27 Feb 2021

BOAST - Providing a Continuous Safe Elective Orthopaedic Environment



Date Published: February 2021
Last Updated: February 2021
BOAST - Providing a Continuous Safe Elective Orthopaedic Environment

A sufficient and stable bed base is essential for effective year round orthopaedic care. This optimises resource use by securing admission, preventing cancellation due to lack of capacity, co-locating key staff, optimising discharge and minimising adverse events, particularly implant infection, which can have catastrophic consequences.

Central to this concept is the physical separation of resources or ‘ring-fencing’, specifically of the bed-base, for the exclusive use of orthopaedic patients, undergoing clean procedures, to ensure safe and consistent practice even in the context of high activity in other hospital areas. Ring-fencing is of proven financial benefit in orthopaedic surgery and is also associated with improved outcomes, particularly related to reduction of implant infection rates.

This pathway should apply to all orthopaedic patients including, for example, those attending for day case surgery or fracture care who fulfil the inclusion criteria listed below. It is accepted that escalation policies may be necessary in periods of exceptional clinical activity which will impact on the provision of services for clean orthopaedic procedures.


All patients undergoing orthopaedic procedures who have completed a screening and decolonisation process prior to admission.


Planned cases with clinical evidence of infection or known colonisation.

  1. All surgical providers should have a defined facility that exclusively accepts appropriate orthopaedic patients. This should be distinct from other clinical areas either within an acute site or at a separate geographic location.
  2. Standard Operating Procedures (SOP) must be in place to:
    1. Ensure that all appropriate orthopaedic patients have access to these facilities throughout the year.
    2. Enable effective administration and regular audit of the ring-fenced pathway.
    3. Ensure that individual rooms are available to accommodate all patients with infection including implant infections.
  3. If this facility is situated in an acute clinical area, separation must be maintained by configuration of estate and resources to ensure that all components, including staff, are used exclusively for ring-fenced patient care.
  4. Before breaking ring-fenced policy, immediate review of available capacity should be undertaken by the Duty Consultant Orthopaedic Surgeon and Duty Matron. The decision to breach should be sanctioned by the Duty Executive Officer.
  5. If the ring-fenced capability is breached, all planned cases must be cancelled until the integrity of the facility is reestablished, whilst supporting the safe management of patients.

Clean procedure: ‘A procedure in which no inflammation is encountered, without a break in sterile technique, and during which the respiratory, alimentary and genitourinary tracts are not entered’.
Colonisation: ‘ the presence, growth and multiplication of micro-organisms without observable signs or symptoms of infection’.
Decolonisation: ‘the use of topical treatments, predominantly physical agents (soaps) to remove colonising organisms'.

Evidence Base
  1. National Health Service. NHS Long Term Plan. Available from: https://www.longtermplan.nhs.uk/ [Accessed 21st January 2021].
  2. National Health Service Getting it Right First Time. Getting It Right in Orthopaedics: a follow up report. Available from: https://gettingitrightfirsttime.co.uk/wp-content/uploads/2020/02/GIRFT-orthopaedics-follow-up-reportFebruary-2020.pdf [Accessed 21st January 2021].
  3. Biant LC, Teare EL, Williams WW, Tuite JD. Eradication of methicillin resistant Staphylococcus aureus by "ring fencing" of elective orthopaedic beds. BMJ. 2004; 329(7458): 149-151.
  4. Green M , Tung E, Al-Dadah The value of ring-fenced beds in elective lower limb arthroplasty. Br J Hosp Med. 2019 Jul 2;80(7):405-409.
  5. Jeans E, Holleyman R, Tate D, Reed M, Malviya A. Methicillin sensitive staphylococcus aureus screening and decolonisation in elective hip and knee arthroplasty. Journal of Infection. 2018 77(5):405-409.
  6. Nixon M, Jackson B, Varghese P, Jenkins D, Taylor G. Methicillin- resistant Staphylococcus aureus on orthopaedic wards: incidence, spread, mortality, cost and control. J Bone Joint Surg Br. 2006; 88(6): 812-817.
  7. Tsang STJ. et al. Evaluation of Staphylococcus aureus eradication therapy in orthopaedic surgery. J Med Microbiol. 2018 Jun;67(6):893-901.
  8. Chow A; Hon PY; Tin G; Zhang W; Poh BF; Ang B. Intranasal octenidine and universal antiseptic bathing reduce methicillin-resistant Staphylococcus aureus (MRSA) prevalence in extended care facilities. Epidemiology & Infection. 2018 146(16):2036-2041.
  9. The Royal College of Surgeons of England. Surgeons call for 5-year-plan to tackle record NHS waiting lists. Available from: https://www.rcseng.ac.uk/news-and-events/media-centre/press-releases/rtt-waiting-times-june-2019/ [Accessed 21st January 2021].
  10. The British Orthopaedic Association. NHS England waiting list figures show T&O patients are worst affected. Available from: https://www.boa.ac.uk/resources/press-releases-and-statements/nhs-england-waiting-list-figures-showt-o-patients-are-worst-affected.html [Accessed 21st January 2021].
  11. The British Orthopaedic Association. Current BOA position regarding elective activity, waiting lists and restart. Available from: https://www.boa.ac.uk/resources/press-releases-and-statements/current-boa-position-regardingelective-activity-waiting-lists-and-restart.html [Accessed 21st January 2021].