Journal of Perioperative Practice
PROCUREMENT GUIDE May 2015 Volume 04 Issue 02 01423 881300 www.afpp.org.uk
01423 881300 www.afpp.org.uk
Journal of Perioperative Practice PROCUREMENT GUIDE May 2015 Volume 04 Issue 02 www.afpp.org.uk
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Contents 03
Journal of Perioperative Practice PROCUREMENT GUIDE May 2015 Volume 04 Issue 02 www.afpp.org.uk
Welcome to your May 2015 Guide 05 A cause for concern:
10 Product news:
08 Product news:
11 Product news:
Prevention is better than cure
Pre-warming to reduce risk of inadvertent perioperative hypothermia
09 Product news:
Are you putting your patients at risk?
VacSax
11 Product news: Optimus
New triple enzyme giga zyme速 foam
Journal of Perioperative Practice Procurement Guide information In print within the AfPP Journal of Perioperative Practice covering national AfPP members, but also with a dedicated print and e-distribution to supplies and purchasing managers. Key Sectors: NHS Supply Chain, Independent Hospitals, Higher Education. Medical Device Companies. Published 6 times a year we will focus on procurement issues in every edition as well as specialist subjects which for the following year include:
July 2015 Consumables/Innovation September 2015 Airway Management/Anaesthesia November 2015 Safety/Sharps January 2016 Recovery/Patient Warming
Contact Information: Advertising, Sponsorship & Partner Packages. Frances Murphy Account Manager Open Box M&C T: 0121 200 7820 E: frances.murphy@ob-mc.co.uk Editorial Chris Wiles Head of Publishing/Editorial AfPP T: 01423 882950 E: chris.wiles@afpp.org.uk
PR & press material. All press releases welcome and we will feature as many as we can in each issue, all press releases need to be submitted to: Frances Murphy Account Manager Open Box M&C T: 0121 200 7820 E: frances.murphy@ob-mc.co.uk
Journal of Perioperative Practice PROCUREMENT GUIDE May 2015 Volume 04 Issue 02 www.afpp.org.uk
Product News 04
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Journal of Perioperative Practice PROCUREMENT GUIDE May 2015 Volume 04 Issue 02 www.afpp.org.uk
Infection Prevention
A cause for concern: Prevention is better than cure The care of the patient undergoing an anaesthetic and surgical procedure is delivered by a complex team of perioperative staff with each member of that team playing a significant part in ensuring that the risks to patient are kept to the minimum, regardless of their professional status. The risks of surgery are well documented (Weaving 2008). This dynamic interaction with the patient is focused on ensuring that the extrinsic perioperative environment (Clancy et al 2002) is maintained at such a level that the patient’s intrinsic physiology is maintained, assisted and regulated (NICE 2008) to provide a stable platform for recovery and rehabilitation (or to a peaceful death) (Henderson 1966): • Homeostasis, also spelled homoeostasis (from Greek: ὅμοιος homœos, ‘similar’ and στάσις stasis, ‘standing still’ (Wikipedia 2015) • Examples of homeostasis include the regulation of temperature and the balance between acidity and alkalinity (pH). It is a process that maintains the stability of the human body’s internal environment in response to changes in external conditions (Rogers & McCutcheon 2015). Any surgical intervention exposes this internal environment to the risk of postoperative surgical site infection (SSI) (Public Health England 2014): • A surgical site is the incision or cut in the skin made by a surgeon to carry out a surgical procedure and the tissue handled or manipulated during the procedure.
• A surgical site infection occurs when micro-organisms get into the part of the body that has been operated on and multiply in the tissues. • Infections of the surgical site account for approximately 16% of all hospital acquired infections (HAIs), are estimated to double the length of postoperative stay in hospital and significantly increase the cost of care. The Right Honourable Joseph Lister, 1st Baron Lister [1827 - 1912] Wellcome Library, London
Lister’s antiseptic technique of surgery 1867 (Chandak 2014) recognised the significant burden on a patient’s homeostasis that continues today during your operating list. Superficial, deep or organ space/joint SSIs diagnosed prior to a patient’s initial discharge from hospital, within 30 days of surgery and with implants up to one year following surgery, demonstrate that a breakdown of environmental homeostasis has occurred and must be investigated for key factors/ potential risk factors described by Consultant Microbiologist Dr Peter Wilson (2015): • The category of the wound (e.g. is it clean or contaminated) • Presence of prosthesis or drain • Prolonged surgery • End of list operating (tired surgeon and team can affect technique)
• Surgeon (level of experience) • Aseptic technique (surgeons vary in standards of aseptic technique) • Length of preoperative stay (longer length of stay increases exposure to healthcare associated pathogens in environment) • Carriage of Staph aureus (carriers are three times more likely to have poor wound healing) • Old age ( ageing population with chronic illnesses / steroids at risk) • Obesity (BMI increases rate of infection) and many more.
In our opinion However let me concentrate your minds on a particular issue raised by observers of orthopaedic perioperative team’s practice, which, I believe, can be translated to all surgical specialities? After a worldwide investigation into the prevention, diagnosis and treatment of periprosthetic joint infections (Parvizi et al 2013) a consensus statement was published on question responses, which the majority of surgeons agreed on (amazing really). Two hundred and seven questions were asked. For a super majority, indicating a strong agreement, 66-99% of respondents need to agree. Only one question received a unanimous vote, 100% response agreement, on the statement that: • Operating theatre staff traffic should be kept to a minimum When many theatre teams face maintaining safe recommended staffing levels (AfPP 2015), is >>
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Journal of Perioperative Practice PROCUREMENT GUIDE May 2015 Volume 04 Issue 02 www.afpp.org.uk
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this significant viewpoint on the world wide theatre team discipline just a new worrying concern in need of a robust response or a well known failing of us all?
A reasoned response AfPP (2011) Standards and Recommendations for Safe Perioperative Practice recognises that people are the main source of infection, and that: • The purpose of controlling traffic (that is, movement within the theatre) is to minimise movement of bacteria from the theatre environment itself, theatre personnel and patients. • Only the number of personnel required to manage the case safely should be present in theatre.
Infection Prevention
• There should be a restriction on movement and talking within theatre. • The doors to the operating theatre should remain closed to ensure the effective ventilation of the area as far as possible, all potential equipment and supplies for a case and / or list should be available prior to the case commencing. This will reduce the traffic in and out of theatre and therefore maximise the efficiency of the ventilation system. • People are the main source of infection therefore the number of visitors to the theatre environment should be restricted. However, from queries placed with AfPP’s professional advisory service, discussions
with study day delegates, and coffee room chatter the number of ‘visitors’ having to be accommodated daily, appears to, on reflection, identify challenging issues?
Introducing visitors to the basics of theatre discipline in a timely manner can be difficult, rushed and in the constraints of current team working practice, difficult.
Not just numbers
This increased body count in theatres raises the threat of surgical field and instrument trolley contamination and although horizontal trolley and tray surfaces/contents are recognised as restricted clinical areas, breaches of their integrity need to be identified even before surgery begins.
Providing medical, nursing, paramedical (ambulance, physiotherapist, pharmacist and occupational therapists) the opportunity to follow a patients care pathway is vital but not without risk. Clear guidelines and policies for these visitors within the theatre environment must support theatre staff supervising and teaching students, whilst at the same time ensuring environmental infection control standards are not breached (Weaving et al 2008).
Increased movement by personnel past these items is a risk as is equipment at different height levels: the Mayo table / main instrument trolley(s) / operating table (which may be raised and lowered).
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Journal of Perioperative Practice PROCUREMENT GUIDE May 2015 Volume 04 Issue 02 www.afpp.org.uk
Increasing complexity of surgical procedures require a significant number of instrument trays, supplementary items and pharmaceutical items. Each item transfer into the surgical field requires positive observed action and intent by the scrub practitioner and circulating staff: is this item sterile, in date and safely transferred? Space occupying supplementary devices, such as image intensifiers, add to the demand for movement and space, non-theatre operators and raise spacial awareness threats to surgical team. All these bodies/equipment increase the burden on ventilation systems. Increased rate of access in and out of theatre for breaks, stock collection and changeovers increases risk index.
Time The turnaround time and surgical instrument set up time appears to be increasing in direct relationship to the complexity of the surgical intervention intended, the level of experience of the scrub practitioner and the number of student Operating Department Practitioners (ODP) / newly appointed / qualified Registered Nurses (RN) requiring supervised learning opportunities. Although preoperative team briefing, list planning and orthopaedic implant templating should ensure that equipment and implants are readily available for use. Anatomical anomalies, dropped instruments, specimen handling and untoward incidents also add to theatre traffic.
Conclusion Our current safety first target driven culture seeks to balance care of the patient, service and education outcomes. Kate Woodhead’s (Past President NATN) recent review (2015) of the The Code of Practice and Control of Infection 2008 (The Health and Social Care Act (Regulated Activities)) highlights compliance criteria which should challenge the perioperative team’s commitment to develop
Infection Prevention
Infections of the surgical site account for approximately 16% of all hospital acquired infections (HAIs), are estimated to double the length of postoperative stay in hospital and significantly increase the cost of care.
and sustain periopstasis (i.e. maintaining ideal conditions within the operating theatre): • Systems to manage and monitor the prevention and control of infection. These systems use risk assessment and consider how susceptible service users are and any risks that their environment and others users may pose to them • Provide and maintain a clean and appropriate environment in managed premises that facilitate the prevention and control of infections. Your environmental thought for the day (Chandak 2014): “There is only one rule; put yourself in the patient’s place.” - The Right Honourable Joseph Lister, 1st Baron Lister [1827-1912] Adrian Jones Surgical Care Practitioner, Norfolk & Norwich University Hospital AfPP Trustee/Vice President References Association for Perioperative Practice 2011 Standards and Recommendations for Safe Perioperative Practice (3rd Ed) Harrogate, AfPP (pp182-183 & 191) Association for Perioperative Practice 2014 Staffing for Patients in the Perioperative Setting Harrogate, AfPP Chandak P 2014 RCS / J&J Lister Essay Prize Winner [online] Available from: www.rcseng.ac.uk/courses/ documents/lister-2014-winner/ view [Accessed March 2015] Clancy J, Mc Vicar, Baird N 2002 Perioperative Practice: Fundamentals of Homeostasis Abingdon, Taylor Francis Ltd Henderson, Virginia (1966). The Nature of Nursing: A Definition and its Implications for Practice, Research and Education New York, Macmillan Publishing
National Institute for Health Care and Clinical Excellence 2008 NICE clinical guideline 74: Surgical site infection. Prevention and treatment of surgical site infection [online] Available from: http://www.nice. org.uk/guidance/cg74/resources/ guidance-surgical-site-infectionpdf [Accessed March 2015] Parvizi J, Gerhrke T, Chen A 2013 Speciality Update: Arthroplasty - Proceedings of the International Consensus on Periprosthetic joint Infection The Bone and Joint Journal 95-B 1450-2 Public Health England 2014 Surgical site infection (SSI): guidance, data and analysis [online] Available from: www. gov.uk/government/collections/ surgical-site-infection-ssiguidance-data-and-analysis [Accessed March 2015] Rogers K, McCutheon K 2015 Four steps to interpreting arterial blood gases Journal of Perioperative Practice 25 (3) 46-52 Wikipedia 2015 Homeostasis [online] Available from: http://en.wikipedia.org/wiki/ Homeostasis [Accessed March 2015] Weaving P, Cox F, Milton S 2008 Infection prevention and control in the operating theatre: reducing the risk of surgical site infections (SSIs) Journal of Perioperative Practice 18 (5) 199 -204 Wilson P 2014 Reducing HCAIs 2014 - The Worldwide Effort Conference: New approaches to surgical site infection prevention [online] Available from: http:// worldwide.hcais-conference. co.uk/index.php?option=com_ elem&elemid=1795&Itemid=256 [Accessed March 2015] Woodhead K 2015 Code of practice on HCAI prevention The Clinical Service Journal March Ed 17-19
Product News 08
Journal of Perioperative Practice PROCUREMENT GUIDE May 2015 Volume 04 Issue 02 www.afpp.org.uk
Pre-warming to reduce risk of inadvertent perioperative hypothermia Research shows that patients can lose up to 1.6°C during the first 60 minutes of anaesthesia1, due to anaesthesia induced vasodilatation. One of the most important factors controlling the extent redistribution hypothermia affects the patient’s temperature, is their initial body heat content.2 Core body temperature remains relatively constant, even in warm environments. However as the peripheral tissues warm, the body heat content increases reducing the core-to-periphery gradient. As heat requires a gradient to flow, the extent to which
redistribution hypothermia affects body temperature decreases as body heat content increases. Actively pre-warming patients before surgery has been shown to reduce the effect of redistribution temperature drop, maintain normothermia3 and improve patient outcomes by reducing postoperative shivering3 and aid in the reduction of postoperative wound infection.4 Pre-warming has also been shown to reduce length of stay in the recovery room and reduce the cost of anaesthesia.5 The 3MTM Bair PawsTM System uses Bair HuggerTM therapy
to provide both preoperative warming, that will contribute to increasing body heat content, as well as perioperative clinical warming for many surgical procedures. With only a minimum of 10 to 20 minutes of pre-warming required,6 The Bair Paws system offers an easy method of ensuring you can provide your patients with a high standard of care and assist in reducing the adverse effects of inadvertent perioperative hypothermia. www.3m.co.uk/bairpaws or call 0845 873 4164
References 1. Sessler, DI. Current concepts: mild perioperative hypothermia. New England Journal of Medicine, 336: 1730-1737, 1997 2. Sessler, DI. Perioperative Heat Balance. Anesthesiology, 92: 578-596, 2000 3. Bernard et al. Prevention of Intraoperative Hypothermia by Preoperative Skin-Surface Warming, Anesthesiology, 79:214-218, 1993 4. Melling et al. Effects of preoperative warming on the incidence of wound infection after clean surgery: a randomised controlled trial, The Lancet, 358:876-880, 2001 5. Bock et al. Effects of preinduction and intraoperative warming during major laparotomy, British Journal of Anaesthesia, 80:159-163, 1998 6. Horn et al. The effect of short time periods of pre-operative warming in the prevention of peri-operative hypothermia, Anaesthesia, 67:612-617, 2012
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Product News
Journal of Perioperative Practice PROCUREMENT GUIDE May 2015 Volume 04 Issue 02 www.afpp.org.uk
New triple enzyme gigazyme® foam New gigazyme® foam from schülke is a ready-to-use spray foam designed for the immediate cleaning and disinfection of surgical instruments, including flexible endoscopes before reprocessing and before being transported for cleaning. The unique formulation includes three different enzymes for cleaning and disinfection. Gigazyme foam also keeps soiled instruments moist for a prolonged period of time. Compared to soaking instruments in water, gigazyme® foam has ten times the degreasing cleaning power
(DCP) against organic soiling on stainless steel. In recent tests, using the state-of-the art ProReveal system, gigazyme® foam removed over 70% of the protein residue on instruments before reprocessing1.
schülke UK Ltd, Cygnet House, 1 Jenkin Road, Meadowhall, Sheffield S9 1AT
www.schulke.co.uk
1. schülke data on file 2014
Email: mail.uk@schuelke.com
Tel: 0114 254 3500 References
Journal of Perioperative Practice PROCUREMENT GUIDE May 2015 Volume 04 Issue 02 www.afpp.org.uk
Product News 10
Are you putting your patients at risk? Even mild hypothermia (when the patient’s core temperature drops below 36°C) can increase postanaesthesia recovery time, blood loss and morbid cardiac outcomes and lengthen hospital stays (AORN 2007).
Not knowing the exact temperature of the irrigation fluid at point of use can jeopardise patient safety.
Maintaining normothermia should include the use of warm irrigation fluid for surgical procedures as part of the holistic approach to keeping the patient warm throughout the procedure. NICE guidelines state that fluids should be warmed to 37°C and that all irrigation fluids used intraoperatively should be warmed in a thermostatically controlled cabinet to a temperature of 38–40°C (NICE 2008). However, how many operating teams check the temperature of the fluid leaving the warming cabinet and can be sure of the exact temperature of the fluid being used to irrigate the patient? How confident are you that the fluid is the same as the temperature reading on the warming cabinet? A recent survey carried out by Ecolab Healthcare at the AfPP conference in York, identified that out of 28 participants, only 12 % were able to correctly
“guess” the temperature of the warmed irrigation fluid, when using the traditional “finger dip” test. The tried and tested method of adding some warm or cold water to get to the correct temperature before being used does raise questions. Not knowing the exact temperature of the irrigation fluid at point of use can jeopardise patient safety. Irrigation with hot solutions has resulted in patient injuries (AORN 2012) and we know that fluid temperature drops by 1°C per minute after removal from a warming cabinet. Do you know the exact temperature of the irrigation fluid that you are using? The new Intratemp Fluid Warming System from Ecolab prevents this risk by taking out the guesswork of irrigation fluid temperatures. For further details contact Alison on 0113 232 2480
References Association of perioperative Registered Nurses Recommended Practices Committee. Recommended practices for the prevention of unplanned perioperative hypothermia AORN Journal 85 (5) 972-988 Association of periOperative Registered Nurses 2012 Perioperative Standards and Recommended Practices: For Inpatient and Ambulatory Settings Denver, AORN (p371) National Institute for Health and Care Excellence 2008 Inadvertent Perioperative Hypothermia Clinical Guideline 65 London, NICE (p12)
Product News 11
Journal of Perioperative Practice PROCUREMENT GUIDE May 2015 Volume 04 Issue 02 www.afpp.org.uk
VacSax VacSax, UK leaders in the design and manufacture of disposable suction system for use in all Departments within the hospital, has taken the unprecedented step to manufacture all Suction Liner Products with Antimicrobial Protection. Founded in 1996, the company currently exports to more than 25 countries around the world. The VacSax BactiClear® Antimicrobial system is seen by over 60% of hospital beds across the UK and has been proven to reduce harmful bacteria such as MRSA and E-Coli by up to 99% as independently tested to the ISO 22196:2011 standard. VacSax BactiClear® Antimicrobial Suction Liner system is the only system where all external services are totally antimicrobial, designed to minimise the risk of cross-infection.
Tracing its foundations to 1945, Optimus British Hospital Metalcraft is a leading provider of British made Hospital Metalcraft and specialist steel products. These products are designed and engineered to be used in a demanding hospital and healthcare environment. The Optimus design team have particular expertise in delivering metalcraft solutions into a wide variety of healthcare locations including; central sterile services departments (CSSD),
VacSax Bacticlear® Antimicrobial liners are available in 1 litre, 2 litre and 3 litre version and are PVC-free, producing only carbon dioxide and water upon 100% combustion. The unique patented designed liner is folded for ease of storage and begins to inflate as soon as the vacuum is attached. VacSax Bacticlear® Antimicrobial canisters fit any bracket within the hospital and are suitable for all clinical areas. www.vacsax.com
operating theatres, general wards, sluice rooms and the Emergency Department. Optimus combine crucial elements to deliver a unique product offer: • 70 years manufacturing experience • British made quality at the right price • Products designed specifically for hospital use • Standard products ready for delivery
• Personal customer service • Fast delivery • Project management support We recently provided a bespoke designed solution to an NHS customer. By taking account of specific logistical issues and operating theatre workloads our Design Team engineered the CSSD trolley to give the best fit features of mobility, ease of use and load capacity specifically for this NHS customer.
Our customer planned to purchase ‘off the shelf’ units but after discussions with the Optimus team they realised they would require less trolleys if tailor made to their requirements. Due to their enhanced load capacity, the hospital now has a more efficient and safer CSSD trolley, saving money on the capital purchase.