Excising Infection in the Surgical Environment [ExISE]

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 4-5 minute 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.


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.

Publications and outputs

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