Excising Infection in the Surgical Environment [ExISE]

Lead Research Organisation: University of Cambridge
Department Name: Architecture


ExISE addresses Key Area 3 of the AHRC Antimicrobial Resistance Call, 'Creative, Collaborative and Disruptive Innovation, Experiments and Design in Indoor/Built Environments'. Its overarching Aim is to eliminate airborne acquired Surgical Site Infections (SSI) in operating theatres OTs, traditionally countered with antibiotics. Our microbiologist colleagues emphasise that any antibiotic use, suboptimal or optimal, creates AMR and so avoidance of antibiotic use, in this case post-operative, is paramount. ExISE proposes to achieve this aim through the evidence-based reinvention of the actual physical environment in which surgery is practised, the Operating Theatre OT. Eliminating airborne SSI will reduce the number of infections and the reactive use of antibiotics in recovery and recuperation and in some cases repeat surgery and renewed risk. Airborne transmission of infection has long been feared, the post war custom and practice position on its mechanisms has dominated OT design. SSI is not eliminated in contemporary OTs. The position is not wholly substantiated. Surgeons do not question OT design. Is there another way?
ExISE will search for alternative approaches: its historians of science, art and architecture will research a history of Operating Theatre design, of making 'safe', appropriate environments for surgery within their designers' and patrons' theories and beliefs over some 150 years. The search will extend to exhuming still and moving images of surgery in action within its set environments. The Royal College of Surgeons believes this is an as yet unwritten history. The team will be searching for accompanying evidence for environmental intent to enable meaningful reconstructions of their theatres and environments against the original criteria for success. What did they think a healthy environment with healthy air looked like? ExISE scientists will assemble laboratory models and environments from the historical reconstructions of OTs alongside a contemporary 'Ultraclean' OT, the familiar 'cooker hood' issuing truly prodigious flows of cool air through the OT over all the occupants and contents, up to 40 air changes/hr, making a bizarre and not wholly welcome working environment for surgical teams. In parallel, ExISE will achieve greater understanding of the physical and psychological experience of being in/working in a contemporary OT for surgical teams and support staff by visiting teams and interviewing them in situ and at the Royal College. We hope to translate these insights into a meaningful critique from which design and redesign leads can be drawn, leading to a radical step change in fundamental approaches to the design of OTs. Approaches which appeal to our stakeholders and partners will be interrogated and tested physically with both analogue and theoretical models to enable wide dissemination of research outputs with real confidence and thence make significant impacts on the aspirations for and expectations of environments for surgery. Pursuing the international success of our earlier Robust Hospitals project film, we will make a 4-5minute animation out of our drawn reconstructions of OTs, our ideas for redesigning the OT superimposing the fluid flow modelling and calculated environmental performance. Our partners will post the film for their constituencies as will Cambridge University on its streaming media site and YouTube
Much detailed and painstaking work will be required subsequently to implement such radically new OTs in practice but ExISE should achieve the 'great leap forward' that breaks more than 60 years of standard practice.

Planned Impact

Researchers and Project Partners will connect collectively with their respective wide-reaching constituencies in healthcare across the UK and internationally. Our short but broadcast standard animation of the findings will expedite this international dissemination of ExISE findings in AMR elimination in the following ways:
Policy-makers and advisers: the UK Department of Health DH Estates and Facilities functions particularly those serving Lord Carter's ongoing Efficiency Review (PI's NHS EEF work). AMR robs resources from healthcare. Drumright and PI will introduce ExISE to the Cambridge Centre for Science and Policy, bridge between policy makers and scientists to support the translation of robust scientific findings into practice via policy.
Public sector agencies: Project Partner NHS Sustainable Development Unit (NHS SDU) Director Dr David Pencheon will disseminate ExISE findings across NHS including the most direct beneficiaries, surgical patients and their kin. There is a major sustainability implication for the NHS in AMR. ExISE will inform DH commissioned guidance as updated and disseminated through iNHS, HTM03-01 Part A (PI rewrote HTM07-02 in 2015); Drumright will introduce ExISE to her current UK/US surgeon network established to examine an electronic SSI predictive model. The findings may not only inform better redesign and new design of OTs, but may also be useful in risk prediction of SSIs in existing OTs. Project Partner IHEEM, the Institute of Hospital Engineers and Estates Managers' new President Peter Sellars speaks to/for hospital engineers in UK and overseas; CIBSE the Chartered Institute of Building Services Engineers speaks to/for all Mechanical, Electrical, Environmental engineers; PI, Co-Is and officers will disseminate through UKGov Healthcare UK 'export' vehicle for UK healthcare knowledge regular conferences and events at Westminster and overseas.
International organisations: Project Partner Royal College of Surgeons RCS international outreach through Martyn Coomer, Head of Research and RCS Fellows Network led by Project Partner Dr Ellie Edlmann, Department of Clinical Neurosciences University of Cambridge and Francis Wells: Cardiothoracic surgeon at Papworth Hospital; dissemination through the World Health Organisation WHO Europe; 'Healthcare Without Harm' Global Green and Healthy Hospitals, globalnetwork@hcwh.org; Centre for Sustainable Healthcare: Sustainable Operating Theatres Network; Kaiser Permanente, Oakland California, charitable health insurer serving 40Million subscribers, PI holds regular telecons on health building issues; China Ministry of Science and Technology through PIs EPSRC/NSFC LoHCool project network, Chinese Academy of Building Research, Ministry of Education [PI is MoE Distinguished Professor], Zhejiang, Chongqing and Tsinghua Universities' Architecture and Civil Engineering schools.
The commercial/private sector: hospital designers: medical campus masterplanners, environmental engineers, medical planners, specialist health architects including Project Partners Gensler, Happolds ExISE team will deliver CPD sessions in the practices.
Looking to the Future: ExISE focuses on UK OT configurations/standards. The experimental and design outcomes, however, address the much broader phenomenon of infection risks in all OT environments in well-resourced and resource-limited settings alike suggesting a future programme of potentially highly productive work to support the paradigm shift in making environments for surgery. There is bigger project extending investigation beyond the airborne route, attacking transmission as a multi-headed beast.


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Short C (2018) Excising Infection in the Surgical Environment (ExISE) in The Bulletin of the Royal College of Surgeons of England

Description Our detailed digital model of a radically different configuration for a space for surgery with a largely natural hybrid environment indicates that significant savings in associated carbon emissions should be possible. We are currently working on corrections to our summary paper for Buildings and Cities in response to reviewers' comments whilst the responses from our focus group of surgeons are being analysed by Drumright and colleagues for future publication.
Exploitation Route We hope that the Dept of Health, NHSi, and industry will pursue the configuration with the surgical community. Our film URL is not accepted by the box above but is:
Password: exise,
Sectors Aerospace, Defence and Marine,Energy,Healthcare

Description We have approximately 70 surgeons being interviewed for responses to the proposed design, transcripts yet to be coded and processed, the term of the THIS Institute/Wellcome ISSF Post-doctoral Fellowship is being extended at no cost to enable completion and then publication with the Royal College of Surgeons
First Year Of Impact 2021
Sector Healthcare
Impact Types Policy & public services

Description EPSRC Impact Acceleration Account COVID-19 Rapid Response Grant, University of Cambridge 2020 for 'Coronavirus Pandemic: Making safer emergency hospitals', see project film at https://youtu.be/Nzs3AwffK-Q winner of the tve Global Sustainability Film Awards 2020 AI Film Award https://www.gsfa.org.uk/ai
Geographic Reach Multiple continents/international 
Policy Influence Type Influenced training of practitioners or researchers
Impact Investigation into the risk of airborne cross infection in ad hoc conversions of large spaces to serve as emergency hopsitals for COVID-19 patients prompted by request from Prof. Shashidhara at Ashoka University india for on the suitability of marriage halls in india for this purpose. The physical modelling at the BP Institute in Cambridge shows that the subdivision of the space and the configuration of air supply and exhaust is critical and that top down supply and exhaust will mix the air and spread pathogens through the space. At the time the NHS was discounting the airborne route. Cambridge Universsity press released the experimental findings and the film made by Monika Koeck at Cinetecture, these were published worldwide, notably the Daily Telegraph Cambridge University news article https://www.cam.ac.uk/stories/emergency-hospitals New video version https://youtu.be/dVuPKgSJjP8 Stills available: https://www.dropbox.com/sh/injrdnr8y9tfcft/AADJh24JxHHUhf58UwxmSSVa?dl=0
URL https://youtu.be/dVuPKgSJjP8
Description THIS Institute Post- doctoral Fellowship Awards in collaboration with the Wellcome Institutional Strategic Support Fund
Amount £74,814 (GBP)
Funding ID THIS-ISSF_PD_2020-003 
Organisation Wellcome Trust 
Sector Charity/Non Profit
Country United Kingdom
Start 03/2020 
End 09/2021
Title Bespoke R Scripts for Routine Clinical Data Analysis - Automated Data Cleaning 
Description We have established a series of pipelines for data processing for routinely collected electronic clinical data. These pipelines are now being shared among those who are working with data from Cambridge University Hospitals NHS Trust in order to facilitate data cleaning and increase efficiency in data processing for research studies. 
Type Of Material Improvements to research infrastructure 
Year Produced 2019 
Provided To Others? Yes  
Impact It is too early to measure impact as we have just launched this activity. However, we anticipate that this will increase accessibility of data and increase the speed at which it can be processed. 
Title Surgical Site Infection (SSI) Natural Language Processing (NLP) Bespoke query 
Description Using a commercial NLP engine, we developed a bespoke query to identify surgical site infections from free text surgical and clinical notes. 
Type Of Material Data handling & control 
Year Produced 2019 
Provided To Others? No  
Impact We need to be able to measure SSI as an outcome to understand the effects that surgical theatres may have on risk. In order to do this we need to be able to identify SSI, which occur in 5-20% of surgical patients, however, a huge number of surgeries would have to be reviewed to identify these. Automating this through the NLP engine allows us to make this possible in a timely and cost efficient manner. 
Description Film making and 3D modelling of Operating theatre designs and the design process 
Organisation Cinetecture
Country United Kingdom 
Sector Private 
PI Contribution Providing information on the operating theatre environment based on the literature and interaction with colleagues working in surgery to help develop realistic designs: -information on team structure - according to surgery type -type of surgical equipment and specifications - according to surgery type -layout of equipment -PPE used in operating theatres Providing information on types of materials for operating theatre furnishings and fittings: -from architectural contacts -research
Collaborator Contribution Providing operating theatre design images and videos for qualitative element of the project
Impact No output at the moment. Multidisciplinary: -film making -architectural design -healthcare
Start Year 2019
Description Royal College of Surgeons 
Organisation Royal College of Surgeons of England
Country United Kingdom 
Sector Charity/Non Profit 
PI Contribution The Royal College of Surgeons of England has followed Excising Infection in Surgical Environments ExISE research findings closely, not least the modelling of the post 1968 Ultraclean downdraught flow operating theatre type at the BP Institute for Multiphase Fluid Flow in Cambridge University which we are confident we have shown does not deliver the degree of infection control claimed for it but which is highly consumptive of energy and unpleasant to work under. We have developed a radical much lower carbon, potentially safer, cheaper alternative for newbuild and adaptation of existing theatres. We will present animations and diagrams of the new version to a series of workshops with surgeons recruited by the Royal College of Surgeons through the last two weeks of April in London, Cambridge and Manchester. The workshops will be filmed by our partners cinetecture and analysed by our new THIS/WELLCOME Fellow Dr. Rabiya Zia. The film of the ExISE findings will be complete by October 2020 for dissemination through RCS, NHS, IHEEM (Institute of Hospital Engineers).
Collaborator Contribution The Royal College of Surgeons provides critical overview and hosts Sounding Panel and Project Team meetings in its current temporary accommodation whilst it rebuilds its HQ.
Impact Excising Infection in Surgical Environments (ExISE) 2017-19, funded by the AHRC from the cross council Antimicrobial Resistance AMR call (£248k), with the BP Institute for Multiphase Fluid Flow, the Interdisciplinary Research Centre in Infectious Diseases & the Dept. of History of Art at the University of Cambridge, History of Science at Kings College, Leeds University Civil Engineering Department, The Royal College of Surgeons. Our RA Dr.Rabiya Zia has just won a THIS Institute/Wellcome ISSF Post-doctoral Fellowship from March1st 2020 to continue the project until September 30th 2021. The Royal College of Surgeons has published an introduction to the ideas driving the project and early results in its Bulletin and will publish a peer reviewed research paper and disseminate the film of the project.
Start Year 2018
Description Cultural Histories of Air and Illness, Warwick University, June 2018: J. S. Billings and the Conundrum of the Naturally Ventilated Hospital 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact Invited oral presentation of paper at the excellent 2 day conference, Cultural Histories of Air and Illness at Warwick University, June 2018: J. S. Billings and the Conundrum of the Naturally Ventilated Hospital which has extended the ExISE project network considerably.
Year(s) Of Engagement Activity 2018