20 Jan 2018 - An interdisciplinary project led by CID member Professor Alan Short (Department of Architecture) is re-examining surgical operating theatre design with superbugs in mind.

Excising Infection in the Surgical Environment [ExISE]

'Excising Infection in the Surgical Environment [ExISE]' is a newly funded Arts and Humanities Research Council research project within the major cross UK Research Council initiative 'Tackling Antimicrobial Resistance'. The perhaps unusually interdisciplinary team of academics in infectious diseases, pathogen transmission, architecture, history and philosophy of science, fluid mechanics and history of art, were brought together through the Cambridge Infectious Diseases Interdisciplinary Research Centre and will introduce a design perspective to antimicrobial resistance research by investigating the physical environments for surgery. Project Partners include RCS Research Fellows and Fellows, the NHS Sustainable Development Unit, the Institute of Hospital Engineering and Estate Management, NHSi, leading engineering and design practices Happold and Gensler and the international hospital contractor Skanska.

The aim of the research is to eliminate aerosol related surgical site infections in operating theatres through re-examining the evidence. The work may lead to the reinvention of the physical surgical environment to a greater or lesser degree. Designing out transmission routes for surgical site infections could ultimately reduce the reactive use of antibiotics post-surgery and hence their contribution to antimicrobial resistance.

The importance of airborne transmission in operating theatres appears to have dominated design through the past 60 years or so, but design has not kept pace with modern surgery. Sadly surgical site infections are not eliminated in contemporary operating theatres and so the research team asks, 'Is there another way?' Our medical school colleagues advise us that the impact of answering this question for the NHS could save lives and costs. Current surveillance may have underestimated surgical site infections by up to 50%, and the costs of readmissions due to surgical site infections (including increased length of stay, and additional procedures and treatment) may be as much as £700 million/year in the UK.

 The primary mechanisms of airborne related transmission are thought to be due to pathogens already within the room - normally bacteria or fungi – being released into the air. This may be from a surgical procedure that aerosolizes droplets containing microorganisms from the patient's own body or released on skin from the surgical team. Rather than being inhaled as in classical airborne infection, these pathogens deposit out, directly into wound sites or indirectly by contaminating instruments. These microorganisms pose a major problem when they enter a wound site. The mid- 20th Century redesign of the operating theatre was driven by the idea that infections could be dramatically reduced by pumping cool air through the operating theatre, over all occupants and contents.

Operating theatres in the UK currently conform to one of two configurations; the Ultra Clean down-flow Ventilated (UCV) or the 'Mixed' Ventilation (MV) theatre. Both cases deliver high ventilation rates, creating a cold and breezy working environment. The guidance has become established in industry, yet has not kept pace with surgical developments. The same rooms and ventilation are now used for both complex surgery using robotic techniques, where equipment and the heat load disrupt airflow patterns, as well as keyhole surgery with the smallest of incisions in the body.

The project will use the skills of historians to develop a detailed history of operating theatre design through the ages, so that we can understand how we have got to where we are. In parallel with the search for useful historical precedent, we will model the behaviour of pathogens within common airflow patterns, and explore the human dimension to gain greater understanding of the physical and psychological experience of being in and working in a contemporary operating theatre. Researchers will be visiting surgical teams and interviewing them in situ and at the Royal College of Surgeons. The research team is also extremely interested to hear of (and potentially visit) surviving or well documented historical operating theatres. Please email Prof Alan Short at cas64@cam.ac.uk

Team members

Prof. Alan Short (PI) cas64@cam.ac.uk University of Cambridge (UoC) Department of Architecture (CID)

Dr Ronita Bardhan (PI), Department of Architecture, CID & CPH

Dr Lydia Drumright - UoC Department of Medicine (CID)

C. Noakes - University of Leeds Institute for Public Health and Environmental Engineering

A. Woods - UoC BP Institute for Multiphase Fluid Flow

C. Gainty -  Kings College London, Department of History

K. Schoefert-  Kings College London, Department of History

L. Tantardini - UoC Clare Hall/Dept. of History of Art.