Worcestershire Health and Care NHS Trust

Provide a brief overview of your project?

One component of the Trust Antimicrobial Strategy is linked to the ongoing monitoring of antibiotic usage in real time in the absence of E-prescribing.  This project has been managed and developed by the Trust Infection Prevention and Control (IPC) Team in conjunction with pharmacy and clinical teams.  It is acknowledged that whilst supply data is available it did not provide reliable information on actual prescriptions or indications for use.  The process developed has provided the opportunity to:

• Review antibiotic prescribing quarterly across all inpatient community and mental health areas (number of patients on each review ranges from 250-350) enabling collection of trend data linked to patient demographics, antibiotics used and their appropriateness (e.g. % of patients on antibiotics during stay range 23-40; on the day 11-18) and documented need for the agent.  Findings inform development of guidance, in 2018, succinct escalation antibiotic guidance was drafted for community hospital patients linked to frailty based on findings from the review, compliance with this and Trust Antimicrobial Prescribing Guidance is measured providing a real time footprint of antibiotic usage for each ward to identify issues, celebrate success and inform actions and learning.
• Share with prescribers and wider Trust information linked to prescribing of antibiotics thus enhancing knowledge of stewardship activities and promoting compliance.
• Ensure IPC update sessions accurately detail prescribing information and facilitate novel teaching sessions to raise awareness of stewardship responsibilities for all healthcare staff including provision of a ‘STRICTLY ANTIBIOTICS’ session involving over 100 staff to “keep antibiotics working”.

Undertaking reviews prompts discussion with healthcare staff and patients enabling valuable messages promoting stewardship to be shared enhancing patient and staff knowledge.  Additionally, they enable informal reviews of key IPC practices that supplement the Trusts formal programme promoting prevention of infection, enhanced stewardship, reduction of antibiotics and ensuring human factors are addressed.

Please cite 3 examples of outcomes or impacts from the project on tackling AMR.

Outcomes/Impacts from this project include:
• Increased commitment, engagement and knowledge of staff on stewardship activities based on personal communications out from IPC and Pharmacy Team and Medical Director, social media, review findings and education.  For example, the adoption of NICHE concept in documentation, use of relevant prescribing guidance and importance of prompt and accurate diagnosis.  Promotion of the need for the reason to be documented has occurred and data collected indicates increasing compliance with this being recorded on the drug chart by the prescriber, as opposed to not indicating or indicating in patient notes alone.  A reduction in attributable Clostridium difficile cases in the Trust has been recorded (as of Jan 2019 one case in 2018/2019).
• The opportunity for patient discussion at time of monitoring their drug chart during the quarterly reviews enhances patient knowledge and has facilitated discussion linked to infection and how infections such as Urinary Tract Infections (UTIs) are treated thus increasing patient awareness, knowledge about their treatment, how to prevent infection and also the importance of accurate information on reported allergies.  This has led to wider healthcare staff discussing at the bedside the need for stewardship, what it means and the importance of preventing infection including use of vaccination as a tool to reduce antibiotic usage.
• Availability of assurance data linked to antibiotic usage within the Trust informs on agents used and documented reason.  It also provides trend data for agents and wards, demonstrating levels of compliance with Trust guidance and assists in development of further guidance if indicated.  Data ensures targeting of awareness raising and education based on a real time picture.  A workbook is currently available in draft format due for launch in April which sets out to further enhance knowledge and practice within the Trust.

How is the project to be developed in the future?

The actions and outcomes demonstrate commitment to stewardship and these will continually be enhanced with regular celebrations and shared learning particularly during Antibiotic Awareness events and through social media to further enhance knowledge and commitment.
The integration within IPC will continue as stewardship is an essential component in the Trust four key IPC elements which include preventing infection, using antimicrobials wisely, promptly diagnosing infection and ensuring appropriate management and precautions to prevent spread.
The process in place provides strong foundations to promote future guidance.  It is proposed to consider additional guidance linked to UTIs and the process will support the development of this guidance and enable compliance and outcomes to be monitored.
The value of the process in providing assurance data and monitoring of trends over time linked to antibiotic use, appropriateness, compliance with guidance cannot be underestimated at the point of care as it provides many opportunities to further promote stewardship and IPC at ward level and understand barriers including human factors that may be present which limit compliance.

Health Protection Scotland

Provide a brief overview of your project?

Preventing infections reduces the overall need to use antimicrobials and helps to reduce selection pressure for the development of antimicrobial resistance. The NHSScotland National Infection Prevention and Control Manual (NIPCM) http://www.nipcm.hps.scot.nhs.uk/ was first published in January 2012.  This evidence based guidance is mandatory for NHSScotland. In all other care settings, to support with health and social care integration, the content of this manual is considered best practice.  The NIPCM has supported Scotland in standardising infection prevention and control precautions; aligning practice, monitoring, quality improvement and scrutiny.

In developing the NIPCM colleagues representing health and social care from across Scotland meet regularly to agree the content of the national policy.  This ongoing collaboration is important and ensures the guidance produced:
• Is in a format relevant, applicable and accessible to all frontline care staff
• Informs and complements the content of IPC/HAI education programmes and tools
• Supports improvement programmes, including the development of national and local measurement plans and tools

The advantages of this standardised guidance approach include a common understanding of Infection Prevention and Control (IPC) practice requirements; simple rules for all staff (specialist and generalist) leading to improved understanding and consistency of application – which is the underlying principle of the NIPCM.  This approach seeks to support the development of a NHS workforce that is IPC knowledgeable and prepared to effectively respond to current and emerging infection threats.

It is important to point out that the content of the NIPCM is not fixed; it is updated real time; the Health Protection Scotland National Policy, Guidance and Outbreak Health Protection Programme Team continuously monitor the published literature for any new evidence, revising the literature review(s) and practice guide accordingly.  All of the NIPCM literature reviews also highlight gaps in IPC evidence and are accessible to all interested researchers.

Please cite 3 examples of outcomes or impacts from the project on tackling AMR.

Lowering the burden of human infection will lead to fewer antimicrobials being used and less risk of resistance. That puts preventing and managing infections firmly at the core of any AMR strategy.  Ensuring that health and social care providers have the capacity, capability, physical environment and tools for effective infection prevention and control (IPC) is critical.

This once for Scotland approach has the potential to save Infection Prevention and Control Team (IPCT) time in not duplicating effort on policy development which may otherwise be spent on other infection prevention and control activities, such as supporting implementation of guidance and practice improvement.

A further opportunity is the level and consequence of engagement with all stakeholders; a Consensus Group of frontline care staff across the care sectors has continued to formally work with Health Protection Scotland to agree content of the NIPCM; and overarching the Consensus Group is a stakeholder Steering Group, ensuring good governance and suitability of content for care settings/specialities.

The NIPCM has been mandated in NHS Scotland and adopted by Public Health Wales, endorsed by all Chief Officers in Scotland, and recognised internationally as an innovative approach to IPC policy and guidance production.

How is the project to be developed in the future?

Health and social care providers have a key role in preventing and controlling infection (and its contribution to the growth of AMR) through their policies and practice. Individual workers can be vectors for infection in health and care settings; and healthcare facilities are often a reservoir for infection and resistance (Tackling antimicrobial resistance 2019–2024 The UK’s five-year national action plan, published 24 January 2019).  The 2019 UK’s five-year national action plan mandates that England will adopt the Scottish NIPCM and care standards.  Exciting times ahead as we continuously develop the content of the NIPCM… the principal author of the NIPCM has been working with NHS Improvement as a Clinical IPC Fellow over the last year developing a national hand hygiene policy for NHS England – due to be launched on 13th March 2019.

Delivered Health Solutions

Provide a brief overview of your project?

TECCare is one of the world’s most advanced infection prevention and control products, relied upon by organisations as varied as the health care providers to national governmental bodies, to tackle serious outbreaks and keep them at bay.

TECCare comes in three solutions, providing world class antimicrobial technology platforms that are designed to interrupt the transmission pathways that spread of bacteria, viruses, fungi and bacterial spores across surfaces, air and skin. The product twins the highest standards of antimicrobial efficacy with an incredible level of safety, setting it apart from all competitor disinfectants and solutions.

As an example, TECCare Control, the cleaning and disinfectant solution, is effective against all microbial classes up to and including bacterial spores. Control causes rapid and significant changes at multiple sites of microbes, including denaturation of essential microbial proteins and physical disruption of membrane lipids. This is typically lethal to microbes within minutes of contact.

TECCare Protect transfers this same impact into a skin sanitiser, providing unrivalled efficacy for settings where infection prevention and control is essential. It is water based, alcohol free, moisturising, non-toxic and fully safe in use.  In lab-tests it has been proven to offer prolonged antimicrobial effects for up to 2 hours.

TECCare Ultra is the safest and most potent spondaic disinfectant on the market. Its hydroxyl free-radicals destroy microbes in less than five minutes. Extensive testing demonstrates exceptional levels of log reduction in contact times between 1-5 minutes for a range of bacteria, fungus, virus, spores and mycobacteria. In independent lab tests it was proven to have the longest efficacy versus competitor solutions.

TECCare is provided in a host of solutions, including canisters, wipes, spray and pump dispenser, fulfilling all customer requirements.  As a non-corrosive, non-irritant, non-toxic, food safe, safe in use and cost-effective product, it twins unparalleled impact with practicality in reducing the bioburden.

Please cite 3 examples of outcomes or impacts from the project on tackling AMR.

1) Ultra has been independently assessed as the safest, most potent sporicidal disinfectant available, destroying microbes in less than five minutes. In extensive testing, it demonstrated exceptional log reduction levels in contact times between 1 and 5 minutes for a host of bacteria, viruses, fungi, bacterial spores and mycobacteria. For example, Ultra achieves a greater than Log 6 reduction in C.difficile spores, within one minute. It has been assessed as providing the highest sustained efficacy on all microbial classes, compared to all competitor deep clean agents.
The advanced chemistry behind the Control technology platform has resulted in the production of a 6th generation quaternary ammonium compound (QAC). With 5th generation QACs offering outstanding levels of antimicrobial activity, this ‘next-level’ product offers unsurpassed excellence.

2) The single-step cleaning and disinfectant solution, TECCare Control, provides a powerful lytic agent that is lethal to the cellular structures of microbes. With a low-use of chemicals, and a chlorine and alcohol-free solution, it is safe in all settings. Control gives a greater than Log 3 reduction in C. difficile spores within a 60-minute contact time when used with hard water and under ‘dirty’ conditions. This impact is matched by the skin solution TECCare Protect, which has been assessed as offering an antimicrobial impact up to two hours after application.

3) TECCare has been used extensively in many settings where containing and controlling microbial activity is vital – from international agencies responding to humanitarian crises through to NHS and care settings.

In one of the UK’s largest care homes groups, it reduced the number of days where its portfolio has been affected by a D&V outbreaks from 330 in 2014 to 130 in 2016, an astonishing 61% reduction. At Yeovil District Hospital NHS Foundation Trust, TecCare generated an 80% improvement in cleanliness in testing of 24 key hospital locations.

How is the project to be developed in the future?

Delivered Health Solutions, one of the UK’s leading infection prevention, control and training organisations are leading the implementation of TecCare across the UK. With the technology and products leading to significant results for major care home groups, NHS settings and even professional sports clubs, it is bringing results in a number of sectors. To support the NHS to adapt to this leading solution, Delivered Health Solutions will be launching a major clinical trial with a large North West STP, which will assess the overall impact of this product being used in large health centres and hospitals – reviewing the overall infection control, prevention and wellbeing impact of the product.
As members of Bunzl Healthcare, Delivered Health Solutions are in an exceptional position to develop TecCare and scale its impact across the UK.

Oldham Care Organisation, Part of the Northern Care Alliance NHS Group

Provide a brief overview of your project:

The incidence of C.difficile infections (CDI) was identified to be a recurring problem on the gastroenterology ward at The Pennine Acute Hospitals NHS Trust. The problem was compounded in 2014 when an outbreak of the hypervirulent 027 strain of CDI occurred in the Trust, which was mostly concentrated on the gastroenterology ward. In response to this, an action plan was developed to mitigate any further cases. This included a number of different work streams being introduced concurrently and sought support from the wider multidisciplinary team to maximise its impact.

As a result of the interventions the rate of CDI attributed to the ward fell by 71.4% from 2015/16 (n=7) to 2016/17 (n=2) and the occurrence of ribotype 027 fell from 4 in 2015/16 to 0 in 2016/17. The interventions resulted in a 17. 5% reduction in the DDD/1000 bed days occupied (BDO) of all antibiotics, 25.6% reduction in the DDD/1000 BDO of carbapenems and a 45.9% reduction in the DDD/1000 BDO of “high risk antibiotics” prescribed. Furthermore there was an average 25.5% increase in compliance with infection control standards during the intervention period.

Cite 3 examples within the project which highlight promotion of the protection of antibiotics?:

Multidisciplinary team meetings were used as a platform to educate the ward’s medical and nursing staff regarding all aspects of antimicrobial stewardship, the importance of prudent antibiotic prescribing. Ward specific antimicrobial guidelines were developed by the microbiology and pharmacy team to promote the use of narrow spectrum antibiotics. Daily visits by the care organisation’s antimicrobial pharmacist helped to ensure that all antibiotics prescribed were reviewed regularly and that an appropriate prescribing decision was made. All of these interventions resulted in a 17. 5% reduction in the DDD/1000 bed days occupied (BDO) of all antibiotics, 25.6% reduction in the DDD/1000 BDO of carbapenems and a 45.9% reduction in the DDD/1000 BDO of “high risk antibiotics” prescribed.

How is the project to be developed in the future?:

The value of this project on improving patient safety has been recognised and the format is being replicated on other wards in the Trust to improve patient care. Due to the nature of the project it is can be easily adapted to facilitate the control of other infections and can be scaled accordingly.

St John Ambulance and University Hospitals of Leicester NHS Trust

Provide a brief overview of your project:

Antimicrobial pharmacists from the University Hospitals of Leicester NHS Trust work with a team infection prevention nurses, one of which is a volunteer for St John Ambulance (SJA) in the role of Infection Prevention Lead in the East Midlands (North). Together the development of a unique educational session and public awareness campaign was created.

The vast majority of volunteers within St John Ambulance are not healthcare professionals and are trained to provide first aid at a variety of different events from village fairs to providing cover at large stadiums and music festivals. There are also healthcare professionals from all disciplines including nurses, doctors, midwives and those from the allied healthcare sector.

The St John Ambulance infection prevention lead provided an educational session for a large number of St John Ambulance volunteers and covered topics such as antimicrobial resistance, the use of antibiotics and the importance of antimicrobial stewardship. This provided a fantastic opportunity for discussion and questions to be raised and some wrongs to be righted! All volunteers were asked to sign up as Antibiotic Guardians on the AG website and ask friends and family to also pledge.

Whilst providing first aid cover for the Leicester Tigers there was an opportunity to deliver further antimicrobial stewardship education to volunteers not at the education session. Antibiotic Guardian pledge posters were printed out and given to the volunteers enabling them to make an antimicrobial stewardship related pledge. Pictures of the pledges were taken and posted on social media accounts to raise awareness within the first aid community and ambulance services.

Cite 3 examples within the project which highlight promotion of the protection of antibiotics?:

The project highlighted to protect antibiotics via the following three ways in line with national public health campaigns:

1: Providing education for St John Ambulance volunteers in Leicester about antimicrobial resistance, what it is, why it is increasing and what the volunteers can do to reduce the risk of antimicrobial resistance. The use of small discussion groups were fundamental in the session, this allowed the SJA infection prevention lead to gauge the level of understanding among the volunteers. Many of the volunteers were not aware of the gravity of the situation and were shocked to discover that there were simple actions to help prevent antimicrobial resistance increasing.

2: St John Ambulance volunteers were also educated about the appropriate use of antibiotics. Key messages such as antibiotics only work for bacterial infections and not viruses were provided, this was new information for many of the volunteers.  Which infections are caused by bacteria and viruses along with education regarding the culture associated with ‘patients expecting/demanding antibiotics from doctors’ were communicated in interactive way.

3: St John Ambulance volunteers were also educated about the importance of preventing infections. Hand hygiene is very important to minimise the spread of infection to friends, family and themselves. Understanding the importance of preventing infection is essential for all volunteers providing first aid at events. Education regarding transmission of infection, safe removal of personal protective equipment and effective decontamination of the environment are also provided.

How is the project to be developed in the future?:

1. To continue to work with antimicrobial pharmacists at UHL to ensure current research and understanding is being delivered to St John Ambulance volunteers at an appropriate level.
2. To increase the education of antimicrobial stewardship awareness to the other areas within the region (Derby, Nottingham, Lincoln and Northampton). There are many adult units in each area that have received no information regarding antimicrobial stewardship and increasing awareness is essential to volunteers providing first aid treatment. To provide refresher training for Leicester based units.
3. To increase the education and support for those volunteers who provide first aid treatment during events in the importance of preventing infections and understanding how to provide advice to those individuals that present with potentially infected wounds.
4. To promote the Antimicrobial Guardian pledge and for many more volunteers to sign up to the website.