolsmart’ training continues to be delivered by IPCN’s to nurses and healthcare assistants at ward level to enable cascade training to continue within that clinical area. It has also now become part of mandatory training for all clinical staff. Infection Prevention & Control Team The majority of the IPC team are members of the Infection Prevention Society (IPS), they receive specialist journals as a benefit of membership which also aids development. IPS Members attend Regional branch meetings which provide the opportunity for professional update and networking. Some members of the IPCT hold regional posts within the IPS, the Lead IPC Nurse in the Trust was Chairperson of the NI IPS Branch during 2015/2016. Representatives of the team attended the IPS Annual Conference which provides not only an excellent scientific programme but the opportunity to network with other specialists and share information.

12.0 Infection Control Team Initiatives 12.1 Infection Control Information and Fast Fact Sheets Infection Prevention & Control is included on the Trust website for patients, relatives and visitors, additionally on the IPC section of Staffnet are patient and visitor information leaflets on Hand Hygiene, MRSA, Norovirus, Clostridium difficile, ESBL, Scabies, Food poisoning, etc.as well as information sheets on reducing the risk of infection whilst in hospital. The above-mentioned leaflets are available in clinical areas as well as leaflets and posters regarding hand hygiene. Infection Control information is also included in the bedside booklets. To complement existing IPC policies the IPC team have developed Fast Facts education sheets. These are concise information sheets on various topics relating to infection control that can be discussed at ward meetings/huddles to raise awareness for clinical staff. Topics covered include Gastroenteritis, Influenza, Management of Sharps, Carbapenemase Producing Enterobacteriaceae (CPE), Standard precautions, etc, these are available on Staffnet. Included on the website are information and care bundles on MRSA screening and eradication, management of patients with C difficile infection, management of Outbreaks, etc. Additional IPC training resources are incorporated on the IPC Staffnet site also.

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12.2 Infection Risk Assessment Tool (IRAT) This risk assessment tool was devised to provide nursing staff with the means to identify and risk assess patients with known or potential IPC risks, ensuring they are placed safely and appropriately in wards. Additionally this tool enables ward staff to communicate information on infection risks between various disciplines, e.g. the patient flow and IPC team to assist them prioritise isolation demands when bed occupancy is high, particularly in wards where the number of side rooms is low. A Risk Assessment road-show was held in October 2015, where staff worked through various scenarios and workshops to assist them with robust isolation risk assessment. The information documented on the IRAT’s is audited periodically to ensure all the relevant details and assessments are recorded to ensure a seamless risk assessment process. A ‘Diarrhoea Decision Tree’ (flowchart) was also devised to assist staff with the prompt management required for patients with diarrhoea. 12.3 Student Nurse Education and Placement The IPC Team continue to offer a Practice Placement for 3rd year student nurses who are supported by dedicated IPC mentors. This placement experience positively influences student nurses to promote and embed safe, quality care at an early stage in their nursing career. It encourages them to reflect on their own practice and it empowers them to confidently influence colleagues and challenge poor practices of others. This has enriched the learner experience, in preparation for entering the nursing workforce as a practitioner who will promote optimum IPC standards. 12.4 Temporary IPC Secondment Post During the winter of 2015 the IPC team had the opportunity of inviting IPC Link nurses to apply for a full time IPC secondment post. This was a professional development opportunity for a link nurse to act a member of the IPC team for 3 months to support them during a time of markedly reduced staffing levels and service pressures. Simultaneously a Band 3 IPC Link support worker was seconded with the IPC team for a few hours per week over a 3 month period. This support worker was trained to undertake audits of hand hygiene, use of personal protective equipment by staff and standards around cleaning and decontamination of equipment and the patient environment. Any observed gaps in practice were fed back to the IPC nurse responsibility for that particular ward. 12.5 Augmented Care Focus Group Meetings The purpose of this focus group was to have a collective discussion on the views and experiences in relation to RQIA Augmented Care inspections; and to provide assurance on the robustness of the systems and processes in place to ensure a consistent approach to clinical interventions in Augmented Care settings. The first meeting was held on March 2015, and it was useful to gain insight into staff’s shared understanding of the RQIA audit process and the expected 3 year continuous improvement programme. It was recognised that whilst managers found the inspection process challenging, they acknowledge that this has raised awareness of accountability and there has been more focused activity directed towards continuous improvement. Whilst the IPC team provide on-going support, it was encouraging to observe that the group have supported each other through the inspection process and have shared their learning and actions towards reducing variation in practice.

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12.6 IPC and Corporate Communications Department The IPC Nursing Team in partnership with the Corporate Communications Department submitted regular updates to promote awareness and involvement to Trust staff, patients, visitors and the public on specific infection control topics. 12.7 Infection Prevention and Control in the Built Environment The Trust has recently undergone significant refurbishment in many clinical areas and has invested in New Build projects both in the Acute Setting and in the Community. The IPC team has been heavily involved from the planning stage with all new building and refurbishment projects and has provided expert advice on key factors within the built environment which can impact on the control of infection. During 2015/2016, the IPC team have been able to provide expert advice into every stage of the following new build and refurbishment projects to ensure that the building design features will minimise the risk of transmission of infection within a healthcare environment. These projects included;

Ballymena Health and Social Care Centre

A1 Refurbishment

New Out-Patient Dental build, Antrim Hospital

Causeway ED Refurbishment

Mid Ulster Pharmacy Refurbishment

Renal Unit Refurbishment

The following refurbishment projects are on-going;

Antrim Hospital ICU Refurbishment

Day Case Theatres Project

Antrim Hospital MRI Unit

12.8 On Call Service The Infection Prevention and Control Nursing Team have continued to provide an ‘on call’ service to the Trust as follows and continue to provide additional service in times of increased incidence or escalation: Monday to Friday; 515pm – 8.45am; Weekends and Public Holidays; 8.45am - 8.45am.

13.0 Conclusion There continued to be very high levels of activity across the Trust in relation to all aspects of Infection Prevention and Control. The Trust remains fully committed to maintaining the highest possible standards in relation to Infection Prevention and Control and will continue to maintain a very high focus on this in 2016/2017. It was extremely challenging for the Trust to attain the target set for C. difficile for 2015/2016. Considering the unprecedented rise in cases over the first half of the 15/16 year, this was a good achievement.