Infection prevention
l Reduces the need for antibiotics. l Reduces waste associated with dressings. l Reduces excess chemicals poured into the water supply (e.g. scrub and skin prep).
l Reduces transport pollution (i.e. travel due to readmissions or having to access/provide treatment for an infection).
There is also a significant financial cost to Trusts if they have high readmission rates caused by SSIs. Sustainability isn’t just about the environment; it is also about financial sustainability, he asserted – ‘Getting it Right First Time’ ensures that the health system runs more efficiently.
SSIs: the key actions required At the Oxford University Hospitals NHS Foundation Trust, the various surgical specialties are given the evidence for a generic care bundle, and this is then tailored to their specific requirements. He pointed out that some practices in theatres are not always supported by the latest evidence. For example, footfall in theatres has historically been seen as important, yet up-to-date evidence shows that this does not have a significant impact. “If someone pops their head around the door, this isn’t a problem. People are missing the point; there are much more important things they can do,” he asserted. Patients showering before surgery is important, but Mr. Bond Smith added that soap and water is acceptable, unless it is hip surgery, for example. He suggested that surgeons can also contribute to sustainability by following the ‘scrub then rub’ approach, to conserve water. Hair should not be removed routinely and, if
hair removal is necessary, clippers not shavers should be used. The amount of clipping should also be minimised. “Even now, surgeons talk a great game, but they don’t do it,” he lamented. The patient should be clipped outside of the
theatre, as close to the time of the procedure as possible, he explained. Ideally, this should be performed on the ward and not the night before. To minimise the debris created by clipping,
patients are prescribed antibiotics unnecessarily when their wounds do not require it. “Antimicrobial stewardship is everyone’s
responsibility,” he asserted. “Can we please challenge the surgeon to give no antibiotics post-operatively?” he asked. “If you have taken out an infected problem, the person has an innate immune system that, by and large, is going to work. With appendicitis, we give the patient antibiotics up to the point of knife to skin, because we are treating them with antibiotics until we get source control. Once the appendix is removed, that is it. There are no post-op antibiotics,” commented Giles Bond Smith.
If antibiotics are absolutely necessary, post-
some devices (e.g. BD) can be provided with an extraction/removal system. Mr. Bond Smith mentioned that his department had carried out an experiment using UV light to see how far debris caused by clipping travelled, and for how long, and this provided convincing evidence that clipping should be carried out outside of the operating theatre. The correct antibiotic should also be given according to local microbiological advice and at the correct time (within two hours of knife to skin, but ideally within 60 minutes). Mr. Bond Smith commented that there is a need for better antimicrobial stewardship – too often
If you can put a digital solution into the hands of the patient with their smart phone, they will embrace it. Hospitals follow up a lot of patients unnecessarily. Seven out of 10 patients do not need follow-up; 70% of your patients do not need to drive in. This is a carbon
footprint that we can reduce. Giles Bond Smith, Oxford University Hospitals NHS Foundation Trust.
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operatively, as in the case of a perforated colon, for example – they should be given for 72 hours, then reviewed. “We have adopted this approach for over a
year, now, and we have not seen any increase in adverse events,” he commented. Educating patients is also important with regards to antibiotic usage, however, he added. He advised that skin preparation should be with 2% alcoholic Chlorhexidine (as evidenced by Darouiche et al, 2010) – a strong recommendation in the WHO guidelines. Mr. Bond Smith warned that operating theatres should not be using the “big pink bottles” for skin preparation. “We have cultured bacteria from around those lids,” he warned. He added that using gallipots, requires sterilisation with the associated chemicals, materials and energy. “This has a really bad footprint. As part of a green initiative, we have been trying to eliminate this,” he continued. He pointed out that a Chloraprep application
device uses less plastic than a standard procedure and is also safer, as there is no pooling or ‘run off’, which can present a fire risk in the operating theatre, if ignited.
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