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NatSSIPs2 consists of two inter-related sets of standards: The organisational standards are clear expectations of what Trusts and external bodies should do to support teams to deliver safe invasive care. The sequential standards are the procedural steps that should be taken where appropriate by individuals and teams, for every patient undergoing an invasive procedure. The NatSSIPs2 have evolved to have less emphasis on tick boxes or rare ‘Never Events’ and now include cautions, priorities and a clear concept of proportionate checks based on risk. We recognise that ‘teams’ change or may be newly formed on the day of a procedure, and therefore require clear processes. NatSSIPs2 should form the basis of improvement work, inspections and curricula. Key principles in NatSSIPs2 include: The concept that NatSSIPs2 will help achieve of the triple goals of improved patient safety, better team-working and enhanced efficiency. The categorisation of invasive procedures into major or minor procedures, each requiring different checks which are proportionate to the risk of harm. The benefit of ‘Standardisation, Harmonisation, and Education’ across invasive specialty processes. The need to consider human factors with systems thinking, culture, psychological safety and team-work to underpin NatSSIPs2 implementation. An update of the WHO Five steps to safer surgery of Team Brief, Sign In, Time Out, Sign Out and Handover/Debrief to include three more steps to make the Sequential Standards (Steps): Consent and Procedural verification; Safe use of implants; and Reconciliation of items (to prevent retained foreign objects). ‘The NatSSIPs Eight’ should be in place for every relevant patient. That checks performed by an engaged team enable communication and save misunderstandings, reduce risk, provide clarity and set expectations The central role of the patient as a participant in safety checks. The need for a learning safety system supported by insight, involvement and improvement. A structure of People, Processes and Performance within the organisational standards The requirement for adequately resourced organisational leadership and support for safety. The NatSSIPs2 have been written by practising clinicians, from across the four UK nations, across disciplines, professions and organisations, with patient and organisational input and published by the Centre for Perioperative Care. They incorporate safety science and learning from all UK nations’ patient safety strategies and major reports and investigations. Are you a healthcare professional interested in learning more about NatSIPPs? On the hub we host the National NatSIPPs Network, a voluntary group of healthcare professionals aiming to reduce the number of patient safety incidents related to invasive procedures. You can join by signing up to the hub today. When putting in your details, please tick ‘National NatSIPPs Network’ in the ‘Join a private group’ section’. If you are already a member of the hub, please email hello@patientsafetylearning.org.

Prevention of surgical site infection (SSI) remains a main priority in operating theatres. This has previously led to the introduction of practices, often referred to as rituals and behaviours and sometimes labelled as ‘myths’. Some of them are not underpinned by sound scientific evidence, but they are established in everyday practice, and considered by many as traditional to help ensure discipline and professionalism in the operating theatre. Previous Healthcare Infection Society guidelines were published 20 years ago, and they aimed to debunk some of the practices. Since then, new technologies have emerged, and an update was required. These new updated guidelines, produced in collaboration between Healthcare Infection Society and The European Society of Clinical Microbiology and Infectious Diseases, used NICE-accredited methodology to provide further advice on which practices are unnecessary. Specifically, they discuss the current available evidence for 40 different rituals which are commonplace in the operating theatre and highlight the gaps in knowledge with recommendations for future research. As part of the consultation, we will be hosting a webinar on Wednesday 25 January, 17:00 - 18:00. During the webinar, the attendees will have an opportunity to ask questions to a panel who were involved in the guideline development, and give their feedback.

The authors conducted a literature search to identify quality improvement initiatives that aimed to decrease the environmental impact of the operating room while reducing costs. Data were included from 23 unique quality improvement initiatives that described 28 interventions. Eleven (39.3%), eight (28.6%), three (10.7%), and six (21.4%) interventions, respectively, were categorised as refuse, reduce, reuse and recycle. The researchers found that the potential annual cost savings varied from $2,233 (intervention: transition to a waterless surgical scrub; environmental impact: 2.7 million litre of water saved annually) to $694,141 (intervention: education to reduce regulated medical waste; environmental impact: 30% reduction in regulated medical waste), although the methods of measuring environmental impact and cost savings varied considerably among studies. "The opportunity to reduce our carbon footprint falls squarely on us, and I see surgeons taking a prominent role in leading efforts, not just locally with their green implementation teams, but in setting national standards and policies that will move this effort forward for an overall sustainable way of approaching health care delivery," a coauthor said in a statement.

December issue Delphi Study Round One – A study across NHS England Hospital Trust operating theatres. Managing NHS backlogs and waiting times in England. Steroid injections worsen knee arthritis, according to two new studies. First robotic hysterectomy completed in Wales. World’s first algae-based local anaesthetic another step closer to reality. How new bacterial species siscovered in Asian soil could help battle against antibiotic resistance November issue New research calls for all health and care staff to be trained in AI Reducing noise in operating theatre improves children’s behaviour after surgery, study finds Brain tumour patient operated on awake while playing saxophone No difference between spinal versus general anaesthesia in patients having hip fracture surgery finds study October issue Why are intra-operative surgical Never Events still occurring in NHS operating theatres? Radical rethink needed to improve safety in health and social care. World Anaesthesia Day 2022: History, significance, celebrations and theme. £4 million “space-age” operating theatre will help bring down eye surgery backlog. Two thirds of nurses choosing between food and fuel as cost of living bites and one in five turn to food banks. ‘An inspirational story’: Hartlepool cleaner changes career to become hospital nurse. September issue Service evaluation of the current World Health Organisation’s Surgical Safety Checklist in spine surgery at the University Hospitals of Derby & Burton. Could this lead to a change in NHS Improvement? The Anaesthetic Gas Scavenging System Project. Cancelled operations could be prevented by an earlier anaemia test and time to prepare. The top 10 things experts need you to know about screening during Gynaecological Cancer Awareness Month September 2022 £35.5m for New Friarage Hospital Operating Theatres. New robotic surgical system revolutionises patient care at UHCW. Insourcing: Giving NHS operating theatre teams a helping hand. Arterial stiffness raises blood pressure in adolescents via insulin resistance. Birmingham’s Public Health Chief is among sector leaders to receive university honours,

Delphi study participants Participants were from the seven regions identified by NHS England. The study revisited several questions from round one to gather further knowledge and understanding of the responses received. The debrief was not undertaken due to all team members not being present, staff wanting to go home, current culture and list overruns. Key initial findings of Delphi study round two The second round facilitated a broader engagement in the literature, as well highlighting a number of reasons why full compliance has not yet been universally achieved. The Delphi study is intended to be an exploratory approach to inform a more in-depth doctoral research study intended to improve patient safety in the operating theatre, inform policy making and quality improvement. Participants felt that training on the checklist should be mandated and take place annually. They also felt that learning from other organisations was key, and that the NHS needs to revise how the checklist is currently being delivered by being more proactive and by providing the foundations of an electronic checklist to all NHS trusts. Participants felt that a lack of direction from senior NHS leaders and multidisciplinary team working may impact on why the checklist is not always completed. With regard to Local Safety Standard for Invasive Procedures (LocSSIPs) and their introduction, participants either strongly agreed or agreed that NHS trusts must be held accountable for ensuring they are implemented. Participants overwhelmingly felt that surgical fires (non-airway) should be classed as a Never Event. To ensure cyclical learning occurs, details of each and every Never Event should be provided to all NHS Trusts Context of the Delphi study The literature to support a greater understanding of the impact on the implementation of checklist is still emerging. The review to date is not intended to be exhaustive, but begins to frame further questions, identify some of the contextual issues and plan for the third and final Delphi round. The use of a Delphi study was born out of curiosity to see to what the theatre safety experts (matrons, managers and clinical educators) think of the current checklist since its introduction across England thirteen years ago. Contextually it can be anticipated that invasive procedures in the NHS and indeed in healthcare globally will continue to rise, in part as a result of the advancement of new supportive technologies, such as robotics and enhanced minimally invasive approaches. Furthermore, access to these treatments is more readily available to different patient groups whose needs and longer-term rehabilitation can be more complex and demanding. While in this regard clinical outcomes, quality of life, and indeed life expectancy can be improved and extended, this is only the case if surgery takes place within optimum conditions. Taking all other factors into consideration, the number of Never Events continues to remain a constant yet stubborn patient safety concern. Future work - Delphi study round three The author is not yet in a position to draw further conclusions as the final Delphi study round is aiming to draw together the results from the first and second rounds, as well as asking further research questions. In acknowledging that the participant rate was 16%, the study cannot claim to know how other Trusts are utilising the SSC. Given the timing and context in which the Delphi study was carried out, it is appreciated that other priorities could have had an impact on trusts' ability and willingness to participate. Nevertheless, it was perhaps surprising to discover over a decade after the initial launch, that there is a lack of direction/leadership and that lack of multidisciplinary team engagement is still an issue. LocSSIPs 2 are due to launch early in 2023 and in order for this to be successful, training must take place, but most importantly NHS England need to hold trusts to account for not introducing them. A long-standing debate around whether surgical (non-airway) fires should be classified as a Never Event was asked to the theatre safety experts, with an overwhelming response agreeing that this type of event should be added to the reportable Never Event list. The study has also raised questions that will be answered in the third Delphi round.

To make the best of this approach we need to make sure patients and all health care professionals including GPs and multidisciplinary hospital teams work together to: Identify anaemia early in the pathway. Make the patient aware of this and all actions going forward. Find the cause of the anaemia. Use tried and tested treatments for anaemia before surgery. This could include advice on changes in diet, oral treatments such as iron supplements and the use intravenous iron when necessary. Make sure the patient has a personalised treatment programme including providing appropriate information about the pros and cons of the different approaches suggested to the patient and how long these should be continued. Communicate clearly between different members of the team so that operations are not cancelled unnecessarily and improve the interface between primary care and hospitals. Talk openly to the patient about the benefits and risks of managing anaemia and the surgery.

Ian Lindsley, Secretary of the SHBN, began by welcoming those on the call and talking through the speakers and the presentations. The first presentation was given by Martin McMahon of the Health and Safety Executive on the Post Implementation Review (PIR) of the Sharps Regulations 2013 by the HSE. The PIR will assess post implementation effectiveness of these legislative regulations against the objectives as laid out in the original impact assessment and must be concluded, submitted and agreed by Minister by 10 May 2023. The HSE are currently engaged in the evidence and analysis process to inform the final report to Parliament and asked those on the webinar and others to complete the questionnaire. The next presentation was given by Terry Grimmond, Consultant Microbiologist, and provided attendees with an update on the progress of the new national Blood and Body Fluid Exposures (BBFE), or sharps injuries, survey and database. Attendees were informed of the importance of the creation of a national database for sharps injuries. To date, thirty trusts have responded to the survey which has now been shortened to three key questions in order to encourage further responses. Trusts informed the BBFE working group that workloads are currently incredibly high so it was agreed a shorter survey could increase response rates by taking significantly less time than the original 20+ question survey. The data so far indicates a lower rate of sharps injuries than perhaps expected, especially when compared with the RCN survey published in 2021. Terry called for more trusts to complete the survey and encouraged attendees to reach out with any questions or queries. The third presentation continued with the theme of sharps injuries and healthcare worker safety and was given by Rose Gallagher, Professional Lead Infection Prevention and Control and Leona Cameron, Head of Health, Safety and Wellbeing, Royal College of Nursing. The presentation explained, in terms of sharps injuries, it is not just healthcare staff who are at risk; ancillary staff who work in healthcare environments or handle healthcare waste or equipment are also at risk. The RCN Survey published in 2021, with responses from more than 7,000 members, found that 63% have had a sharps injury in their career. Employers have a legal duty to carry out a suitable and sufficient sharps risk assessment in order to identify and implement adequate control measures to reduce the risk of harm. Controls in practice aim to change the behaviour of workers to reduce exposure to occupational hazards and should be implemented widely. The presentation concluded with a note on sustainability – healthcare is the 5th largest greenhouse gas producer globally and therefore action to reduce its climate warming emissions through procurement, transport, waste management and energy consumption are key. The fourth presentation was given by Lindsay Keeley, Patient Safety & Quality Lead of the Association for Perioperative Practice (AfPP) and covered the topic of theatre safety. The presentation explained the current legislation in place around theatre safety and focussed on risk management and safety in the perioperative environment. The point was made that risk management and patient safety is one of the most fundamental principles of service delivery in healthcare today especially in the operating theatre. There is a minimum benchmark standard of five staff for each operating theatre depending on skill mix, speciality, complexity, and patient care and those staff have a duty to take reasonable care of their own health and safety and that of others who may be affected by their actions. The presentation concluded by setting out the six key elements of effective safety programmes: hazard assessment, training, policies & procedure, accident investigations, measurement and management commitment. Lindsay informed attendees that the AfPP provides evidence-based guidance, standards and recommendations on risk management to enhance perioperative practitioners’ knowledge on safe handling and positioning of patients in the perioperative environment. The final presentation was a case study on surgical smoke and creating a smoke free environment in theatres by Lisa Nealen, from the Queen Elizabeth Foundation Trust, Newcastle. Lisa spoke about her own personal experiences of not only the hazards of surgical smoke but also the health hazards posed by surgical fluid waste and explained why it is so important that we create safer theatre environments for patients and staff. The presentation detailed how to create a smoke free operating theatre and the guidelines which have been adopted which help to deliver a safer working environment.