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

 

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

 

 

 

__._,_.___

 

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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

 

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