Jochen
 
We are identical to Airdale in every respect.
I second Alex’s advice on compromise.
Alex, are you sure you’re not working in Crewe?!
 
Cheers
 
Cefin
 
cid:image001.png@01CF6DCB.71C861A0
Mr Cefin Barton MB BCh, MRCS, FRCS(Tr&Orth)
Consultant Orthopaedic Surgeon
Clinical Lead in Trauma and Orthopaedics
Mid Cheshire Hospitals NHS Foundation Trust
PA Christina Russell 01270 273968
 
From: orthodirectors@yahoogroups.com [mailto:orthodirectors@yahoogroups.com] 
Sent: 13 June 2016 23:21
To: orthodirectors@yahoogroups.com
Subject: RE: [orthodirectors] Infection control
 
  
Yes – but have strict criteria
No
No
No
 
At Airedale (Normal DGH) we have a fully ring-fenced Elective Ward and the Trauma Ward. In times of crisis we decant MRSA negative ‘clean’ trauma (No open wounds, frames, #NOF etc etc) that we have selected ourselves as possible transfers to the elective ward but not otherwise.
No outliers of any other speciality accepted.
Single breach of ring fence = complete cessation of elective inpatient activity until all patients cleared and Ward deep cleaned
Invariably this takes 2-5 days at the best of times and when the break it for one they open the floodgates sometimes!
Yes we still get breaches but management understand the significant consequences and the key to this strategy is having a group of surgeons who all work together completely and have 100% compliance, I’m very lucky we do and the management know this.
 
Don’t compromise – it’s the road to ruin and more infections.
 
Best of luck Jochen
 
Alex Acornley
Clinical Lead in Orthopaedics
Airedale Hospitals NHS Foundation Trust, Yorkshire
 

From: orthodirectors@yahoogroups.com [mailto:orthodirectors@yahoogroups.com
Sent: 13 June 2016 15:27
To: orthodirectors@yahoogroups.com
Subject: [orthodirectors] Infection control
 
  
I need some opinions please, i've posted on a similar topic recently and it takes a bit of a lengthy explanation. It's a strange place - working in the nhs. constant compromise is required in all areas to keep the ship afloat in a climate of chronic underfunding. Our Execs have recently tightened the thumbscrews again by closing a ward. Essentially we now have a mixed elective and trauma ward and we are bedding trauma patients into a mixed trauma and general surgery daycase ward. In terms of infection control for elective patients and especially arthroplasty this poses a number of problems and challenges. We are obviously a long way away from the boa goldstandard of a dedicated elective (let alone arthroplasty) ward and we are forced to compromise on an almost daily basis. But the question is now what level of compromise is acceptable. And that again depends on a number of factors. What would be acceptable in a developing country may not be necessarily acceptable in a highly developed country and what may be acceptable to a manager or a microbiologist may not be acceptable to a arthroplasty surgeon. For example: during a meeting today our microbiologist suggested that it would be acceptable to bed a elective/arthroplasty patient in the same room as a patient with a chest/water infection for as long as they are mrsa negative. He may have a point there - after all he's the infection control specialist. At the same time a clinician's opinion is formed by talking to peers and reading current state literature as well as guidelines and all these suggest that infection control should be much stricter. As a clinician i'm also thinking down the medicolegal route: what is the acceptable level of care (and compromise) that a reasonable body of likeminded colleagues would feel is acceptable and that is therefore defendable in a court of law??
Keeping all of the above in mind i'm keen to fish for opinions as to what is acceptable in the NHS in the  UK nowadays.
Would it be reasonable to bed a arthroplasty patient in the same room as:
1: Trauma patient, MRSA screening negative, no active infections
2: Trauma patient, MRSA negative, UTI on ABx
3: Trauma patient, MRSA negative, chest infection on ABx
4: patient with a "contained" infection like flexor sheath/septic arthritis (all preop, no breach of skin)
I know what standards I would like for myself or my mother....
 
I'm much looking forward to everyone's comments!
Kind regards
Jochen 
Macclesfield
 
 
 
__._,_.___
 

Posted by: "Barton Cefin (RBT) Mid Cheshire Tr" <Cefin.Barton@mcht.nhs.uk> 
 
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__,_._,___
orthodirectors@yahoogroups.com
Inbox
14 June 2016 16:07
Hi Jochen,
 
Exactly the same as in Northampton (below) at Aintree.
There should not be clean elective orthopaedic patients on the same ward as patients with infections.
We close down the elective ward if anyone is admitted onto it with antibiotics / infection.
If you all agree to these standards will that not force the issue.
 
Regards,
 
Paul
From: orthodirectors@yahoogroups.com [mailto:orthodirectors@yahoogroups.com] 
Sent: 13 June 2016 21:30
To: orthodirectors@yahoogroups.com
Subject: Re: [orthodirectors] Infection control
 
  
This is a desperate situation.
I am sure you have used the Girft argument, no protected ward then no arthroplasty work?
In Northampton we will not accept mixed trauma/elective or mixed elective with other surgical specialities.
There is a concession that a low risk fracture patient who needs a planned admission and follows an elective pathway after a consultant clinic ie pre op assessment and MRSA screen can be treated as an elective patient and be on the screened orthopaedic ward.
So only scenario 1 is a possibility.
Tim Briggs has the ear of the DOH, why not ask the BOA to wheel out the big guns?
The old lessons about mixed speciality wards are not easy to prove as modern evidence based practice, but they were learned the hard way and should not be forgotten. Ask your bacteriologist for evidence that mixed wards are safe for elective orthopaedics.
David Gidden
Northampton


Sent from my iPad
 
 
 
__._,_._____,_._,___
orthodirectors@yahoogroups.com
Inbox
14 June 2016 06:14
Our thoughts from Northumbria.
 
We have 3 sites, all with medicine, and have protected beds in each this year without cancellations, albeit with some difficult conversations.
Each site has a clean surgery ward into which clean other speciality ops can also go (standard hernia repairs and breast reconstructions for instance).
MRSA testing isn’t much use, it is so rare in UK hospitals. MSSA testing should be added if you want to actually reduce infection rates. All of our patients on the clean wards are MRSA and MSSA screened, or decolonized. Trauma patients that fit that criteria are welcome (testing takes 3 days).
Single rooms are not considered to be protective and are not a substitute for a ring-fenced clean ward.
The list of clean ward exclusions is shown below. 
 
·      Bowel surgery  - open
·      Bowel surgery - laparoscopic
·      Bowel prep
·      Infected joint replacement
·      Diverticulitis on antibiotics
·      Infected bone
·      Non clean plastic surgery / ortho wounds
·      Any patient requiring treatment antibiotics unless chest infection/UTI developed on the ward.
Any breaches to above and we have 100% colleague agreement to cancel lists. 
Hope that helps!
 
Mike

 
Yes – but have strict criteria
No
No
No
 
At Airedale (Normal DGH) we have a fully ring-fenced Elective Ward and the Trauma Ward. In times of crisis we decant MRSA negative ‘clean’ trauma (No open wounds, frames, #NOF etc etc) that we have selected ourselves as possible transfers to the elective ward but not otherwise.
No outliers of any other speciality accepted.
Single breach of ring fence = complete cessation of elective inpatient activity until all patients cleared and Ward deep cleaned
Invariably this takes 2-5 days at the best of times and when the break it for one they open the floodgates sometimes!
Yes we still get breaches but management understand the significant consequences and the key to this strategy is having a group of surgeons who all work together completely and have 100% compliance, I’m very lucky we do and the management know this.
 
Don’t compromise – it’s the road to ruin and more infections.
 
Best of luck Jochen
 
Alex Acornley
Clinical Lead in Orthopaedics
Airedale Hospitals NHS Foundation Trust, Yorkshire
 

__,_._,___
orthodirectors@yahoogroups.com
Inbox
13 June 2016 23:21
Yes – but have strict criteria
No
No
No
 
At Airedale (Normal DGH) we have a fully ring-fenced Elective Ward and the Trauma Ward. In times of crisis we decant MRSA negative ‘clean’ trauma (No open wounds, frames, #NOF etc etc) that we have selected ourselves as possible transfers to the elective ward but not otherwise.
No outliers of any other speciality accepted.
Single breach of ring fence = complete cessation of elective inpatient activity until all patients cleared and Ward deep cleaned
Invariably this takes 2-5 days at the best of times and when the break it for one they open the floodgates sometimes!
Yes we still get breaches but management understand the significant consequences and the key to this strategy is having a group of surgeons who all work together completely and have 100% compliance, I’m very lucky we do and the management know this.
 
Don’t compromise – it’s the road to ruin and more infections.
 
Best of luck Jochen
 
Alex Acornley
Clinical Lead in Orthopaedics
Airedale Hospitals NHS Foundation Trust, Yorkshire
 

From: orthodirectors@yahoogroups.com [mailto:orthodirectors@yahoogroups.com] 
Sent: 13 June 2016 15:27
To: orthodirectors@yahoogroups.com
Subject: [orthodirectors] Infection control
 
  
I need some opinions please, i've posted on a similar topic recently and it takes a bit of a lengthy explanation. It's a strange place - working in the nhs. constant compromise is required in all areas to keep the ship afloat in a climate of chronic underfunding. Our Execs have recently tightened the thumbscrews again by closing a ward. Essentially we now have a mixed elective and trauma ward and we are bedding trauma patients into a mixed trauma and general surgery daycase ward. In terms of infection control for elective patients and especially arthroplasty this poses a number of problems and challenges. We are obviously a long way away from the boa goldstandard of a dedicated elective (let alone arthroplasty) ward and we are forced to compromise on an almost daily basis. But the question is now what level of compromise is acceptable. And that again depends on a number of factors. What would be acceptable in a developing country may not be necessarily acceptable in a highly developed country and what may be acceptable to a manager or a microbiologist may not be acceptable to a arthroplasty surgeon. For example: during a meeting today our microbiologist suggested that it would be acceptable to bed a elective/arthroplasty patient in the same room as a patient with a chest/water infection for as long as they are mrsa negative. He may have a point there - after all he's the infection control specialist. At the same time a clinician's opinion is formed by talking to peers and reading current state literature as well as guidelines and all these suggest that infection control should be much stricter. As a clinician i'm also thinking down the medicolegal route: what is the acceptable level of care (and compromise) that a reasonable body of likeminded colleagues would feel is acceptable and that is therefore defendable in a court of law??
Keeping all of the above in mind i'm keen to fish for opinions as to what is acceptable in the NHS in the  UK nowadays.
Would it be reasonable to bed a arthroplasty patient in the same room as:
1: Trauma patient, MRSA screening negative, no active infections
2: Trauma patient, MRSA negative, UTI on ABx
3: Trauma patient, MRSA negative, chest infection on ABx
4: patient with a "contained" infection like flexor sheath/septic arthritis (all preop, no breach of skin)
I know what standards I would like for myself or my mother....
 
I'm much looking forward to everyone's comments!
Kind regards
Jochen 
Macclesfield
 
13 June 2016 20:38
Hi
Share your pain
One of the few benefits of doing SAFER ward/board rounds is that the consultants know when our weakened ring-fencing has been breached, which happened in winter about once a month.
In response to your questions:
1.       Yes
2.       No
3.       No
4.       No
 
We currently mix our elective ortho with “clean” trauma ie closed #, mrsa screened, no active sepsis, mobile/independent pre-injury
Hip fractures  / low mobility patients are not allowed
If hospital in black we will take “clean” breast, endocrine surgery
I spoke to Tim Briggs when he visited, and he gave a hard stare
Our microbiologists also seem remarkably chilled about having potentially infected patients on the wards; I think this boils down to lack of hard data  and/or big enough numbers, and so pooled accurate data is probably the way forward; as ever this is easier said than done.
I’m decidedly uncertain about our sssi information at present time
Cheers
Sunny, GWH Swindon
A situation many of us would recognise.
Ideally total ring fencing but I would say as a compromise:
1 yes
2 no
3 no
4 no
At Tunbridge Wells hospital we don't have ring fencing. We do have single rooms which gives false reassurance. We have had all four scenarios on our 'elective' ward. Our SSI rate is above the national average.
Politically it would be helpful to me for those with access to the GIRFT raw data to share comparative information on the SSI rates of those units with ring fencing vs those without. 

Kind regards, 
Guy
Guy Slater
from my phone 


Who is responsible if the joint replacement becomes infected?
That is the pertinent question.
From that , flow all the other answers.
 
Babis
Burton on trent 
 
From: orthodirectors@yahoogroups.com [mailto:orthodirectors@yahoogroups.com
Sent: 13 June 2016 15:27
To: orthodirectors@yahoogroups.com
Subject: [orthodirectors] Infection control
 
  
I need some opinions please, i've posted on a similar topic recently and it takes a bit of a lengthy explanation. It's a strange place - working in the nhs. constant compromise is required in all areas to keep the ship afloat in a climate of chronic underfunding. Our Execs have recently tightened the thumbscrews again by closing a ward. Essentially we now have a mixed elective and trauma ward and we are bedding trauma patients into a mixed trauma and general surgery daycase ward. In terms of infection control for elective patients and especially arthroplasty this poses a number of problems and ch allenges. We are obviously a long way away from the boa goldstandard of a dedicated elective (let alone arthroplasty) ward and we are forced to compromise on an almost daily basis. But the question is now what level of compromise is acceptable. And that again depends on a number of factors. What would be acceptable in a developing country may not be necessarily acceptable in a highly developed country and what may be acceptable to a manager or a microbiologist may not be acceptable to a arthroplasty surgeon. For example: during a meeting today our microbiologist suggested that it would be acceptable to bed a elective/arthroplasty patient in the same room as a patient with a chest/water infection for as long as they are mrsa negative. He may have a point there - after all he's the infection control specialist. At the same time a clinician's opinion is formed by talking to peers and reading current state literature as well as guidelines and all these suggest that inf ection control should be much stricter. As a clinician i'm also thinking down the medicolegal route: what is the acceptable level of care (and compromise) that a reasonable body of likeminded colleagues would feel is acceptable and that is therefore defendable in a court of law??
Keeping all of the above in mind i'm keen to fish for opinions as to what is acceptable in the NHS in the  UK nowadays.
Would it be reasonable to bed a arthroplasty patient in the same room as:
1: Trauma patient, MRSA screening negative, no active infections
2: Trauma patient, MRSA negative, UTI on ABx
3: Trauma patient, MRSA negative, chest infection on ABx
4: patient with a "contained" infection like flexor sheath/septic arthritis (all preop, no breach of skin)
I know what standards I would like for myself or my mother....
 
I'm much looking forward to everyone's comments!
Kind regards
Jochen 
Macclesfield
----------------------------------------------------------------------

Trust me stick together, strict criteria that you endorse and cancel if ring fence is breached, do not compromise. It's the only language they understand. It's the only way it works.

Alex Acornley
Airedale

________________________________________________________________________________________________________________________________

This is the usual story.
Ring Fenced beds with 'criteria' to admit non-joint patients do not work for more than a week. The only way is to separate the elective and trauma sites, which fortunately is the case in some trusts, though not by design but by default.

We are struggling to create a small 'implant unit', but with a very small bed-base, which will lead to cancellations due to bed shortage.
BOA & Prof. are advocating 'elective wards', but not many trusts can afford that, more so in absence of any strong evidence on infection rate.

Will keep you all informed what happens.
Regards
Siten Roy

________________________________

Hi

We had ringfenced elective elective beds in Swindon from 1995 to last year when we lost 12 elective ortho beds (“sold” to create a too small trauma ward, so the medics could have our original 36 bed trauma unit) and pure elective ortho surgery ward status such that we have to accept mrsa –ve swabbed patients with:

Isolated msk trauma up to tibial nail magnitude

Elective breast, thyroid, ent and eye surgery

As required

Avg no of outliers  = 3 /24 beds
All of these patients go into side wards, which are terminally cleaned after non-ortho use
We were all very much opposed to this change, but it was nonetheless imposed. We were also opposed to downsizing our trauma unit.
We stated the clinical risks to no avail.
I’m still very concerned particularly about the ent patients, but they still pop up maybe x1 per month
The bed base in our hospital is too small to fully preserve the pure elective ward, and there is limited will or sympathy (+ ignorance of the consequences of implant sepsis) from other services, but I would like to get back to pre-2014.
We’ve had x2 protocol breaches (medical patients) in 18 months when I’ve shut the ward to further admissions.
Thankfully thus far no perceptible increase in infections. Fingers remain x’d.

sunny

______________________________________________________________________________

Hi,
Same as below in Aintree.
Paul
_______________________________________________________________________________________________________________
In Crewe, same as Airdale. We tell management and not the other way round. Patient safety and acute awareness of cost of infected revisions are usually good bargaining tools.

Breach of ringfence = cancelled elective activity until ward clear and deep cleaned. Happened twice last year due to no choice with significant loss of revenue.

Cefin

Clinical Lead in Trauma and Orthopaedics

Mid Cheshire Hospitals NHS Foundation Trust

________________________________________________________________________

No outlying specialities. No acute orthopaedic admissions. Any tramua patients decamped onto elective ward are selected by Consultant teams as apporprite post op, MRSA negative proven and documented(#NOF for THR, ankles post-op usual crown). No wet wounds, UTI, Chest inefctions, Frames. No #NOF except trauma THR which are often home in 2-3 days like an elective anyway.

Any breaches to the ring-fence = cancellation of elective activity until resolved and deep cleaned.

It's a lot easier to manage as a "black and white" system for all. It only works when everyone works together to achieve without exception so a cohesive apporach from all orthopaedic colleagues is vital.

Cheers

Alex Acornley

CD Airedale Hopitals NHS Foundation Trust
____________________________________________________________________
We have a “protected” ward for elective orthopaedic admissions, but due to fluctuating bed requirements from our department and pressure from elsewhere we have rules in place that allow pre-screened clean general surgical cases (eg breast or hernia surgery) to sometimes use beds, and acute patients admitted from own home deemed low risk can be admitted to a side room and rapid screened for MRSA before then being allowed on the ward (both orthopaedic and surgical / gynae)
The GIRFT report recommends “ring-fenced beds” but is not totally specific about what this means.  We want to exclude other surgical and medical teams as much as possible (even with “clean” patients) from the ward to limit footfall, but are not being supported in doing this by our infection control team.
What are your criteria for ring-fencing elective orthopaedic admissions?
If the criteria are breached, what happens?
Mr Ben Lankester
Yeovil District Hospital

  
At North Tees in theory we have ring fenced beds.
Reality is medical boarders have taken over a surgical ward with the consequence is surgical patients on Ortho wards.
Clean surgery only and medical boarders that are MRSA screened.
The truth is occasionally non screened are slipped in!
This causes a halt to elective surgery from that bay, not effective use of beds.
We have how ever largely managed to continue elective surgery, but lot of micro management of beds/patients
Chris Tulloch
 
From: orthodirectors@yahoogroups.com [mailto:orthodirectors@yahoogroups.com
Sent: 18 March 2015 12:30
To: orthodirectors@yahoogroups.com
Subject: RE: [orthodirectors] Digest Number 1563
 
  
In Hereford we have a ring fenced MRSA free ward for elective work and a separate trauma ward.
 
That’s the theory.
 
Reality: For the last 10 days (and for the foreseeable future) the elective ward has been an acute medical admissions/ general surgery/ trauma ward with no elective orthopaedic  work being done.
 
The trauma ward has closed to admissions due to an outbreak of diarrhoea
 
Nurses are seconded all over the hospital due to staffing issues.
 
All elective care group managers have been seconded to “The incident room” to cope with the “Level 4 bed crisis” and the result?
 
Well predictable really…………
 
Apologies for not attending the meeting which I am sure will be very informative
 
Best regards
 
Darren
 
From: orthodirectors@yahoogroups.com [mailto:orthodirectors@yahoogroups.com
Sent: 18 March 2015 11:51
To: orthodirectors@yahoogroups.com
Subject: {Disarmed} RE: [orthodirectors] Digest Number 1563
 
  
Sudhi,
 
Cross covering is potentially an issue – yet at the moment we do not even screen our own staff or ourselves to check whether we and they are MRSA free.
 
A strange situation if you think that the patients are transient on the ward yet the personal working there could potentially spread the problem with “clean” patients coming in.
 
In my time in Germany I was the infection control lead in a Lvl 1 trauma centre and what we did first was screening the staff.
 
We actually had to eradicate several nurses from MRSA and surprisingly had no “outbreaks” of MRSA ever since…
 
That was in a mixed Trauma and Orthopaedic patient setting but in a seperate hospital block, so no danger of medical outliers ever…
 
Best wishes,
 
Mr Daniel Engelke
Consultant Trauma & Orthopaedics
Service Line Director T&O
Gloucestershire Royal Hospitals NHS Trust
Phone: 0300 422 6712
 
From: orthodirectors@yahoogroups.com [mailto:orthodirectors@yahoogroups.com
Sent: 18 March 2015 11:30
To: orthodirectors@yahoogroups.com
Subject: RE: [orthodirectors] Digest Number 1563
 
  
Ian, this is precisely why we need this debate. Prof Briggs will be talking on GIFRT at meeting on 8th May and it will be interesting to know what his take will be on the practicalities of implementing ring fenced beds in our work place.
 
It is also interesting that no one touched upon the issue of nurses cross covering wards in this debate. What are people’s views if nurses are asked to cross cover wards even if one of the wards is “ring fenced” for orthopaedics. Our nurses cover ENT as well and we recently has a spike of total joint infections with strange upper respiratory tract bugs!
 
Thanks for all your contributions. I am finalising the programme for the meeting and will send you the programme shortly but it would help if you could confirm your attendance on 8th May for purposes of catering. Thanks to those who have already done so. 
sudhi
 
From: orthodirectors@yahoogroups.com [mailto:orthodirectors@yahoogroups.com
Sent: 18 March 2015 11:15
To: 'orthodirectors@yahoogroups.com'
Subject: RE: [orthodirectors] Digest Number 1563
 
  
In Rotherham we have been unable to ring fence beds. Outliers are MRSA negative but we have little understanding from management or patient flow about the need for ring fencing. Mainly, we take trauma as our trauma ward gets full of medical outliers.
 
I will be using both this and Prof Briggs visit as a very large stick to beat them with, however.
 
Ian C
Director for Surgery
Consultant Orthopaedic Surgeon
 
From: orthodirectors@yahoogroups.com [mailto:orthodirectors@yahoogroups.com
Sent: 17 March 2015 16:13
To: 'BODS'
Subject: FW: [orthodirectors] Digest Number 1563
 
  
Hi Paul

Don't mix Trauma or Elective pts. Separate wards for both.
All elective MRSA & MSSA screened.
All beds just for T&O pts, presently. We don't outlie and don't have outliers, presently.
Trauma acute admissions not screened till admitted. Trauma planned admissions screened pre-admission.

BW
N



Nigel Rossiter
Consultant Trauma & Orthopaedic Surgeon