Lessons Learnt

Lessons learnt

Ring fencing of elective orthopaedic beds and simple

infection control measures significantly reduced the

incidence of postoperative infections in patients

undergoing joint arthroplasty, and MRSA was eradicated.

As a consequence of fewer complications and

more predictable bed occupancy, as well as not having

beds blocked for long periods by trauma patients and

non-orthopaedic patients, we were able to do 17%

more joint arthroplasties without increasing the

number of operating lists, beds, or surgeons.

Staff, patients, and visitors had to undergo a major

change in culture in order to implement the changes.

The senior medical and nursing staff acted as role

models in the implementation of new policy, as

described by Ching and Seto.3

We acknowledge that the reduction in infection

rate was achieved by several factors: ring fencing, simple

infection control measures, and reducing the

number of agency staff to a minimum. However, the

model as a whole shows important and significant

results.

This work showed an increase in healthcare

associated infection, including MRSA, in an elective

orthopaedic ward containing patients from other

specialties, including trauma. The importance of the

theatre environment on joint arthroplasty has been

understood for many years; we have shown that the

ward environment is also highly important in the rate

of infection in patients having joint arthroplasty.

Plowman et al suggested that hospital acquired

infection increases patients' length of stay (up to 11

days per case) and the cost of treatment (Ð'Ј2917 per

case).4 Although infection in joint replacement

surgery may be caused by direct contamination at the

time of surgery, the total infection rates can be further

reduced with an appropriate ward environment. We

strongly recommend the ring fencing of elective

orthopaedic patients and simple infection control

measures to reduce the risk of postoperative infection

and allow an increase in the number of patients

treated.

We thank J Dowell, M Taylor, and H Lyall, who operated on

patients and participated in infection control regimens, and G

Virich for help with data collection.

Contributors: LCB coordinated the project, collected the data,

wrote the paper, operated on patients, and participated in infection

control regimens. ELT advised on setting up the study,

devised the decontamination protocol, advised on infection

control procedures, and devised treatment regimens for

infected patients. WWW and JDT devised, set up, and

coordinated the project, educated staff in infection control procedures,

operated on patients, and advised on data collection.

LCB is the guarantor.

Funding: None.

Competing interests: None declared.

Ethical approval: Mid Essex NHS Trust ethics committee

approved the study.

1 Amstutz HC. Complications of total hip replacements. Instr Course Lect

1974;23:248.

2 British Orthopaedic Association recommendation on sterile procedures in operating

theatres. London: BOA, 1999. www.boa.ac.uk/BOAsterilerec.htm

(accessed 22 June 2004).

3 Seto WH, Ching TY, Chu YB, Ng SG, Ong SG. Evaluation of staff compliance

with influencing tactics in relation to infection control policy implementation.

J Hosp Infect 1990;90:157-66.

4 Plowman R, Graves N,Griffin M, Roberts S, Swan A, Cookson B, et al. The

socio-economic burden of hospital acquired infection. London: Public Health

Laboratory Service, 2000.

(Accepted 18 March 2004)

The Tao of PoohÐ'--a philosophy that changed my practice

My mother in law gave me The Tao of Pooh by Benjamin Hoff for

Christmas, I suspect because she thought my mentality was suited

to the cuddly toy of the title. I dutifully added it to my collection

of books to read while on holiday, intending to have a complete

break from books and journals about medicine. However, when I

settled down to read it, on a sunny beach far from my consulting

room, I was struck by its relevance to my work, and The Tao of

Pooh has made a greater change to my practice than much of my

regular medical reading.