Orthopaedic surgery
tenfold improvement in air quality is essential for significantly reducing infection rates.15 Consequently, the study observed that if all orthopaedic theatres in the UK could reach this standard, it could potentially cut the deep infection rate for joint replacement surgeries by half, from 2000 to 1000 per year. This improvement would not only lower the number of revision surgeries required due to infections, but is also predicted to save millions of pounds annually.
A new national audit Building on the pilot study, a national audit on air quality in operating theatres has now been initiated, spearheaded by orthopaedic surgeon Andrew Thomas; Professor Deborah Eastwood, the British Orthopaedic Association President; and Professor Susan Hopkins, the Chief Medical Advisor at the UK Health Security Agency. This audit is part of the the National Infection Teams Collaborative for Audit and research (NITCAR), and is supported by NHS England, the UK Health Security Agency, and the British Orthopaedic Association. The Joint Orthopaedics and Infectious diseases National Theatre Clean Air Services Evaluation (JOINTCASE) is an ongoing national, multicentre, prospective audit. The JOINTCASE audit aims to evaluate the air quality in UCA operating theatres while actually in use for elective total hip and total knee arthroplasty surgeries. All elective orthopaedic units in the UK are encouraged to participate in this study. This includes major elective centres, tertiary units, and district general hospitals. Initially, the audit will focus on UCA theatres used for joint replacement surgery in the UK. This audit is a collaborative effort involving local orthopaedic and microbiology/ infectious disease departments in elective orthopaedic units across the nation. The methodology employed is based on the settle plate technique established during the pilot study. For this, the packs of 10 microbiology plates, specially developed by Cherwell, can be simply peeled apart aseptically for easy sterile dispensing onto surgical instrument trolleys and next to the wound. To further minimise contamination risk, during transfer for incubation after exposure, the plates can be secured with sterile elastic bands which are also supplied within the packs. The new peel apart packs were required because settle plates are generally packed double or triple wrapped and sterilised for laboratory or cleanroom use, which is not sufficient during surgery in an operating theatre. Aseptically opening regular plate packs requires sterile scissors and there is
a risk of de-sterilising the outside of the settle plates. Cherwell’s peel apart pack provides a solution, as the plates can be dispensed onto the sterile instrument trolley, just like any other piece of equipment that is dispensed to the scrub nurse by the circulating staff. The NITCAR system is designed to be trainee- led, with one or two trainee leads (trauma and orthopaedic or microbiology/infectious diseases trainees) managing the setup, local approvals and coordination with supervising consultants in orthopaedics and microbiology/infectious diseases, at each participating centre. While the primary measure of the national audit is the number of microbial colonies per settle plate, in the various standardised locations during arthroplasty procedures, the following variables will also be recorded to assess their impact on the microbiological air quality in UCA theatres
in use: l Theatre type l Number of persons in the theatre l Number of scrubbed persons in the clean zone l Type of clothing used l Type of procedure (total hip replacement or total knee replacement)
l Use of image intensifiers l Use of robots l Use/type of warming devices
The audit may eventually be extended to other types of UCA systems and surgical procedures, such as neurosurgical valves and vascular grafts, which also require high air quality but have not been systematically studied. Recent genomic studies have emphasised the importance of operating theatre air quality in clean, soft tissue surgeries.16
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