Journal of Perioperative Practice PROCUREMENT GUIDE May 2013

Journal of Perioperative Practice

PROCUREMENT GUIDE May 2013 Volume 02 Issue 02 www.afpp.org.uk 01423 881300

Journal of Perioperative Practice PROCUREMENT GUIDE May 2013 Volume 02 Issue 02 www.afpp.org.uk

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Journal of Perioperative Practice PROCUREMENT GUIDE May 2013 Volume 02 Issue 02 www.afpp.org.uk

Contents

Welcome to your May 2013 Guide 05

General considerations when planning laparoscopic surgery

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Product News

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A brief insight into endoscopy

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Product News

Journal of Perioperative Practice Procurement Guide information In print within the AfPP Journal of Perioperative Practice covering national AfPP members, but also with a dedicated print and e-distribution to supplies and purchasing managers.

Key Sectors: NHS Supply Chain, Independent Hospitals, Higher Education. Medical Device Companies.

Published 6 times a year we will focus on procurement issues in every edition as well as specialist subjects which for the following year include:

July/August 2013 Infection prevention September 2013 Airway management November 2013 Safety January 2014 Recovery

Contact Information: Advertising, Sponsorship & Partner Packages.

Frances Murphy Account Manager Open Box M&C T: 0121 200 7820 E: francesmurphy60@yahoo.com Editorial Chris Wiles Head of Publishing / Editorial AfPP T: 01423 882950 E: chris.wiles@afpp.org.uk

PR & press material.

All press releases welcome and we will feature as many as we can in each issue, all press releases need to be submitted to: Frances Murphy Account Manager Open Box M&C T: 0121 200 7820 E: francesmurphy60@yahoo.com

Journal of Perioperative Practice PROCUREMENT GUIDE May 2013 Volume 02 Issue 02 www.afpp.org.uk

+ Have you any ‘New Products’ to launch or ‘Established Products’ you wish to push to the forefront of the ‘NHS Supply Chain & Private Sector’?

Call our sales contact, Frances, to discuss including them in our upcoming editions

Frances Murphy +

44 (0)121 200 7820

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Surgery

General considerations when planning laparoscopic surgery The first laparoscopic cholecystectomy was performed in 1985 and since then the growth of technology and innovation in laparoscopic surgery has been phenomenal.

Today, operations can be performed through a single incision in the umbilicus or through a natural orifice such as the vagina, leaving no visible scars. Major operations such as colonic resections are now routinely performed using a laparoscopic approach. The benefits of laparoscopic surgery include reduced postoperative pain, improved cosmetic results and patient satisfaction, and reduced hospital stays (Perrin & Fletcher 2004).

Although there are differences in the procedures that are carried out across the field of laparoscopic surgery, there is a standardisation of equipment and the way access is gained to the abdominal cavity. However, there are a number of variations that occur in the specialist equipment used, particularly surgeons’ personal preferences with regard to ports, telescopes and number of assistants.

When planning laparoscopic surgery for any patient there are a number of considerations that should be taken into account by the surgeon and the operating theatre team. Every patient undergoing laparoscopic surgery should have a comprehensive preoperative assessment to determine the risk of anaesthesia and any limiting factors that may hinder laparoscopic surgery.

Patients with previous abdominal surgery, obesity or multiple co-morbidities need careful evaluation. These factors are not absolute contraindications for surgery. These patients may not need extra care from an anaesthetic point of view, but there is an increased chance of conversion to open surgery and additional ports may be required (Srivastava & Niranjan 2010).

Obesity may be associated with

multiple co-morbidities such as cardiopulmonary or metabolic disorders. Extra long instruments may be required in these patients as they tend to have a very thick subcutaneous layer of fat. The use of additional equipment that is not part of the standard procedure should be identified as part of the World Health Organisation (WHO) Surgical Safety Checklist (NPSA 2009).

Once the patient is anaesthetised it is important that they are positioned correctly on the operating table with specific attention to the potential for nerve injuries that result from prolonged compression or stretching (Philosophe 2003).

If improperly placed, the use of arm boards to prevent slippage in steep Trendelenburg position may also cause significant nerve compression. The use of ‘bean bags’ to support/ immobilise patients in the steep Trendelenburg position or those who require significant left /right tilting (Moss 2009). It is important that patients are informed that postoperative numbness or tingling usually resolves after approximately five days. Patient positioning does depend on the operation to be performed, for example Trendelenburg position (head down) for gynaecological

The last decade has seen considerable growth in the use of laparoscopic surgery with increasingly complex procedures being carried out.

This presents perioperative practitioners with the challenge of understanding not only the procedures performed but also the diverse equipment required to successfully complete each operation. Patient safety remains at the forefront of care.

procedures and some general surgical procedures, reverse Trendelenburg (head up) for upper abdominal procedures.

The position of the patient can have an impact on their cardiopulmonary function (Srivastava & Niranjan 2010).

The Trendelenburg position may increase the pressure on the diaphragm, whereas in the reverse Trendelenburg position pulmonary function tends to improve. However, this position can lead to hypotension.

Pooling of blood in the lower extremities also predisposes the patient to a risk of deep vein thrombosis (DVT). Therefore it is essential to use appropriately fitting compression stockings and a pneumatic device unless contraindicated (NICE 2010).

An open Hasson technique or a Veress needle can be used to establish the pneumoperitoneum.

Either of these methods can be used depending on the surgeon’s preference and limitations imposed by the patient’s physique. In a study carried out by Dunne et al (2011) it was concluded that there is no evidence to support the superiority of one technique over the other.

Carbon dioxide is the most frequently used gas for establishing a pneumoperitoneum of the abdomen as it is colourless, non-toxic, non-flammable and has the greatest margin of safety in the event of venous embolus (Perrin & Fletcher 2004). However, it is important that individuals are aware of the potential physiological consequences associated with insufflating the abdomen with this gas. Stretching the peritoneum can cause cardiac arrhythmias, although these are more pronounced at the beginning of the insufflation due to rapid introduction of

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gas. Other effects include subcutaneous emphysema or venous gas embolism.

Electrosurgery in laparoscopic surgery is another important consideration. A thorough knowledge of the fundamentals of electrosurgery by the entire theatre team is essential for patient safety and for recognising potential complications (Alkatout et al 2012). Appropriately applied electorsurgery is safe and effective. Electrothermal injury may result from direct application, insulation failure on equipment, direct coupling and capacitive coupling. Insulation failure is now thought to be a main cause of laparoscopic electrosurgical injuries (Vancaille 1998). It is defined as a break or defect in the insulation that coats the instrument.

Disposable instruments have a lower incidence of insulation failure compared with reusable instruments. The distal third of laparoscopic instruments is the most common site of insulation failure. With the advent of new technology, it is crucial theatre staff know how instruments work to minimise the risk of injury and understand their mode of action.

The Ligasure and the Harmonic Scalpel are both instruments that contribute to the quality of the surgery but also to the cost. These instruments have efficient haemostatic properties which must be used whenever appropriate.

Thermal injury can also occur secondary to the fibreoptic light source (Hindle et al 2008). In a study carried out by Hindle et al (2008) they found that when surgical drapes were exposed to the tip of the light source, the time to char was 3-6 seconds, and significant injury was recorded with the optical cable 3mm from the skin. Burns to the patient can also occur when the cautery tip is not placed in its insulated container on the surgical field.

The use of electrosurgical instruments produces various quantities and consistencies of smoke plume which can have an effect on laparoscopic visibility (Weld et al 2007). Practitioners

Surgery need to be aware that the smoke plume can contain toxic gas and vapours. This supports the need for smoke evacuation systems to reduce the potential acute and chronic health risk to patients and theatre staff (Spruce & Braswell 2012).

Unlike open surgery, the field available to the surgeon and his/ her assistant is two dimensional.

This makes it difficult to acquire a perception of depth and extreme caution is required. The issue can be further compounded if there is a lack of illumination and vision is restricted. The assistant also needs to be aware of the differences in the visual field when using a zero degree scope compared to a thirty degree scope.

The last decade has seen considerable growth in the use of laparoscopic surgery with increasingly complex procedures being carried out.

This presents perioperative practitioners with the challenge of understanding not only the procedures performed but also the diverse equipment required to successfully complete each operation. Patient safety remains at the forefront of care, with the WHO checklist a valuable tool in support of this.

Lisa Graham RN, DipN, BA, MSc Laparoscopic Nurse Specialist University Hospitals of Leicester

References Alkatout I, Schollmeyer T, Hawaldar N, Sharma N, Mettler L 2012 Principles and safety measures of electrosurgery in laparoscopy Journal of the Society of Laparoendoscopic Surgeons 16 130-139 Dunne N, Booth M, Dehn T 2011 Establishing pneumoperitoneum: Verres or Hasson? The debate continues Annals The Royal College of Surgeons of England 93 (1) 22-24 National Institute for Health and Care Excellence 2010 Venous thromboembolism: Reducing the risk of venous thromboembolism (deep vein thrombosis) in patients admitted to hospital Available from:

www.nice.org.uk/nicemedia/ live/12695/47195/47195.pdf [Accessed March 2013] Hindle A, Brody F, Hopkins V, Rosales G, Gonzalez F, Schwartz A 2008 Thermal injury secondary to laparoscopicoptic cables Surgical Endoscopy 23 17201723.

Moss R 2009 Patient Positioning.

In Rothrock J, Seifert P Assisting in Surgery: Patient Centred Care (pp 1-37) Competency & Credentialing Institute National Patient Safety Agency 2009 WHO Surgical Safety Checklist Available from: www.nrls.npsa.nhs.uk/ resources/?EntryId45=59860 [Accessed March 2013] Perrin M, Fletcher A 2004 Laparoscopic abdominal surgery Continuing Education in Anaesthesia, Critical Care and Pain 4 (4) 107-110 Philosophe R 2003. Avoiding complications of laparoscopic surgery Sexuality, Reproduction and Menopause 1 (1) 30-39 Spruce L, Braswell ML 2012 Implementing AORN recommended practices for electrosurgery AORN Journal 95 (3) 373-384 Srivastava A, Niranjan A 2010 Secrets of safe laparoscopic surgery: Anaesthetic and surgical considerations Journal of Minimal Access Surgery 6 (4) 91-94 Vancaille T 1998 Active electrode monitoring. How to prevent unintentional thermal injury associated with monopolar elecrosurgery at laparoscopy Surgical Endoscopy 12 10091012 Weld K, Dryer S, Ames C, Cho K, Hogan C, Lee M, et al. (2007) Analysis of surgical smoke produced by various energry based instruments and effct on laparoscopic visibility Journal of Endourology 21 (3) 347-351

When planning laparoscopic surgery for any patient there are a number of considerations that should be taken into account by the surgeon and the operating theatre team. Every patient undergoing laparoscopic surgery should have a comprehensive preoperative assessment to determine the risk of anaesthesia and any limiting factors that may hinder laparoscopic surgery. Patients with previous abdominal surgery, obesity or multiple co-morbidities need careful evaluation.

Journal of Perioperative Practice PROCUREMENT GUIDE May 2013 Volume 02 Issue 02 www.afpp.org.uk

Four more NHS Trusts Product News convert to Inditherm 07

Inditherm Medical has secured orders to equip all theatres in four further NHS trusts in the last four months.

The trusts concerned will equip nine hospitals between them, in the South, Midlands, North-West and North-East of England. The orders will account for a total of 140 Inditherm perioperative patient warming systems for use in operating theatres and recovery rooms. In all four cases the implementation of Inditherm patient warming represents an opportunity for very significant cost savings to the trusts concerned, as highlighted in the NICE guidance released in 2011 (www.nice.org.uk/guidance/mtg7).

At the same time it will become normal to warm all surgical patients, providing higher levels of clinical care than typically achieved using traditional forced air warming technology. One trust alone is set to save well over £0.5 million in the coming five years, with additional reductions in energy usage, clinical waste disposal and costs of buying and stocking consumables.

Inditherm is the only company manufacturing patient warming systems in the UK and so increasing uptake of their products in the NHS represents a welcome boost for British industry and jobs.

Inditherm Chief Executive, Nick Bettles, commented: “As reported previously, the time taken to convert initial interest in our systems to orders has been a protracted process over the last year, so it is pleasing to see four significant new installations finally come to fruition. We are hopeful that more NHS hospitals will recognise the growing acceptance of the benefits Inditherm can deliver in improving clinical care and substantially reducing costs, and will have the confidence to embrace our technology. Over 4,000,000 surgical patients have now been warmed by Inditherm systems, so the clinical efficacy is well established.”

For more information contact Lisa Hayes, at Inditherm Plc Tel: + 44 1709 766614, E-mail: lhayes@indithermplc.com

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Product News

Springtime sizzling Scopetech give away!!

Serchem is acutely aware that the NHS is changing, quickly.

With budgets being squeezed and standards being driven to remain high then something has got to give!

in the manual cleaning of flexible endoscopes.

It is down to suppliers to find new ways of being creative to keep hospital managers and procurement interested in the product ranges they supply, so bearing this factor in mind Serchem would like to introduce you to an offer that will blow your socks off!!

Scopetech benefits are as follows: 1. It flushes 2. It leak tests 3. It’s compatible with all scopes 4. It dispenses the desired detergent 5. It monitors water temperature 6. It has traceability 7. It’s free of cost, no purchase necessary!!

The Serchem spring Scopetech give away is directed at endoscopy departments to aid

The Scopetech will be installed, validated and maintained, and also provided without charge.

I hear you say ‘what’s the catch, it’s just too good to be true, there’s no such thing as a free meal’ the answer is simple.

All you need to do to benefit from this offer is simply to use Serchem chemistry on your manual cleaning sinks. Whether it be enzymatic or neutral, Serchem can accommodate your specific requirement with a range of products totally compatible with all makes and manufacture of scopes.

Why pay £3,000 and above for a system per sink when you can have the investment for free just by a simple switch of chemical supplier. The prices of the

products are not inflated to offer this promotion and can be found on the NHS supply chain at a very competitive rate.

The offer is limited; it’s a first come first serve basis so be quick.

A free Scopetech for every 35 scopes cleaned on a daily basis so more Scopetechs can be supplied for greater numbers.

Serchem, more than just a chemical company!

Serchem Ltd Tel 01952 22310 [Davinia] Mobile 07812 993776 [Paul] www.serchem.co.uk

Journal of Perioperative Practice PROCUREMENT GUIDE May 2013 Volume 02 Issue 02 www.afpp.org.uk

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Endoscopy

A brief insight into endoscopy Endoscopy is a visual inspection of any cavity of the body for medical reasons using an endoscope. Unlike most other medical imaging devices, endoscopes are inserted directly into the organ.

Endoscope

There are many different kinds of endoscopes. Most are thin, long, flexible tubes that have a light source and a video camera at one end. Images of the inside of your body are relayed to a television screen.

Some endoscopes are stiff, while others are flexible. Endoscopes can vary in length and shape.

Each type is specially designed for looking at a certain part of the body.

Endoscopes can be inserted into the body through a natural opening, such as through your throat or anus. Alternatively, it can be inserted through a small surgical cut made in the skin.

Management of CJD Incidents and Dissolution of the CJD Incidents Panel The Creutzfeldt-Jakob Disease (CJD) Incidents Panel was dissolved at the end of March 2013. Responsibility for investigating, assessing and managing CJD incidents (and where appropriate notifying patients) rests with local trusts, health boards and health protection teams in the same way as most other incidents that place patients at infection risk. Guidance on CJD incident management is available at: www.hpa.org.uk/Topics/

Types of endoscopes

Some of the most commonly used types of endoscopes include: • arthroscopes - to examine the joints • hysteroscopes - to examine the uterus in women • cystoscopes - to examine the bladder Other types of endoscope include: • endoscopic retrograde cholangiopancreatography (ERCP) - to check for gallstones • broncoscopes - to examine airways and lungs • colonoscopes - to examine the large intestine

InfectiousDiseases/InfectionsAZ/ CreutzfeldtJakobDisease/ CJDGuidanceAndAdvice/ Long term public health surveillance of CJD exposures will continue and trusts, health boards and health protection teams are asked to continue reporting the occurrence of incidents to the CJD Section, in particular if they involve a patient notification exercise.

Novel issues that arise with respect to CJD risk management and infection control, or difficulties with interpretation of current guidance, can be referred to the CJD Section at Colindale.

If necessary advice may be sought from the ACDP TSE RM SG which may be contacted via

An endoscopy can be used to investigate if symptoms suggest there might be a problem. It can also be used to help perform some types of laparoscopic surgery such as removing the appendix or gallbladder.

An endoscopy will usually be performed on an outpatient basis and is generally carried out while the patient is awake. It is not painful, but can be uncomfortable so a local anaesthetic or sedative may be administered.

Decontamination of endoscopes

Decontamination of endoscopes should be in accordance with the general procedures set out in CFPP 01-06 Choice Framework for local Policy and Procedures 01-06 – Decontamination of flexible endoscopes: Operational management (DH 2013) Aldehyde disinfectants with fixative qualities tend to stabilise, rather than inactivate prions. The use of non-fixative disinfectants, if this is in accordance with manufacturer’s instructions, is therefore preferable (AfPP 2011).

Disinfectants with fixative properties should not be used on flexible endoscopes for any procedure on patients with a diagnosis of definite, probable or possible CJD, where the

the CJD Section.

Infection control guidance from the Advisory Committee on Dangerous Pathogens Transmissible Spongiform Encephalopathy Risk Management Sub-Group (ACDP TSE RM SG - formerly the TSE Working Group) to reduce the risk of the spread of TSEs in health care and community settings can be found at: www. gov.uk/government/publications/ guidance-from-the-acdp-tse-riskmanagement-subgroup-formerlytse-working-group Further/background information: What is a CJD Incident?

A surgical incident has occurred when a patient with or at increased risk of any human prion disease, including all forms of CJD, has had

diagnosis of CJD is unclear, or the patient is at risk of developing CJD (AfPP 2011).

There should be an effective tracking and traceability system in place. In the event that a patient is subsequently diagnosed as either a probable or definite vCJD, then patients who have undergone procedures with the same instrument can be identified and monitored (AfPP 2011). If it is necessary for an endoscopic procedure to be performed on a confirmed CJD or vCJD patient, a single use endoscope should be used and incinerated after use. For suspect CJD or vCJD patients the endoscope should be quarantined pending a confirmed definite diagnosis (AfPP 2011).

References Association for Perioperative Practice 2011 Standards and Recommendations for Safe Perioperative Practice Harrogate, AfPP Department of Health 2013 CFPP 01-06 Choice Framework for local Policy and Procedures 01-06 – Decontamination of flexible endoscopes: Operational management London, DH Available from www.gov.uk/government/ publications/management-anddecontamination-of-flexibleendoscopes [Accessed April 2013]

an invasive procedure involving high or medium infectivity tissues for CJD and where TSE instrument precautions were not taken.

Patients subsequently exposed to the implicated instruments may need to be informed that they are at increased risk of CJD, depending on the specific circumstances.

Questions relating to the interpretation of the guidance should be sent to the CJD Section at Colindale either via the CJD mailbox cjd@phe.gov. uk or to: Dr Katy Sinka: Email: katy.sinka@phe.gov.uk Tel: 020 8327 6411 Emma Hollis: Email: emma.hollis@phe.gov.uk Tel: 020 8327 6406

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Product News

The ProReveal Fluorescence Protein Detection Test The ProReveal Fluorescence Protein Detection Test has been developed in response to the need to find a more sensitive and accurate method of checking for residual proteins that can sometimes remain on surgical instruments after the washer disinfection process.

Commonly used tests include on-instrument swab tests or visual inspection. However, it has been found that neither of these can detect the lower levels of protein than can remain on an instrument after washing and which can be a major source of cross infection particularly with prions such as vCJD.

The quality of any washer disinfection process is dependent on a number of variables – type of washing machine, the process, instrument position in the washing tray, water quality, detergent, to name just a few. Hence, an effective check process is required to ensure that surgical instruments have been cleaned to the required standard during the washing process.

The added problem with any swab test is that only part of an instrument can be tested and the results remain very subjective as to whether the operator has performed the test correctly and interpreted the results accurately. Instruments that remain ‘dirty’ after washing can be a prime source of infection and can result in cancelled operations, closed theatres and of course worse still have a catastrophic effect on patient safety.

The ideal cover for reducing infection and protecting equipment One of the great challenges for any surgical team conducting any procedure, but particularly fluid rich operations, is how to protect the valuable equipment used, especially operating tables. Ecolab, the infection prevention specialists, have introduced the protective cover system CleanOp, to the UK surgical market.

CleanOp Technology provides three significant benefits: 1. CleanOp prolongs the life expectancy of expensive equipment by effectively protecting it 2. CleanOp reduces theatre turnaround times by making

post-operative clean-ups much faster 3. CleanOp helps protect staff and patients from Healthcare Acquired Infections CleanOp achieves these benefits through its advanced wicking technology, comprising of three layers: a breathable, comfortable upper patient layer; the patented Mojave layer with its super-absorbent polymers; and the impervious backing which prevents bodily fluids and liquids reaching the mattress and table. CleanOp is also adhesive free, unlike many disposable drapes, and so avoids the additional mattress corrosion this can cause.

With medical engineers reporting the average cost of replacing a mattress to be anywhere between £1,200 and £1,500, together with the reduced servicing time required, this can provide a compelling financial case for the budgetconscious theatre manager.

“We find that once a customer has had the opportunity to try the CleanOp System,” says Ecolab’s Surgical Sales Manager, Tim Eaglen, “they are very keen to continue using the product, such are the obvious benefits”.

“Longer term, they appreciate the convenience of the System and added financial benefits,” he concludes.

Free trials of the CleanOp Hygienic Protective Cover System, can be arranged by calling 0113 232 2480 or emailing alison.waite@ecolab.com

The Association for Perioperative Practice is a registered charity (number 1118444) and a company limited by guarantee, registered in England (number 6035633). AfPP Ltd is its wholly owned subsidiary company, registered in England (number 3102102).

The registered office for both companies is Daisy Ayris House, 42 Freemans Way, Harrogate, HG3 1DH.

Journal of Perioperative Practice PROCUREMENT GUIDE May 2013 Volume 02 Issue 02 www.afpp.org.uk

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