Consensus generation of a minimum set of outcome measures for auditing glaucoma surgery outcomes-a Delphi exercise.

PURPOSE: To identify the key set of glaucoma surgery outcome measures considered most important and practical to collect by glaucoma specialists. METHODS: One hundred two glaucoma specialists (57 members of the UK and Eire Glaucoma Society (UKEGS) and 45 members of the European Glaucoma society (EGS)) took part in an Online Delphi exercise. The RAND/UCLA appropriateness method was used analyse data from each round and generate a disagreement index. RESULTS: Participants agreed on 13 baseline data points and 12 outcomes that were considered important and practical to collect. For intraocular pressure (IOP) percentage reduction in IOP from baseline (last three IOP readings pre-op) and reduction below a specified target were considered important. For visual fields, change in a global visual field index, e.g. MD, and development of progression as assessed by linear regression were considered important. From a safety perspective, any visual loss resulting in a doubling of the minimal angle of resolution, loss of 5 dB or more of visual field or development of advanced field loss (Hodapp Parrish Anderson Stage 4) was considered important. The importance of routinely using patient reported outcome measures (PROMs) was highlighted. Consensus suggested that outcomes of glaucoma treatments should be reported at 1, 5 and 10 years. CONCLUSIONS: There was broad consensus on a minimum dataset for reporting the outcomes of glaucoma surgery and outcome measurement intervals.

The carbon footprint of cataract surgery.

BACKGROUND: Climate change is predicted to be one of the largest global health threats of the 21st century. Health care itself is a large contributor to carbon emissions. Determining the carbon footprint of specific health care activities such as cataract surgery allows the assessment of associated emissions and identifies opportunities for reduction. AIM: To assess the carbon footprint of a cataract pathway in a British teaching hospital. METHODS: This was a component analysis study for one patient having first eye cataract surgery in the University Hospital of Wales, Cardiff. Activity data was collected from three sectors, building and energy use, travel and procurement. Published emissions factors were applied to this data to provide figures in carbon dioxide equivalents (CO2eq). RESULTS: The carbon footprint for one cataract operation was 181.8 kg CO2eq. On the basis that 2230 patients were treated for cataracts during 2011 in Cardiff, this has an associated carbon footprint of 405.4 tonnes CO2eq. Building and energy use was estimated to account for 36.1% of overall emissions, travel 10.1% and procurement 53.8%, with medical equipment accounting for the most emissions at 32.6%. CONCLUSIONS: This is the first published carbon footprint of cataract surgery and acts as a benchmark for other studies as well as identifying areas for emissions reduction. Within the procurement sector, dialogue with industry is important to reduce the overall carbon footprint. Sustainability should be considered when cataract pathways are designed as there is potential for reduction in all sectors with the possible side effects of saving costs and improving patient care.

The precautionary principle: what is the risk of reusing disposable drops in routine ophthalmology consultations and what are the costs of reducing this risk to zero?

BACKGROUND: Instilling eye drops is a ubiquitous procedure in eye clinics. This audit aimed to assess the risk of contamination of disposable droppers and to quantify the financial and waste implications of reducing this risk to zero by using disposable droppers only once. METHODS: A total of 100 disposable Minims were used to place one drop in each eye of 70 patients. The dropper tip was then cultured for aerobic and anaerobic microbes. RESULTS: Coagulase-negative staphylococcus was cultured from five samples. The contamination rate per drop application was 2.5%. The risk of cross-contamination with coagulase-negative staphylococcus would be between 1 : 400 and 1 : 80 if the bottle was reused once or six times. Reducing this risk to zero costs between pound2.75 and pound4.6 million per annum and generates between 6.85 and 11.42 more tonnes of paper waste and between 12.69 and 21.15 more tonnes of plastic waste than a strategy that reuses the disposable dropper. CONCLUSION: Reducing the risk of dropper contamination and subsequent cross infection has financial and environmental costs. As exposure to coagulase-negative staphylococcus is not necessarily associated with infection, it would be useful to decide acceptable risk levels for a given cost to maximise both cost-effectiveness and patient safety.

Surgical scrubbing: can we clean up our carbon footprints by washing our hands?

A growing scientific consensus states that the global climate is changing and that human activity is responsible for these changes. It folLows that each of us has a responsibility to look at how our own lives impact on the environment. This study aimed to investigate water use during surgical scrubbing. Two water delivery systems were assessed to see whether technological innovation can promote more 'environmentally friendly' scrubbing behaviour. At least 10 different individuals, comprising surgeons, assistants and scrub nurses, were observed at two sites. Twenty-five separate surgical scrubs were observed in each location and the length of time for which the tap was on recorded. The tap was on during surgical scrubbing for a mean of 2 min 23 s at Gartnavel General Hospital (maximum: 4 min 37 s; minimum: 49 s; SD: 55 s) and for a mean of 1 min 7 s at Stobhill Hospital (maximum: 2 min 25 s; minimum: 19 s; SD: 33 s). The mean 'tap on' time (in seconds) at Gartnavel was significantly greater than that at Stobhill [t(39.5)=P<0.001]. A different tap design resulted in a net saving of 5.7 L of hot water, approximately 600 kJ of energy and 80 g of carbon dioxide emitted per surgical scrub. Surgical scrubbing is a ubiquitous procedure performed daily in healthcare settings. A simple technological solution can reduce water and energy use by modifying hand-washing behaviour and thereby reduce the carbon footprint of surgical scrubbing.

Node retrieval in axillary lymph node dissections: recommendations for minimum numbers to be confident about node negative status.

AIMS: To determine the minimum number of lymph nodes needed in an axillary lymph node dissection (ALND) specimen to be confident that the axilla is free from metastases. METHODS: The Edinburgh Breast Unit selects patients with large and high grade tumours for ALND; 609 consecutive ALNDs performed between October 1999 and December 2002 were reviewed. Full data about the underlying invasive breast cancer were available for 520 patients. Data were collected regarding number of positive nodes and total number of nodes collected, tumour size and grade, and presence of lymphovascular invasion. RESULTS: Axillary node metastases were seen in 64% of patients. The mean number of positive nodes found was 3.56, with a mean of 17.9 nodes collected. The highest proportion of patients with lymph node metastases were in the group with 16-20 nodes recovered/specimen (68%); specimens with >20 nodes recovered did not have a higher rate of nodal involvement. There was a significant difference between the proportion of metastasis positive specimens in those with 1-15 nodes recovered (58.5%) and those with 16 or more recovered (69.1%). A linear association test showed a direct correlation between the number of nodes collected and presence of node metastasis (p = 0.0005). CONCLUSIONS: Although there is no minimum number of nodes that should be recovered in an ALND specimen, 16 nodes should be regarded as a target to ensure a high level of confidence that the nodes are negative. Node positivity in an ALND specimen appears to obey the law of diminishing returns.