Lister, Carbolic Acid & Alcohol– have we come full circle?

I recently received my annual Nurses’ League Journal from my training hospital, Kings College Hospital, London – the same one featured in one of my previous blogs on the TV show, ’24 hours in Emergency’. The League is essentially the ‘old girls’ association which we joined on completion of our training. The journal is full of news of us ‘old girls’, the reunions that have taken place and general news of the hospital’s activities. The journal usually features an aspect of the hospital’s history, a South London institution since the early 1800s. In this edition, the story of the eminent 19th century surgeon, Joseph Lister was featured. He is widely regarded as transforming surgery into a practice governed by science due to his pioneering work on antisepsis.

Joseph Lister

Joseph Lister

Why am I telling you all this? Well, at the time I was reading about Lister in the journal, I was also editing the chapter on asepsis and infection prevention for the forthcoming second edition of ‘Perioperative Nursing: An Introductory Text’, due for release in May 2016 at the ACORN Conference in Hobart. I was interested to read about Lister’s infection control practices in 1867 and how they contrast with our present day practice. He, like many of his contemporaries, were appalled and puzzled by the high rates of surgical site infections (SSI) which often led to post op death.
It was the work of French chemist of Louis Pasteur’s that influenced Lister’s thinking about what might cause infection. Pasteur had postulated that fermentation of wine and milk was due to bacteria found floating in the air and not just the air itself that caused infection, as had been traditional thinking. Armed with this light bulb moment, Lister’s next step was to experiment with a variety of antiseptic agents which he thought might kill the bacteria that infected surgical wounds. He settled on carbolic acid (phenol) after hearing about its success in cleaning up the city’s stinking sewers. He introduced it into his operating theatre at the Glasgow Royal Infirmary, Scotland, which must have been a most uncomfortable place to work as he sprayed carbolic acid over the operative field (and all the assistants) continuously during surgery and soaked dressings in the solution. His breakthrough moment came when treating a compound tibial fracture in an 11 year old boy, James Greenlees using dressings soaked in carbolic acid. After a few days there was no evidence of the usual infection that blighted such procedures and James made a full recovery.

Lister spraying carbolic acid during surgery

Lister spraying carbolic acid during surgery

Lister continued this type of wound dressing on other surgical patients and his post-operative infection rates dropped dramatically. If Lister had access to the internet, news of this dramatic breakthrough in infection prevention would have spread like wildfire and perhaps been accepted a little sooner, but it was two years before he published a number of articles about his work in the Lancet medical journal. Even then his results were viewed with a degree of scepticism, by many colleagues, particularly in London and it would be another 20 years of further experimentation before the medical profession accepted Lister’s theory and practical application of antisepsis.
Lister carried out much of his research at my old training hospital, King’s College, where he was appointed Chief of Surgery in 1877 and confronted many of his fiercest critics. The hospital had prohibited open surgery into joints due to the high risk of infection, but Lister believing in his antisepsis methods bucked the system (after all he was the boss!), forging ahead with his work, which eventually paid off, laying the foundations for our modern understanding of antisepsis and ultimately aseptic technique.

operating theatre at Kings College Hospital, London

operating theatre at Kings College Hospital, London

Even though we have come a long way since Lister in our understanding of antisepsis and infection prevention, SSIs are still of great concern in the 21st century. Hand washing continues to be a vital strategy in the fight to reduce the risk of infection and what struck me about surgery in Lister’s era, the late 19th century was the use of alcohol as a hand hygiene product. Three to five minutes pre-operative cleansing of the hands using 90% ethanol was common practice amongst surgeons of that era. The efficacy of alcohol to kill microorganisms on the skin has therefore been known for sometime and with the recent introduction of alcohol based surgical scrub solutions (ABSS) in many Australian operating theatres, it feels like we are back to the future!
Moving to ABSS will require a change of culture in our operating theatres – the ritual of the surgical scrub is one which many instrument nurses may be somewhat reluctant to give up – that five minutes or so at the sink was good thinking time when you could gather your thoughts and prepare yourself mentally for the procedure ahead. Replacing that with a 90 second rub with alcohol based product will not come easy to some! For the surgeons too, it is a big change, although having witnessed some surgeons undertake what passes for a surgical scrub by a momentary waving of hands under running water, an application of alcohol will at least kill a few bugs!

Alcohol based surgical scrub

Alcohol based surgical scrub

Many of you have perhaps already been involved in trialling the variety of ABSS products that medical companies are now clamouring the sell us. It’s big business for them! What’s important is to ensure that we make choices based on available evidence of the efficacy of the products and not the hard sell and promises of the company reps. There are many different products on the market –some containing differing percentages of alcohol and those that combine alcohol with other antimicrobial products eg chlorhexidine. Which one to choose? Don’t be afraid to ask the reps for research evidence to back up their claims, but it’s also important to do your own independent research – there is plenty out there and World Health Organisation has some good resources too.
It seems we have come a full circle in the 150 years since Lister first laid the foundations of infection prevention with the introduction of ABSS in the 21st century. It will become one more strategy we can use to reduce the risk of SSIs that continue to be a cause of morbidity and mortality in our hospitals.
Let us know if you are using ABSS in your workplace and how this new procedure is being received.
Bye for now
Menna

From Postie to PEPEN: A Water cooler conversation

We were delighted to receive these words from Mark Quealy recently in response to “Where are they now?” on our Water Cooler page.

POSTIE TO PEPEN

It’s never too late to take up nursing. At 46 years old & a postman in Kahibah NSW, I was encouraged by several nurses on my run (identified by their LAMP subscriptions I was delivering) to consider nursing. An inspiring Trainee Enrolled Nurse (TEN) program closely followed by the very supportive 12 month Perioperative Education Program for Enrolled Nurses (PEPEN) based at Prince of Wales Hospital in July 2005. I never would have believed that I was capable of working in theatres if it wasn’t for the multitude of mentors on the way. I have since completed my Bachelor of Nursing, thanks in part for the persuasion from preceptor Beth Mangelsdorf but mostly my wife who had more confidence in my aptitude than I was capable of. I am very happy working in the many & varied specialties at Randwick Campus Operating Suite with a truly inspiring bunch of colleagues. I hope I can encourage others to aim for what seems impossible initially.

Mark Quealy

What a great journey and thanks for sharing this on our website Mark! It’s an inspiring story about the empowerment of education and influence of mentors (and wives!).

Menna and I have known Mark since 2005 when he was selected for a place in PEPEN No.1.

But I’m getting ahead of myself!

Ms Deb Thoms presenting Certificates to PEPEN graduates 2003

Ms Deb Thoms presenting Certificates to PEPEN graduates 2003

PEPEN No.1 and Mark’s group followed the successful PEPEN pilot in 2003, which produced seven graduates and was a catalyst in establishing an advanced practice role for the Enrolled Nurse instrument nurse in New South Wales.

These photos from the Pilot graduation in 2003 show Ms Debra Thoms (then Area Director Of Nursing for South East Health) as well as Amanda Gore (Pilot Project Officer) with Invited Speakers Rebecca Roseby (then ENPA Representative) and Menna (then NSW OTA President) with me tucked in the middle – feeling very proud of the graduates and the large team of educators and managers who worked with Amanda and me to facilitate this area-wide project.

PEPEN Pilot key personnel and guest speakers with Graduates

PEPEN Pilot Graduation 2003

Two years later following changes to Enrolled Nurse education in New South Wales, the PEPEN no. 1 cohort in 2005 were all – like Mark Quealy – newly qualified medication-endorsed ENs, and keen to embark on a career in the operating suite.

This pic (below right) shows Mark during a PEPEN clinical teaching session facilitated by Graham Hextell (PEPEN Project Officer 2005-2008) at Prince of Wales Hospital.

Mark Quealy with Lily Peng and Hazel Poon and other students of PEPEN No 1 in 2005.

Mark Quealy with Lily Peng and Hazel Poon and other students of PEPEN No 1 in 2005.

He’s with PEPEN colleagues Anne Faulkner (left), Lily Peng and Hazel Poon (right), whose perioperative nursing careers have also thrived under the supportive team at the Randwick Campus Operating Suite, where until recently Menna has been the CNC.

In the decade since PEPEN, Mark has also found time time to be a local representative for NSW Nurses’ Association in his workplace. What a varied and satisfying career path!

As Mark says “I hope I can encourage others to aim for what seems impossible initially”.

If you’ve got an interesting story to tell about your career path or you’ve worked with us in the past, we’d love to hear from you again! Get in contact with us and we’ll post your story (and pics) too.

Bye for now and very best wishes for the festive season, Sally.

Times Past – Future Views

During my trip to UK, I visited the Old Operating Theatre of St Thomas’ Hospital which is tucked away on the top floor of an English Baroque church near London Bridge (Southwark, London) and adjacent to the famous teaching hospital Guy’s (St Thomas’ Hospital having moved to a new location in Westminster). I had seen photos of this operating theatre and although I was brought up in London, had never had the opportunity of seeing it first hand.OR at St Thomas' Hospital

The operating theatre is the oldest surviving theatre in Europe, dating back to 1822 and was used until 1860. Its location is rather odd, being on top of a church, but the wards of the old St Thomas’ Hospital were built adjacent to the church. The theatre was only rediscovered in 1956 and underwent an extensive refurbishment allowing it to be opened as a museum exhibiting a number of surgical artefacts and pharmacological potions. Whilst viewing the exhibition, it struck me that although we are nearly two hundred years down the track, many of the instruments on show looked remarkably familiar – a sigmoidoscope, Sims speculum, birthing forceps, assorted other surgical instruments. The operating theatre itself is of course drastically different, as you can see it is set up with a viewing gallery to accommodate the budding surgeons of the day, all jockeying to get the best view of the latest surgical techniques – hence the term ‘theatre’. But unlike today’s modern surroundings this theatre has a crude wooden table with a tray of sawdust underneath ready to catch the blood. Blood stained aprons hung near the door with a mirror so the surgeon could clean himself of blood spatters. The bowl was available for the surgeon to wash his hands after surgery rather than before! Anaesthesia and antisepsis were still some years away, therefore the procedures undertaken were very limited. Amputation was one of the most common procedures performed and surgeons vied for the reputation of being the quickest – often asking a member of the audience to time them. One such surgeon was Robert Liston who in the mid 1800s, it is claimed, carried out an amputation of the leg in 25 seconds! He also, so the story goes, accidently sliced off the poor patient’s testicles too!

In a hundred years time, will someone stand looking at our current operating theatres and wonder how we worked in such conditions? What will the operating theatre of 2114 look like and how will surgery be different?

Our operating theatres may cease to exist in their current configuration and may look more like high tech radiology suites. We will see more minimally invasive surgery using technologies such as those currently being trialled eg High-Intensity Focused Ultrasound (HIFU) and Magnetic Resonance guided Focused Ultrasound Surgery (MRgFUS). These technologies can be used for a variety of procedures including treatment of uterine fibroids, metastatic bone tumours, Parkinson’s disease with patients likely to be walk in/walk out same day surgery. Surgery may be undertaken by robots operated by surgeons located remotely. 3D printing is already being used in innovative ways and I am sure in the future we will see prostheses being made to measure within the operating theatre! I came across this information in an interesting blog on the ACA Research website describing the modular operating room at QEII Jubilee Hospital, Brisbane – The Operating Room of the Future OR at John Flynn Hospital

Where does this view into the future leave perioperative nurses?   Will we survive this technological revolution? We will need to reinvent ourselves using new skills and knowledge to care for patients in this brave new world. With National Perioperative Nurses Day fast approaching on 12 October, it is a perfect opportunity to consider our current and future roles. Many of us won’t be around to see the new technologies and innovations, but we can think of ways in which we can lay the foundations for the next generation of perioperative nurses to meet the challenges of the future.

What are your thoughts on the future of surgery, operating theatres and of course perioperative nurses? Get in touch and tell us what you think.

Back to Australia next week, so til then….
Menna

Safer Australian Surgical Teamwork – Human Factors in Action

My blog, ‘In Safe Hands – Flying High’, described the importance of good communication and teamwork and the importance of these non-technical skills or human factors in ensuring patient safety.

Recently, I had the privilege of being involved in an initiative, ‘Safer Australian Surgical Teamwork’ (SAST) conducted through the Royal Australasian College of Surgeons (RACS) aimed at improving non-technical skills within surgical teams. RACS have conducted programs in non-technical skills for surgeons (NOTSS) for a number of years using the work of industrial psychologist, Rhona Flin from Aberdeen University. Flin’s work also involved identifying anaesthetic non-technical skills (ANTS) and scrub practitioner list of non-technical skills (SPLINTS).

Seeking to broaden the original NOTSS program and develop a program that included all members of the surgical team, RACS invited representation from ACORN, Australian College of Nursing (ACN) and Australian & New Zealand College of Anaesthetists (ANZCA) to participate in a working party to develop a series of human factors workshops conducted at selected rural centres around Australia.

I was honoured to be invited to represent ACORN alongside Elissa Shaw, with fellow perioperative nurses Vicky Warwick, Emma Woodhouse and Rona Tranberg representing ACN. The combined working party met at RACS HQ in Melbourne several times to develop the content and identify presenters for each workshop, organise venues and travel plans. As the whole program was government funded through Rural Health Continuing Education, the venues selected were Albany (WA), Darwin (NT), Bega (NSW) and Traralgon (Vic).

A team, the RACS Faculty, comprising of an anaesthetist, surgeon, one or two nurses and a RACS Project Manager facilitated each workshop.

The presentations, aimed at exploring team dynamics, reflected the non-technical skills identified by Flin’s work in each discipline – situation awareness, communication, teamwork, task management, decision making and leadership.

I presented ‘Situation Awareness’ in Traralgon and at two workshops in Darwin (photo shows  me with Vicky Warwick and NT ACORN Director, Sharon Harding) – quite a contrast in temperature and the sand flies saw me coming in NT causing a very uncomfortable week as I desperately tried to find a relief for the itchy bites! I did find it interesting (and at times challenging) to present to interdisciplinary groups, I wasn’t sure how the surgeons and anaesthetists in particular would react to the content, but there were some great experiences shared which added to the richness of discussions. There was some amusing banter between the disciplines, along with some robust discussion and overall I came away energised by the openness of the groups to embrace new ideas and strategies for improving their local teamwork. I also had the chance to meet new people, caught up with old nursing buddies and enjoyed working with such a committed group of surgeons, anaesthetists and perioperative colleagues, all of whom gave their time voluntarily to participate in this exciting project.Vicky Warwick and Sharon Harding in Darwin

Participants in each centre were restricted to 15 to allow for plenty of interaction and ensure an even spread from each discipline. A combination of didactic sessions, group work, video scenarios, and observational assessments were greeted enthusiastically by all the participants. The evaluations were very positives with participants identifying the following ‘take home’ messages:
• greater team involvement in Time Out process
• get to know your team
• reduce distractions during important phases of surgery (‘sterile cockpit’)
• recognise fatigue amongst team members
• have confidence to speak up and contribute to patient safety

Hopefully the positive evaluations will lead to further funding and more workshops across the country. In particular, it is hoped that local champions for human factors can be identified, so that ‘in house’ human factors workshops can be conducted.

I invite you to view some of the websites related to human factors and keep an eye out for future workshops at your hospital.

Clinical Human Factors Group

Scrub Practitioners List of Non-Technical Skills (SPLINTS)

bye for now
Menna

In Safe Hands – Flying High

Recently I was sitting on Qantas flight contemplating the 23 hour journey ahead of me to London when the Captain’s voice came over the speaker system with a cheery greeting. Often I tune out at this stage as I busy myself with seatbelts, headsets and claiming elbow room from my close neighbour! But the name of the Captain stopped me in my tracks – ‘Good afternoon, ladies and gentlemen, this is Captain Richard De Crespigny speaking.’ The name may not be familiar to you, but to me it sent my mind back four years to November 2010 when the same pilot brought stricken flight QF32 back safely from the brink of what could have been one of the worst air disasters.QF32_1

QF32 was an A380 airbus with 469 passengers and crew on board which had just left Singapore on the final leg of the long haul flight from London. Four minutes into the flight an engine blew up, caught fire, severing a number of vital electrical and hydraulic systems within the wing. The resulting catastrophic emergency tested the experience and teamwork of the flight crew to their limits in trying to assess the damage and its consequences for the plane. The good news was that the flight crew were able to land the plane safely back in Singapore. What makes this a somewhat personal story is that I should have been on that flight, but extended my stay in UK by a day, thereby missing this near disaster.

Hearing Captain De Crespigny’s cheery welcome last week got me thinking about what he and his crew must have gone through managing the emergency four years ago. It also made me consider the parallels between the teamwork required in the cockpit during that emergency and similar situations in an operating theatre when good teamwork and communication are vital components of a safe outcome for the patient. I have just watched a recreation of the events on QF 32 and struck me was the calm leadership of Captain De Crespigny as he delegated jobs to his flight crew whilst he took over flying the plane. In one of the many interviews you can view on You Tube, he tells of importance of using his hearing to ascertain how well the engines were working – not relying on the myriad of controls at his disposal, many of which were showing alarms and therefore unreliable. How many times do we in an operating theatre rely on watching monitors rather than use our eyes and ears to tell us the condition of a patient?

One of the roles he delegated during the emergency was to his First Officer who took fifty five minutes to investigate each one of the hundred alarms that had been triggered, with each alarm having its own checklist to work through! Ignoring any one element of the checklist could have meant disaster for the plane and its passengers. How often you see teams going through the motions of our ‘Time Out’ checklist without really engaging with each aspect and how that may put our patients at risk?

The other aspect that struck me watching the recreation was the teamwork of the flight crew and the contributions each made to working out solutions for the many problems they faced. None were afraid to speak up and all were encouraged by the Captain to contribute their thoughts to finding solutions. Are there parallels we can draw between the flight crew and teams in the operating room? How easy or challenging is it for you to speak up if you witness unsafe practices or to voice concern about the way in which surgery is progressing? Hierarchical barriers which once plagued the cockpit are still in evidence in many surgical teams. What can be done about this? We know from the reading reports following adverse events that poor communication and dysfunctional teams are often the root cause of such events. Non-technical skills such as teamwork and communication are just as important to the safe outcome for the patient as the technical expertise the surgical and nursing teams possess.

In my next blog I will describe an initiative with which I have recently been involved aimed at improving multidisciplinary surgical teamwork and communication.

Until then – ‘sit back, relax and enjoy the flight’ – I certainly did.

Cheers
Menna

You can view a recreation of the events that took place on QF32:

‘Airbus A380 (Qantas Flight 32) – Engine on Fire – The Titanic in the Sky Seconds from Disaster’

Excel with data and the real reason we should wear surgical masks: Lessons from recent Informa Conference

Ben Lockwood is an engaging presenter and self-avowed technology geek. I was fortunate to hear Ben speak at last month’s Informa Operating Theatre Management Conference in Sydney. It seems Ben’s made good use of technology – MS Excel in particular – in his project work implementing the National Standards at Flinders Medical Centre in South Australia. Ben recommended perioperative managers download the appropriate NSQHS Monitoring Tool from the NSQHS website and develop an audit schedule from this Gap Analysis that is achievable and meaningful. Ben finished by saying that “the data have to help you to improve!” If you’ve not yet heard Ben speak about the Nationals Standards, then you might like to check out his slides from the Informa Conference.

Elsie Truter from Rotorua, New Zealand gave a rather memorable presentation on infection control. Wonderful slides, including one of an ancient Peruvian skull showing signs of surgical trephining as well as evidence of healing – confirming that the patient didn’t die as a result of this rather dramatic surgery. In addition to the wonderful slides, Elsie provided some surprising statistics about new infections as well as developments in health and science. Did you know that the human genome has shown that we are 8% virus? Did you know that during the Crimean War, Florence Nightingale dropped the infection rate to 4%, but never accepted germ theory? I was rather startled to learn that in less than an hour a patient’s hospital room will be colonised and reflect the patient’s unique ‘microbiome’. Elsie made the point that patients’ visitors may also be a source of infection in hospital because their behaviour can be risky – she supported this view with a photo she’d taken of some visitors sitting on the gutter next to rubbish bins outside the hospital ED. However, the most memorable slide was the one Elsie used to strongly defend the use of surgical masks – it stops us from picking our nose. Worth a look? You bet!

You can view many other presentations from this recent conference, including an update on ACORN’s activities from ACORN President Ruth Melville, some great insights from Kathy Flanigan on Communication plus a fascinating presentation on the TPOT by Aaron Shergis as well as my presentation on “Delegation and Supervision: Implications for managers”. For those of you keen to read more, be sure to check out the Informa Healthcare blog.