The Control of Infections in Hospitals 9781487574543

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THE CONTROL OF INFECTIONS IN HOSPITALS

THE CONTROL OF INFECTIONS IN HOSPITALS With special reference to a survey in Ontario

W. Harding le Riche

M.D., M .P.H.

Carolee E. Balcom R.N.,B.S.

and Gerald van Belle M.A.

UNIVERSITY OF TORONTO PRESS

© University of Toronto Press 1966 Printed in Canada

Reprinted in 2018

Published and distributed in the U.S.A. by CHARLES C THOMAS • PUBLISHER

Bannerstone House 301-327 East Lawrence Avenue, Springfield, Illinois, U.S.A. Natchez Plantation House 735 North Atlantic Boulevard, Fort Lauderdale, Florida, U.S.A. ISBN 978-1-4875-8578-5 (paper)

In memory of

EVERITT GEORGE DUNNE MURRAY bacteriologist

Preface

is based mainly on a questionnaire study of general hospitals in Ontario. It is not a general treatise on hospital infections, but rather a practical document, based on current procedures, which we hope will help administrators, nurses, and physicians to improve infection control techniques in their institutions. The book should also be useful in the instruction of nurses and medical students. We have, of course, used as general background the relevant technical literature. 1 After the study was started, it soon became obvious that a survey in itself would not necessarily produce beneficial change in hospitals. What administrators, nurses, and physicians asked for were practical suggestions which could be used in infection control in their own institutions. These we have tried to provide, both in the body of the report and in certain of the appendices. In areas of controversy, we have made those suggestions which appear to be the most reasonable in terms of current knowledge and practice. We have tried to be constructive, but we have not hesitated to record those practices which we felt to be wrong or outdated. In all instances, we have supported our case either by direct observation, by quotations from the questionnaires received from hospitals, or by views expressed in current technical literature. Most of the observations are based on our lengthy questionnaires, these being the most feasible method of carrying out a large survey THE PRESENT BOOK

lln this connection we would particularly recommend Hospital Infection: Causes and Prevention, by R. E. 0. Williams, R. Blowers, L. P. Garrod, and R. A. Shooter (Year Book Publishers, 200 East Illinois Street, Chicago, Ill., 1960); Control of Infections in Hospitals, by J. C. Colbeck, Hospital Monograph Series No. 12 ( American Hospital Association, 840 North Lake Shore Drive, Chicago 11, Ill., 1962); and also two conference reports, the first being Infection in Hospitals, Epidemiology and Control, edited by R. E. 0. Williams and R. A. Shooter ( Blackwell Scientific Publications, Oxford, 1963), and Proceedings, National Conference on Institutionally Acquired Infections, Public Health Service Publication 1188 ( U.S. Government Printing Office, Washington, D.C., 1964). A Review of Sterilization and Disinfection by S. D. Rubbo and J. F. Gardner (Year Book Medical Publishers, 35 East Wacker Street, Chicago, Ill., 1965) is similarly recommended.

viii

PREFACE

since it was not possible to visit and study each hospital in detail. However six institutions of various sizes were studied in detail. Each of these six investigations took about two months and included interviews with hospital staff, the writing of a report, and subsequent discussion of the report with the hospital administrator. In this way these intensive investigations helped the hospital authorities to improve their institution. The questionnaire study also had a stimulating effect in many institutions, as people had probably not given much previous thought to the questions we raised. We made it quite clear in discussions with hospital staff that no hospital would be identified in any of our analyses of practice. As a result, we feel that we obtained accurate information on what was happening in the institutions concerned. At the present time, with mounting public interest in disease, health, physicians, nurses, and hospitals, it is more necessary than ever to study problems in this field with a view to constructive improvement. On the other hand, it is far too easy, especially for the press and other mass media of communication, to be unreasonably critical of people in hospitals who are already doing the best job possible with the means and resources at their disposal. What we hope the present report will do, more than anything else, is to stimulate constructive change and give support to improvements in individual hospitals. In many cases the need for this was already well known to the staffs of the hospitals concerned, but they could not obtain acceptance for change. The comment may be made that we ask in this book for a very high standard of infection control in our hospitals. This we readily admit, with the proviso that such high standards are not impossible, but merely difficult, to attain. The conquest of these and other problems is the essence of progress, a commendable ideal at all times. In the future, hospitals will increasingly be faced by two serious problems. One group of problems is associated with overcrowding, with too many patients, too many people ministering to these patients, and, in all this, too many sources of infection. The other set of problems is associated with a lack of adequately trained staff. And it may be even more difficult to alter the latter set of circumstances than the former, because it is easier to construct more buildings to counter overcrowding than it is to train the multitude of technical people for all the wide reaches of medical science and service. Realizing these facts, hospitals should be so constructed, staff should be so trained, and equipment should be so designed that infection control should be the most efficient possible under conditions of stress and shortage of personnel. Mechanization and rationalization of pro-

PREFACE

ix

cedures should be used, but only as a result of careful, well-planned research in hospitals. Unplanned, untested use of mechanical contrivances and procedures could lead to more, rather than less, spread of hospital infection. In our attack on hospital infection we must remember to maintain a sense of proportion. We should never forget the views of Dr. Charles Chapin, Superintendent of Health of Providence, Rhode Island, from 1884 to 1932, that infectious disease is far more often spread by persons than by things. He stated the following principles, still the basis for much modern epidemiology: 1. Disease germs are parasites, adapted to live in the human body ( and

that of other animals) and generally dying out rather rapidly in the external environment. 2. The primary source of these disease germs is always the human body ( or that of the higher animals). This source may be either a well carrier or a well individual. 3. In view of their poor survival powers in a non-living environment disease germs ( except spore formers such as anthrax) must be transferred rather promptly from one human being to another, if new infection is to occur. 4. The disease germs are particulate objects and, on account of this fact and of their tendency to die outside the body, aerial dissemination and transmission by fomites are relatively unimportant. 5. The major modes of transmission are: (a) Direct or indirect contact, ( b) Food and drink, ( c) Insect vectors.

When considering hospital infections we should therefore maintain a reasonable balance in the intensity of our control measures; between people, who are the most important, and things, which may vary in degree of importance under various circumstances. In hospitals, where there is a high degree of concentration of infection, fomites and air as vehicles are probably relatively more influential than in situations where there is less crowding and a slower turnover of people. School of Hygiene, University of Toronto, October, 1965

W. H. le R., C. E. B., C . van B.

Acknowledgments

could not have been written without the generous help of many people, especially the hospital administrators and staff who completed the questionnaires. For a great deal of background information we are very much indebted to all the members of the Medical Research Council Associate Committee on Hospital Infections, particularly Dr. D. H. Starkey. The late Chairman of that Committee, Dr. E. G. D. Murray, reviewed our manuscript a few weeks before his death. As a result of this review, the manuscript was extensively rewritten. At various times during the preparation of the report different sections were carefully studied by an enthusiastic group of experienced nurses, Mesdames Audrey Schiach, Kathleen De Marsh, Helen Palmer, Dorothy Atkins, Marjorie Patriquin, Marie Sewell, Doris Hamilton, and Sister M. Patricia. Their comments added greatly to the value of our presentation. Dr. Lawrence Mautener and Dr. W. D. Leers made constructive suggestions concerning parts of the manuscript, and we gained a great deal of practical information concerning the control of hospital staphylococcal infection from the late Dr. E. Earle Shouldice and members of his staff. Major A. S. O'Hara contributed background material for a section of the book and Mr. Stanley Pearson made many useful comments. Mr. Douglas Griffiths and Dr. John F. Flowers helped us with tabulating and computer problems. The Central Health Laboratory, Ontario Department of Health, in Toronto, and the Laboratory of Hygiene, Department of National Health and Welfare, in Ottawa, carried out much work in connection with our studies. We wish particularly to thank Dr. L. E. Elkerton, Dr. C. R. Amies, Dr. Jeanne Ikeda Douglas, Mr. M. Magus, Dr. E. T. Bynoe, Dr. L. Greenberg, Dr. R. H. Elder, Mr. R. E. Comtois, and their associates for dealing so well with the extra load we placed on their shoulders. TIITS BOOK

XU

ACKNOWLEDGMENTS

Financial support for this study during the period 1961 to 1964 came from a National Health Grant, Number 605-7-181, through the Ontario Deparhnent of Health. We wish to express our appreciation for this assistance, especially to Dr. L. B. Pett. The Ontario Hospital Association made a generous contribution towards publication costs of the book. In this connection we particularly wish to thank Mr. R. Alan Hay, Mr. Stanley Martin, Mr. Harold Dillon, and Mr. Stuart Roberts. The whole study was well launched in the hospitals of Ontario as a result of a letter of commendation written to them, at the beginning of the survey, by Dr. John B. Neilson, Chairman of the Ontario Hospital Services Commission, to whom we wish to express our appreciation. Dr. W. Douglas Piercey, Executive Director, Canadian Hospital Association, kindly gave publicity to the study in the journal, "Canadian Hospital." Miss J. Zahig, Miss M. Schoenemann, Mrs. M. Murray and Mrs. E. Webber, of the library staff of the School of Hygiene, spared no effort to provide us with references, often at very short notice. Our office staff worked hard on this book. We particularly wish to thank Miss Sarah McCausland, Mrs. Olive Eaton, Mrs. Shirley Vincent, Mrs. Jean MacPherson, Miss Myra MacLean, Mrs. Neta Doughty, and Mrs. Ruth Knechtel. Miss Francess Halpenny, the Managing Editor, and the staff of the University of Toronto Press helped us in many ways. Their skill, patience, and professional technical knowledge were placed unstintingly at our disposal. We thank them all. W. H. le R., C. E. B., G. van B.

Contents

Preface, vii Acknowledgments, xi I. Introduction, 3 1.1 Preview, 3 1.2 Documented reports of hospital cross-infections, 5 References, 7

PART 1

2. Design and Methods of Study, 11 2.1 Preview, 11 2.2 The design of the questionnaire, 12 2.3 Methods of study, 16 References, 18

PART 2 3. Specific Nursing Practice, 21 3.1 3.2 3.3 3.4 3.5

Preview, 21 Thermometer technique, 21 Care of glasses and pitchers, 24 Disinfection of blankets, pulows and mattresses, 26 Care of bedside equipment: .1 washbasin, 26 .2 bedpans, 27 .3 urinals, 29 3.6 Enema technique, 29

4. Dressing Techniques, 31 4.1 Observations of dressing techniques, 31 4.2 Guide for dressing wounds, 32 4.3 Guide for handwashing, 34

5. Prevention and Care of Urinary Infection 5.1 Causes of urinary infections, 36 5.2 Closed irrigation and dralnage system, 38 References, 40

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CONTENTS

PART 3

6. Present Isolation Facilities, 43 6.1 6.2 6.3 6.4

Preview, 43 Present isolation facilities, 44 Present isolation precautions, 45 Staffing of isolation areas, 47

7. Specific Control Measures in Isolation Areas, 49 7.1 Handwashing practices, 49 .1 A guide for handwashing in isolation areas, 49 7.2 Gown technique, 51 7.3 Mask technique, 52 7.4 Disposal of secretions and excreta: .1 secretions, 52 .2 excreta, 53 7.5 Care of bedside equipment, 54 7.6 Care of dishes and eating utensils, 54 7.7 Disposal of contaminated bedding, 55

8. The Control of Infections in and beyond the Hospital, 57 8.1 8.2 8.3 8.4 8.5

The hospital as a reservoir of community infection, 57 Infections in the home, 58 Control of infections in the home, 59 The role of public health agencies in the control of cross-infection, 61 Infection control committees, 63

References, 67 PART 4

9. Physical Structure of the Surgical Suite, 69 9.1 Preview, 69 9.2 Zoning, 69 .1 contaminated cases, 71 9 .3 Movement to operation area and recovery room, 71 9.4 Personnel facilities, 73 9.5 Scrub areas, 73 9.6 Equipment, 74 9.7 Sub-sterilizing areas, 74 9.8 Walls, 'floors, ceilings, 75 9.9 Ventilation, 77

10. Surgical Aseptic Techniques, 79 10.1 Pre-operative preparation of the operative site, 79 .1 preliminary preparation, 79 · .2 preparation in the operating room, 81 10.2 The surgical scrub, 82 10.3 Operating room clothing: .1 gowns, 84 .2 masks and caps, 84 .3 conductive footwear, 85 .4 surgical gloves, 85

CONTENTS

10.4 Carriers in critical areas, 86 10.5 Anesthesia asepsis, 88

References, 92 PART 5

11. General Hospital Housekeeping, 97 11.1 11.2 11.3 11 .4

Preview, 97 Observation of current housekeeping, 98 Training of housekeeping personnel, 99 Specific housekeeping functions: .1 fl,oors, 102 .2 walls, 106 .3 ceilings, 107

12. Disinfection of High Risk and Other Hospital Areas, 108 12.1 High risk areas .1 general patient areas, 108 .2 isolation areas, 110 .3 operating rooms and case rooms, 112 .4 nurseries, 113 .5 bathrooms and showers, 114 .6 utility and treatment rooms, 115 12.2 Other areas .1 radiology departments, 116 .2 emergency and outpatient departments, 116 .3 autopsy rooms, 116 12.3 Summary of minimum recommended housekeeping protection, 117

13. Disinfection of Blankets, Pillows, and Mattresses, 118 13.1 Blankets as vehicles of infection, 118 .1 laundering of blankets, 119 .2 the acceptance of cotton blankets, 120 13.2 Pillows as vehicles of infection, 120 .1 laundering of pillows, 121 13.3 Mattresses as vehicles of infection, 123 .1 disinfection of mattresses, 123

14. Laundry Practice, 125 14.1 14.2 14.3 14.4

Hospital laundries v. commercial laundries, 125 Laundry chutes as vehicles of infection, 125 Laundry collection and delivery, 127 Health of laundry personnel, 128

15. Other Aspects of Environmental Control, 130 15.1 Control of arthropod and rodent infection, 130 .1 rodents, 131 .2 roaches, 131 .3 flies, 132 .4 public health aspects, 132 15.2 Plumbing .1 water supply, 132 .2 waste disposal, 133

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CONTENTS

15.3 Use qf refuse chut~, 135 15.4 Ventilation, 135 References, 138

PART 6

16. Chemical Disinfection with Special Reference to Skin, 142 16.l 16.2 16.3 16.4 16.5 16.6

Preview, 142 Definitions and requirements, 144 The general purpose scrub, 145 Disinfection of the skin before parenteral injections, 148 Pre-operative preparation of the hands and forearms, 150 Pre-operative preparation of the operative site, 152

17. Sterilization of Hospital Equipment, 155 17.1 17.2 17.3 17.4 17.5

Small water sterilizers, 155 Autoclaves, 156 Dry heat sterilization, 156 "Cold" sterilization, 157 Sterilization by gases, 158 .1 ethylene oxide, 158 .2 beta-propiolactone gas, 159 .3 formalin vapour, 160 17.6 Irradiation sterilization, 160

18. Environmental Disinfection, 161 18.1 Chemical disinfection of the hospital environment, 161 18.2 Recommended germicidal-detergents, 162 References, 164

PART 7 19. Statistical Analysis of Questionnaire Data, 169 19.1 19.2 19.3 19.4

Preview, 169 Preparation for analysis, 169 Classifications qf hospitals and basic tabulations, 170 Variation of aseptic practice within classifications, 172

20. Evaluation of Aseptic Practice in General Hospitals Only, 187 20.1 Method qf evaluation, 187 20.2 Results, 188 20.3 Discussion of the results, 190

PART 8

APPENDICES

A. The Infectious Disease Process and Mechanisms of Disease Spread and Control A .1 Preview, 195 A.2 Definition qf disease, 195

CONTENTS

A.3 Portals of entry, 195 A.4 Stages of infection: .1 incubation period, 196 .2 host-parasite interaction, 196 .3 infectious period, 196 A.5 Agents of infection, 197 .1 bacterial agents, 197 .2 spirochetal agents, 198 .3 viral agents, 198 .4 fungal agents, 199 · .5 protozoan agents, 199 A.6 Reservoirs of infection, 199 A.7 Air-borne diseases, 201 .1 direct droplet, 201 .2 direct air-borne, 201 .3 indirect air-borne, 201 A.8 Water and food-borne infections, 202 A.9 Arthropod-borne diseases, 202 A.10 Zoonoses, 203 A.11 The contact diseases, 204 A.12 Parasitic worm diseases, 204 A.13 An epidemic outbreak of staphylococcal cross-infection in a chronic disease hospital in Ontario, 204 .1 case histories, 205 .2 bacteriological findings, 206 .3 control, 206 A.14 Specific communicable disease techniques, 208 References, 218 B. Comments from Hospitals

B.l

Non-isolation techniques (Section IA): .1 on thermometer technique, 219 .2 on the care of glasses and medicine cups, 220 .3 on dressing technique, 221 .4 on the disinfection of bedpans and urinals, 223 .5 on enema technique, 224 .6 on the care of blankets, 17Ul#resses, and pillows, 226 .7 on linen change, 227 .8 on cleaning patient areas, 227 .9 miscellaneous, 227 B.2 Isolation techniques (Section IB): .10 on the isolation of infectious patients, 228 .11 on thermometer technique, 231 .12 on the care of dishes and medicine cups, 231 .13 on the wearing of masks and gowns, 232 .14 on hand washing techniques, 233 .15 on the dressing of wounds, 233 .16 on the disinfection of instruments, 233 .17 on the disinfection of utensils and disposal of excreta, 234 .18 on airing of room and mattress disinfection, 234 .19 on the care of blankets and linen, 235 .20 on the cleaning of isolation areas, 235 .21 on infection control committees, 236 .22 miscellaneous, 236

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CONTENTS

Housekeeping techniques (Section II): .23 on the education and training of executive housekeepers, 236 .24 on the general cleaning of hospitals, 237 .25 on precautions in isolation areas, 238 .26 on laundering procedures, 239 .27 on the changing of curtains, 239 .28 on the disposal of garbage, 239 .29 miscellaneous, 240 B.4 Operating room techniques (Section Ill): .30 on the size and structure of the surgical suite, 241 .31 on staphylococcal carriers in the operating room, 241 .32 on the surgical scrub for patients and personnel, 242 .33 on operating room clothing, 243 .34 on contaminated cases, 244 .35 on infection control committees, 244 .36 on the transport of patients to the surgical area, 245 .37 on the ventilation of surgical suites, 245 .38 on the cleaning of surgical areas, 245 .39 on laundering and laundry chute, 246 .40 on precautions in anesthetizing areas, 246 .41 on disinfecting anesthesia equipment, 247 .42 miscellaneous, 247 B.3

C. Tables of Answers to Questionnaire Cl.

Non-isolation techniques (Section IA): Tables 23.1 .1 to 23.1.61, 249 C .2 Isolation techniques (Section 1B ): Tables 23.2.62 to 23.2.119, 264 C.3 Housekeeping techniques (Section II): Tables 23.3.120 to 23.3.222, 277 C.4 Operating room techniques (Section III): Tables 23.4.223 to 23.4.318, 300

D. Scoring of Selected Questions D.1 D.2 D.3 D.4

Non-isolation techniques (Section IA), 323 Isolation techniques (Section IB), 325 Housekeeping techniques (Section 11), 328 Operating room techniques (Section III), 333

Index, 337

THE CONTROL OF INFECTIONS IN HOSPITALSv

1. Introduction

I.I. PREVIEW

In summarizing the history of hospitals it is well to remember that this practical expression of charity began only after the Emperor Constantine recognized Christianity as the most vital and vigorous religion of the times. At the Council of Nicaea called in A.O. 325, the bishops were instructed to provide a hospital in every cathedral city. For centuries the early institutions for the ill were places of fearful peril. The convalescent, the infectious, and the dying patients were all grouped together indiscriminately. Cholera, typhoid fever, smallpox, and other infectious diseases were unwittingly introduced directly into the ward and ravaged those patients not already dying from surgical or other causes. The surgical patient faced many grave ordeals. Once the surgery was finally over, wound infection was almost inevitable. If his wound did heal, it was only by chance. More often he succumbed in the process. Hands and instruments contaminated from the surgery of one patient were used to contaminate that of the next. Just less than one century ago in England, voices were raised in alarmed concern over the increasing number of deaths occurring among hospitalized patients. In a pioneering research study, James Young Simpson ( 18111870 ), professor of midwifery in the University of Edinburgh, collected data on 2000 amputees who had been hospitalized during and after the procedure, and on 2000 who had remained at home [11]. He found the mortality rate greatly increased in those persons admitted to hospital. The term ''hospitalism" was coined to give some definition to this perplexing situation. In 1843, Oliver Wendell Holmes ( 1809-1894) published his classical paper, "On the Contagiousness of Puerperal Fever," in which he suggested that parturient women should not be attended by physicians

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TIIE CONTROL OF INFEcnONS IN HOSPITALS

who had been conducting post-mortem examinations, or who had recently attended mothers with infectious diseases [8]. It was not until five years later that Ignaz Phillip Semmelweis ( 1818-1865) published the first scientific findings on the causes of puerperal fever [16]. Through observations and painstaking records, he was able to demonstrate a reduction in maternal mortality following the introduction of a calcium chloride solution for handwashing, and strict attention to this aspect of aseptic practice. Several decades were to pass, however, before the causative organism was to be identified as the streptococcus. Hospital sanitation has made great strides since 1854, when Florence Nightingale ( 1820-1910), arriving at the barracks hospital in Scutari, found a filthy hospital, swarming with vermin and lacking both the simple items of medical care as well as primitive sanitary arrangements [20]. Through her persistent and determined efforts, however, the death rate from contagion fell from 42 per cent of cases in February of 1855, to 2 per cent in June of the same year [11]. It was Joseph Lister ( 1827-1912) who recognized that sepsis was the principal obstacle to any great advance in surgery. His attempts at antisepsis, or elimination of organisms after they entered the wound, would be later followed by asepsis: the elimination of bacteria before they entered the body [3, 11]. With the rise of bacteriology in the last two decades of the nineteenth century, the microbial concept of infectious diseases was at last understood. This new awareness opened up entirely new frontiers in surgery, medicine, and nursing. Changes in surgical techniques and procedures quickly followed. Instruments were sterilized. Air in operating rooms, first sprayed with carbolic acid, was later filtered through complex ventilation systems. The introduction of antibiotics was hailed as still another advance in the control of cross-infection. Guided by this new knowledge, hospitals undertook far-reaching campaigns to control the spread of disease within their walls. Nurses were made largely responsible for the cleaning of hospitals, which was rigidly supervised. This was the period before organized housekeeping. It was also the era before the unprecedented changes in nursing roles and practices. Yet in spite of all our modem advances and our modem medical armamentarium, cross-infections have continued to plague hospitals. Ironically, modem advances in health have indirectly contributed to these infections. Prepayment medical plans and early detection of disease have placed an increasing demand on hospital facilities, often

INTRODUCTION

5

resulting in gross overcrowding of all hospital services. In the face of increased and indiscriminate overuse of antibiotics, there have arisen new generations of organisms, each becoming more resistant to antibiotics than its parent strain. In addition, a new generation of medical and nursing personnel has also evolved. This latter generation, relying so completely on antibiotics, has become careless about the importance of aseptic practice in hospitals. For many, asepsis is interwoven with archaic medical concepts and is considered to have little relevance in contemporary practice. 1.2. DOCUMENTED REPORTS OF HOSPITAL CROSS-INFECTIONS Over the past decade, hospitals in many countries have revealed the serious problems they were having with cross-infection [2,4,5,7,9,10, 12,13,14,15]. Over-all infection rates in these hospitals have ranged from LO to 15.0 per cent. In addition, cross-infections have not only involved patients, but also nursing and medical personnel. In 1958 one hospital in Alberta reported the case of a student nurse who had an almost fatal staphylococcal infection [19]. A three-year study of staphylococcal disease at Temple University Medical Center revealed that in 1956 the staphylococcal infection rate among student nurses was 24 per cent [5]. Yet the actual infection rates reported by hospitals remain highly inaccurate. That true infection rates are not always apparent was revealed in 1960 when, in one of several Veterans Admini~tration Hospitals selected by the United States Veterans Administration Division of Research, the purported infection rate was between 1 and 2 per cent, a rate considered to be reasonably safe [l]. When an energetic assistant chief of service personally sought out all infections in an effort sustained over several months, however, he found that the rate of cross-infection fluctuated between 13 and 15 per cent. This 12 to 13 per cent difference between the low and high rate first reported is more than mere chance. Complete awareness and recognition of hospital cross-infection is lacking in many hospitals. Another hospital in Iowa City reported in 1957 that a cursory pilot study indicated an over-all infection rate of 11.1 per cent [6]. A more detailed and comprehensive study revealed that the infection rate was 17.0 per cent on the surgical service, and 12.0 per cent among medical patients.

6

THE CONTROL OF INFECilONS IN HOSPITALS

In recent years, attention also has been · focused on the apparent increase in cross-infections within hospitals caused by certain members of the coliform group of organisms and by Pseudomonas pyocyanea. A report in 1960 of five deaths occurring on a medical ward in a hospital in London, England, showed all five were caused by a secondary invasion of Pseudomonas pyocyanea [18] . The authors concluded that "there seems to be no doubt that the patients reported here acquired their infection after admission to hospital." The coliform organisms and the Pseudomonas resemble the staphylococci in that they, too, have a tendency to become resistant to the commonly used antibiotics. The potential danger of infections from the coliform organisms was predicted over a decade ago, when past clinical experiences suggested that there might be an actual increase in the frequency of infections due to these organisms, following the introduction of wide-spectrum antibiotics. The suppression of other bacteria by the widespread use of antimicrobial agents, and the alteration of the normal bacterial Hora, have increased the comparative importance of these organisms as agents of infectious disease. A report, published in 1959, on a high incidence of septic fingers occurring among nursing personnel at St. George's Hospital, London, revealed that the infections were caused by the herpes virus [ 17]. Septic fingers are frequently assumed to be caused by Staphylococcus aureus, and it is thus possible that many cases of virus infections are overlooked. In this particular epidemic outbreak, two possible sources of infection were determined: one, patients with obvious herpetic lesions; and two, symptomless salivary carriers. In the latter group, laboratory study showed four patients to be harbouring the infective virus. Each patient had had a tracheotomy, and the infective material was transmitted directly to the nurses' hands when suctioning the patients. It was shown that these four patients were the source of infection among six nurses wh6 developed septic fingers. In each case, the herpes simplex virus was the causative agent. It is possible then, in view of our knowledge of infection, that viral diseases may become a formidable problem in our efforts to control infectious processes in hospitals.

INTRODUCTION

7

REFERENCES

1. An evaluation of hospital infection with analysis in mortality and morbidity. United States Veterans Administrative Cooperative Study Committee for Hospital Infection. Surgery, Gynecology and Obstetrics, 110: 157, Feb. 1960. 2. Barber, M., and Dutton, A. A. C. Antibiotic-resistant staphylococcal out~ breaks in a medical and a surgical ward. Lancet, 2: 64, July 1958. 3. Bishop, W. J. The Early History of Surgery. Robert Hale, London, 1960. 4. Caswell, H. T., Schreck, K. M., Burnett, W. E., Carrington, E. R., Leamer, N., Steel, H. H., Tyson R. R., and Wright, W. C. Bacteriologic and clinical experiences and the methods of control of hospital infections due to antibiotic resistant staphylococci. Surgery, Gynecology and Obstetrics, 106: 1, Jan. 1958. 5. Caswell, H. T., Schreck, K. M., Learner, N., Burnett, W. E., Carrington, E. R., DeLaurentis, D. A., Rogers F. R., Shulman C. R., Steel, H. H., Tyson, R.R., Wright, W. C., Bloomberg, N. J., and Brown, F. E . A threeyear study of staphylococcal disease with observations on control. Surgery, Gynecology and Obstetrics, 110: 527, May 1960. 6. Godfrey, M. E., and Smith, I. M. Hospital hazards of staphylococcic sepsis. Journal of the American Medical Association, 166: 1197, March 1958. 7. Gray, J. D. A., Chandler, G. N., Roberts, J. G., and Lambert, R. A. Staphylococcal infection in a general hospital. Lancet, 2: 1251, Dec. 1962. 8. Holmes, Oliver W. On the contagiousness of puerperal fever. In Medical Classics, 1: 211, Nov. 1936. 9. Howe, C. W., and Marston, A. T. A study on sources of post-operative staphylococcal infection. Surgery, Gynecology and Obstetrics. 115: 266, Sept. 1962. 10. Lowbury, E. J. Infection of burns. British Medical Journal, 1: 944, April 1960.

11. Major, R. H. A History of Medicine, vol. II. Charles C. Thomas, Springfield, Ill., 1954. 12. Miller, A., Gillespie, W. A., Linton, K. B., Slade, N., and Mitchell, J. C. Post-operative infection in urology. Lancet, 2: 608, Sept. 1958. 13. Monro, J. A., and Markham, N. P. Staphylococcal infection in mothers and infants: maternal breast abscesses and antecedent neonatal sepsis. Lancet, 2: 186, July 1958. 14. Roy, T. E., McDonald, S., Patrick, M. L., Keddy, J. A., Coles, E. T., Fremes, I. A., Fujiwara, M. W., Hunnisett, F. W., Lindsay, W. K., and McNaughton, G. A. A Survey of hospital infection in a paediatric hospital. Part I. Canadian Medical Association Journal, 87: 531, Sept. 1962. 15. Schimke, R. T., Black, P. H., Mark, V. H., and Swartz, M. N. Indolent staphylococcus albus or aureus bacteremia after ventriculoatriostomy. New England Journal of Medicine, 264: 264, Feb. 1961. 16. Semmelweis, Ignaz. The etiology, the concept and the prophylaxis of childbed fever. In Medical Classics. 5: 350, Jan. 1941.

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THE CONTROL OF INFEGnONS IN HOSPITALS

17. Stem, H., Elek, S. D., Millar, D. M., and Anderson, H.F. Herpetic whitlow : a form of cross-infection in hospitals. Lancet, 2: 871, Nov. 1959. 18. Williams, R., Williams, E. D., and Hyams, D. E. Cross-infection with Pseudomonas pyocyanea. Lancet, 1: 376, Feb. 1960. 19. Wilson, T. S. Observations on surgical infections and their treatment. Canadian Journal of Surgery, 1: 350, July 1958. 20. Woodham-Smith, C. Florence Nightingale. Whitefriars Press, London, 1955.

2. Design and Methods of Study

2.1. PREVIEW During the summer of 1958, the senior author was asked by the Board of Governors of the Toronto Western Hospital to make a detailed study of staphylococcal and other infections occurring in this particular hospital, and to make recommendations for alterations and additions to improve the services in this already well-run institution. Following two months of comprehensive study, a confidential report was submitted to_the Board of Governors [1]. Many of the proposed recommendations were accepted in order to improve existing practice and organization. Included in the above report were the observations of Dr. Charles Robinson, a bacteriologist, who was admitted as a "patient" into a surgical ward with the concurrence of the senior surgeon. The observations of this "patient" proved to be extremely interesting and instructive, and gave further indication of the need for education and training of ancillary personnel. The experience gained in this survey provided a framework for subsequent studies of a similar nature. Towards the end of the same year, the senior author was appointed to the Associate Committee for the Control of Hospital Infections of the National Research Council of Canada ( now the Medical Research Council), which was established in 1957 to meet the growing challenge of infections in hospitals [3]. This Committee, under the chairmanship of the late Professor E.G. D. Murray, and composed of experts engaged in many hospital and related fields, provided the wide background essential for the study of so complex a matter as cross-infections. It should be pointed out that the Associate Committee has not confined itself solely to staphylococcal disease, but it is concerned with cross-infections of any nature. . In 1959, the senior author, along with Miss Edith Young, Director of Nursing, Ottawa Civic Hospital, and Mrs. Edna I. LaFlair, then

12

11IE CONTROL OF INFEcnONS IN HOSPITALS

Research Assistant at the School of Hygiene, carried out a small survey on aseptic technique used in twelve Canadian hospitals [2]. Most of the information was obtained directly from the procedure manual submitted by each hospital. Utilizing all of this background information, the present research group, consisting of an epidemiologist (W. H. leR.), a nurse with special interest in hospital infections ( C. E. B. ) , and a statistician ( G. van B.) developed a comprehensive set of questionnaires which were used to elicit information from the hospitals on current aseptic practice in their institutions. In addition, the nurse on the team personally visited six hospitals, three located in the metropolitan area of Toronto and three in other parts of the province, in order to make detailed observations on infection control techniques. 2.2. THE DESIGN OF THE QUESTIONNAIRE It was decided that the best way to assess as fully as possible the existing aseptic practice in hospitals in this province, was to conduct a questionnaire survey. Following a review of current and past literature on the many aspects of infection spread and control, an initial draft of the questionnaire was prepared. On completion of the preliminary draft of the questionnaire, a pilot study was conducted to determine its application and workability. The ten largest active treatment hospitals in Metropolitan Toronto were selected and asked to participate by filling in the questionnaire, and adding their comments and criticisms. The response was excellent. Those hospitals participating in the pilot study were as follows: Doctor's Hospital, Hospital for Sick Children, New Mount Sinai Hospital, Saint Joseph's Hospital, Saint Michael's Hospital, Toronto East General and Orthopedic Hospital, Toronto General Hospital, Toronto Western Hospital, Wellesley Hospital, and Women's College Hospital. Various people, in each of the selected hospitals, were asked for their help in setting up the final questionnaire. These included staff nurses, nursing supervisors and directors, operating room supervisors, head housekeepers, hospital administrators, bacteriologists, and physicians. All contributed valuable ideas and suggestions, and as a result of these, the entire questionnaire was revised. Questions which appeared vague or ambiguous were deleted, and the size of the questionnaire was considerably reduced.

DESIGN AND METHODS OF STUDY

13

The questionnaire in its final form was then prepared and printed. The sections, with main subheadings, are as follows: Section I (A) : NON-ISOLATION TECHNIQUES A. B. C. D. E. F.

Thermometer Technique Medicine Cup Technique Bedpan and Urinal Technique Technique Used in Caring for Enema Equipment Sterile Dressing Technique Ward Housekeeping Technique

Section I ( B) : ISOLATION TECHNIQUES A. B. C. D. E.

General (regarding communicable disease control) Mask and Gown Technique Thermometer Technique and Care of Examining Equipment Food Management and Medication Technique Isolation Housekeeping Technique and Communicable Disease Techniques

Section II:

HOUSEKEEPING TECHNIQUES

A. General Housekeeping Techniques B. Isolation Housekeeping Techniques

Section III: A. B. C. D. E.

OPERATING ROOM TECHNIQUES

General Physical Structure Patients and Personnel Housekeeping Techniques Anesthesia

The first section of the questionnaire pertained to the routine disinfection of such commonly used hospital equipment as thermometers, medicine cups, bedpans and urinals, and enema cans and tubing. Included also were questions on various hospital routines, such as the dressing of wounds, and ward housekeeping techniques. We were aware that there were other practices which should be considered in this assessment of hospital aseptic practice, particularly techniques used in catheterizing and irrigating bladders, but each section had to be limited in order to keep the final questionnaire of a manageable size. Procedures relevant to the total problem of asepsis and infection control are numerous and varied. Routines not included in the questionnaire itself were carefully observed during hospital visits, and are discussed in addition to the questionnaire findings. Section I (A) was directed primarily to nurses working at the ward level. It was preferable to have as respondent a person employed in

14

THE CONTROL OF INFECI'IONS IN HOSPITALS

a staff position, or at the most a head nurse, for it was the feeling of the authors that a person having direct contact with patients could more fully describe the situation as it actually was. In the analysis, however, while many of the sections were answered by persons involved in actual work situations, many were also answered by nurses in supervisory positions and higher. Some were completed by Directors of Nursing Education. However, the answers could be quite accurately assessed by correlating the respondents' replies with the sizes of the particular hospitals. If the section had been answered by a Director of Nursing of a small hospital ( 50 beds or less) it was reasonable to conclude that the respondent was aware of what was happening at the patient level. If, conversely, the section had been completed by the Director of Nursing of a 500-bed hospital, it was likewise reasonable to assume that the information was taken directly from the ward procedure manual and did not necessarily reflect actual practice. Section I ( B) was designed to gather information on current aseptic practice in isolation areas, and to compare the routines with those carried out in general patient areas. Since we were aware of the fact that only a few hospitals have special facilities for the segregation of infectious patients, the questions in this section were worded in such a way so as to be applicable to the care of infectious patients in general and convalescent hospitals as well. Information was requested on currently used mask and gown techniques, methods of thermometer disinfection, and the disinfection of examining equipment used for patients with infectious diseases. Other queries concerned food management procedures and the use of disposable dishes or utensils. Questions on housekeeping routines were included in order to give the investigators some insight into differences, if any, between cleaning routines carried out in general patient areas, and cleaning carried out in areas of recognized high contamination. Section II of the questionnaire was designed to be answered by the executive housekeeper, or hospital administrator. Cleaning methods were the chief interest of this section, and were divided into two subsections: those routinely carried out in general patient areas, and those carried out in areas of increased bacterial contamination, i.e., the isolation unit. Information was asked on the method of mopping used ·for floors, whether wet, or dry, and what chemical disinfectants were used hi general hospital cleaning. Schedules for the cleaning of floors and walls were also requested, as well as information on the equipment in use. More detailed questions were asked on the methods used for the

DESIGN AND METHODS OF STUDY

15

disinfection of mattresses, blankets, and pillows. Although similar questions were asked of nurses in Section I ( B), this overlapping was deliberate. Housekeeping responsibilities still remain a part of nursing, either directly or indirectly, and it was felt that nurses should be made more aware of the importance of housekeeping in the over-all picture of disease control. The final section ( Section III, Operating Room Techniques) was primarily concerned with those techniques and practices which comprise surgical asepsis. Included in this section were questions relating to the physical structure of the surgical suite, the mode of transport of patients to the operating room, skin preparation of the patient before surgery, and the surgical scrub. Further queries were concerned with the cleaning of the surgical suite, and the care of anesthesia equipment. A discussion of hospital policy regarding carriers in critical areas is outlined. Since nurses comprise the largest single group of hospital personnel, and have perhaps the most intimate knowledge of day-to-day hospital life, the questions were designed to be answered in the most part by nurses. In addition, because it was felt that sound housekeeping techniques were basic to any program of infection control in hospitals, the importance of cleaning was emphasized, not only by devoting one entire section (II) to housekeeping practice, but also by incorporating the concept of environmental sanitation into questions related to other areas of hospital practice as well. The questionnaire was designed to apply to general practices in hospitals. Sections on obstetrical and nursery areas, on food-handling and dishwashing, or on maintenance routines were not included, since certain hospitals would not have obstetrical and nursery departments, and the size of the questionnaire was an important consideration. Although it was realized that infection control programming is a total hospital concept, space did not allow for such a comprehensive questionnaire. Even by including questions on such specialized, but common, areas as isolation and surgical asepsis, it was recognized that many of the questions would not have general application to all of the 261 hospitals to which questionnaires were sent. This was later confirmed by the number of hospitals which returned Section I ( B) and Section III marked "non-applicable." By including questions on routine daily practices which were common to all hospitals, whether active treatment, chronic or convalescent, it was hoped that enough information could be obtained to attempt to assess current hospital aseptic practice.

16

TIIE CONTROL OF INFECTIONS IN HOSPITALS

2.3. METHODS OF STUDY ( See Chapters 19 and 20) Following completion of the proposed questionnaire, each question was coded in order to be later tabulated by electronic computer. The questionnaires were then printed, numbered consecutively, and the four sections were assembled. In July 1962, a total of 261 questionnaire sets were mailed to hospitals in the province of Ontario from a listing provided by the Ontario Hospital Services Commission. Each set of four sections was numbered so that the names of hospitals were not required for the analysis. The total number of questionnaires completed and returned is as shown in Table 2.1. TABLE 2.1 Type of service

Complete

Incomplete

Total returned

General Chronic Communicable disease Convalescent Maternity Orthopedic Other Total

169 23 1 3 4 1 7 208

5 5 0

174 28 1 7 4 1 8 223

4

0 0 1 15

A total of 223 or 85.4 per cent of the questionnaires were returned; of this total, 15 were incomplete and had to be discarded. The remaining 208 questionnaires comprised an 80 per cent return, a response which was both significant and gratifying. In addition to the questionnaire survey, observations of actual aseptic practice were made in six hospitals. These hospitals were selected for a variety of reasons. Two requested help with infection control programming, which required a personal survey of actual practice in their institution. Three other hospitals were studied because of their proximity to the University and ease of travelling, and the last was selected because of personal interest on the part of the authors. Five of the hospitals were active treatment centres; the sixth was a chronic disease hospital. Observations were made of all hospital services, including medical, surgical, obstetrical, and nursery areas. All nursing personnel were made aware of the presence of the observer, and nurses were very willing to co-operate in the study. Following one or two weeks of

DESIGN AND METHODS OF STUDY

17

observations on each service, a short discussion was held with the head nurse, and the findings of the observer were discussed. In this way, any possible misconceptions were clarified, and the head nurse was made aware of the findings in her particular area. Further, she was acquainted with what information would be passed on to the nursing director and/or hospital administrator. All information obtained was regarded as confidential, and findings from those hospitals visited are included in the text in composite form. For obvious reasons, a list of hospitals in which the observations were made will not be included in this report. Following the completion of each hospital assessment, a report of the findings was prepared, and submitted to the particular hospital administrator upon request. Recommendations were included with each report.

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THE CONTROL OF INFECOONS IN HOSPITALS

REFERENCES

1. le Riche, W. Harding. A study on staphylococcal infections in the Toronto Western Hospital. Unpublished confidential mimeographed report. 1958. 2. le Riche, W. Harding, Young, Edith G., and LaFlair, Edna I. Aseptic techniques used in twelve Canadian general hospitals: a survey in 1959. Unpublished mimeographed report. 3. Staphylococcal infections in Canadian hospitals. Canadian Medical Association Journal, 82: 403, Feb. 1960.

3. Specific Nursing Practice

3.1. PREVIEW

In this chapter, an outline of the most obvious nursing procedures will be presented with reported findings from the questionnaire survey, as well as observations of inadequate practice, and suggested recommendations. Traditionally, nursing has been largely associated with hospitals, but it is important to recognize that aseptic practice is part of all medical and nursing practice whether carried out in the hospital or in the home. In discussing nursing aseptic practice, it is first of all important to define exactly what is meant by the word asepsis. Simply defined, it means absence of infection from micro-organisms. When the term asepsis is used in a practical sense, it means those techniques or procedures which are carried out to prevent or control the transmission of disease from some person or some thing ( fomes) to a second person or thing. More particularly, hospital cross-infection can be defined as " . . . any infection acquired by a patient in the hospital environment. Clinically it is an infection arising during the course of another illness for which the patient was originally admitted to hospital, and may attack the respiratory tract, gastro-intestinal tract, wound, skin, · or mucous membrane, or be manifested as one of the specific fevers" [ 1] . 3.2. THERMOMETER TECHNIQUE The taking of temperatures is perhaps one of the most often repeated routines in hospitals. This may be the responsibility of the nursing aide, the nursing student, the graduate nurse herself, or the doctor. The recommended procedure for taking temperatures may vary slightly from hospital to hospital, but basically it remains the same.

22

11IE CONTROL OF INFECI'IONS IN HOSPITALS

One of the fundamental purposes in establishing a thermometer technique is to ensure that thermometers are adequately disinfected after use. In a large number of hospitals, there are not enough thermometers to go around. Instead of each patient receiving his own thermometer upon admission, the practice has been to keep a communal supply, traditionally in the utility room. After rounds of temperature talcing, the thermometers are usually cleaned and stored in a disinfectant solution. Findings from the questionnaire survey showed that 45.8 per cent of hospitals in the province of Ontario used communal ( nonindividual) thermometer technique ( Appendix Table C. 1.1). An additional 27.1 per cent stated that both individual and non-individual thermometer technique was used. The problem is not whether the use of thermometers is individual or communal, but whether or not they are adequately disinfected between use. The mouth and throat are potential reservoirs for such pathogenic micro-organisms as the staphylococcus, the hemolytic streptococcus, the diphtheria bacillus, and the tubercle bacillus. Hospitalized persons have some degree of debility, and may either cause infection or be highly susceptible to infection themselves. If their resistance to disease is lowered, then additional care must be taken to prevent further insult to their health. Personal observations in three of the hospitals visited have revealed that this aspect of disease prevention has been largely overlooked [10]. Shortages of thermometers have resulted in nursing personnel merely rinsing thermometers under running water between patient use. When thermometers were disinfected, this procedure was usually carried out in a dirty utility room in the midst of contamination. Observations also showed that, on occasion, thermometers were put directly into the disinfecting solution without preliminary cleaning. Findings from the survey indicated that the most widely used disinfectants were quaternary ammonium compounds ( aqueous Zephiran 1: 1000) and iodophors ( Wescodyne). Over 51 per cent of the hospitals used these products for disinfecting individual thermometers, while 48.4 per cent used the two products for communal thermometers (C.1.4). Other less widely used solutions included Lysol, Dettol, and green soap. A total of 2.5 different solutions or dilutions were reported to be used for disinfecting individual thermometers, while 37 were used for non-individual thermometers. In addition to the various products named, a wide divergence of strengths was indicated in the survey. For example, aqueous Zephiran

SPECIFIC NURSING PRAGnCE

23

was reported to be used in several strengths, including 1:750, 1:1000, and 1:2500. All were used for a similar purpose. It is immediately clear that not all solutions, or all strengths, can possibly have the same disinfectant power. Besides the use of a proven germicide, there are other factors that must also be brought into focus. It is now well recognized that protein matter, such as mucus or sputum, will interfere with the action of even the most penetrating germicide. It is therefore essential that thermometers be cleaned thoroughly before being placed in a disinfectant solution. Even the cleaning of thermometers requires careful consideration. Price has reported that minute quantities of soap will inactivate the quaternary ammonium disinfectants, such as Zephiran and Cetavlon [11]. Green soap, because it is the panacea in so many hospitals, is widely used for cleaning purposes. Unless every trace of this soap or any other soap is removed from thermometers, the disinfectant becomes merely an innocuous solution. Claims have been made as to the colour of certain iodine disinfectants, stating that their shade is an indicator of the disinfectant property. The question is then asked: at what precise moment during this colour change does the solution lose its disinfectant qualities? This type of promotional advertising gives hospital personnel a false sense of security, and only impedes further inquiry. Through extensive and careful studies carried out at the Communicable Disease Center in Georgia, simple, inexpensive procedures for the disinfection of oral and rectal thermometers have been suggested [14,15] . They are recommended here: ORAL

a. Wipe the contaminated oral thermometer with a cotton ball moistened with equal parts of 95 per cent ethyl alcohol and tincture of green soap. b. Rinse the soap off the thermometer with cold running water. c. Place the thermometer in a solution of 0.5 per cent to 1 per cent iodine in either 70 per cent ethyl alcohol or 70 per cent isopropyl alcohol for ten minutes. RECTAL

a. Use water-soluble lubricants such as surgical jelly. b. Wipe with cotton ball containing equal parts of 95 per cent ethyl alcohol and tincture of green soap.

24

TIIE CONTROL OF INFECTIONS IN HOSPITALS

c. Rinse with water. d. Immerse for 10 minutes in ( l) 70 per cent ethyl or isopropyl rubbing alcohol; or ( 2) 0.05, 0.25 to 0.5 per cent iodine solution in either 70 per cent ethyl or isopropyl alcohol. The time required for disinfecting thermometers in the survey hospitals varied from 5 minutes to longer than one hour. One hospital wrote that 2 minutes were required to disinfect thermometers, while another considered that 8 hours were needed. Still another replied that a thorough washing in detergent was an adequate means of disinfection. With a recommended germicide, complete thermometer disinfection should require a maximum of 10 minutes, the time required to kill all vegetative bacteria and fungi, tubercle bacilli and all viruses, except the hepatitis virus. The disinfectant is not expected to kill spores [16] . Conditions representing extreme contamination require several hours of disinfection even by the strongest germicide. 3.3. CARE OF GLASSES AND PITCHERS The survey showed that 70 per cent of the hospitals in Ontario used either glass or plastic medicine cups only; of this number, almost onehalf admitted that water glasses were not disinfected after each use (C.1.6,7) . Of those hospitals remaining which did disinfect medicine cups, 64.8 per cent used chemical disinfection. Almost one-quarter ( 24.7 per cent) of this latter group used green soap as a "chemical disinfectant"-a somewhat dismaying disclosure, but one that is not surprising ( C.1.9) . In most hospitals visited, medicine cups were washed either in the medicine cabinet sink or in the utility room sink after use. Findings showed that 55.2 per cent of the survey hospitals also used these areas ( C.1.11). A further 30.5 per cent of the hospitals washed medicine glasses in the ward kitchen, while only 3.4 ·per cent returned medication glasses to the main kitchen to be washed. Only one hospital reported that it had a central Medicine Department with a clean-up room specifically for this purpose. Observations in all six hospitals revealed that the care of glassware, including water jugs or carafes, medicine cups or drinking glasses, is a hospital function which should be more clearly defined. In only two of the hospitals visited was this distinctly a nursing function. In the other four, the responsibility was relegated to the housekeeping

SPECIFIC NURSING PRAGnCE

25

personnel, who had to interrupt their cleaning routines to distribute ice water and wash glasses. In one Metropolitan Toronto hospital, a nursing aide was observed making her morning rounds with ice water (10]. On her cart she had a dirty-looking pail filled with ice, much of which had melted. Into this solution of ice and water she scooped an ordinary plastic tumbler. As a consequence, each time the glass was submerged, the aide also immersed her hand into the drinking water. Observations of washing facilities revealed that in one hospital kitchen, dirty glasses were seen soaking in a grimy solution of detergent and water. The dishcloth being used was grimier still (10]. Few hospitals required that glasses be returned to the dietary department for re-sterilization. In two hospitals in which this was the policy, nurses were reluctant to send glasses to the kitchen because they stated that the glasses were never returned. In one hospital, glasses used by patients were not separated from the dishes used by personnel. This presented a potentially dangerous situation to patients and personnel alike, for the washing facilities were not sterilizing the dishes. High colony counts of Staphylococcus aureus and Escherichia coli were cultured from numerous plates selected at random. In a study carried out in Boston, close inspection of patients' water carafes revealed turbid malodorous water in the majority of cases (18]. The original findings stimulated the bacteriological examination of the water carafes in 24 Boston hospitals. The results of the cultures showed that the density of coliform organisms was higher than the United States Public Health Service Standards for drinking water. A high density of staphylococci was also found. It was shown in the Boston study that direct contamination of the water in the glass occurs each time it is sipped through a straw. The residual water in the tube at the end of the sip drains back, carrying saliva. This contamination also occurred in cases where the carafes had dual-purpose lids. Residual liquid was returned to the carafe when the cup-shaped lid was inverted and positioned as a lid. Water pitchers and glasses used in hospitals should withstand a water temperature of 160° F., the recommended temperature for sterilizing dishes (13] . In addition they must be sterilized in a clean area, preferably the dietary department. In most of the hospitals visited, water pitchers were washed in dirty utility rooms, usually adjacent to areas or within the same area that washbasins, bedpans, and urinals were cleaned [ 10]. In view of the unsatisfactory way in which glassware is disinfected

26

'IHE CONTROL OF INFECl'IONS IN HOSPITALS

in hospitals, it would seem far simpler, and less time-consuming, to substitute disposable glasses whether for medication or nourishment, wherever possible ( see 7.6). For pills, small paper cups should be used. Liquid medications should be carefully dispensed in accurately calibrated disposable medicine cups, which are now on the market. In addition, water pitchers and tumblers should be replaced by waxed cardboard cartons. Waxed straws are certainly much more widely accepted in hospitals today than are glass straws, which are difficult to clean and are easily broken. In view of the findings, disposable water pitchers and glasses are recommended for patient use. 3.4. DISINFECTION OF BLANKETS, PILLOWS, AND MATTRESSES See Chapter 13. 3.5. CARE OF BEDSIDE EQUIPMENT 3.5.1. WASHBASINS In most hospitals visited, it was found that bedside equipment was communal [10]. Washbasins were stored in racks in the utility rooms when not being used for the traditional morning bath. Upon completion of morning care, the basins were returned to the utility room and cleaned. Observations have shown that cleaning, .even at its best, is often cursory. In one hospital, an ordinary abrasive cleaner was used for cleaning washbasins. In another, nurses were observed wiping out basins with a disinfectant solution. These methods do not in any way comprise adequate disinfection. If utensils are to be properly disinfected after use, they must either first be cleaned and then soaked in a disinfectant, or boiled or autoclaved. In one hospital visited, cultures were taken of a washbasin after it had been cleaned with an ordinary abrasive powder [10]. Bacteriological findings revealed a heavy growth of Staphylococcus aureus. Random cultures of washbasins in other areas also revealed growths of organisms. While the latter were not in the strictest sense pathogenic organisms, the fact that they were present after the washbasins had been "disinfected" is condemnation enough of the cleaning practices used. It is impossible to disinfect bedside equipment along with such contaminated equipment as enema cans and tubing and used dressing

SPECIFIC NURSING PRACTICE

27

trays. Once disinfected, utensils may become recontaminated from the environment even before reaching the patient. Preferably, all bedside equipment should first be cleaned well and then autoclaved upon the discharge of each patient. Washbasins, emesis basins, and cups should be packaged as a unit, and sterilized. When a patient is admitted he should then be given his own set of equipment. The sterilizing tape is silent witness to the fact that the packaged unit has never been opened.

3.5.2. BEDPANS Over 79 per cent of the hospitals replied that individual bedpans were used (C.1.12). The methods of terminal disinfection for these bedpans included chemical disinfection ( 21.0 per cent), the use of the bedpan sterilizers (34.7 per cent), and autoclaving (18.5 per cent) . A further 24.2 per cent of the survey hospitals reported that they used two or more of the above combinations, while 1.6 per cent did not name the method or methods used ( C.1.16). From personal observations in all six hospitals, it was found that utility room sinks were too small to allow for complete immersion of these utensils [IO]. In lieu of this, bedside equipment was frequently seen on the floor filled with a disinfectant solution. In many cases the bedpans were not cleaned adequately prior to the disinfection, in which case protein and fatty substances impeded the penetration of the germicide. In addition, that part of the bedpan which comes in direct physical contact with the patient received no cleaning at all. In one hospital visited, disinfection of the equipment was earned out in patients' bathtubs. In those hospitals in which utility room sinks were of sufficient size to allow for chemical disinfection, the strength of the disinfectant solutions generally was a haphazard guess. As a rule, an unmeasured amount of pure disinfectant solution was poured into the sink, to which water was added. The strength was rarely accurate, and if an estimate was to be made of the strength of the dilution it was generally on the side of weakness, out of consideration for the nurses• hands. In many hospitals today, housekeeping personnel have been given the responsibility for the cleaning of bedside equipment, as well as floors and walls. If nurses are willing to pass this task over to nonprofessional personnel, they must ensure that the work is carried out adequately. Unfortunately, however, it is at times the professional nurses themselves who lack adequate information on disinfectants and scientific cleaning methods.

28

TilE CONTROL OF INFECI'IONS IN HOSPITALS

While 34.7 per cent of the hospitals using individual bedpans reported that bedpan sterilizers were used for disinfection, 46.2 per cent replied that non-individual (communal) bedpans were sterilized this way ( C.1.20) . This would suggest that communal bedpans are sterilized more often after each use than are individual ones, and that bedpan sterilizers are the most common method used. This is supported in part by the questionnaire findings which revealed that only 9.3 per cent of the hospitals disinfected individual bedpans concurrently (C.1.13), while 54.9 per cent replied that communal bedpans were disinfected after each use ( C.1.19). In the case of most bedpan sterilizers seen, the brief exposure to water and steam was not sufficient to sterilize the bedpan, let alone even remove particulate matter. In our opinion, bedpan sterilizers should be more rightly named bedpan "fl.ushers" for this is really all that the vast majority accomplish, and even then they do not always adequately clean it. A study in England found that bedpans were reservoirs of such infectious organisms as Pseudomonas pyocyanea [9]. Such sterilizers should be part of the hospital equipment, however, because they provide the only safe means of disposal of excreta. Dumping bedpans, urinals, or emesis basins into an open hopper causes splashing, and not only contributes to droplet air-borne spread, but frequently contaminates the uniform, hands, and arms of hospital personnel. What is needed is a bedpan sterilizer with a revolving brush, constructed in such a way as to clean thoroughly the inside of the pan; then allow for flushing and a timed sterilization. Most of the "sterilizers" used in those hospitals visited were the antiquated type with manual control of steam. It is suspected that bedpans were steamed in direct relation to the available time of the nurse. Considering the available time in most hospitals today, it would be very brief. The time stated by survey hospitals to sterilize bedpans, using a bedpan fl.usher, ranged from 2 minutes to more than 10 minutes, with the majority of hospitals requiring less than 5 minutes ( C.1.22). Considering that a "fl.ash" sterilizer in the surgical area requires a minimum of 10 minutes to sterilize carefully cleaned instruments, a mere 2 minutes can hardly be considered adequate for bedpans, particularly when full of excreta. Twelve hospitals required 10 minutes or longer. Unless these latter hospitals had sterilizers capable of cleaning the equipment adequately, 10 minutes or even longer may not be sufficient time for sterilization.

SPECIFIC NURSING PRACTICE

29

3.5.3. URINALS The disinfection of urinals is another item in hospitals which has received little attention. Unless utility rooms are provided with sinks of adequate size, urinals cannot be praperly disinfected. Without a comparable "urinal sterilizer" similar to the traditional bedpan sterilizers, urinals are infrequently cleaned. In one hospital visited, an orderly was observed carrying urinals into the utility room for emptying [10]. These were later redistributed to the patients without any knowledge of the rightful owner. The disinfection of urinals, when it was observed, consisted of filling the inside with a chemical disinfectant. The outside received no particular consideration. Both bedpan and urinal covers were often observed to be soiled, the former with feces. Instead of being discarded, these continued to be used. The questionnaire survey showed that 93.1 per cent of the hospitals used cloth covers ( C.1.28). Only 4.4 per cent reported that disposable covers were used exclusively. At present there are several disposable covers on the market. Some have not come up to hospital standards, but there are others which have been very satisfactory. What is needed is a cover of sufficient body and tensile strength to keep it from sliding from the bedpan. In addition, it is important that the cover be flushable. Some of the hospitals have found that covers claimed to be flushable would not dissolve, and often resulted in Hooding. All bedside equipment should be distributed for the exclusive use of each patient, and sterilized before being used by another. The use of communal equipment in hospitals is an unsatisfactory practice which should cease. If each patient is given his own equipment, the amount of nursing time required for disinfection would be greatly reduced. Concurrent disinfection would be less frequently needed and certainly not generally required after each use (see 7.5) . 3.6. ENEMA TECHNIQUE Approximately three-quarters of the survey hospitals used the traditional enema routine, using such equipment as enema cans, rubber tubing, connecting rods, and rectal tubes ( C.1.30). It is of note that 41.9 per cent of this latter group of hospitals replied that complete enema equipment was not disinfected after each use (C.1.31). Observations in three of the hospitals visited revealed that enemas

30

TIIE CONTROL OF INFECilONS IN HOSPITALS

were given using communal equipment [10). Upon completion of the procedure, the can and tubing were usually rinsed through with running water, while the enema tips or rectal tubes were washed and then either chemically disinfected or boiled. This observation is supported by the questionnaire findings which revealed that 98.3 per cent of the hospitals reported that they disinfected rectal tubes after use ( C.1.39). The chemical disinfectant most widely used by survey hospitals was Wescodyne. Second on the list was green soap. Considering that this material has been found on occasion to support the growth of coliform organisms, this should not be accepted practice in hospitals. In one hospital visited rectal tubes were merely soaked in green soap after use [10). On enema days in this particular institution, the equipment was not disinfected between patient use and was barely cleaned. It was interesting to learn from the questionnaire survey that 52.6 per cent of the hospitals were now autoclaving their enema equipment ( C.1.33). This finding is consistent with the trend observed in three of the hospitals visited which required that enema equipment be packaged and autoclaved in the Central Supply Room.

4. Dressing Techniques

4.1. OBSERVATIONS OF DRESSING TECHNIQUES Perhaps no other aspect of nursing and medical practice requires as much scrutiny and revision as the current procedures used in the dressing of wounds. Masks were infrequently used, according to our study, and when not worn over the mouth and n~e, were often observed dangling about the neck of the wearer, or hanging from the uniform pocket. ( See 7.3.) This observation is confirmed in findings from the survey which showed that only 28.2 per cent of the hospitals reported that masks were worn while doing dressings ( C.1.45). In addition, nurses were observed on two occasions dressing wounds in full view of other patients and personnel. One of the most common observations made regarding dressing technique was the neglect of pick-up forceps. These were not only found standing in scant amounts of disinfectant solution, but from the amount of sediment observed in the bottom of some of the forceps holders it was suspected that they had not been cleaned or sterilized for several weeks. In one hospital nursery, pick-up forceps were observed standing in a dry container [10]. Upon inquiry, the observer was told that no solution was needed because the forceps were changed every twentyfour hours. The concept of air-borne contamination was foreign to these particular nursery personnel. Dirty dressing carts were a frequent observation in the six hospitals visited [10] . These were not only the silent recipients of spillages of disinfectants, creams, and salves, but more often were dust-laden as well. Swabs were seen sticking out from under the lids of "sterile" containers. Sterile dressing trays were set up next to contaminated trays. Dirty dressings were seen sticking out of the tops of paper bags, disseminating their organisms into the environment. It was surprising, in view of our actual observations in hospitals, to

32

'IHE CONTROL OF INFECTIONS IN HOSPITALS

find that only 19.4 per cent of the survey hospitals reported that dressing carts or carriages were used routinely ( C.1.42). Practical experience would seem to indicate that these are still in general use in many hospitals. . In four of the six hospitals visited, dressings were done in the midst of patient areas [10]. That these observations were representative is revealed in the questionnaire survey in which 75.6 per cent of the hospitals reported that dressings were carried out on the wards (C.1.40). A discrepancy is immediately apparent in the answers to the question: "Is provision made for clean and dirty dressing areas?" While 152 hospitals ( 75.6 per cent) previously stated that wounds were dressed on the ward, 112 of these hospitals replied that they had provision for clean dressing areas ( C.1.41) . This would seem to indicate that all but 40 of the survey hospitals regarded wards as clean dressing areas. 4.2. GUIDE FOR DRESSING WOUNDS The considerations involved in the proper dressing of wounds are numerous and detailed. In addition to the wearing of masks, the wearing of gowns has also been suggested (see 7.2). Except in cases in which wounds are contaminated, and the possibility of cross-infection is high, gowns need not be worn when doing dressings. It is our hope that patients with contaminated wounds would be placed in immediate isolation and the wearing of gowns would therefore be required apparel. It has been recommended that two persons be assigned as a dressing team, one person to do the actual dressing of the wound, while the second person refrains from having contact with the patient or his bedding, and supplies the dresser with the necessary supplies from the dressing cart [4]. In most of today's understaffed hospitals this would indeed be a luxury, and is mentioned here only as another approach to dressing wounds. In our opinion, except in the most extensive wounds, a single dresser using the aseptic precautions listed should be adequate. The use of large dressing cans cannot be recommended here. Large containers of gauze dressings were observed on the floors of dressing rooms [10]. In addition, containers with sterile swabs and "flats" readily become contaminated by air-borne organisms during repeated usage. Roller adhesive tape; if cultured, may conceivably yield large

DRESSING TECHNIQUES

33

Iilililbers of organisms. Ideally, individual prepackaged adhesive bands should be used for all sterile dressing procedures. It is generally recognized that the agitation of contaminated textiles, such as the removal of dressings, can cause a build-up and sustain a high level of air-borne bacteria. At a burns unit of the Birmingham [England] Accident Hospital, through the use of adequate ventilation that delivered eleven changes of air per hour, the number of air-borne bacteria was considerably reduced five minutes after the departure of the patient from the room [2]. In this way, the next patient to be admitted to the dressing room would have his wound dressed in a relatively clean area. Contrast this with the dressing of wounds on a busy ward, at which time one may find cleaning staff busily stirring up dust and pathogenic organisms. For this reason, a well-ventilated room is recommended for the dressing of wounds. Such rooms are not always available in most hospitals, but the dressing of wounds in the ward must follow certain rules established for the safety of the patient. With some modification a guide for dressing wounds may be given as follows [19]:

a. Dusting, sweeping, bedmaking and traffic should cease 15 minutes before wound dressings are begun, and the patient should be screened. b. After masking, the nurse ( or doctor) should first wash her ( or his) hands thoroughly using a bacteriostatic soap, and drying them on a clean towel. c. Individual dressing trays should be used for each patient in lieu of a dressing cart or trolley. d. The tray with necessary equipment should be taken to the patient's bedside. Position the patient and the bedclothes, and remove outer dressing, leaving innermost dressing in place. e. Discard soiled outer dressing into a waxed or similar impervious container. f. Wash and dry the hands ( optional, depending upon facilities available). g. Remove inner dressing and discard forceps. h. Carry out dressing, using one swab per wipe, working from the centre of the wound outwards. "No touch" technique must be observed throughout. i. Place dirty inner dressing and used swabs in waxed bag and seal. f. Wash and dry hands.

34

THE CONTROL OF INFECI'IONS IN HOSPITALS

k. Return instruments and dressing tray to utility room. Clean and return to central area for re-sterilization. l. Wash and dry hands.

Handwashing was another observed aspect of the dressing procedure which needs more careful scrutiny. Observations made during surgical ward rounds in one hospital, revealed that eleven patients were seen and examined by the medical staff [10]. Dressings were lifted to enable the interns and residents to "peek" at the wounds, but hands were not washed before, during, or after rounds. In another hospital, a nurse, questioned about her lack of handwashing before doing a dressing, told the observer that if hexachlorophene soap is used, a single wash upon arrival on duty was sufficient for the entire day [10]. In two hospitals, although sinks were provided in wards or patient rooms, soap and/ or towels were often lacking. The largest percentage ( 32.3) among the survey hospitals reported that a one-minute scrub was required before beginning a dressing ( C.1.46). It was interesting to note that 60.6 per cent of the survey hospitals replied that sterile gloves were worn when doing contaminated dressings (C.1.48). It should be pointed out, however, that the wearing of gloves is not a substitute for scrubbing the hands. 4.3. GUIDE FOR HANDWASHING ( see 7.1) In an attempt to provide hospital personnel with some guide when to wash hands, the following suggestions are made [19]: A thorough wash is essential: a. on arrival on the ward for duty. b. before leaving the ward after duty. c. before and a#er any procedure for which gloves or forceps are necessary. d. before and after any procedure requiring sterilized equipment. e. after rounds of taking temperatures, bedmaking, and after giving and emptying bedpans or urinals, and any handling of excreta and discharges. f. before and after routine back care. g. after bathing a baby, and after cleaning its eyes, nose, mouth, or umbilicus. h. after changing diapers. i. following personal toilet.

DRESSING TECHNIQUES

35

All wards should be equipped with sinks having elbow- or kneecontrolled taps. Hexachlorophene soap should be used regularly and soap dispensers should be foot-controlled. Hospital personnel whose skin is extra-sensitive to repeated usage of this type of soap should apply an emollient cream, preferably containing a disinfectant, after each handwashing. In an investigation of cross-infection carried out at the Bristol [England] Maternity Hospital, it was shown that the regular use of hexachlorophene soap followed by a hand cream containing chlorhexidine reduced the number of staphylococci on nurses' hands, and its use by nursing staff was followed by a reduction of infection among infants [5] . Hands should always be dried after washing. Recontamination from a clean, although non-sterile, towel is less than that from water running down the forearms, often into the wound. Roller type communal towels are condemned. The best way of providing towels is in a dispenser.

5. Prevention and Care of Urinary Infections

5.1. CAUSES OF URINARY INFECTIONS Although a large number of patients with genito-urinary conditions seem inevitably to develop infections following catheterization, many of these infections can be prevented through careful application of antiseptic and aseptic principles. In a report in 1955 from St. James Hospital, Leeds, on an outbreak of bladder infection with Pseudomonas pyocyanea in patients following prostatectomy, it was shown that when one patient became infected with the organism there was every opportunity for it to spread to other patients in the same vicinity [12]. Pseudomonas pyocyanea was found in the ward dust ( suggesting the possibility of air-borne spread), on the hands of an orderly, on the nailbrush, and in the disinfectant in which the nailbrush was immersed. The nurse or physician would thus begin every dressing with hands contaminated by the infecting organism. Other causes of bladder infections may include: a. faulty sterilization of equipment. b. errors in technique resulting in contamination of sterile supplies. c. infection carried from anterior urethra to the bladder during insertion of the catheter. d. infection travelling up the lumen of the catheter from the drainage tubing and contaminated drainage bottle. The faulty sterilization of equipment is caused either by mechanical failure or by human error. The three remaining causes of bladder infection can be summarized under the general category of catheterization technique. Errors in techniques resulting in contamination of sterile supplies

URINARY INFEC.TIONS

37

are mostly individual, and their resolution depends upon the personal responsibility of the individual concerned. The anticipation and avoidance of errors in techniques should be mandatory in hospitals. Unfortunately, even today with the recognized high incidence of bladder infections, precautions taken for simple catheterizations are frequently cursory and haphazard. In certain hospitals, the use of gloves for doing this procedure has been reserved for doctors; nurses being required only to scrub their hands. It should be immediately apparent to every nurse who has had to catheterize a patient in a ward, tha:t contamination of the hands before actual insertion of the catheter is practically unavoidable. As most female patients are catheterized by nurses, the , high incidence of bladder infections in hospitals not requiring sterile gloves to be worn should come as no great surprise. Today, with more orderlies being permitted to catheterize male patients, hospitals must recognize the potential danger of the situation. Preceding any sterile procedure, hands should be scrubbed and sterile gloves worn. Masks are not required except when the opening into the bladder is supra:pubic. In this case, the same technique required for dressing wounds applies ( see 4.2). The risk of inducing a bacteriuria after a single catheterization in normal women has been shown to be between 2 and 4 per cent [7]. This incidence increases when catheterization is repeated or if there is trauma of the tissues, or when labour and delivery are complicated. In a study carried out in England, reported in 1961 the passage of a catheter caused infection in 22.8 per cent of abnormal obstetrical cases, and in 9.1 per cent of normal cases [3]. In a controlled study in the United States, it was found that 5.3 per cent of patients catheterized before gynecological surgery developed urinary tract infections [ 17]. It was also found that complications in the form of urinary tract infections were limited to only those patients who had been catheterized pre-operativelt There were no similar infections among patients who had not been catheterized, and who served as the control group. The preparatory catheterization of patients is a ritual in all gynecological services. The above studies have shown some of the potentially harmful effects and should bring about a reconsideration of the routine use of this procedure. The prevention of transmission of organisms from the anterior urethra into the bladder is not totally possible. One trial, using chlorhexidine for disinfecting the urethra, reduced urinary tract infections by gram-negative bacilli to 17 per cent compared with 52 per cent of

38

1llE CONTROL OF INFECTIONS IN HOSPITALS

control patients [6]. An even more effective method was found by disinfecting the bladder immediately after catheterization by instilling dilute chlorhexidine solution. 5.2. CLOSED IRRIGATION AND DRAINAGE SYSTEM Another potential cause of urinary tract infection is open drainage into non-sterile bottles. In three of the hospitals visited empty intravenous bottles served as receptacles for urine. These were often open at the neck, admitting dust particles which could carry pathogenic organisms. It is poorly understood that endemic strains of pathogenic organisms can easily ascend the drainage tube, usually being carried to the bladder by rising air bubbles. The endemic persistence of Pseudomonas pyocyanea in surgical wards is probably responsible in this way for many of the urinary tract infections that occur after surgery or routine catheterizations [9, 12]. As a general rule, urine bottles, once measured, are emptied, rinsed, and replaced under the drainage tube. Urine bottles are changed (sterilized) at bi-weekly or weekly intervals. Hospitals using the closed system of irrigation and drainage on the other hand reveal their urinary infection rates have decreased. Closed drainage and irrigation systems are available with indwelling catheters, but they must be set up aseptically and not interrupted until the catheter is removed. Full drainage bottles or empty irrigation bottles must be replaced by sterile containers. The system of closed irrigation is preferred to the open method, in which failures or lapses in aseptic technique result in contamination of the irrigating solution or equipment. In the system of open irrigation, when bladders were irrigated twice daily or more often, it was common practice to set up one irrigation tray to be used for as long as twenty-four hours. The high risk of contamination following repeated usage should be self-evident. Today most hospitals require that strict sterile technique be used for bladder irrigation. A second frequent error in technique results when disconnecting the catheter from the drainage tubing for irrigation [10] . The glass or plastic connecting rod is usually placed on the bedclothes and contaminated. Once the irrigation is completed, the contaminated tip is reinserted into the catheter, carrying with it contamination from the surrounding environment.

URINARY INFECTIONS

39

It was common to see in the urological wards visited drainage bottles by the side of a bed with the tubing pinned to the draw sheet, while the patient was ambulatory [10]. The connecting tube was either uncovered or a piece of paper tissue covered the tip. Contamination of the lumen of the catheter was almost inescapable. In more recent years, findings have indicated that the dialysing fluid of the twin-coil-artificial kidney has been contaminated with bacteria. In a study carried out at the Department of Surgery, University of Melbourne, the use of chlorhexidine after each dialysis held in check the heavy contamination from bacteria [8]. The disinfection and monitoring of this highly technical equipment poses one more problem in the prevention of urinary tract infections.

40

THE CONTROL OF INFECITONS IN HOSPITALS

REFERENCES

1. Allison, V. D., Bourdillon, R. B., Craig, W. S., Crooks, J., Crosbie, W., Gaisford, W., Gunn, W., Lightfoot, R., Spence, J. C., Vining, C. W., and Watkins, A. G. Cross-infection in children's wards. British Medical Journal, 1: 673, May 1946. 2. Bourdillon, R. B., and Colebrook, L. Air hygiene in dressing rooms for burns or major wounds. Lancet, 1: 561, April 1946. 3. Brumfitt, W., Davies, B. I., and Rosser, E . I. Urethral catheter as a cause of urinary-tract infection in pregnancy and puerperium. Lancet, 2: 1059, Nov. 1961. 4. Colbeck, J.C. Control of Infections in Hospitals. Hospital Monograph Series no. 12, American Hospital Association, Chicago, Ill., 1962. 5. Gillespie, W. A., Simpson, K., and Tozer, R. C. Staphylococcal infection in a maternity hospital; _epidemiology and control. Lancet, 2: 1075, Nov. 1958. 6. Gillespie, W. A., Lennon, G. G., Linton, K. B., and Slade, N. Prevention of catheter infection of urine in female patients. British Medical Journal, 2 : 13, July 1962, 7. Kass, E. H. Bacteriuria and the diagnosis of infections of the urinary tract. Archives of Internal Medicine, 100: 709, Nov. 1957. 8. Kidd, E. E . Bacterial contamination of dialysing fluid of artificial kidney. British Medical Journal, 1: 880, April 1964. 9. McLeod, J. W. The hospital urine bottle and bedpan as reservoirs of infection by Pseudomonas pyocyanea. Lancet, 1: 394, Feb. 1958. 10. Personal observations. 11. Price, P. B. Surgical antiseptics. Chapter 15, in Antiseptics, Disinfectants, Fungicides and Sterilization. Edited by G. F. Reddish. Lea and Febiger, Philadelphia, 1954. 12. Pyrah, L. N., Goldie, W., Parsons, F . M., and Raper, F. P. Control of Pseudomonas pyocyanea infection in a urological ward. Lancet, 2: 314, Aug. 1955.

13. Scientific criteria in procedures for the cleaning of eating utensils. Edited by Charles V. Letourneau. Hospitals, 27: 115, June 1953. 14. Sommermeyer, L., and Frobisher, M., Jr. Laboratory studies on disinfection of oral thermometers. Nursing Research, 1: 32, Oct. 1952. 15. Sommermeyer, L., and Frobisher, M., Jr. Laboratory studies on disinfection of rectal thermometers. Nursing Research, 2: 85, Oct. 1953. 16. Spaulding, E. H., and Emmons, E. K. Chemical disinfection. American Journal of Nursing. 58: 1238, Sept. 1958. 17. Sweeney, W. J. Perinea} shaves and bladder catheterizations: necessary and benign, or unnecessary and potentially injurious? Obstetrics and Gynecology, 21: 291, March 1963. 18. Walter, C. W., Rubenstein, A. D., Kundsin, R. B., and Shilkret, M. A. Bacteriology of the bedside carafe. New England Journal of Medicine. 259: 1198, Dec. 1958. 19. Williams, R. E . 0., Blowers, R., Garrod, L. P., and Shooter, R. A. Hospital infection. Year Book Publishers, Chicago, 1960.

6. Present Isolation Facilities

6.1. PREVIEW The isolation of patients with infectious diseases presents problems to hospitals today that were non-existent a few years ago. When highly contagious diseases began to be isolated the incidence of epidemics began to subside. Once disease spread could be controlled, the large fever hospitals came to be regarded as wasted space, and plans were made to utilize them in other ways. New general hospitals were designed without adequate planning for infectious disease control, with the result that when the recent epidemic outbreaks of staphylococcal disease erupted, hospitals were at a loss how to stem the spread of this disease. Without facilities for isolating patients, private rooms had to be used for segregating infectious patients. Along with the decreased emphasis on infectious diseases has come a decline in aseptic standards in general. Medical and nursing students are no longer required to spend time in infectious disease hospitals, with the result that strict aseptic practice is not learned. The success of an infection control program is dependent upon the education and knowledge of all persons concerned. To achieve this, continuing in-service education on the concepts and applications of asepsis must be part of total hospital programming. One of the groups most in need of education and re-education are the physicians themselves, a situation which is generally overlooked. This was seen in the questionnaire survey which showed that only 14.3 per cent of the reporting hospitals with internes had established programs for them on the principles of aseptic techniques ( C.2.66). Presented in this part of the text will be observations of isolation techniques, the tabulated findings from the questionnaire survey and suggestions for improved techniques in isolation areas.

44

THE CONTROL OF INFECTIONS IN HOSPITALS

6.2. PRESENT ISOLATION FACILITIES From our experience, it is apparent that when a specific area is designated for the care of patients with known or possible transmissible diseases, and when personnel are carefully trained for this specialized area, attitudes and techniques are excellent. Conversely, when isolation areas are makeshift arrangements, and ward personnel are responsible for the care of both infectious and non-infectious patients, standards tend to deteriorate, and techniques are not adequate to control the transmission of disease. Well-staffed, physically adequate facilities are the prime requisites in controlling the spread of cross-infections in hospitals. Most hospitals at the present time would reject any suggestion to have 10 per cent of their total hospital beds reserved for patients with infectious diseases. Similarly, they would dismiss as impracticable the idea of setting aside a fully staffed ward in the hospital for the care of infectious patients. In lieu of this, they would establish some means of priority for recognized infectious conditions, and only the most highly communicable diseases would be isolated. In all hospitals visited, isolation areas consisted of private or semiprivate rooms usually situated in the midst of patient areas [12] . The inclusion of infectious patients in the midst of those without infections frequently culminated in a confused intermixing of clean and dirty areas, with the one utility room being used for all patient equipment. One hospital in particular interspersed infectious patients throughout its surgical wing. In some of the rooms, a thin cloth curtain was optimistically used to separate patients and their infections from postoperative patients. In almost all instances, the patients were being isolated for infections which had developed post-operatively-a finding which was not surprising. In other hospitals, individual rooms were often without washing facilities, which necessitated setting up stands outside patient rooms to hold basins of disinfectant solutions [12] . Upon questioning, the nurses admitted that they paid little attention to the amount of disinfectant used. Realizing that the solutions were replaced at a maximum of every eight hours, the "disinfectant" was more probably a fluid culture medium. Observations of current isolation practices in hospitals seemed to indicate that staphylococcal infections are now regarded as transmissible and are being isolated [12] . This was further indicated in the questionnaire findings which revealed that 71.2 per cent of the

PRESENT ISOLATION FACILITIES

45

reporting hospitals stated that all cases of staphylococcal disease were isolated ( C.2.63). It was learned from talking with nurses on surgical areas of two of the hospitals visited, that their views on ·possible wound infections were often disregarded. Nurses related that patients whom they would regard as being highly infectious were isolated only on the attending doctor's preference. Meanwhile it was the nurse herself who was in most frequent direct contact, and had the greatest exposure to the patient. In another hospital visited, there was a conflict among nurses regarding the necessity of isolating staphylococcal infections. In this particular instance, the evening supervisor had isolated a child admitted with a draining abscess, only to return the next day to find the child playing with other children in the same ward. Policies regarding the isolation of patients should be clearly defined in all hospitals. The head nurse should be given authority to segregate any patient whom she regards as being potentially infectious to others. This is particularly essential in surgical areas, where the head nurse may be the first person to detect possible post-operative infections. If she is permitted to take a culture of what she suspects to be possible purulent drainage, then bacteriological evidence will point the way to prompt and more adequate treatment. In addition, if the head nurse is acutely aware of and trained to look for post-surgical sepsis, she may be able to prevent either a severe wound infection or possible epidemic outbreak of cross-infection on her ward. That the need for rules concerning isolation procedures is not being completely met in hospitals was seen in the replies by the survey hospitals. These indicated that only 56.5 per cent of the hospitals had standard orders by the Medical Advisory Board regarding the isolation of suspected cases of communicable diseases ( C.2.64). It is of interest, however; to see that 85.7 per cent of the hospitals reported that the nurse-in-charge was permitted temporarily to isolate suspected infectious cases without a doctor's prior order ( C.2.65). 6.3. PRESENT ISOLATION PRECAUTIONS Two general categories of isolation precautions are in cU1Tent practice. They are [9]: a. preventive isolation. b. protective isolation.

46

THE CONTROL OF INFECTIONS IN HOSPITALS

Preventive isolation means the segregation of an individual with a known or suspected infectious condition in an attempt to halt further spread of the disease to other people, either in hospital or home. In addition to segregating the patient, all belongings and equipment used in the care and treatment of the patient must be regarded as potentially infectious, and should be sterilized. Protective isolation is a method of disease control in which attempts are made to prevent spread of disease to an individual who is highly susceptible to infectious illness because of a marked lowered resistance. This method of isolation would be carried out for patients hospitalized for such debilitating diseases as agranulocytosis or leukemia, total body irradiation, or extensive burns. Protective isolation areas should probably be physically separated from preventive areas. The methods of isolating patients vary from hospital to hospital, and from disease to disease. The techniques used may be very rigid and absolute, or modified in whole or part. An example of a modified technique is the traditional barrier technique which has been used for many decades as a means of controlling infectious diseases. In lieu of a private room, the patient is segregated from others by being placed at the end of a large ward or wherever convenient washing facilities are located, and screened off from his fellow patients. Equipment used by and for the patient is regarded as highly infectious and not used for any other patient. There are many dangers in modified isolation techniques. Perhaps when aseptic standards were at their highest this was a reasonably safe means of disease control. From personal observations and experience, it is recommended here that isolation precautions either be complete or non-existent. Considering how difficult it is to maintain high standards even when attempting to carry out absolute aseptic techniques, it is felt that any lowering of standards would only further increase the potential spread of disease. As Caswell states [l] , "There is no such thing as partial isolation. It is either isolation or it isn't." It should become the accepted policy in every hospital that any patient admitted to hospital with infectious upper respiratory disease, diarrhea or lesions of the skin and mucous membrane from acute disease must be regarded as potentially infectious. To do so is the only certain means of controlling potentially epidemic infections. A case in point was an expectant mother admitted to one Metropolitan Toronto Hospital delivery room [12]. Although the admitting nurse noted some diarrhea on admission, it was assumed that the patient had taken a laxative, and

PRESENT ISOLATION FACILITIES

47

no stool culture was obtained. Hours later following delivery, it was discovered that the mother had a Salmonella infection. Shortly after this, two babies in the nursery developed diarrhea, one baby belonging to the infected mother. Only immediate and rigid precautions ( and good fortune) prevented a full-blown epidemic among patients and staff. It is assumed that this was not an isolated instance, but that similar unrecognized infections frequently occur in hospitals. Such situations can best be prevented by establishing an admission ward or screening area, which would be used to classify patients with suspected infectious diseases. Such an area could be patterned after a communicable disease unit, having an individual room or cubicle for each patient, and staffed with specially trained personnel. Patients not requiring emergency care could then be observed for a period of twenty-four to forty-eight hours, during which time blood work and additional investigations would be completed. This would not only help to prevent the possible transmission of communicable diseases directly to other hospital areas, but would also help in classifying patients correctly. In addition to having a specific admission area for screening potentially infectious patients, other modifications are needed in existing or proposed isolation areas. Isolation units should be constructed having large glass windows which would enable personnel to observe patients without having to enter the contaminated area. This principle has already been incorporated into many designs for intensive care units. Allowing the patient to view activities about him would help him to feel less removed from the rest of hospital life. A disposable paper blind would guarantee the patient's privacy. Considering the amount of paper space required to outline the procedure for using watches in isolation areas, it would seem very practicable to install a clock in or near patients' rooms which would then allow the nurse or doctor to time procedures without having to bring a watch into the contaminated area. The more articles taken into or brought out of a contaminated area, the greater the possibility of disease transmission. 6.4. STAFFING OF ISOLATION AREAS Ideally, all specialized areas should be staffed by specially trained personnel. This is particularly essential in infectious disease units. The

48

THE CONTROL OF INFECilONS IN HOSPITALS

means of controlling communicable diseases in hospitals at large should now be well understood. One infrequently recognized possibility, however, is the potential for cross-infection within isolation units. The potential of cross-infection increases when isolation units are set up in the midst of regular patient areas. It is inconceivable that personnel can care for infectious patients side-by-side with patients admitted for non-infectious reasons. Transmission of organisms can take place in one or more of several ways. They can be carried on clothing, on the hair, on the skin, and on mucous membranes. An example of skin carriage of a pathogenic organism is seen in the following observation made in one of the hospitals visited [12]: Cultures were taken from both hands of a nurse caring for a patient with an antibiotic-resistant staphylococcal infection. Each hand was swabbed, after the nurse had washed with G-11 liquid soap. A culture was also taken of the patient's lesion. Following twenty-four hours incubation on blood agar medium, the cultures from each hand grew three separate strains of Staphylococcus aureus, one of which was identical with the strain taken from the patient's lesion. Both were highly resistant strains of Staphylococcus aureus. It is of note that this particular nurse had been caring for the patient over a period of several days, and that her hands were very red and irritated from repeated handwashings. It is recommended here that personnel with breaks in the skin not be assigned to care for patients suHering from infections involving the skin or mucous membrane.

Each nurse should have sound knowledge of the incubation period, the reservoir of each specific organism, and she must also know when a patient no longer requires isolation. Too frequently patients remain on isolation precautions when they are no longer infectious. The isolation of patients, even at its best, is a traumatic ordeal. Not only must they suffer rejection by being removed from other patients, but they are frequently stigmatized by the fact that they have an infectious disease. Negative attitudes of nursing personnel towards cumbersome isolation techniques only serve to reinforce the feelings of guilt and rejection already being experienced by the patient. Furthermore, patients are often placed in isolation without being given the necessary details about their condition. Anxiety is also frequently present on the part of nursing personnel in their attempts to carry out isolation procedures, as failure to carry out good techniques may result in self-infection. Such an actuality · carries with it a stigma all its own. ( Further details about infectious diseases and suggested isolation procedures are given in Appendix A.)

7. Specific Control Measures in Isolation Areas

7.1. HANDWASHING PRACTICES ( see 4.3) Any hospital area utilized for the segregation of infectious patients should be equipped with running water, preferably with the sinks having elbow- or foot-controlled taps. In addition, soap used for scrubbing should be of sufficient disinfecting strength to inhibit the growth of micro-organisms. Cultures taken of green soap by the present authors revealed abundant growths of coliform organisms in the solution [12] . For this reason, if green soap is to be used, a bacteriostatic agent such as hexachlorophene should be added to the soap to guard against bacterial growth. The questionnaire survey showed that while 13.1 per cent of the hospitals still use green soap, over one-half ( 57 per cent) are now using bacteriostatic preparations (C.2.78). Frequent repeated washing with this product will result in a residual layer of the bacteriostatic agent on the skin, and will impede further build-up of micro-organisms. Liquid soap has been found to be more effective than bar soap in this respect, because of the lanolin base which enables the soap to adhere more readily to skin surfaces. Soap solutions should also be in footcontrolled closed containers. A large percentage ( 73.4) of hospitals in the survey replied that liquid soap was dispensed from closed containers (C.2.79). Only 7.6 per cent of the survey hospitals replied that soap solutions were cultured routinely in isolation areas ( C.2.80). 7.1.1. A GUIDE FOR HANDWASlllNG IN ISOLATION AREAS [6] a. Standing back from the sink, using either elbow or foot, turn on water to a temperature comfortable to hands. b. Moisten hands and apply a heavy lather of soap, covering the hands and arms, paying particular attention to the areas between the

50

c. d.

e.

f.

TIIE CONTROL OF INFECTIONS IN HOSPITALS

fingers and under the nails. ( If finger nail files or orange sticks are used, they should be individual and not communal. The use of tooth picks for cleaning under the nails has been suggested. Care must be taken not to injure the skin regardless of what procedure is used for cleaning nails) . Use friction, one hand upon the other. Rinse hands thoroughly under running water, allowing water to Bow from the elbows towards the finger tips. Repeat steps b through d. Dry hands thoroughly, using paper or individual towels.

The approximate time required for completing the above procedure is 90 seconds. Questionnaire findings showed that a one-minute wash was most frequently reported, both before and after removing the gown (C.2.76,77). The value of a timed scrub in an isolation or any other area is questioned, however, because little regard is given to the amount of time specified. In addition, hospital personnel rapidly tire of too much detail and the basic importance of the procedure is often obscured by the myriads of minutiae. The fundamental purpose of the "social wash," as opposed to the surgical scrub, is to rid the hands and arms of transient pathogenic organisms, i.e., organisms deposited on the hands and arms from contact with recognized or unrecognized contagion. This removal cannot be accomplished merely by an outline describing in detail this elementary practice, but only through conscientious efforts. The drying of hands has been open to controversy in nursing circles for some time. Whether or not hands should be dried is much less important than whether or not hands are washed. The present authors advise the drying of hands, not only because it is more expedient to do so, but because insufficient evidence has been advanced to support the superiority of air-drying of hands. It is also recommended that a disinfectant hand-cream be used after each washing to prevent irritation of the skin. Only 19.1 per cent of the survey hospitals reported that disinfectant hand-creams were routinely used by personnel on isolation areas ( C.2.81). In light of our observations, this practice would seem to be a necessity in isolation units. In summary, from observations of handwashing practices ( or perhaps more accurately, the lack of such practices) in hospitals, two conclusions are apparent:

a. That no well-defined statement of handwashing procedure is visibly available to remind personnel of its importance.

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51

b. That committees seeking to establish a routine for handwashing fail to realize that, while they are seeking an ideal procedure, handwashing is not actually being carried out. 7.2. GOWN TECHNIQUE Gowns used in isolation areas should be long enough to cover the uniform of the nurse or doctor, and should be short-sleeved. Hands and arms cannot be adequately washed wh!'n long-sleeved gowns are worn. In addition, sleeves may become dampened from water during procedures, and thus offer only false security to the wearer. Yet findings from the questionnaire survey revealed that 74.6 per cent of the hospitals in Ontario still used long-sleeved gowns in isolation areas ( C.2. 71). A "one-use" gown technique should be enforced policy in all isolation units. Each area should have a large enough supply of gowns to enable each person to put on a fresh one before entering the contaminated area. Once used, the gowns should not be re-used, but should be directly discarded into a specially marked linen hamper. The inevitable contamination from repeated usage of a communal gown should be self-evident. Although 95.5 per cent of the hospitals replied that total patient care was given whenever possible, 62.4 per cent stated that the same gown was worn by more than one person (C.2.73,74). The questionnaire survey showed that most ( 49.2 per cent) of the survey hospitals changed gowns after each shift, and a further 32 per cent changed gowns daily. Only 12.7 per cent of the hospitals reported that gowns were changed after each use ( C.2.72). A simple "discard gown" technique is outlined as follows [6]:

a. Wash hands and forearms. 0 b. Unfasten neck band. c. Untie waist tapes. d. Slip out of gown rolling clean side out over hands and forearms as it falls forward. e. Discard in laundry hamper. f. Wash hands. 0 Handwashing must take placeJ·ust before removing the gown and always before leaving a specific contaminat unit.

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Over 69 per cent of the hospitals reported that isolation gowns were routinely worn when taking oral temperatures, while 93.7 per cent replied that gowns were routinely worn when taking rectal temperatures ( C.2.83,84) . The increased use of isolation gowns when carrying out procedures in which there is more physical contact with the patient, would be expected. 7.3. MASK TECHNIQUE (see 4.2) Except in certain communicable diseases in which transmission of the infective organisms is by air-borne or droplet-spread, the wearing of masks is not recommended. This is primarily because masks are not worn properly and are more of a serious menace than a safety measure. Masks are generally used for an entire eight-hour shift, or even longer. Observations revealed that when not on the face, masks were either worn about the neck, or stuffed into a uniform pocket. The potential dissemination of oro-nasal organisms from repeated and careless handling of the contaminated mask often goes unrecognized. Over 70 per cent of the survey hospitals reported that masks were worn routinely when carrying out isolation techniques ( C.2.67). To prevent their prolonged use, paper disposable masks are recommended. A note of precaution, however, must be included regarding paper masks. Unless fitted with a disposable filter or plastic shield, paper masks rapidly become moist, and the transfer of organisms can readily take place in both directions. Once a mask is damp it no longer has any protective value. In caring for a patient over an extended period of time, the use of more than one mask is strongly recommended. The survey showed that 60 per cent of the hospitals used cloth masks, while 32 per cent reported that disposable masks were worn ( C.2.68) . • To remove the mask, first wash the hands, untie strings holding mask by the strings only, place in a marked container, and again wash the hands. When using a disposable mask which has elastic ear fasteners, the same rules apply. 7.4. DISPOSAL OF SECRETIONS AND EXCRETA

7.4.1. SECRETIONS The organisms causing communicable upper respiratory infections

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53

are in discharges from the nose and throat of the infected person, and occasionally from the ears. Additional reservoirs may include discharges from laryngeal and bronchial mucous membranes, including such organisms as the tubercle bacilli, which are found in sputum. With infections such as chickenpox or smallpox, organisms are present in the lesions of the skin and mucous membranes as well as in the upper respiratory secretions. Each patient should be provided with paper tissues and waxed paper bags. He should also be given simple instructions in the hygienic disposal of secretions from nose and throat. Used tissues should not be left lying around on bedside table tops, or thrown on the :floor. The practice of emptying paper bags into receptacles and then repinning the bag onto the bed only further contributes to air-borne dissemination of infectious organisms. Paper bags, when filled, should be tightly closed and placed into a lined waste receptacle. They should be replaced by fresh unused bags. Disposable sputum cups should be used by all patients with tuberculosis and by persons having any amount of sputum. The cups should be waxed cardboard, and tightly covered. In addition, sputum cups should be collected at least once a day, placed in a special container, and labelled "To BE BURNED." 7.4.2.

EXCRETA

Assuming that each patient is provided with his own bathroom or bedpan and/or urinal, with few exceptions, excreta can be emptied directly into the toilet, taking precautions not to contaminate the outside of the toilet bowl. In the case of typhoid fever, infectious diarrhea, poliomyelitis, and infectious hepatitis, the procedure for handling excreta depends upon the sewage disposal facilities available. In most instances, where hospital wastes enter a treated municipal sewage system, bedpans can be emptied directly into toilets and hoppers without any prior disinfection. In the case of smaller hospitals which do not have treated sewage disposal facilities, or have inadequate septic tanks, disinfection of the excreta is mandatory before emptying into the sewage system. As a further precaution, however, it is recommended that excreta be disinfected before disposal, regardless of available sewage disposal facilities. The recommended procedure for disinfecting excreta is as follows [6]: a. Break up stools with tongue depressor. 0 0

Urine, vomitus, and food wastes should be treated in the same manner as stools.

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TIIE CONTROL OF INFECflONS IN HOSPITALS

b. Empty contents ( and depressor) into a can containing a 5 per cent solution of a phenol or creosol type of disinfectant. c. Cover and allow mixture to stand for one hour before emptying into toilet or hopper. 7.5. CARE OF BEDSIDE EQUIPMENT (see 3.5) The rules applying to the distribution of bedside equipment apply equally well, if not more so, to the equipment of patients with communicable diseases. Each patient should be given his own equipment upon admission ( see 3.5). It is further desirable that freshly sterilized equipment be reissued at weekly intervals during hospital stay, in order to reduce the build-up of pathogenic organisms that would be inevitable after prolonged usage of equipment. In a "one-for-one" exchange arrangement, contaminated bedside equipment should be wrapped separately, and first autoclaved before being cleaned. After cleaning it should be repackaged and again autoclaved. The difficulties encountered in attempts at "cold" disinfection of equipment have been discussed earlier. There can be no compromise in the disinfection of equipment used by patients with known transmissible diseases. Autoclaving is the only certain means of complete sterilization. 7.6. CARE OF DISHES AND EATING UTENSILS One of the most perplexing problems faced by nursing personnel in caring for patients in isolation areas is the disposal of uneaten food and the disinfection of dishes. Again, some system is needed in the care of dishes, and the best one seems to be to use disposable dishes whenever possible. More than one-half (55.2 per cent) of the survey hospitals reported that disposable dishes were used in isolation areas. At first glance the use of disposable dishes may appear to be an additional expense, but this can be justified in the time and effort conserved by nursing personnel who would otherwise have to disinfect dishes. Further, the use of disposable dishes and/or utensils greatly simplifies this particular aspect of isolation. Over 91 per cent of the survey hospitals reported that dishes and utensils were disinfected

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55

after each use ( C.2.91). The most widely used method was chemical disinfection ( 45 per cent) . An iodophor was the most commonly used disinfectant ( C.2.92). It can be reasonably assumed that in the past a great deal of crosscontamination resulted from faulty attempts to decontaminate dishes and utensils. These were usually disinfected in the utility room, with a resultant contamination of other areas of the utility room during the process. The use of disposable dishes and utensils would greatly simplify the task of caring for dishes used by infectious patients. The use of disposable equipment should also extend to medicine cups ( see 3.3). It is of interest to note that 57.9 per cent of survey hospitals used disposable medicine cups in isolation areas, while only 14.5 per cent used disposable cups in general hospital areas ( C.1.6; C.2.96).

7.7. DISPOSAL OF CONTAMINATED BEDDING Bedclothes, including sheets, pillowcases, and bedspreads, are rapidly colonized by the patients' pathogenic organisms. For this reason, a complete (daily) linen change is recommended in all isolation areas. Over 96 per cent of the hospitals reported that linen used in isolation areas was placed in specially marked containers ( C.2.110). Ideally these should be designated, either by a coloured tab, or by the word "coNTAMINATEo." There are certain rules required in handling linen, which if observed, will keep further environmental contamination at a minimum. They are as follows : a. Remove cotton pillow cover first, and use as receptacle for other linen. b. Remove linen carefully from the bed, with a minimum of handling. c. A second nurse, outside of the contaminated area, should have a marked laundry bag ready to receive the contaminated linen. A mask must also be worn by the second nurse if the linen is from the bed of a patient with an air-borne infection. d. The second nurse should hold the laundry bag in such a manner as to allow the open top of the bag to cover her hands and arms. e. The first nurse should carefully place the contaminated packaged linen in the marked laundry bag.

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Tim CONTROL OF INFECTIONS IN HOSPITALS

f. The laundry bag should be then tightly sealed by the second nurse,

and either taken to the laundry immediately, or placed in an impervious container awaiting transport. ( Laundry hags which disintegrate during the washing cycle are discussed elsewhere. See 14.3.)

g. Both nurses should wash their hands. Soiled and contaminated linen can be placed together safely if the contaminated linen is placed in a bag which is impervious to moisture. Contaminated bedding should be sent to the laundry as soon as possible and not stored in the ward. It is further recommended that the linen of all patients suffering from disease caused by pathogenic spore-forming organisms be autoclaved before being sent to the laundry ( see 14.4). In addition to sheets and pillow cases, blankets and pillows also must be considered under the general category of bedding. It is interesting to note that 35.8 per cent of the hospitals reported that all-wool blankets were used, while an almost equal percentage of hospitals (33.5 per cent) used cellular cotton blankets (C.2.112). Only easily launderable blankets should be used, and cellular cotton or disposable blankets are recommended for use in isolation areas. In answer to the question, "Are all blankets disinfected routinely after discharge of patient?" 95 per cent of the survey hospitals answered yes ( C.2.113). Amongst these, 38.6 per cent replied that blankets were disinfected at intervals not exceeding two weeks if the patient's stay was prolonged (C.2.114). Over 93 per cent of the hospitals reported that all pillows were disinfected after discharge of the patient ( C.2.115).

8. The Control of Infections in and beyond the Hospital

8.1. THE HOSPITAL AS A RESERVOIR OF COMMUNITY INFECTION

While instances of infection occurring after admission to hospital have been copiously documented, infections transmitted after discharge from hospital to home have received less emphasis. There are perhaps at least two reasons for this: the first, because limited research has been carried out tracing the spread of infections from hospitals to homes; second, because this aspect of cross-infection has been overlooked in attempts to focus attention on the causes of intra-hospital infections. The possibility of inter-hospital contagion as well as hospital-to-home infection was recognized a few years ago, when the incidence of postpartum staphylococcal breast abscesses was then reaching epidemic proportions [3,ll,13,16,17,18,20]. At first these cases were not recognized as hospital cross-infections because the abscesses did not develop until two to six weeks after delivery; long after discharge from the maternity hospital. When the infection became more serious, it became necessary for the new mother to be admitted to a general hospital for incision and drainage of the abscess. In this way the maternity hospital became a source of infection not only for the community, but also for the general hospital. In 1957, in a general hospital in England, the number of cases admitted with breast abscesses during lactation reached such serious proportions that an epidemiologic investigation was carried out [10]. It was found that many of the mothers had been delivered at the same maternity hospital. These findings, carried out over a period of twelve months, showed that 31 out of the 37 mothers who developed breast abscesses had to be hospitalized for incision and drainage. All had

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THE CONTROL OF INFECTIONS IN HOSPITALS

coagulase-positive staphylococci isolated from their abscesses, 24 of the 31 having phage pattern 80/81. The possibility of cross-infections occurring among family units and compact communities has been long recognized. In a study in general practice carried out from 1951 to 1958 in London, England, it was found that in 11 out of 17 families, pathogenic organisms could be traced in their repeated spread from one family member to another [15]. The pathogen in this case was a coagulase-positive staphylococcus. In two families, infections caused by the same strain of Staphylococcus aureus persisted for over six years. Although the initial source of infection in the family was not always traceable, in one instance it was found to be the hospital nursery. Shortly after birth, one particular infant developed a staphylococcal infection of the nail beds and a few septic spots on its face. Four months• later the mother developed boils on her face. This was the first time that the mother had ever had a staphylococcal infection. Pus from the infant's and mother's lesions revealed growths of penicillinresistant Staphylococcus aureus, phage type 79. Epidemic outbreaks of infections caused by the beta hemolytic streptococci, while less prevalent today, still continue to occur. One such epidemic, which occurred in the maternity unit of a hospital in London, England, required closure of the department for over two weeks [5]. Follow-up cultures revealed that 12 mothers continued to be infected with the same epidemic streptococcus even after discharge from the hospital. 8.2. INFECTIONS IN THE HOME With the continual increase in antibiotic-resistant strains of staphylococci, their eradication in the home, as elsewhere, is becoming increasingly more difficult. In one particular family epidemic, occurring in the United States, the infection was first manifested as a superficial breast abscess in the mother and impetigo on the face of the newborn child [8]. Within a short tjme, the child developed seborrhea of the scalp with scaling. A culture of the latter yielded coagulase-positive staphylococci. The sister who handled the infant developed boils on her hands and arms. Cultures revealed that these were also positive for Staphylococcus aureus. Both the infant's and the mother's infections became worse, requiring the mother to be hospitalized. The grandmother, who was caring for the child during the mother's hospitaliza-

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tion, developed boils on the left side of her face and ear; the side she held the child against while burping him. The child was hospitalized for intensive aureomycin treatment and improved. After returning home, the child developed massive impetigo on his face and body, and at the same time boils developed on the hands and arms of the mother. During this time a carbuncle developed on the father's leg, who also required hospitalization for incision and drainage. Streptococcal infections are perhaps more evident in the home than are generally suspected [8]. One eight-year-old girl who developed tonsillitis passed the pathogen on to her young brother who developed otitis media. A 12-year-old sister, who had had rheumatic fever at nine years of age, began to have fever and cervical adenitis. Nose and throat cultures carried out on the entire family revealed that each member had a Group A beta hemolytic streptococcus, type 12. 8.3. CONTROL OF INFECTIONS IN THE HOME Not all infections can be traced directly to hospitals. It is therefore important also, to consider the family as a possible reservoir of infection, both for the community and for the hospital. All infectious disease processes, regardless of where they are contracted, are public health problems. The potential infectivity of hospitals also reflects the existing state of the public health. It has been a long recognized and accepted fact that overcrowding predisposes to contagion. Families live in close contact, and infection in one member is readily transmissible to another. Certain communicable diseases cannot be easily controlled in families, particularly air-borne diseases in which the individual is infectious before the disease is apparent. Staphylococcal infections can be more easily managed if simple aseptic control measures are instituted. A list of instructions given to patients at the Queen Mary Veterans Hospital, Montreal, for the control of staphylococcal infection in the home, is presented below [19]. CARE OF STAPHYLOCOCCAL INFECTIONS IN THE HOME

Particularly during the time when a person has a boil or carbuncle, there are germs all over the skin and in the nose. These germs will survive drying on clothes, towels, face-cloths, handkerchiefs, bed-clothes, pillows, and so on. Soap does not kill these germs and many can be found in a "ring" in the bathtub or on toilet seats. For some weeks (three months at least) you must

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THE CONTROL OF INFECrIONS IN HOSPITALS

protect yo1,1rself from re-infection and must protect your family by reducing the numbers of germs in the household to as low a point as possible .. 1. Until your boil has dried up you must always keep it covered with the antiseptic dressing (or cream) advised by your doctor and the dressing must be changed as frequently as is necessary to prevent it soaking through. 2. Take two showers a day using hexachlorophene soap or detergentwashing well all over, including the hair. ff you have no shower, take two baths a day {not too hot) and wash out the tub well with a cloth soaked in the hexachlorophene or other disinfectant. {see 8 below) . 3. Wash your hands as frequently as possible ( at least six times a day); keep nails short and use a nail brush at least twice a day; never scratch near the infected area of skin. 4. All clothing that cannot be laundered must be sent to the cleaners. Your pillow must be sent to the cleaners or taken to the hospital for steaming in an autoclave. 5. If possible, send all personal clothing, towels, face-cloths and bedclothes (linen) to a commercial laundry. ff this is not possible, special precautions must be taken at home. 6. Shirts, pyjamas, night-gowns, underwear must either be placed in very hot water before laundering or must be ironed moist ( or ironed with a steam iron) if laundered at home. Synthetic materials (nylon, orion, celanese, etc.) that will not take high temperatures should not be worn unless a special disinfectant soap can be obtained (hexachlorophene soap or detergent). The easiest way to deal with cotton clothing, bed linen, towels, face-cloths, etc. in the home laundry is to place them in a tub and to pour one or more large kettles of boiling water over them ( enough to soak all clothes well). Allow the clothes to soak until cool enough to handle (do not add cold water) and then they may be mixed with the rest of the • family washing. 7. Use disposable tissues instead of handkerchiefs and throw them away into paper bags-not into the waste-paper baskets. When dressings are changed, wrap in paper and dispose in paper bags to garbage. 8. Particular care must be taken of bathroom fixtures. A non-corrosive disinfectant should be obtained, such as: Roccal ( 10%) or San-Pheno-X {1%) or Wood's DRX (5%) or New Lysol (full strength) After each use, the toilet seat, the hand basin or bath must be wiped over thoroughly. After each shower the floor and mat of the shower-stall must be wiped over with disinfectant. 9. Any small spots that appear on the skin should be .painted with tincture of iodine. If a spot comes to a head-dip the point of a needle in iodine, puncture the spot and paint well with iodine. ·

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8.4. THE ROLE OF PUBLIC HEALTH AGENCIES IN THE CONTROL OF CROSS-INFECTION The public health nurse is in the unique position of being able to view disease epidemiology in her own community. Her district is not too large, generally, and with adequate training she should be able to assess the disease picture with a great deal of accuracy. This is particularly essential in the detection of possible hospital-to-home spread of disease. While staphylococcal infections are not notifiable diseases, they still remain communicable. The public health nurse on her daily visits to homes, either for the purpose of caring for the sick or for health maintenance, is able to gain first-hand information on recent hospital admissions and possible hospital-to-home contagion. Unfortunately, however, in many instances the nurse's role in preventive medicine is often too fragmented and not completely defined. An example of this is her role in tracing an outbreak of breast abscesses. For visiting nurses particularly, the care of breast abscesses is one of the more common problems encountered in the early post-partum period. Should several breast abscesses occur, it would seem reasonable for the public health nurse to seek a common denominator. This could include a common hospital or nursery, or a particular physician or nurse. If the nurse in public health is fully to realize her role in prevention, what then is she to do when faced with this situation? Perhaps in many cases it would be easier to pretend that no problem existed. In fact, it may be much less embarrassing to ignore the situation entirely than to attempt to follow up events to their conclusion. In large cities with many hospitals, and with public health nursing districts further divided into numerous small units, it is sometimes difficult to establish a continuity in health programming. Cases which actually are epidemic may appear to be sporadic, and several nurses may each report one or two direct instances. It is only when this is seen in its entirety that full assessment is possible. Ideally, all health agencies, whether hospital or community, are organized for the total good of the population. It is an unfortunate fact, however, that to many hospital personnel the concept of disease control and prevention is one that must be structured within the framework of a hospital. The role of the public health agency in respect to hospitals often seems ill-defined and poorly understood. This is also reciprocal. A case in point is the public health supervisor who told a group of hospital volunteers to refrain from taking their lending

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TIIE CONTROL OF INFECTIONS IN HOSPITALS

library into the local hospital because it had a "staph. problem." The hospital administrators in this particular situation were naturally reluctant to allow the local public health officials to assist with the epidemiology and control of cross-infections in their hospital, and the continuity of health care between hospital and community was broken [12]. In the province of Ontario, local health units have a great deal of autonomy. Hospital boards are similarly separate bodies. In addition, both the Provincial Department of Health and the Hospital Services Commission try to interfere as little as possible with local health and hospital organizations. As a result of this situation, there is often inadequate co-operation at local levels between hospitals and local health units. For example, findings from a survey carried out in 1960 of health unit services in eight provinces of Canada showed that in Ontario there were 16 organized hospital infection control committees in hospitals, and in only 11 out of the 40 health units was the medical officer of health a member of this committee [14]. This means that medical officers of health and their staffs, who should know about the existence and techniques of infection control, are, in general, not being used effectively by their local hospitals. From C.4.227, Ontario hospitals list 94 infection control committees, a considerably larger number than shown in the 1960 survey. The situation in regard to the inspection of hospital kitchens in Ontario is somewhat better. The health unit survey found that, in 22 of the 40 units studied, public health inspectors inspected hospital kitchens. However, this is still not satisfactory. The public health physician and nurse, with training in epidemiology and bacteriology, are in perhaps the best position to assist with disease prevention in hospitals. If the public health nurse is to be given this responsibility, she will require additional preparation over and above her preliminary hospital and public health training, and facilities should be available for advanced training of this type. Certainly if hospitals continue to be a source of infection for communities, much more careful study and action is needed at the public health level. From our observations, it is evident that cross-infections should be a constant concern of all responsible persons. Our impressions would further lead us to affirm that the control of infection can only be successfully effected through the organized, consistent efforts of all health workers, whether in the hospital or the community.

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8.5. INFECTION CONTROL COMMITTEES The basis of any infection control programme is a committee of interested and well-informed professional personnel. One suggested composition of such a committee is as follows: Hospital Administrator or his Assistant Senior Clinicians: Surgery, Medicine, Obstetrics, and others as required Medical Officer of Health Bacteriologist, and/or Pathologist Director of Nursing Service Director of Nursing Education Special Nursing Representatives: Public Health Nurse Operating-Room Supervisor Executive Housekeeper The basic functions of such a Committee should include: a. A continuous review of methods, procedures and practices in the hospital, with a view to revision if necessary. b. A thorough investigation of any outbreak of cross-infection, either in hospital or community. c. The establishment of a sound basis for reportable infections, and an efficient method of recording these infections. d. The setting up of in-service education programmes on infection control on all staff levels. Our experience with infection control committees in hospitals has been disappointing. They are often established either to stem a sudden epidemic outbreak of infection, or to satisfy one of the partial requirements of accreditation. There are, perhaps, several reasons for the failure of infection control committees to function as integral parts of the total hospital situation. The first is possibly an insufficient knowledge of all aspects of hospital practice. Even with representatives of the various areas present, they usually comprise the top echelon of hospital administration, and may have only indirect contact with patient areas. In addition, without knowledge of disease transmission in the community, attempts to control disease within hospitals fail. Disease spread then becomes a vicious circle. .

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THE CONTROL OF INFECTIONS IN HOSPITALS

There is also the human tendency to act on dramatic events rather than to prevent such events from occurring. As much of the control of cross-infection is based on circumstantial evidence, unimaginative persons may have some difficulty in convincing themselves of the value of programmes aimed at prevention. Finally, committees are frequently unwieldy bodies. While information is generously disseminated at the top, unless a specific person is selected for the purpose of enforcing the recommendations made, the value of such resolutions often may be lost. Various suggestions have been put forth regarding the enforcement of proposed control measures [2, 7]. One has been the appointment of a full-time infection control officer. This person may be a bacteriologist or a physician with a particular interest in this aspect of preventive medicine. He would be solely responsible for carrying out the proposals made by the infection control committee. More recently, it has been proposed that a nurse be selected for this role [ 4] . From our observations in one particular hospital in Ontario this concept has already been in effect for a few years. In addition, it has been shown to be a successful practice. And it would seem more reasonable to establish this role for a nurse already trained in community health. If we assume then that hospital infections can only be controlled through the organized efforts of hospital and public health workers, and that infection control committees have been less than effective in this respect, the most realistic solution to the problem is to create a new role for the public health nurse in infection control. Two important considerations in creating this role for a nurse is that such a person would not only have an intimate knowledge of patient care and aseptic practice, but her position in the hospital would perhaps be less threatening to other hospital personnel than that of her medical colleague. In an attempt to define this new nursing role, it is required that the person selected should have both hospital and public health background, as well as advanced training in bacteriology, epidemiology and perhaps most important of all, a sound understanding of interpersonal relations. She must then be provided with the backing and whole-hearted support of the infection control committee. Her functions would include teaching personnel on all hospital levels, particularly housekeeping and maintenance; the investigation of possible epidemic outbreaks of infection and any transmission of disease to the community; a concise recording and reporting of all infections, post-

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operative, post-partum, and general; and the supervision of aseptic practices in all patient areas, both in hospital and in home. In general, she would lead campaigns aimed at infection control in all areas of the community. With a qualified nurse assuming the executive leadership of the committee, excellent resolutions would be put into force which might otherwise conceivably be neglected. In our opinion, it can only be through the conscientious and consistent efforts of such an individual that sound infection control practices will be realized. In larger communities, the responsibility may be so great as to require the selection of an additional nurse, perhaps on a part-time basis. Smaller hospitals may wish to employ the services of an established nurse epidemiologist on a consultant basis. In any respect, this new role for nurses in disease control is realistic, can be rewarding, and is essential to the welfare of patients. It has been our observation that active programmes dedicated to the control of cross-infection not only achieve this end, but in so doing also raise the general standard of medical and nursing care.

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REFERENCES I. Caswell, H. T. Incidence and origins of surgical wound infection. Hospital Topics, 40: 75, March 1962. 2. Colbeck, J. C. Control of Infections in Hospitals. Hospital Monograph Series no. 12. American Hospital Association, Illinois, 1962. -3, Fekety, F. R., Buchbinder, L., Shafer, E. L., Goldberg, S., Price, H. P., and Pyle, L. A. Control of an outbreak of staphylococcal infection among mothers and infants in a suburban hospital. American Journal of Public Health, 48: 298, March 1958. 4. Gardner, A. M. N., Stamp, M., Bowgen, J. A., and Moore, B. The infection control sister. Lancet, 2: 710, Oct. 1962. 5. Gray, J. D. A. Outbreak of streptococcal infection in a maternity unit. Lancet, 2: 132, July 1956. 6. Guide for the Prevention and Control of Infections in Hospitals. New York State Department of Health and the American Public Health Association, April 1958. 7. Infection in Hospitals: Epidemiology and Control. Edited by R. E. O. Williams and R. A. Shooter. Blackwell Scientific Publications, Oxford, 1963. 8. Kempe, C. H. The family as a reservoir of childhood infections. Journal of the American Medical Association, 151: 1472, April 1953. 9. Medical Research Council (Canada), Associate Committee on Control of Hospital Infections. Unpublished material. 10. Monro, J. A., and Markham, N. P. Staphylococcal infection in mothers and infants: maternal .breast abscesses and antecedent neonatal sepsis. Lancet, 2: 186, July 1958. 11. Murray, W. A., McDaniel, G. E., and Reed, M. Evaluation of the phone survey in an outbreak of staphylococcal infection in a hospital nursery for the newborn. American Journal of Public Health, 48: 310, March 1958. 12. Personal observations. 13. Ravenholt, R. T., and LaVeck, G. D. Staphylococcal disease-an obstetric, pediatric and community problem. American Journal of Public Health, 46: 1287, Oct. 1956. 14. Report of the Survey of Health Unit Services in Eight Provinces of Canada, 1960. Department of National Health and Welfare, Ottawa, 1961. 15. Roodyn, L. Epidemiology of staphylococcal infections. Journal of Hygiene, 58: 1, March 1960. 16. Sarason, E. L. and Bauman, S. The problem of breast abscess in the puerperium. Surgery, Gynecology and Obstetrics, 105: 224, Aug. 1957. 17. Sawyer, C. D. and Walker, P. H. A bacteriologic and clinical study of breast abscess. Surgery, Gynecology and Obstetrics, 99: 368, Sept. 1954. 18. Sherman, A. J. Puerperal breast abscess. Report of an outbreak at Philadelphia General Hospital. Obstetrics and Gynecology, 7: 268, 1956. 19. Starkey, H. and Turgeon, P. A. Recurring furuncles or other forms of staphylococcal skin infection in the home. Medical Services Journal of Canada, 18: 783, Dec. 1962. 20. Webb, Jean F. Newborn infections and breast abscesses of staphylococcal origin. Canadian Medical Association Journal, 70: 382, April 1954.

9. Physical Structure of the Surgical Suite

9.1. PREVIEW With the apparent sudden increase in post-operative wound infections a decade ago, attention became focused on the structure and design of surgical suites. Up until the 1950's most operating rooms were closely associated with patient areas. Once it became generally recognized that wards were reservoirs of pathogenic organisms, a movement was underway to separate, as completely as possible, sterile from nonsterile areas and to prevent traffic through the surgical suite to other hospital areas [37] . Further attempts at controlling surgical sepsis included the revaluation of existing surgical techniques, followed by stricter adherence to prescribed procedures and the use of bacteriostatic preparations in the surgical scrub. Increased emphasis was placed on the role of the nasal carrier in the transmission of disease. Included in Part 4 will be an outline of recommended physical planning, a review of the literature regarding surgical techniques, and a recommended policy regarding the employment of staphylococcal carriers in critical hospital areas. Included also will be a brief review of anesthesia asepsis. 9.2. ZONING

Like many emergency measures that are brought into play with immediate and dramatic results, interest in zoning seemed to fade once the emergency situation was past. The lack of sustained interest and effort was very apparent in several of the hospitals visited. In one institution, the observer was taken on a complete tour of the surgical areas dressed in street clothes. This was the same hospital in which elevator doors opened directly into "sterile" areas, depositing personnel

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and equipment from various hospital departments. In a visit to another surgical area which was not restricted, one operating room was closed off from the busy corridor by means of a portable bedside screen, at eye level [25]. Even in the two hospitals visited which did restrict their surgical areas, the inconsistency in routines left large gaps in their aseptic practice. Surgeons' and nurses' change areas were located in the midst of the restricted area, making it necessary for personnel to retrace routes previously contaminated upon the initial entrance to the surgical area. In these latter hospitals, the observer was required to change· into complete surgical attire, including cap, gown, mask and conductive footwear before being permitted to enter the restricted areas. It was also noted that the tightening up of surgical restrictions was, in fact, a reflection of the strict adherence to asepsis in the remainder of the hospital. The infection rates per month in these hospitals ranged from an average low of 0.25 to 0.5 per cent of surgical admissions. One excellent design of a surgical area is that of the new Kaplan surgical wing of the Michael Reese Hospital, Chicago [2]. Innovations in structure include:

a. Sharp delineation of sterile and unsterile areas, with strictly enforced control of every person entering the surgical suite. b. Grouping of the 18 major surgeries in four units of four around centralized scrub-substerile rooms so that surgeons can move from one operating room to the next without going out into the corridor; with provision of two out-size surgeries ( 20 by 25 feet) for operations that require several pieces of equipment and larger than normal numbers of personnel. c. Glass-enclosed monitoring rooms adjoining the large surgeries to house electronic equipment which is not explosion-proof. d. Overhead stalactites containing anesthetic gases, suction and electrical outlets; hangers for intravenous bottles mounted on ceiling tracks. e. Ceiling-mounted equipment for X-ray and closed-circuit television in three operating rooms. f. A sterile set-up area in which all instruments, supplies and equipment are placed on large instrument tables in advance of each operation so the tables can be wheeled into the surgery all ready for the surgeon to go to work.

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g. A complex intercommunication system by which contact is maintained throughout the entire pavilion. h. Separate patient corridors in the surgical suite to prevent tangling of staff and patient traffic.

i. An outpatient suite-removed from the major unit-with four operating rooms, waiting room, small recovery area, and workrooms. 9.2.1.

CONTAMINATED CASES

Over 74 per cent of the survey hospitals reported that they did not have a separate operating room for contaminated cases ( C.4.226). It seemed to be a general practice in most of the hospitals visited to place known contaminated cases at the end of the operating schedule. In the other hospitals, contaminated cases were interspersed throughout the surgical day. The dangers arising from the intermixing of cases should be readily apparent. The bacterial air count has been shown to rise dramatically when contaminated cases were brought into clean areas [43]. In addition, the patient with an artificial portal of entry, resulting from surgery that is to any degree open to aerial contamination is risking surgical sepsis. If separate surgical areas for contaminated cases are not maintained, known infectious cases must be scheduled at the end of the operating day. Following surgery, the room and all equipment, including lamps, must be thoroughly cleaned and disinfected, and the room allowed to remain idle until the aerial bacteria have settled to the floor. The effectiveness of the disinfection process should be frequently monitored by the hospital's department of bacteriology. A further consideration is the disinfection of anesthetizing areas. If the anesthetic is given in an area other than the operating room, this should also be considered contaminated. Patients suffering from lesions, even if not open and draining, do harbour organisms on their skin, and hence on their clothing. Scheduling of room use is very important if surgical asepsis is to be adequately carried out. 9.3. MOVEMENT TO OPERATION AREA AND RECOVERY ROOMS One essential in surgical zoning that is often overlooked is the recovery room area. In most hospitals visited, the recovery room was separated

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from the surgical suite. It was frequently found on another floor, and adjacent to patient areas. In either case, it was located some distance away from the surgical suite, the surgeon and the anesthetist. From the ward, the patient should be first brought to a transfer or holding area by ward personnel, using ward equipment. Once in this area, he should be transferred to a recovery room stretcher and covered with a pre-sterilized cotton blanket. Ward personnel should not be permitted beyond the transfer area. Survey findings have indicated that in 48 per cent of the hospitals, patients were brought directly to the operating room by ward personnel (C.4.249). It has been suggested that transfer of patients to the operating room proper increases the amount of activity in the room, thereby raising the bacterial air count. It was therefore proposed that operating room tables be moved outside the room and the transfer of patients take place in the restricted corridor [43]. It is our opinion that this would not necessarily reduce the air count, could conceivably increase it, and in all probability would maintain it at a similar level. We feel, though it is only an assumption, that other matters are far more relevant to the increase of bacterial air count. If an operating or recovery room stretcher is used, and if the patient is covered with a sterile blanket, transfer to the operating room proper should not increase the bacterial air count appreciably. The count in the air depends on many other factors, particularly the method of floor cleaning and disinfection used [3, 42]. Over 94 per cent of the survey hospitals reported that patients were transferred to the operating tables in the operating room proper ( C.4.251). Immediately following surgery, the patient should be taken to the recovery room by surgical personnel [26]. This area must then, of necessity, be a zoned area, and the recovery room staff must be restricted along with other surgical staff. The rules regarding surgical attire must apply to recovery room staff as well. When the patient is ready to return to his unit or ward, the ward must be told. A small transfer region should be provided outside the restricted recovery room area, and the patient given over to the intern and/ or nurse. In most surgical cases, an additional transfer to a stretcher is unfeasible because of possible drop in blood pressure. For this reason, it will be necessary for patients to be taken to the ward on surgical stretchers. These stretchers must be immediately re.turned to the surgical holding area, where they can be thoroughly disinfected by the surgical orderly and held ready for the next surgical patient.

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9.4. PERSONNEL FACILITIES Adequate facilities for surgical personnel should be included in the architect's design of every surgical suite, whether large or small. Provision for change rooms should be made in the semi-restricted area. Dirty and clean areas should be separated by showers [43]. Personnel should be provided with sufficient locker space to enable t;hem to enter the dirty section in the change area, discard their street clothing, shower and pass directly into the clean change area where they will dress in surgical attire. The inclusion of adequate change areas in surgical suite designs should greatly simplify the problem of wearing apparel in strategic areas. If surgical personnel leave the restricted area to go to the ward, they must then again pass from dirty to clean areas, and discard their contaminated clothing. An indication that this practice is not generally carried out was seen in the answers to the questionnaire. While 87 per cent of the hospitals reported that surgeons' change rooms were provided with showers, only 18 per cent stated that the showers divided the change areas into clean and dirty sections (C.4.276, 277) . Nurses, although they comprise the highest percentage of total surgical staff, have received the least consideration with regard to lockers or rest rooms. While surgeons, residents, and interns have been provided with facilities, inadequate as these sometimes may be, the need for similar areas for nursing personnel has been overlooked. In some of the hospitals visited, nurses were forced to share bathroom facilities with patients [25]. Observations in two hospitals revealed that coats and personal belongings had to be closeted in utility rooms, bathrooms, and storage cupboards, in lieu of locker rooms which were unavailable. Locker rooms, when provided by hospitals, were often cramped, dimly lighted, and poorly ventilated. At the time when most nurses lived in an adjacent nurses' residence, the need for change rooms was not considered necessary. Today, with so many nurses commuting to hospitals from the community, provision also must be made for their comfort. 9.5. SCRUB AREAS In several of the hospitals visited, there was direct communication between scrub and operating rooms. Accurate information has been

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documented on the aerial spread of contamination from the scrub areas to the operating rooms, and for this reason all scrub-up and operating areas should be physically separated. In one hospital, while the surgeon was busily scrubbing, contaminated equipment was being brought from an adjacent operating room and placed in the next sink for cleaning [25]. In other hospitals, the scrub area also served as a utility room. Suction bottles were emptied into the hopper beside the scrub sink and linen was stuffed to overflowing in linen hampers. Considering that 65 per cent of the participating hospitals had only one scrub area for two or more operating rooms (C.4.234), the additional use of this area for a utility room cannot help but result in gross overcrowding with a high potential of cross-contamination. Surgical design should provide for sink and clean-up areas well apart from scrub-up and operating areas. The practice of mixing the two is to be condemned. 9.6. EQUIPMENT The first rule in every modern operating room is the complete removal of all unnecessary equipment. It is still common to find cabinets in operating rooms being used for the storage of surgical instruments, the latter not only being unsterile, but infrequently used [25] . Some of the operating rooms visited more closely resembled surgical supply houses. The tabulated results from the hospital survey indicate that 47.4 per cent of the hospitals had instrument closets located within the operating room proper ( C.4.236) . Preferably, these cabinets should be removed from the actual surgical area entirely, and transferred to a substerile area. Hot-air radiators are hopelessly outdated in operating rooms. They not only increase the difficulties of maintaining a safe relative humidity and comfortable working temperature, but also serve as dust collectors. Wherever possible, such necessary equipment as non-explosive electrical outlets and X-ray viewing boxes, should be :Bush with wall surfaces. There should be as few dust-collecting ledges as possible. 9.7. SUBSTERILIZING AREAS

It is again emphasized, that clean-up and sterilizing areas should be separated from the operating rooms. Lack of foresight in most hospi-

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tals has inevitably clumped together clean and dirty areas, with the result that clean-up departments are found in the midst of sterile regions. This is illustrated in the conventional plan of the surgical suite in which the substerilizing area is placed between two operating rooms. Substerilizing areas may be provided between pairs of operating rooms in order to provide Hash sterilization facilities, or for storage of emergency supplies of instruments and solutions [20]. If dirty instruments are to be handled they must be cleaned and sterilized in a room apart from the substerilizing area. The clean-up area should not only be physically separated from the restricted surgical area by doors, but should also be pressurized to prevent an outward How of contaminated air into the sterile areas. A two-way lift or receiving system should be provided, in order to keep sterile and contaminated instruments separate. In more recent hospital design, clean processing and sterilizing has been centralized in one area, and soiled procedures centralized in another. Other designs have incorporated the use of conveyors for supplying the sterile areas. Most surgical suites depend upon small lifts, or carts and trucks to bring in supplies. With a conveyor system the amount of traffic will be reduced considerably, and the mixture of clean and dirty supplies should be eliminated. 9.8. WALLS, FLOORS, AND CEILINGS Several important considerations are necessary in the selection of operating room walls. They should be smooth and impervious to moisture, and should stand repeated cleanings. They should require a minimum amount of maintenance. The survey showed that almost one-half of the hospitals ( 49.1 per cent) had either painted plaster or rubber tiled walls, or both, in their operating rooms ( C.4.237). Ceramic tile walls were found in some of the hospital surgical suites visited. These walls, however, have mortar joints which are difficult to clean, and the tiles often loosen and need replacing. Painted plaster walls are the most common in hospitals. Although they require frequent repainting, they are probably the best walls for use in operating areas. Stainless steel walls would probably fulfil all the requirements, but they may have too high a light reflection factor unless modified in some way. All walls should make a smooth transition to the floor. There should be no dust collecting ledges or

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crevices, and walls and ceilings should meet directly, without interposition of a false ceiling [43]. Windows, comprising part of the operating room walls, were found in four of the six hospitals visited. In one hospital, the window was opened during surgery for ventilation. In a design for the surgical suite, the Associate Committee on Hospital Infection states [20]: The psychological value of windows in an operating room is normally outweighed by the problems they impose. In requiring north light or special sunlight control systems they dictate the planning of the surgical suite; they can be a source of glare by day and throw undesirable reflections by night. They are more expensive than exterior wall to build and maintain. They complicate the proper flow of the air conditioning system, cause difficulties of condensation and increase dust catching surfaces. The possibility of failure of the air supply system must be overcome by a good preventive maintenance program. Windows in auxiliary rooms of the suite should satisfy the need for day-light of the nursing staff.

Floors in operating rooms should meet the standards of the National Board of Fire Underwriters and should not be porous or subject to cracks or openings [38]. The questionnaire survey showed that 46.6 per cent of the hospitals in Ontario had terrazzo floors in operating rooms ( C.4.238). While terrazzo floors are in general use, however, they are not entirely satisfactory. It has been found that the carbon black used in the bonding cement has a tendency to weaken the mortar [22]. If this binding material is not properly mixed, the mortar will tend to disintegrate. Conductive vinyl, used by 29.3 per cent of the participating hospitals, is considered to be the best flooring now available for operating rooms. While conductive flooring is required by law in all operating rooms using flammable anesthetics, it is of no safety value unless all personnel and movable equipment make satisfactory electrical contact with the floor. This was clearly demonstrated in one hospital visited in which sparking occurred during the swabbing of a patient's arm with alcohol prior to a pentothal induction [25]. Subsequent testing indicated that the floor was completely devoid of any conductivity. Observations made in many hospitals showed that plaster ceilings were found to be full of cracks, and peeling paint was witnessed in several operating areas [25]. The housekeeping and maintenance of this part of the hospital structure seemed to receive the least consideration. The best available material for hospitals at the present time is a well-maintained, air-tight, painted plaster ceiling.

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9.9. VENTILATION (see 15.4) A great deal of controversy is still raging over the role of air as a mode of transmission in wound infection. Some authors conclude that air contamination is an unimportant factor in the over-all problem of surgical cross-infection [ 4, 15]. Others, the majority, consider it to have much significance [5, 19, 33]. Until slit and sedimentation air sampling procedures are carried out near the site of the surgical incision, and the results compared with the post-operative infection rates, the role of air in wound sepsis must remain speculative. Considerable thought has gone into the design of ventilation systems for hospitals and the type of air to be used. While outside air is generally used for ventilating hospitals, air in cities is more contaminated with smoke and pathogenic organisms than that in rural areas. The question of how the air should be delivered to and removed from an individual operating theatre has also been the subject of study and is still under active investigation in several centres. Whether or not air-currents should be advocated and if so, in what direction and at what speed, is a matter still undecided. Studies of bacterial "fall-out" under working conditions in the operating theatre indicate that the area of maximum deposition usually occurs around the anesthetist and the head of the patient, particularly when intubation procedures are undertaken [20]. People working in the operating room throw off bacteria in various ways. It is recognized that the air around the surgeons and their assistants and the floor near the operating table are potentially contaminated zones. It would therefore appear logical to postulate that a minimal number of organisms would reach the operative site if the air around the head of the patient, the surgeons or assistants, and the organisms that have fallen to the floor in the vicinity of the operating table, are all constantly being moved away from the site of operation. Temperatures should be held at a comparatively low level (68°720 F.) to combat sweating and to suit the physiological status of the anesthetized patient. Humidification must be maintained at a safe level in relation to the build-up of static electricity, and 8 to 12 changes of air per hour are recommended. We cannot discuss here the problem of aerial contamination in its entirety. We do feel, however, that a well-maintained air-conditioning system is essential in all surgical areas. Good maintenance must include frequent change of filter and humidifying water. In addition, humidifying water should be cultured frequently. That this is the exception

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rather than the rule is shown in Ontario, where only 16.4 per cent of the 111 hospitals with ventilation plants cultured the humidifying water routinely ( C.4.243) . The maintenance of a constant temperature and fresh air supply improves working conditions and negates the temptation to open windows during surgery. The maintenance of a relative humidity of over 50 per cent reduces the possibility of a build-up of static electricity [43]. Finally, the maintenance of a positive pressure within the operating rooms themselves will prevent the suctioning in of contaminated air from other hospital areas. Only 24.3 per cent of the 169 hospitals in the questionnaire survey having surgical suites had pressurized operating rooms ( C.4.245) .

10. Surgical Aseptic Techniques

10.1. PRE-OPERATIVE PREPARATION OF THE OPERATIVE SITE ( see 16.6) Two groups of bacteria can be found on or in the skin: the transient bacteria, which are generally abundant on exposed skin but scarcer on clean exposed skin, and the resident bacteria, which form a relatively stable population in size and type [29] . The resident flora appear to reside mainly in the hair follicles and sebaceous glands. The preparation of the patient's skin before surgery involves the removal of the transient bacteria, and the suppression of the resident organisms. Although most of the transient bacteria are removed by a 2 to 3 minutes scrub, only about one-half of the resident flora are removed after scrubbing for 7 minutes [29]. For this reason, further reduction of the resident flora must depend upon the use of chemicals. The time available for the preparation of the patient before surgery will depend upon whether the procedure is elective or emergency. Generally, patients undergoing elective surgery are admitted two or three days prior to surgery, in order that laboratory or other routine procedures may be completed. Upon admission to hospital, the patient is exposed to a new environment in which pathogenic bacteria are present in large numbers. The longer the exposure, the greater is the contamination of the skin, hair, and clothing. In a recent study it was shown that 10 per cent of surgical patients had hospital strains of staphylococci on their skin just prior to final preparation in the operating room [15]. For this reason prolonged pre-operative stay is ill advised.

10.1.1. PRE;LIMINARY PREPARATION The first step in skin preparation consists of shaving the skin. Even at best this is a traumatic process and can rarely be accomplished without some degree of damage to the skin. Each small scratch evokes

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an inflammatory response, and within a few hours bacteria are thriving in the serous exudate. By the time the surgical incision is made, there may be numerous living organisms already present on the operative site. The practice of not shaving the area until the patient is brought into the operating room has not had widespread acceptance. Although it is recommended by Walter, it is felt that this would be an inconvenience in the operating room, and also could conceivably increase the danger of air-home organisms [41]. The optimum time for shaving the skin prior to surgery is 30 hours, after which time the permeability of the skin returns to normal [27]. In most hospitals the surgical incision is made 12-24 hours after preparing the skin. The skin should be shaved at the time of the bath or shower on the evening before surgery. Meticulous care should be taken in cleaning the operative area. The razor and blade should be sterile, as well as the solution basin. The old pre-surgical skin routine of covering the area with a sterile towel has been open to criticism, and has been gradually discarded. It was suggested that this procedure promoted sweating and encouraged the multiplication of the deeper resident bacteria [10]. It is of note, however, that this traditional practice was generally discarded at approximately the same time that post-operative infections became more prevalent. This may have been simply coincidence, or it may have been cause and effect. In either event, the current situation in hospitals may well demand a return to this earlier technique. Because the operative area may become contaminated by pathogenic organisms from the patient's nose, his perineum, or his skin, or from the environment by blankets, sheets, and mattresses, the meticulous soap, ether, and alcohol preparations should be carefully reconsidered on its own merits. More recent studies on depilatory creams have indicated that these may be of value in pre-operative removal of body hair. Ideally, a good depilatory cream should be non-toxic locally and systemically, should not produce an allergic reaction, or interfere with wound healing. In addition it should be effective in less time, and should be less uncomfortable than shaving. Studies carried out a decade apart were favourable to the use of depilatory creams prior to surgery [31, 40]. A minimum of 10 minutes was required before removal of the cream, but no deleterious effects were witnessed when the cream had prolonged contact with the skin. In addition, there were no untoward reactions when the cream

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was applied around lacerations, or over inflamed sites, but chemical conjunctivitis was caused from direct contact with the eyes. The use of the cream required more careful application in gynecological conditions, as contact with the mucous membrane was found to be irritating to the patient. Other side effects included complaints of stinging and burning, both of which disappeared within minutes after removal of the cream. It has been suggested that the operative site, in the case of elective surgery, be scrubbed by the patient twice a day for a week prior to surgery, using a recognized antibacterial detergent [ 41]. This, of course, must depend upon the individual patient, but is also recommended here. J0.1.2.

PREPARATION IN THE OPERATING ROOM

The choice of solutions used for the pre-operative preparation of the patient's skin varies not only from surgeon to surgeon, but also from hospital to hospital. Over 78 per cent of the survey hospitals replied that more than one solution was used for skin preparation in the operating room ( C.4.253). The various solutions and strengths listed included: Alcohol 70% (propyl) with Iodine 2.5% Alcohol 70% (propyl) Betadine Bichloride of Mercury 1: 500 Cetavlon (in water) 1:100 Dettol cream (pure) Dettol (surgical) Distilled water Green soap and tincture of Zephiran ( no strength given) 2% Hexachlorophene liquid soap Isoprep Merthiolate (in alcohol) 1:1000 Metaphen (in alcohol) 1:200 Metaphen (in alcohol) 1:750 Metaphen (in alcohol) 1:2000 Zephiran with acetone ( no strength given for Zephiran) Zephiran (in alcohol 70%) 1:1000 Zephiran ( in water) 1: 1000 Zephiran ( in water) 1:750

With 19 different disinfectants and/or dilutions used in Ontario alone, it is readily apparent that some standard or guide is needed by hospitals in evaluating and purchasing disinfecting solutions. While the timed skin preparation is recommended, questionnaire

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findings indicated that pre-operative skin preparation is not generally timed. Only 25.7 per cent of the hospitals surveyed reported that the preparation of the patients' skin was timed ( C.4.254) . A careful, rigorous, and prolonged scrubbing of the operative site is necessary in order to remove most of the transient bacteria, and to suppress the growth of the deeper resident flora. 10.2. THE SURGICAL SCRUB (see 16.5) Survey findings indicated that the surgical scrub varied considerably from hospital to hospital, not only in respect to timing but also in respect to the solutions used. The routine scrub ranged from less than 4 minutes to 10 minutes, with most hospitals ( 40.4 per cent) reporting a 5-minute scrub routine ( C.4.257). It is very difficult to assess the importance of timing the surgical scrub. To date it has never been clearly demonstrated that the increase or decrease in scrubbing time is directly related to the incidence of post-operative infection. The primary objective of the scrub is to remove all transient bacteria from the surface of the hands and forearms by using a chemical which will also suppress the growth of the resident flora. This in tum should help to reduce the build-up of contamination in the moisture occurring under the gloves as a result of sweating. Studies have shown that scrubbing clean skin with sterile water reduced the total flora by one-half every 6 minutes or by two-thirds every 10 minutes [29] . Less than one-half of the hospitals ( 46.3 per cent) required a IO-minute scrub (C.4.256). In answer to the question on the timed scrub, one small ( 25 to 99 beds) hospital wrote "strongly disapprove of timed scrub, dangerous." No further evidence to support this conclusion was submitted. Price states that the surgical scrub should require 7 minutes [30]. The hands and arms should first be washed with a recognized antibacterial ( G-11) detergent, followed by a systematic friction scrub of the arms and forearms with particular emphasis on the palms and fingertips. This process should remove all the transient bacteria, and one-half of the resident flora as well. Repeated and consistent use of an antibacterial soap will suppress the growth of the resident bacteria in the skin. ·A recommended surgical scrub proposed by the Associate Committee on Control of Hospital Infections is as follows [20]:

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a. Rinse arms with water from above the elbow down. b. Lather hands and clean nails. 0 c. Using a brush and detergent: ( i) scrub hands, 20 strokes to each surface. (ii) scrub each area separately to above the elbows. d. Rins~ e. Scrub hands and each arm to just below elbow. f. Rinse. g. Scrub hands. h. Rinse. A ten-minute scrub should be mandatory before each case, regardless of whether detergent, germicidal detergent, or bar soap is being used. Once scrubbed, if the gown and gloves have not been removed, a five-minute scrub is satisfactory for a second case. The largest number of survey hospitals ( 45 per cent) reported that 3 minutes were required for the partial scrub ( C.4.266). The most preferred ( 40.3 per cent) surgical soaps were 2 per cent Hexachlorophene liquid soap, and pHisoHex ( C.4.258). Other solutions used for the surgical scrub included: Betadine Surgical Scrub, Dial soap, Ivory soap, Gamophen, green soap with hexachlorophene, green soap (alone), ordinary toilet soap, R 4 X soap, Allenbury's white soap. The surgeon and surgical nurse or technician, should wear a plastic apron while scrubbing to prevent the clothing from becoming wet and subsequently dampening the sterile gown making it pervious to moisture and contamination [8]. Only 7.4 per cent of the hospitals reported that plastic aprons were worn while scrubbing ( C.4.264). It is further suggested that a second sterile impervious apron be worn by the surgeon and his assistants during surgery to provide a barrier against contamination if the sterile gown should become wet. The apron should be of a soft, light-weight composition, comfortable to wear, and easy to autoclave. Unless a plastic or some similar impervious protection is worn, sterile cotton gowns must be water-proofed [9]. 10.3. OPERATING ROOM CLOTHING It is restated here that no member of the surgical staff should be permitted to enter the actual operating area unless clothed in standard •Frequent use of additional water and detergent is advised.

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operating room attire. This should include gown, mask, cap, and conductive footwear. These items will all be considered separately below. Surgical gloves will also be discussed. 10.3.1. GOWNS After discarding street clothing, surgical personnel should shower using an antibacterial soap before putting on scrub clothing. In addition, fresh clothing should be worn daily. Hosiery and undergarments of synthetic fabrics ( i.e., nylon) may be worn if they make complete contact with the skin, providing, however, that the outer garment is made of cotton [38]. What to wear becomes a problem when having to leave and re-enter the surgical suite. Sixty-four per cent of the hospitals replied that surgical personnel were permitted to wear operating room clothing outside of the suite ( C. 4.272) . Only 52.6 per cent of the hospitals required personnel to protect their scrub clothing with a clean laboratory coat ( C. 4.273) . Attempts to maintain a safe environment will be defeated if contamination is directly introduced from patient areas on clothing. The very best procedure to follow regarding clothing is a complete change before re-entering the restricted area. Recognizing that this is not always possible, laboratory coats are suggested as an alternative. The complete disregard of either of these alternatives is regarded as a lack of responsibility. 10.3.2. MASKS AND CAPS While studies have demonstrated that only small numbers of staphylococci are discharged during normal breathing and talking, masks are still recommended for use in operating rooms [35]. They should always be worn whenever entering an operating room, whether or not surgery is in progress, in order to prevent any further build-up of aerial contamination. Most hospitals ( 82.9 per cent) reported that absorbent gauze masks were used. A negligible number ( .6 per cent) stated that disposable masks were used ( C. 4.269) . If gauze masks or other non-disposable masks are worn, they should be sterilized after laundering to preclude the possibility of contamination in transit. In addition masks should be changed at least every hour, and certainly after each case. The conventional practice of wearing a mask about the neck, or dangling from a uniform pocket, only enhances the dissemination of oronasal discharges. Today, with disposable masks being constantly improved, it would be wise for

SURGICAL ASEPTIC TECHNIQ~

85

hospitals to determine for themselves whether the gauze mask is as effective and as inexpensive as hospital folklore maintains it to be. The exact duration of the effectiveness of masks has never been clearly demonstrated. Ability to screen the wearer's organisms exists only so long as the mask is impervious to moisture. This is dependent both upon the temperature of the operating room and the individual. Over 60 per cent of the 174 hospitals to which the question applied, answered that they changed masks between surgical cases ( C. 4.271). The remaining hospitals reported that they changed masks every hour, twice daily, or after coughing or sneezing. The suggestion that masks should be changed every hour in the operating room if surgery is prolonged may need further consideration. At the end of an hour, masks may be moist enough to allow for easy passage of organisms from and to the wearer and become reservoirs for oronasal organisms. Changing these in the operating room may result in disseminating organisms into the air, which may fall directly into the wound. If hospital policy requires that masks be changed when surgery is in progress, this must be carried out away from the surgical area. Because of the real possibility of infection arising from the use of cotton masks, the use of disposable masks should be carefully considered. Caps should completely cover the hair. Either cloth or disposable articles should be used. If these are worn outside the surgical area, they also must be changed before re-entering the restricted area. Disposable paper caps are gradually reaching more widespread acceptance. 10.3.3. CONDUCTIVE FOOTWEAR ( see 9.8) Conductive floors are essential in surgical areas using combustible gases, but are of no value unless all movable equipment and personnel make satisfactory contact with the floor. The only means to prevent the accumulation of static charges is to provide conductive pathways by which the charge may be drained away as quickly as possible. Electrostatic sparks may be created by flipping a sheet on the operating room table, or by merely handling the rubber breathing bag and tubing. All surgical personnel must wear conductive shoes which should be tested for conductivity by the wearer each time they are worn [38]. Enforcement of this regulation is the responsibility of the operating room supervisor. 10.3.4. SURGICAL GLOVES The current practice of hospitals in testing gloves for punctures is

86

'l1fE OONTROL OF INFECTIONS IN HOSPITALS

to inflate the glove with air ( either by hand or by using a special machine). Once inflated, the glove is held close to the face in an attempt to perceive escaping air. This is a highly ineffective and risky means of detecting punctures. In the first place, the only areas of the glove being grossly inflated are the palm and back of the hand [21] . Secondly, individual sensitiveness makes this a highly unreliable manner in which to detect pinholes. Ideally, gloves should be adequately expanded and immersed in water to detect air bubbles. It is necessary to inflate the fingers separately, otherwise they will not be expanded sufficiently. Although this still is not a foolproof method, it should be satisfactory provided that the fingers are sufficiently expanded. During surgery, the surgeon or nurse is not always aware when glove punctures occur. For this reason an electric instrument has been designed for use in operating rooms to make sterility tests of surgical gloves while they are being worn [23] . If this proves to be effective it may be a very satisfactory means of controlling wound sepsis following transfer of skin pathogens through punctured gloves. It is necessary to keep in mind, however, that once the apparatus has been effective in detecting punctures, it can no longer be considered sterile when used for intact gloves. Considering that approximately one-third to one-half of the gloves used by surgeons are pedorated during the course of an operation, frequent checking to ensure the impermeability of the gloves should be routine practice in operating rooms.

10.4. CARRIERS IN CRITICAL AREAS Fifty-three ( 30.3 per cent) of the 175 survey hospitals to which the questions applied, reported that nose and/or throat cultures were taken on operating room personnel routinely (C.4.229). Surveys by the present authors on the nasal carriage of Staphylococcus aureus by hospital staffs have revealed a 30 to 40 per cent carrier rate, with 10 per cent of this group being persistent or permanent carriers [39]. The remainder were classed as intermittent or noncarriers, non-carriers being the majority of hospital personnel. The causes of post-operative infections are not always apparent, and many factors must be considered in any epidemic outbreak of wound infection. It is possible that the causative organism may have been present on the patient's skin, or that he was a nasal carrier of

SURGICAL ASEPTIC TECHNIQ~

87

the same strain; infection may have occurred as a result of dust dropping into the wound from an overhead lamp, or as a result of faulty sterilization of instruments. Another consideration is the possibility of an unsuspected staphylococcal infection in a member of the surgical team. Much has been published regarding the role, both actual or potential, of nasal carriers in the spread of disease [ 12, 24, 32, 34]. One of the most interesting cases of nasal carriage was reported by a Metropolitan Toronto hospital [6]. This small institution was able to prove bacteriologically that one particular surgeon, who was a persistent nasal carrier, was directly responsible for ten consecutive cases of wound infection. Treatment programs aimed at ridding the carrier of his pathogenic strain have not been successful. Instead, the use of antibiotics has resulted in ridding the nares of sensitive strains, only to permit the nose to become recolonized by antibiotic resistant strains which defy treatment [16] . In addition, antibiotic creams have offered only temporary freedom from the organisms, with the nose again becoming colonized [13, 28]. A program currently being conducted by the present research group is aimed at detecting persistent carriers, and treating them with a topical application of a vaccine, in the hope of bringing about a local immunity in the nose [18]. The completed results of this undertaking are not available. In addition to the problem of nasal carriers of Staphylococcus aureus, it has also been suggested that certain persons may be perinea} carriers. Staphylococci have been cultured in the feces, but only within recent years has the possibility of perinea} carriers been considered [ 11]. In a report of an outbreak of infection following 175 cases of open heart surgery at the Vancouver General Hospital, the causative organism was found to be Staphylococcus aureus, phage type 7/ 47/53 [7]. An investigation, however, failed to discover the origin of the pathogen. Finally, after further study, a sampling of the clothing of operating room personnel showed one of the men to be a perinea! carrier of the phage type responsible for most of the infections [17]. There is no valid reason for removing asymptomatic carriers from the operating room during non-epidemic periods. Surgical personnel are highly skilled, and while nursing personnel may be able to adjust to a less critical hospital area, e.g., a medical ward, the barring of surgeons from the operating room will result in a loss of livelihood and status.

88

THE CONTROL OF INFECTIONS IN HOSPITALS

If carriers are permitted to work in the operating room, however, a constant vigil must be maintained. Nasal swabbing should be carried out periodically on all employees in the surgical suite, and a distinction should be made between carriers and those carriers who shed many organisms. All positive strains should be phage-typed, and tested for antibiotic sensitivity. In that way the hospital and chief of surgery are aware of the potential infectors and can more readily eliminate or incriminate carriers as one of the sources of postoperative infections, should these occur. If carriers are permitted to work in critical areas, then each hospital must safeguard its patients and its reputation by being prepared quickly to stem potential epidemic post-surgical infections. The recent implication of perineal carriers in surgical infection may compel hospitals to have a record of both nasal and perinea! carriers. Employees with open lesions should be excluded from sensitive areas until such lesions are healed. 10.5. ANESTHESIA ASEPSIS One aspect of the surgical care of patients which is frequently overlooked is anesthesia asepsis. While admittedly, the anesthetist is concerned with a part of the patient which is generally at some distance from the operative site, there has been concern over the real possibility of introducing contamination from improperly disinfected equipment. In a study carried out in the United States on the bacterial count of anesthesia masks, tubes, and rebreathing bags, the bacterial count was very large [14]. In the rinsing fluid of five tubes not cleaned after use, the bacterial counts averaged 1,454,000 per tube. Bacteriologic investigation of rebreathing bags found a mean count of 462,700. Cleaning with a detergent solution of 3 per cent hexachlorophene ( pHisoHex) reduced the bacterial counts in a third group of tubes to 480 per tube, while counts of breathing bags were reduced to 425 per breathing bag. This, however, still cannot be regarded as adequate disinfection. This was realized by other investigators who cultured 41 pairs of endotracheal tubes cleaned by soaking in a pan of water containing an antiseptic soap with a hexachlorophene content of 0.6-0.8 per cent and found that less than 50 per cent were sterile [36]. Observations

SURGICAL ASEPTIC TECHNIQ~

89

of disinfection in one Metropolitan Toronto hospital revealed that the laryngoscope was disinfected by wiping it with three alcohol swabs and then replacing it in the drawer [25]. It is reasonable to assume that cases of post-operative pneumonia could follow introduction of respiratory pathogens during intubation. The most widely reported methods for disinfecting endotracheal tubes and air ways were washing with soap and water and using a chemical disinfectant ( 68.6 per cent). The most widely used chemical was an iodophor ( C.4.297). In answer to the question, "Are face masks disinfected after each use?" less than one-half of the hospitals ( 44.4 per cent) reported they were, while 55.6 per cent reported that face masks were not disinfected after each use ( C.4.298). In lieu of disinfection, most hospitals 97.1 per cent) reported that face masks were washed with soap and water after use. The disinfection of endotracheal tubes, suction catheters and airways, and rebreathing bags, including respiratory or expiratory tubing, presents numerous problems. Not only do the intricate inner surfaces make cleaning difficult, but certain chemicals, and more particularly heat, have a damaging effect on the rubber. The use of ethylene oxide gas is preferred for the sterilization of this equipment, but if this is unavailable, chemical disinfection should be used [1] . All surfaces should be thoroughly brushed while submerged to remove secretions, and a minimum of 15 minutes contact time allowed. Under no circumstances should plain soap, or detergent and water be used in washing contaminated ( once used) equipment, as the equipment may emerge from the wash covered with soap film which may trap bacteria. Random bacteriologic cultures should be taken frequently to test the sterility · of the anesthesia equipment. Although there has been some controversy about the anesthetists' equipment as a source of infection, it cannot be denied that pathogenic micro-organisms, mainly Staphylococcus pyogenes, Pseudomonas aeruginosa, and Mycobacterium tuberculosis, have been recovered and identified repeatedly from face masks, connecting tubes, rebreathing bags, and other parts of anesthetic apparatus. As has been pointed out by Dr. Andre Leduc, in a submission to the Associate Committee on the Control of Hospital Infections [20], these accessories should therefore be considered contaminated and a potential cause of infection once they have been used by any patient. He suggests the following recommendations:

90 A. 1.

2.

3.

4. 5.

6.

1.

2. 3.

TIIE CONTROL OF INFECI'IONS IN HOSPITALS GENERAL OPERATING ROOM REGULATIONS SPECIALLY APPLICABLE TO THE ANESTHETIST AND STAFF

All persons entering the immediate vicinity of the operating theatres must be dressed in fresh operating room clothing, including boot covers if special operating room shoes are not being worn. No one with active infection ( particularly respiratory or skin infection) should be allowed in the clean zone of the operating room suite. All persons in operating theatres must wear a mask covering both nose and mouth at all times. Masks must be changed between cases and/ or every hour. Talking must be reduced to a minimum and masks changed after any coughing or sneezing. Only in emergencies should staff go from one operation to another without re-scrubbing and re-dressing. All those assisting directly with the operation, or handling instruments, for use in the operative field, must prepare their hands by using the standard surgeon's hand scrub technique and must wear sterile gloves. Except when handling cases with !mown respiratory infection, anesthetists need not wear gloves, but must scrub hands and nails well before and after attending to each case. For !mown infected cases, anesthetists should wear gloves as well as gowns, caps, masks and hoots, all of which must be discarded before leaving that particular theatre. General operating room clothing (greens) must not he worn outside the operating suite for visiting wards or for going to meals. In exceptional circumstances, anesthetists making brief visits to wards or recovery rooms may do so in their operating room clothes, provided they protect them by wearing a clean white coat over them. If operating room clothes are worn while outside the operating room suite, fresh clothing must be donned on re-entry.

B. CARE OF PATIENT When the anesthetist makes his pre-operative visit to a patient, he must appraise himself the status of each patient in respect to respiratory infection. If the patient is classified as infected, the anesthetist must order the necessary protective routines for the operating room and must make the necessary arrangements for the patient's immediate post-operative care away from the recovery room. Patients !mown to have respiratory infections or !mown to be nasal carriers of pathogenic bacteria should he masked, while in the operating room, for as much of the time as possible. All patients must have a protective head-screen between their faces and the operating site, such a screen being put in position before the final skin preparation.

C. CARE OF EQUIPMENT AND JNSTRUMENTS As a general rule, after each use for a patient, particularly for an infected case, all equipment and instruments should be sterilized, when feasible, or at least disinfected according to the following procedures:

SURGICAL ASEPTIC TECHNIQUES

1.

2.

3.

4.

91

Tables and anesthetic apparatus should be wiped over with a cloth moistened with a germicidal detergent. All detachable parts of the apparatus likely contaminated by the patient's breathing or otherwise must first be rinsed in cold water and well cleaned with a brush and germicidal detergent. To avoid the coagulation of proteins they must not be allowed to dry while contaminated. Between use, the brushes must be kept in an antiseptic solution. Cleaning personnel should wear rubber gloves. After cleaning, all washed parts and accessories of the apparatus that will withstand autoclaving should be sterilized by this procedure, well recognized as the most efficient. In particular cases where autoclaving would be damaging to certain instruments, rubber parts or other components, the following techniques, listed by order of efficiency, may be used for decontamination: a. Ethylene-oxide sterilization, if care is taken afterward to aerate rubber material to eliminate all traces of irritating gas. Rubber often remains sticky after this type of sterilization. b. Autoclaving for 15 minutes at a pressure below 15 pounds. c. Boiling for 20-30 minutes. d. Immersion in water baths at 85° C. for 20 minutes.

Although these last three makeshift procedures will not kill Bacillus subtilis spores, and the last one may not destroy enterococci in vitro, they will at least kill staphylococci, the coli-aerogenes group, pseudomonas, and proteus. Enterococci- and Mycobacterium tuberculosiscontaminated parts will be decontaminated in one hour at 85° C. The risk of contracting tuberculosis through anesthetic equipment is real and should be seriously considered by anesthetists. When at all possible, disposable parts and accessories should be used. Chemical disinfection should only be used when no other means of decontamination is possible; it should be kept in mind that no antiseptic or germicide is entirely satisfactory and they have not yet replaced steam or ethylene-oxide sterilization or even boiling in water; on the other hand, when there is no alternative and they should be used, it should be remembered that the longer the chemical is in contact with the object to be disinfected, the better is the disinfection.

92

TIIE CONTROL OF INFECrIONS IN HOSPITALS

REFERENCES

I. Beeuwkes, H., and v.d. Vijver, A. E. D. Disinfection in anaesthesia. British Journal of Anaesthesia, 31: 363, Aug. 1959. 2. Barton, J. Control is the key to new surgical suite. Modem Hospital, 99: 79, Dec. 1962. 3. Bernard, H. R. and Cole, W. R. Postoperative surgical infection. Medical Times, 90: 897, Sept. 1962. 4. Bernard, H. R., and Cole, W. R. Bacterial air contamination and its relation to postoperative sepsis. Annals of Surgery, 156: 12, July 1962. 5. Blowers, R., and Crew, B. Ventilation of operating theatres. Journal of Hygiene, 58: 427, Dec. 1960. 6. Browne, A. F., Ryan, E. A., Glassow, F. J., Martin, C. J., and Shouldice, E. E. Staphylococcic wound infections. Journal of the American Medical Association, 170: 1274, July 1959. 7. Cockroft, W. H., and Johnstone, F. R. C. Asepsis in operating theatre. Canadian Medical Association Journal, 90: 659, March 1964. 8. Colbeck, J. C., and Sutherland, W. H. Staphylococcal infections in surgical units: the need for comprehensive control. Canadian Journal of Surgery, 1: 8, Oct. 1957. 9. Editorial. False faith in the surgeons' gown and surgical drape. American Journal of Surgery, 83: 125, Feb. 1952. 10. Girdlestone, G. R., Bourdillon, R. B., and McFarlan, A. M. Infection of "clean" surgical wounds by the surgeon and from the air. Lancet, 1: 597, March 1951. 11. Hare, R., and Ridley, M. Further studies on the transmission of staphylococcus aureus. British Medical Journal, l: 69, Jan. 1958. 12. Hare, R., and Thomas, C. G. A. Transmission of staphylococcus aureus. British Medical Journal, 2: 840, Oct. 1956. 13. Henderson, R. J. and Williams, R. E. 0. Nasal disinfection in prevention of post-operative staphylococcal infection of wounds. British Medical Journal, 2: 330, Aug. 1961. 14. Joseph, J. M. Disease transmission by inefficiently sanitized anesthetizing apparatus. Journal of the American Medical Association, 149: 1196, July 1952. 15. Kinmonth, J.B., Hare, R., Tracy, G. D., Thomas, C. G. A., Marsh, J. D., and Jantet, G. H. Studies of theatre ventilation and surgical wound infection. British Medical Journal, 2: 407, Aug. 1958. 16. Klein, J. 0 ., Rogers, E. F. H., and Rogers, M. D. Use of a nasal antibiotic cream during a nursery outbreak of staphylococcal disease. New England Journal of Medicine, 260: 1012, May 1959. 17. Letters to the Journal. Canadian Medical Association Journal, 90: 1091, May 1964. 18. le Riche, W. H., Balcom, C. E., and van Belle, G. The use of polyvalent somatic antigen vaccine as a nasal spray in the treatment of carriers of

REFERENCES IN PART

19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 49 43.

4 93

staphylococcus aureus. Canadian Journal of Public Health, 54 : 371, Aug. 1963. Lidwell, 0 . M., and Williams, R. E. 0. The ventilation of operating theatres. Jvumal of Hygiene, 58: 449, Dec. 1960. Medical Research Council (Canada) Associate Committee on Control of Hospital Infections. Unpublished material, 1964. Morse, A. R., and Sereda, C. J. Checking surgical gloves and conductive footwear. Canadian Hospital, 38: 46, July 1961. O'Connell, W. R. Choosing floor, wall and ceiling coverings. Hospital, 34: 62, March 1960. Penikett, E. J. K., and Gorrill, R. H. The integrity of surgical gloves tested during use. Lancet, 2 : 1042, Nov. 1958. Penikett, E. J. K., Knox, R., and Liddell, J. An outbreak of post-operative sepsis. British Medical Journal, 1: 812, April 1958. Personal observations. Pickens, W. R., and Mousel, L. H. Surgical suite at Swedish hospital designed to reduce contamination. Modem Hospital. 98: 105, March 1962. Pijoan, M., and Wheeler, S. Use of extravasating dye as a measure of skin permeability to bacterial invasion. Archives of Surgery, 34: 591, April 1937. Porter, I. A., Miller, I. T., McNeill, I. F ., and Green, C. A. Effect of topical framycetin on staphylococcal nasal carriage. British Medical Journal, 1: 1515, June 1963. Price, P. B. The bacteriology of the normal skin. Journal of Infectious Diseases, 63: 301, 1938. Price, P. B. Fallacy of a current surgical fad-three minutes preoperative preparation with hexachloraphene soap. Annals of Surgery, 134: 476, Sept. 1951. Prigot, A., Garnes, A., and Nwagbo, W. Evaluation of a chemical depilatory for preoperative preparation of 515 surgical patients. American Journal of Surgery, 104: 900, Dec. 1962. Roodyn, L. Recurrent staphylococcal infections and the duration of carrier states. Jvurnal of Hygiene, 58: 11, March 1960. Shooter, R. A., Taylor, G. W., Ellis, G., and Ross, J. P. Postoperative wound infection. Surgery, Gynecology and Obstetrics, 103: 257, Sept. 1956. Shooter, R. A., Griffiths, J. D., Cook, J., and Williams, R. E . 0 . Outbreak of staphylococcal infection in a surgical ward. British Medical Journal, 1: 433, Feb. 1957. Shooter, R. A., Smith, M. A., and Hunter, C. J. W. A study of surgical masks. British Jvurnal of Surgery, 47: 246, Nov. 1959. Smith, J. R., and Howland, W. S. Endotracheal tube as a source of infection. Journal of the American Medical Association, 169: 343, Jan. 1959. Smylie, H. G., and Dudley, A. A. G. Some principles in operating theatre design. Scottish Medical Journal, 6 : 589, Dec. 1961. Standards of the National Board of Fire Underwriters. Report No. 56, July, 1958. National Board of Fire Underwriters, 85 John Street, New York 38. Unpublished material. Vestal, P. W. Preoperative preparation of skin with depilatory cream and detergent. American Journal of Surgery, 83: 398, March 1952. Walter, C. W. Preoperative skin preparation. Hospital Topics, 33 : 74-9, Sept. 1955. Walter, C. W., and Kundsin, R. B. The floor as a reservoir of hospital infection. Surgery, Gynecology and Obstetrics, 111: 412, Oct. 1960. Williams, R. E. 0., Blowers, R., Garrod, L. P., and Shooter, R. A. Hospital Infections. Year Book Publishers, Chicago, Ill., 1960.

11. General Hospital Housekeeping

11.1. PREVIEW Scientific hospital housekeeping is still in its infancy, but its identity and importance has begun to be recognized. Without the scare caused by the apparent sudden increase in hospital infections, the role of the hospital housekeeper would perhaps have remained obscured. Much remains to be done, however, if the value of hospital housekeeping is to be fully accepted. Executive housekeepers should be more adequately trained, and they in turn must provide better training for the housekeeper on the job. Housekeeping functions spread over into bacteriology, nursing, medicine, dietary, and engineering fields. Sanitation in hospitals, to be effective, must encompass all hospital areas. It includes the cleaning of floors and walls, grilles, air-conditioning ducts, surgical lamps, bed springs, and mattresses. Sound housekeeping practice has to be based on bacteriological principles. Routine cleaning must not only be effective in removing dirt, but also in maintaining low levels of micro-organisms. Perhaps in no other area of hospital practice is asepsis so directly obvious. To accomplish these numerous tasks requires much foresight and planning. Cleaning routines should be constantly reviewed in light of new scientific findings. Tradition should not be the only criterion on which to base current procedures. A sense of scientific inquiry is urgently needed in this developing field. Sound hospital housekeeping is dependent upon the use of chemicals to reduce the microbial concentration. It should follow, then, that this department will eventually have the responsibility for testing out, for itself, the efficacy of the products it uses. Newer and better methods of cleaning must inevitably affect patient care. This part is based on the findings from the questionnaire survey and personal observations of present housekeeping practices. Included also

98

'IHE CONTROi. OF INFECTIONS IN HOSPITALS

will be recommendations which are intended to serve as a guide for hospital housekeepers. 11.2. OBSERVATIONS OF CURRENT HOUSEKEEPING PRACTICES Anyone concerned with the problem of infection control is readily aware of the key role of the hospital housekeeper. Without adequate cleaning and disinfection, hospitals rapidly become reservoirs of large numbers of organisms. It is unfortunate, however, that in many cases the responsibility for this vital area is placed in the hands of persons with little formal education. In many cases, they receive little if any direction from the head housekeeper. As a consequence, efficient hospital housekeeping is too often merely an ideal. This was readily apparent in those hospitals visited. There was unanimous disapproval in one hospital from the head nurse group regarding the housekeeping carried out on their wards. One head nurse in particular remarked that she had not spoken to the head housekeeper for five years. Head nurses in other hospitals expressed concern over the fact that the individual housekeeper on the ward was receiving little or no direction from the head housekeeper. They felt that housekeeping personnel should be directly responsible to someone, either to the head nurse or to the head housekeeper. The following observations would tend to support the nurses' fears that housekeeping techniques are not being carried out adequately [ 29] :

a. A housekeeping aide cleaning isolation rooms proudly pointed out to the observer that fresh gowns were worn upon entering each room. M NTROL OF INFECTIONS IN HOSPITALS

Number

Per cent of total

TABLE C.1.43 Is THERE A SEPARATE DRESSING CART OR CARRIAGE FOR CONTAMINATED CASES? Yes No Total Not answered Not applicable

23 31 54 4 150

42 .6 57.4

169 6 175 2 31

96.6 3.4

57 145 202 2 4

28.2 71.8

41 62 46 20 23 192 10 6

21.3 32.3 24.0

104 94 198 6 4

52.5 47 .5

TABLE C.1.44 IF DRESSING CARTS ARE NOT USED ROUTINELY ARE INDIVIDUAL DRESSING TRAYS USED? Yes No Total Not answered Not applicable TABLE C.1.45 ARE MASKS WORN WHILE DOING DRESSINGS? Yes No Total Not answered Not applicable TABLE C.1.46 ScRUBBING TIME REQUIRED BEFORE DRESSING WOUNDS

30 seconds 1 minute 2 minutes

Longer than 2 minutes Other (not specified) Total Not answered Not applicable

10.4

12.0

TABLE C.1.47 Is MORE THAN ONE PERSON ASSIGNED ROUTINELY TO ASSIST WITH DRESSINGS? Yes No Total Not answered Not applicable

APPENDIX

Number TABLE

C 261

Per cent of total

C .1.48

ARE STERILE GLOVES USED WHEN DOING CONTAMINATED DRESSINGS?

117 76 193

Yes No Total Not answered Not applicable TABLE

60.6 39.4

8

7

C . 1.49

ARE CONTAMINATED INSTRUMENTS DISINFECTED BEFORE BEING RETURNED TO CENTRAL SUPPLY ROOM FOR STERILIZING? Yes No Total Not answered Not applicable TABLE

169 25 194 7 7

87.1 12.9

168 28 196 6 6

85.7 14.3

70 6 130 206 2

34.0 2.9 63.1

131 1 132

99.2 .8

C.1.50

ARE CONTAMINATED DRESSINGS DISCARDED IN A SPECIAL CONTAINER (e.g. WAXED BAG)? Yes No Total Not answered Not applicable TABLE

C.1.51

HOSPITAL DEPARTMENT RESPONSIBLE FOR GENERAL CLEANING OF UNIT OR WARD Housekeeping Nursing Both Total Not answered TABLE

C .1.52

IF BOTH THE NURSING AND HOUSEKEEPING DEPARTMENTS SHARE THE CLEANING OF THE WARD, IS EACH DEPARTMENT AWARE OF ITS OWN RESPONSIBILITIES? Yes No Total Not answered Not applicable

4

72

262

TIIE CONTROL OF INFECITONS IN HOSPITALS

Number

Per cent of total

160

80.4

TABLE C . 1.53 ls THE WARD CLEANING

TIME ARRANGED BETWEEN THE NURSE-IN-CHARGE AND THE EXECUTIVE HOUSEKEEPER?

Yes ~

Total Not answered

~

199

W.6

9

TABLE C.1.54 ARE CLEANING SOLUTIONS IMPREGNATED WITH A DISINFECTANT?

Yes No Total Not answered Not applicable

184 17 201

91.5 8.5

7 0

TABLE C.1.55 DISINFECTANT ADDED TO CLEANING SOLUTION

DRX germicidal detergent Dettol 2% 2% Hexachlorophene liquid soap Lysol 2% Lysol 5% R,L Wescodyne Zephiran 1:1000 (in water solution) Other (not specified) Total Not answered Not applicable

6

27 5 17 11 2

57 4 53 182

3.3 14 .9

2.8

9.3 6.0 1.1 31.3 2.2 29 . 1

10 16

TABLE C . 1.56 INTERVALS AT WHICH LINEN IS ROUTINELY CHANGED

Daily Every two days Twice weekly Weekly Other (not specified) Total Not answered Not applicable

79

68

26

10

23 206

2 0

38 .3 33 .0 12.6 4.9 11 .2

APPENDIX

Number TABLE

C

Per cent of total

C.1.57

ARE INDIVIDUAL BLANKETS USED?

174 30 204

Yes No Total Not answered Not applicable TABLE

85 .3 14 .7

4 0

C.1.58

ARE BLANKETS ROUTINELY DISINFECTED AFTER DISCHARGE OF PATIENT?

122

Yes No Total

64

186

Not answered Not applicable TABLE

65.6 34 .4

3 19

C.1.59

IF PATIENT STAY IS PROLONGED, ARE BLANKETS DISINFECTED AT INTERVALS NOT EXCEEDING 2 WEEKS

64

Yes No Total

132 196

Not answered Not applicable TABLE

32.7 67.3

9 3

C.1.60

ARE MATTRESSES DISINFECTED AFTER DISCHARGE OF PATIENT?

185 21 206

Yes No Total Not answered Not applicable TABLE

89.8 10.2

1 1

C .1.61

IF MATTRESSES ARE NOT DISINFECTED AFTER DISCHARGE OF PATIENT, ARE THEY DISINFECTED AT REGULAR INTERVALS? Yes No Total Not answered Not applicable

10

17 27

2 179

263

37.0 63 .0

264

'IllE CONTROL OF INFECilONS IN HOSPITALS

C.2. Section I(B): ISOLATION TECHNIQUES Number

Per cent of total

TABLE C.2.62 ARE KNOWN COMMUNICABLE DISEASES ADMITTED DIRECTLY TO YOUR HOSPITAL?

Yes No Total Not answered Not applicable

83

99

182

45 .6

54.4

5

21

TABLE C.2.63 ARE ALL CA.SES OF KNOWN STAPHYLOCOCCAL INFECTION ISOLATED AND TREATED AS COMMUNICABLE?

Yes No Total Not answered Not applicable

126 51 177

71 . 2

28.8

9 22

TABLE C.2 .64 ARE THERE STANDARD ORDERS BY THE MEDICAL ADVISORY BOARD REGARDING THE ISOLATION OF SUSPECTED CASES OF COMMUNICABLE DISEASES?

Yes No Total Not answered Not applicable

95

73 168

56.5 43 .5

18

22

TABLE C.2 .65 CAN THE NURSE-IN-CHARGE TEMPORARILY ISOLATE SUSPECTED CASES WITHOUT A DOCTOR'S ORDER?

Yes No Total Not answered Not applicable

156 26 182 5

21

85 .7 14.3

APPENDIX

Number

C 265

Per cent of total

TABLE C . 2.66 Is THERE A FORMAL PROGRAM FOR INTERNS ON THE PRINCIPLES OF ASEPTIC TECHNIQUE? Yes No Total Not answered Not applicable

12 72 84 15 109

14 . 3 85 . 7

TABLE C . 2 . 67 ARE MASKS WORN ROUTINELY WHEN CARRYING OUT ISOLATION TECHNIQUE? Yes No Total Not answered Not applicable

124 53 177 10 21

70 . 1 29.9

TABLE C.2.68 TYPE OF MASK WORN IN ISOLATION AREAS Cloth Disposable Both Other (not specified) Total Not answered Not applicable

105 56 10 4 175 7 26

60 .0 32 . 0 5 .7 2 .3

Yes No Total Not answered Not applicable

65 114 179 7 22

36 .3 63.7

TABLE C .2.70 ARE INFECTIOUS PATIENTS EVER REQUIRED TO WEAR A MASK TO PROTECT THEMSELVES FROM SELF-CONTAMINATION WHEN STERILE PROCEDURES (e.g. DRESSINGS) ARE BEING DONE? Yes No Total Not answered Not applicable

37 140 177 7 24

20 . 9 79 . 1

TABLE C . 2 . 69 ARE INFECTIOUS PATIENTS EVER REQUIRED TO MASK TO PROTECT PERSONNEL?

WEAR A

266

THE CONTROL OF INFECTIONS IN HOSPITALS

Number

Per cent of total

TABLE C . 2 . 71 TYPE OF GOWN WORN IN ISOLATION AREAS

Long sleeved Short sleeved Both Other (not specified) Total Not answered Not applicable

135 39 5 2 181

74.6 21.5

2 .8 1.1

5

22

TABLE C . 2 .72 INTERVALS AT WHICH GOWNS ARE ROUTINELY CHANGED

After each use After each shift Daily Less often than daily Other (not specified) Total Not answered Not applicable

23 89 58 6 5

181

12 . 7 49.2

32 .0 3.3 2.8

5

22

TABLE C . 2. 73 WHENEVER POSSIBLE, IS TOTAL PATIENT CARE GIVEN IN ISOLATION AREAS?

Yes No Total Not answered Not applicable

171 8

179

95 .5 4.5

7

22

TABLE C.2 .74 DOES MORE THAN ONE PERSON USE THE SAME GOWN?

Yes No Total Not answered Not applicable

113

68 181

62.4 37 .6

5

22

TABLE C . 2 .75 Is MORE THAN ONE GOWN WORN BY INDIVIDUAL NURSE WHEN CARING FOR CASE OF AIR-BORNE DISEASE?

Yes No Total Not answered Not applicable

31 130 161 21 26

19 .3

80 .7

APPENDIX

C 2R,7

Number

Per cent of total

46 71

26 .0 40 . 1

13 12

6 .8

TABLE C .2 .76 LENGTH OF TIME HANDS AND/OR ARMS ARE WASHED BEFORE REMOVING GOWN

30 seconds 1 minute 2 minutes Longer than 2 minutes Other (not specified) Total

177

Not answered Not applicable

22

35

19.8 7 .3

9

TABLE C.2 .77 LENGTH OF TIME HANDS ARE WASHED AFTER REMOVING GOWN

30 seconds 1 minute 2 minutes Longer than 2 minutes Other (not specified) Total Not answered Not applicable

35 80 44 11

12

182

19.2

44 .0 24 . 2 6 .0 6.6

4

22

TABLE C . 2 .78 SOAP USED IN ISOLATION AREAS FOR SCRUBBING HANDS AND FOREARMS

Ordinary toilet soap Green soap Green soap with Hexachlorophene 2% Hexachlorophene liquid soap pHisoHex Two or more combinations of the above Other (not specified) Total Not answered Not applicable

17

24

18 35 50 14 26

184

9.2 13.1 9.8

19 . 0 27 . 2 7 .6 14.1

3 21

TABLE C . 2 . 79 ARE LIQUID SOAPS DISPENSED FROM A CLOSED CONTAINER IN ISOLATION AREAS?

Yes No Total Not answered Not applicable

127

46

173

9 26

73 .4 26 .6

268

THE CONTROL OF INFECnONS IN HOSPITALS

TABLE C.2.80 ARE SOAP SOLUTIONS CULTURED ROUTINELY IN ISOLATION AREAS? Yes No Total

13 159 172

7.6 92.4

BY

Not answered Not applicable TABLE C.2.82 TYPE OF DISINFECTANT HANDCREAM USED IN ISOLATION AREAS Catavlex hand cream (.5%) Dettol hand cream (2%) Hibitane hand cream (1 %) Other (not specified) Total Not answered Not applicable TABLE C.2.83 ARE ISOLATION GOWNS WORN ROUTINELY WHEN TAKING ORAL TEMPERATURES? Yes No Total Not answered Not applicable TABLE C.2.84 ARE ISOLATION GOWNS WORN ROUTINELY WHEN TAKING RECTAL TEMPERATURES? Yes No Total Not answered Not applicable

Per cent of total

14 22

Not answered Not applicable TABLE C .2 .81 ARE DISINFECTANT BANDCREAMS USED ROUTINELY PERSONNEL ON ISOLATION UNIT? Yes No Total

Number

35 148 183

19.1 80.9

3 22

1 18 4 12 35

2.9 51.4 11.4 34 .3

3 170

123 53

176

69.9 30.1

9 23

164 11 175 10 23

93.7 6.3

APPENDIXC

Number

Per cent of total

TABLE C.2.85 ARE INDIVIDUAL THERMOMETERS USED IN ISOLATION Yes No Total

AREAS?

Not answered Not applicable

179 3 182

98.4 1.6

4

22

TABLE C.2.86 METHOD OF DISINFECTION USED FOR INDIVIDUAL THERMOMETERS IN ISOLATION AREAS Concurrent Terminal Both Total Not answered Not applicable TABLE C .2.87 CHEMICAL USED FOR CONCURRENT DISINFECTION OF THERMOMETERS IN ISOLATION AREAS Alcohol 70% (ethyl) Alcohol 70% wropyl) Cetavlon 1 % in water solution) Dettol 2% Dettol 4% Green soap 2% Hexachlorophene liquid soap Lysol 2% Rocca) 1: 1000 Wescodyne Zephiran 1:1000 (in water solution) Zephiran 1: 1000 (in alcohol 70%) Other (not specified) Total Not answered Not applicable

58

23 98 179

32.4 12.9 54.7

6 23

5 4 6 13 4 7 8 2 2 28 42 4 42 167

3 .0 2 .4 3.6 7 .8 2.4 4.2 4 .8 1.2 1.2 16.8 25.1 2.4 25.1

12 29

TABLE C.2.88 ARE EXAMINING INSTRUMENTS (i.e. OTOSCOPES, SPECULA, ETC.) DISINFECTED AFTER EACH USE? ·

Yes

No Total · Not answered Not applicable

173 6 179 4 25

269

96.6

3.4

270

TIIE CONTROL OF INFECI'IONS IN HOSPITALS

Number TABLE C.2 .89 ARE STETHOSCOPES DISINFECTED AFTER EACH USE? Yes No Total Not answered Not applicable

Per cent of total

134 46 180 5

74.4 25.6

TABLE C .2.90 ARE DISPOSABLE DISHES USED IN ISOLATION AREAS? Yes No Total Not answered Not applicable

101 82 183 3 22

55 .2 44 . 8

TABLE C.2.91 ARE DISHES AND UTENSILS DISINFECTED AFTER EACH USE? Yes No Total Not answered Not applicable

79 7 86 3 119

91.9 8.1

TABLE C .2.92 METHOD OF DISINFECTION USED FOR DISHES AND UTENSILS Autoclaving Boiling Chemical disinfection Combinations of the above Other (not specified) Total Not answered Not applicable

5 20 36 7 12 80 4 124

6 .2 25 .0 45.0 8 .8 15 .0

3 4 1 3 5 2

6.5 8.7 2 .2 6.5 10 .9 2 .2 4.3

14

30.4

10 46 8 154

21.8

TABLE C .2 .93 CHEMICAL USED FOR DISINFECTION OF DISHES AND UTENSILS Dettol 2% Dettol 4% Green soap 2% Hexachlorophene liquid soap Lysol 2% Lysol 3% Lysol 5% pHisoHex Wescodyne Zephiran 1: 1000 (in water solution) Other (not specified) Total Not answered Not applicable

23

1 1

2

2.2

4.3

APPENDIX

Number

C 271

Per cent of total

TABLE C . 2.94

Is LEFTOVER LIQUID DEPOSITED IN THE HOPPER IN ISOLATION AREAS?

Yes No Total Not answered Not applicable

121 50 171

70.8 29.2

8 29

TABLE C .2.95 Is LEFTOVER FOOD AND/OR LIQUID PLACED IN A SPECIAL CONTAINER? Yes No Total Not answered Not applicable

147 25 172

85.5 14.5

9 27

TABLE C .2 . 96 ARE DISPOSABLE MEDICINE CUPS USED IN ISOLATION AREAS? Yes No Total Not answered Not applicable

106

77

183

57 .9 42 . 1

3 22

TABLE C.2 .97 METHOD OF DISINFECTION USED FOR MEDICINE CUPS Autoclaving Boiling Chemical disinfection Other (not specified) Total Not answered Not applicable

9 21 40 5 75

12.0 28.0 53 .3 6 .7

6 127

TABLE C.2 .98 HOSPITAL DEPARTMENT RESPONSIBLE FOR CLEANING OF ISOLATION AREA Nursing Housekeeping Both Total Not answered Not applicable

38 30 113 181 4 23

21.0 16 .6 62.4

272

THE OONTROL OF INFECTIONS IN HOSPITALS

Number

Per cent of total

111

98.2 1.8

TABLE C .2 .99 IF BOTH NURSING AND HOUSEKEEPING DEPARTMENTS ARE RESPONSIBLE FOR CLEANING ISOLATION UNITS, ARE THE CLEANING AREAS SO DEFINED THAT EACH DEPARTMENT IS WELL AWARE OF ITS OWN RESPONSIBILITY?

Yes No Total

Not answered Not applicable

2

113

7 88

TABLE C .2.100 METHOD OF MOPPING USED FOR FLOORS OF PATIENT AREAS

Wet Dry Both Total Not answered Not applicable

134

1 46 181

74.0 .6 25.4

4

23

TABLE C .2 . 101 IF DRY MOPPING IS CARRIED OUT, ARE MOPS IMPREGNATED WITH A DUST CONTROL SOLUTION?

Yes No Total

Not answered Not applicable

35

9 44

79 .5 20 .5

8

156

TABLE C.2.102 INTERVALS AT WHICH FLOORS IN ISOLATION AREAS ARE MOPPED

Daily Every two days Weekly Other (not specified) Total Not answered Not applicable

172 4 2 2

180 5

23

95 .6 2.2 1.1 1.1

APPENDIX

C 273

Number

Per cent of total

Daily Every two days Weekly Less often than weekly Total

171 5 3 1 180

95 . 0 2 .8 1.7 .5

Not answered Not applicable

5 23

TABLE C . 2 . 103 INTERVALS AT WHICH GENERAL DUSTING OF FURNITURE, BEDFRAMES, WINDOWSILLS, CUPBOARDS, ETC., IS CARRIED OUT

TABLE C.2 . 104 TYPE OF DUSTING CARRIED OUT IN ISOLATION AREAS Damp Dry Both Total Not answered Not applicable

154 4 22 180

85.6 2.2 12.2

5 23

TABLE C.2 . 105 ARE CLEANING DETERGENTS USED IN ISOLATION AREAS IMPREGNATED WITH A DISINFECTANT? Yes No Total Not answered Not applicable

161 18 179

89 . 9 10.1

6 23

TABLE C.2.106 DISINFECTANT USED WITH DETERGENT IN ISOLATION AREAS Dettol 2% Dettol 4% Di-Crobe D .R .X. Lysol 2% Lysol 3% Lysol 5% Pme oil Wescodyne Zephiran 1:1000 Other (not specified) Total Not answered Not applicable

13 8 4 27 11 1 8 3 46 10 30 161 8 39

8 .1 5.0 2.4 16 . 8 6 .8 .6 5.0 1.9 28.6 6 .2 18 .6

274

TIIE CONTROL OF INFEcrlONS IN HOSPITALS

Number

Per cent of total

TABLE C.2 . 107 ARE BEDSIDE UTENSILS (i.e. BEDPANS, WASHBASINS, EMESIS BASINS, ETC.) SENT TO A CENTRAL AREA FOR STERILI· ZATION UPON DISCHARGE OF PATIENT? Yes No Total Not answered Not applicable TABLE C.2.108 METHOD USED FOR DISINFECTION OF PATIENTS' UTENSILS IN ISOLATION AREAS Autoclaving Boiling Chemical Combinations of the above Other Total Not answered Not applicable TABLE C.2.109 CHEMICALS USED FOR TERMINAL DISINFECTION OF BEDSIDE EQUIPMENT Dettol 2% Dettol 4% Green soap 2% Hexachlorophene liquid soap Lysol 2% Lysol 3% Lysol 5% Roccal 1:1000 Wescodyne Zephiran 1:1000 (in water solution) Other (not specified) Total Not answered Not applicable

104

77

181

57.5 42.5

4 23

13 8 52 15 5 93

14.0

8.6

55.9 16.1 5.4

4

111

4 2

1

3 9 1 5 2 31 1 13 72

5 .6 2.8 1.4 4.2 12.5 1.4 6.9 2.8 43.0 1.4

18.0

4 132

TABLE C.2.110

Is CONTAMINATED LINEN PLACED IN A SPECIALLY MARKED

LAUNDRY BAG? Yes No Total

178

Not answered Not applicable

24

172

6

6

96.6 3.4

APPENDIX

Number

C 275

Per cent of total

TABLE C.2.111 Is CONTAMINATED LINEN TAKEN TO THE LAUNDRY IN A SPECIAL CONVEYANCE?

Yes No Total Not answered Not applicable

113

62 175

64.6 35 .4

7

26

TABLE C .2.112 KIND OF BLANKET USED IN ISOLATION AREA

All-wool Wool plus synthetic fibre Cellular cotton Terry towelling Two or more combinations of the above Other (not specified) Total Not answered Not applicable

64

5

35.8 10.6 33.5 2.8

12

6.7

19 60 19 179

10.6

5

24

TABLE C.2.113 ARE ALL BLANKETS DISINFECTED ROUTINELY AFTER DISCHARGE OF PATIENT?

Yes No Total Not answered Not applicable

171

9

180

95.0 5 .0

5

23

TABLE C.2.114 IF PATIENT STAY IN ISOLATION AREA IS PROLONGED, ARE BLANKETS DISINFECTED AT INTERVALS NOT EXCEEDING TWO WEEKS?

Yes No Total Not answered Not applicable

66

105 171

11

26

38.6

61.4

276

THE OONTROL OF INFEcnONS IN HOSPITALS

Number

Per cent of total

169 12 181

93.4 6.6

TABLE C.2.115 ARE ALL PILLOWS DISINFECTED ROUTINELY AFTER DISCHARGE OF PATIENT? Yes No Total Not answered Not applicable

4 23

TABLE C.2.116 ARE ALL MATTRESSES DISINFECTED ROUTINELY AFTER DISCHARGE OF PATIENT? Yes No Total Not answered Not applicable

169 12 181

93.4 6.6

4 23

TABLE C.2.117 METHOD USED FOR DISINFECTING MATTRESSES IN ISOLATION AREAS Airing for specified time Autoclaving Cleaning rubber or plastic cover with chemical Cleaning of mattress itself with chemical Ethylene oxide gas Formaldehyde gas Ultraviolet radiation Combination of washing mattress and/or cover with a chemical and airing Other (not specified) Total Not answered Not applicable

10 3 22 32 1 2 1

5.6 1. 7 12 .4 18.1 .6 1.1 .6

74 32 177

41.8 18.1

5 26

TABLE C.2.118 Is AEROSOL SPRAY USED TO DISINFECT THE ROOM BEFORE CLEANING IS STARTED? Yes No Total Not answered Not applicable

46 129 175 10 23

26.3 73 . 7

APPENDIX

Number TABLE C.2.119 LENGTH OF TIME ROOM IS AIRED AND/OR VACATED AFTER DISCHAlt.GE OF PATIENT 5 minutes 30 minutes 1 hour 3 hours Longer than 3 hours Other (not specified) Total Not answered Not applicable

2

7

11 16 79 65 180

C 277

Per cent of total

1.1 3.9 6.1 8.9 43.9 36.1

6 22

C.3. Section II: HOUSEKEEPING TECHNIQUES

Number

Per cent of total

28 101 129

21. 7 78 .3

TABLE C.3 . 120 NUMBERS OF EXECUTIVE HOUSEKEEPERS WITH FORMAL TRAINING IN HOSPITAL HOUSEKEEPING With training Without training Total Not answered Not applicable

7 72

TABLE C.3.121 METHOD OF MOPPING USED FOR FLOORS OF PATIENT AREAS Wet Dry Both Total

44

21.1 2.9 76 .0

135 25 160

84.4

6 158 208

TABLE C.3.122 IF DRY MOPPING IS CARRIED OUT, ARE MOPS IMPREGNATED WITH A DUST CONTROL SOLUTION? Yes No Total Not answered Not applicable

9 39

15.6

278

THE CONTROL OF INFECTIONS IN HOSPITALS

Number

Per cent of total

91 101 192

52.6

TABLE C . 3 . 123 ARE VACUUM CLEANERS USED TO REMOVE DUST FROM MOPS? Yes No Total Not answered Not applicable

47 .4

15 1

TABLE C . 3 . 124 IF VACUUM CLEANERS ARE USED, ARE DISPOSABLE BAGS USED? Yes No Total Not answered Not applicable

52 36 88 18 102

59 . 0

41.0

TABLE C.3.125 ARE ALL CLEANING DETERGENTS IMPREGNATED WITH A DISINFECTANT? Yes No Total Not answered

141

69.0 31.0

57 3 60 5 143

95.0 5.0

62 203 5

TABLE C . 3.126 IF ALL CLEANING DETERGENTS ARE NOT IMPREGNATED WITH DISINFECTANTS, IS A DISINFECTANT ADDED TO THE DETERGENTS USED IN CERTAIN AREAS? Yes No Total Not answered Not applicable TABLE C . 3 . 127 SPECIFIC AREAS IN WHICH DISINFECTANTS ARE ADDED TO CLEANING DETERGENTS Operating room Case room Nursery All three Operating room and case room Others (not specified) Total Not answered Not applicable

3

1

2

23 2

19 50 12

146

6.0

2 .0 4 .0

46 . 0

4 .0 38.0

APPENDIX

C 279

Number

Per cent of total

38

18.5

6

2.9 45.1 11.7 4 .9 2.4 9 .2 5.3

TABLE C.3.128 TYPES OF EQUIPMENT USED FOR FLOOR CLEANING Double container (separate areas for clean and dirty water) "Floor maintainer" (sweeps, mops, scrubs, waxes, all in one operation) Mop and pail with wringer Both mop and pail and double container Double container and "Floor Maintainer" All three Other combinations of the above Other (not specified) Total Not answered

93

24 10

5 19 11

206 2

TABLE C.3 .129 INTERVALS AT WHICH COMPLETE FLOOR CLEANING AND REFINISHING IS CARRIED OUT Weekly Every two weeks Once a month Less often than once a month Other (not specified) Total Not answered Not applicable

75 16 48 23 40 202

37 . 1 7.9 23 .8 11.4 19 .8

5 1

TABLE C.3 .130 INTERVALS AT WHICH FLOORS OF TREATMENT AND UTILITY ROOMS ARE MOPPED Daily Every two days Weekly Other (not specified) Total Not answered Not applicable

191 3 6

5 205

93 .2 1.5 2.9 2 .4

1 2

TABLE C.3 . 131 ARE OPERATING ROOMS WET MOPPED AFTER EACH OPERATION? Yes No Total Not answered Not applicable

144 30 174 9 25

82 .8 17.2

280

TIIE CONTROL OF INFECTIONS IN HOSPITAlS

Number

Per cent of total

TABLE C.3.132 INTERVALS AT WHICH PATIENT AREAS ARE COMPLETELY HOUSECLEANED

Every three months Every six months Yearly Other (not specified) Total Not answered

73 74 30 30 207

35.3

35.7

14 . 5 14 .5

1

TABLE C.3.133 HOSPITAL DEPARTMENT(S) RESPONSIBLE FOR CLEANING OF NURSERY AREA

Housekeeping Nursing Both Total Not answered Not applicable

58

33 .9

107 171

62.6

6

3 .5

2

35

TABLE C .3 .134 HOSPITAL DEPARTMENT(S) RESPONSIBLE FOR CLEANING OF OPERATING ROOMS

Housekeeping Nursing Both Total Not answered Not applicable

37

17 124 178

20 .8 9 .5 69.7

2

28

TABLE C .3.135 HOSPITAL DEPARTMENT(S) RESPONSIBLE FOR CLEANING OF CASE ROOMS

Housekeeping Nursing Both Total Not answered Not applicable

44

7 118

169

2

37

26 . 0

4.2

69 .8

APPENDIXC

Number

Per cent of total

175 8 11 6 200

87 . 5 4 .0 5 .5 3 .0

TABLE C . 3.136 TYPE OF MOP USED Cotton (rope) Synthetic fibre Both Other (not specified) Total Not answered Not applicable

7 1

TABLE C.3.137 ARE CLEANING PERSONNEL ASSIGNED TO SPECIFIC HOSPITAL AREAS? Yes No Total Not answered Not applicable

183 20 203

90.1 9.9

4 1

TABLE C.3.138 IF PERSONNEL ARE NOT ASSIGNED TO SPECIFIC HOSPITAL AREAS, ARE MOPHEADS CHANGED WHEN GOING FROM ONE PATIENT AREA TO ANOTHER? (e.g. WHEN GOING FROM MEDICAL TO SURGICAL FLOOR?) Yes No Total Not answered Not applicable

22 6 28

78.6 21.4

7 173

TABLE C . 3 . 139 DISINFECTANT ADDED TO CLEANING DETERGENTS Dettol 2% Di-Crobe D.R.X. germicidal detergent Hibitane 1: 5000 Lysol 5% Pme Oil Santophen 1 Wellodyne Wescodyne Zephiran 1:1000 (in water solution) Other (not specified) Total Not answered Not applicable

281

9 4 31 2 9 5 14 1 19 3 89 186 15 7

4 .8 2 .1 16.7 1.0 5 .0 3.0 7.0 1.0 10 . 0 1.0 48.0

282

THE CONTROL OF INFEGnONS IN HOSPITALS

Number TABLE C.3 .140 ARE FRESH MOPHEADS ISSUED DAILY? Yes No Total Not answered Not applicable TABLE C .3.141 ARE APRONS CHANGED DAILY? Yes No Total Not answered Not applicable TABLE C.3.142 Is THE WARD CLEANING TIME ARRANGED WITH THE NURSE-IN-CHARGE? Yes No Total Not answered

93 97 190

Per cent of total

49 .0 51.0

17 1

98 64 162

60.5 39 .5

28 18

178 21 199

89.4 10 .6

9

TABLE C.3.143 INTERVALS AT WHICH PATIENT AREAS ARE WET MOPPED Daily Every two days Weekly Less often than weekly Other (not specified) Total Not answered Not applicable

134 31 23 4 9 201

66.7 15.4 11.4 2.0 4.5

6 1

TABLE C.3 .144 ARE BATHROOM FLOORS WET MOPPED DAILY? Yes No Total Not answered

189 12 201 7

94 .0 6 .0

APPENDIX

Number

C 283

Per cent of total

TABLE C .3.145 INTERVALS AT WHICH BATHROOM FLOORS ARE SCRUBBED Daily Weekly Less often than weekly More often than twice weekly Other (not specified) Total Not answered

88 64

17 14 23 206 2

42.7 31.1 8 .2 6 .8 11 .2

TABLE C.3 .146 INTERVALS AT WHICH SHOWERS ARE CLEANED After each use Twice daily Daily Less often than daily After each use and daily Other (not specified) Total Not answered Not applicable

66 14 80 3 3 2 168 5 35

39.3 8 .3 47.6 1.8 1.8 1.2

160 32 192 12 4

83 .3 16.7

96

54.5 45 .5

TABLE C.3 .147 ARE BATHTUBS DISINFECTED AFTER EACH USE? Yes No Total Not answered Not applicable TABLE C.3 . 148 ARE PLASTIC SHOWER CURTAINS USED? Yes No Total Not answered Not applicable

80 176 8 24

TABLE C.3.149 INTERVALS AT WHICH SITZ BATHS ARE CLEANED After each use Twice daily Daily Other (not specified) Total Not answered Not applicable

134 3 8 4 149 11

48

89 .9 2.0 5.4 2.7

284

THE CONTROL OF INFECTIONS IN HOSPITALS

Number

Per cent of total

TABLE C.3 .150 INTERVALS AT WHICH TOILET SEATS ARE CLEANED

After each use Twice daily Daily Less often than daily Other (not specified) Total Not answered

12 62 128 1 4

207

5.8 30 .0 61.8 .5 1.9

1

TABLE C.3 . 151 INTERVALS AT WHICH TOILET BOWLS AND HAND BOWLS ARE CLEANED

Twice daily Daily Less often than daily More often than daily Daily and more often Other (not specified) Total Not answered

51

141 1 6 5

3 207

24.6 68 .1

.5

2.9 2 .4 1.5

1

TABLE C .3 . 152 IS A DISINFECTANT ADDED TO THE DETERGENT USED FOR THE CLEANING OF BATHROOM FLOORS, WALLS, FIXTURES?

Yes

No Total Not answered

174

24

198

87 .9 12.1

10

TABLE C .3.153 INTERVALS AT WHICH BATHROOM WALLS ARE CLEANED

Every two weeks Every month Less often than every month · More often than every two weeks Other (not specified) Total Not answered

44

71 33 25 33 206 2

21.4 34.5 16 .0 12 .1 16.0

APPENDIX

TABLE C.3 .154 INTERVALS AT WHICH BED CURTAINS ARE CHANGED Weekly Every two weeks Once a month Less often than once a month Other (not specified) Total Not answered Not applicable TABLE C.3.155 INTERVALS AT WHICH WINDOW CURTAINS ARE CHANGED Every month Every three months Every six months Less often than six months Other (not specified) Total Not answered Not applicable TABLE C.3.156 INTERVALS AT WHICH GENERAL DUSTING OF FURNITURE, BEDFRAMES, WINDOWSILLS, CUPBOARDS, ETC. IS CARRIED OUT Daily Every two days Weekly Total Not answered TABLE C.3.157 TYPE OF DUSTING CARRIED OUT IN GENERAL PATIENT AREAS Damp Dry Both Total Not answered

C 285

Number

Per cent of total

6 30 78 33 45 192

3 .1 15 .6 40 .6 17.2 23 .5

6 10

28 55 57 19 35 194

14.4 28.4 29.4 9.8 18.0

11

3

199 3 5 207 1

96.1

123 6 77 206 2

59.7 2 .9 37.4

188 18 206 2

91.3 8 .7

1.5

2.4

TABLE C.3.158 ARE TRAFFIC LANES (e.g. MAIN CORRIDORS) MOPPED DAILY?

Yes

No Total Not answered

286

TIIE CONTROL OF INFECTIONS IN HOSPITALS

Number TABLE

Per cent of total

C .3 .159

IF RESPONSIBILITY (FOR CLEANING) IS ASSUMED BY BOTH DEPARTMENTS, ARE CLEANING AREAS SO ARRANGED THAT EACH DEPARTMENT IS WELL AWARE OF ITS OWN RESPONSIBILITY?

146 0 146

Yes No Total Not answered Not applicable TABLE

100.0 0

59 3

C .3 .160

Is THERE A JANITOR'S CLOSET ON EACH FLOOR?

182 19 201

Yes No Total Not answered Not applicable TABLE

90 .5 9 .5

4 3

C.3 .161

ARE REFUSE CHUTES PROVIDED ON EACH FLOOR?

32 172 204

Yes No Total Not answered Not applicable TABLE

15.7 84 .3

3 1

C.3 .162

ARE REFUSE CHUTES NEAR OR ADJACENT TO PATIENT AREAS?

20 13 33

Yes No Total Not answered Not applicable TABLE

60.6 39.4

3 172

C.3.163

IF REFUSE CHUTES ARE USED IN THE HOSPITAL, ARE THEY SO DESIGNED AS TO PREVENT THE RETURN OF CHUTE AIR TO THE HOSPITAL? Yes No Total Not answered Not applicable

29 3 32 4

172

90 .6 9.4

APPENDIX

Number TABLE

C 287

Per cent of total

C.3 .164

IS THE LAUNDRY CHUTE LOCATED NEAR OR ADJACENT TO PATIENT AREAS? Yes No Total Not answered Not applicable TABLE

110 83 193 2 13

57.0 43 .0

96 20 116 9 83

82 .8 17.2

109 7 116

94.0 6.0

C .3.165

IF LAUNDRY CHUTES ARE USED, ARE THEY SO DESIGNED AS TO PREVENT THE RETURN OF CHUTE AIR TO THE HOSPITAL? Yes No Total Not answered Not applicable TABLE

C.3 .166

IF LAUNDRY CHUTES ARE NOT USED, ARE LAUNDRY CARTS USED FOR TRANSPORTING LINEN? Yes No Total Not answered Not applicable TABLE

8 84

C.3.167

IF LAUNDRY CARTS ARE USED, ARE SEPARATE CARTS USED FOR TRANSPORTING SOILED AND CLEAN LINEN?

104 7 111

Yes No Total Not answered Not applicable TABLE

93.7 6 .3

9 88

C.3.168

ARE SEPARATE AREAS PROVIDED IN THE LAUNDRY ROOM PROPER FOR CLEAN AND SOILED LINEN? Yes No Total Not answered Not applicable

183 14 197 8 3

92 .9 7 .1

288

THE CONTROL OF INFECTIONS IN HOSPITALS

Number

Per cent of total

135 68 203

66 .5 33.5

TABLE C.3.169 ARE ALL BLANKETS ROUTINELY DISINFECTED AFTER DISCHARGE OF PATIENT? Yes No Total Not answered

5

TABLE C.3.170 METHOD(S) USED FOR DISINFECTION OF BLANKETS Airing for specified time Impregnation with a quaternary ammonium compound (e.g. Zephiran) Laundering slightly below boiling temperature Airing and laundering slightly below boiling temperature Other (not specified) Total Not answered Not applicable

24

16.7

2 82

1.4 56 .9

24 12 144

16 .7 8 .3

5 59

TABLE C.3 . 171 TYPE OF PILLOW USED Feather filled Sponge rubber Dacron filled All three Feather filled and sponge rubber Feather and dacron filled Other (not specified) Total Not answered Not applicable

92 10 8 12 49 13 14 198

46.5 5.0 4.0 6 .1 24.7 6.6 7.1

8 2

TABLE C.3.172 ARE ALL PILLOWS DISINFECTED ROUTINELY AFTER DISCHARGE OF PATIENT? Yes No Total Not answered Not applicable

159 42 201 6 1

79.1 20 .9

APPENDIX

TABLE C.3 . 173 METHODS USED FOR DISINFECTION OF PILLOWS Airing for specified time Autoclaving Cleaning of rubber or plastic pillow cover with chemical disinfectant Cleaning of pillow itself with chemical disinfectant Ethylene oxide gas Ultraviolet radiation Cleaning of pillow and/or cover with disinfectant and airing for specified time Other (not specified) Total Not answered :· Not applicable TABLE C.3 . 174 TYPE OF MATTRESS USED Sponge rubber Horse hair Spring filled All three Sponge rubber and spring filled Other (not specified) Total Not answered TABLE C .3.175 ARE ALL MATTRESSES DISINFECTED ROUTINELY AFTER DISCHARGE OF PATIENT? Yes No Total Not answered ' TABLE C.3.176 METHODS USED FOR DISINFECTION OF MATTRESSES Airing for specified time Autoclaving Cleaning of rubber or plastic mattress cover with chemical disinfectant Cleaning of mattress itself with chemical disinfectant Ethylene oxide gas Cleaning of mattress and/or cover and airing Other (not specified) Total Not answered Not applicable

C 289

Number

Per cent of total

21 1

12.1 .6

31 35 15 1

17.9 20 . 2 8 .7 .6

53 16 173

30.6 9 .3

3 32

9 1 133 2 48 13 206

4 .4

.5 64 .5 1.0 23.3 6.3

2

185 17 202 6

91.6 8.4

12 2

6.3 1.1

31 53 32 55 5 190 3 15

16.3 27.9 l.6 . 9 28 .9 2.6

290

THE CONTROL OF INFECilONS IN HOSPITALS

Number

Per cent of total

TABLE C.3.177 IS YOUR HOSPITAL EQUIPPED WITH A VENTILATING PLANT? Yes No Total Not answered Not applicable

96 98 194 13 1

49.5 50.5

29 64 93 26 89

31.2 68.8

30 61

44

28.6 19.5 39.6

9

5.8 6.5

TABLE C.3 .178 Is HUMIDIFYING WATER CULTURED ROUTINELY? Yes No Total Not answered Not applicable TABLE C.3.179 LOCATION OF ICE ROOM In In In In

or near patient area basement dietary department or near patient area and in basement and/or dietary department Other (not specified) Total Not answered Not applicable

10

154 28 26

TABLE C.3 .180 IS ICE SUPPLIED TO WARD IN A COVERED CONTAINER? Yes No Total Not answered Not applicable

90 68 158 26

57.0 43 .0

35 132 33 6 206 2

17 .0 64.1 16.0 2.9

24

TABLE C.3.181 INTERVALS AT WHICH GARBAGE CANS ARE EMPTIED ROUTINELY Once every shift Twice daily Daily Other (not specified) Total Not answered

APPENDIX

TABLE C.3 .182 ARE GARBAGE CANS EMPTIED IN OR NEAR PATIENT AREAS? Yes No Total Not answered Not applicable TABLE C.3.183 ls A CLEAN EMPTY CAN EXCHANGED FOR A FULL CONTAMINATED ONE? Yes No Total Not answered Not applicable TABLE C.3.184 ARE GARBAGE CANS EMPTIED IN A CENTRAL GARBAGE AREA? Yes No Total Not answered Not applicable TABLE C.3 .185 HAS THE GARBAGE AREA READY ACCESS TO THE INCINERATOR? Yes No Total Not answered Not applicable

C 291

Number

Per cent of total

20 180 200

10.0 90.0

5 3

114 46 160

71.3 28 .7

13 35

180

10

190

94.7 5.3

10 8

148 36 184

80 .4 19.6

12 12

TABLE C.3 .186 ARE GARBAGE CANS DISINFECTED AFTER EACH USE? Yes No Total Not answered Not applicable

150 48 198 5 5

75.8

24 .2

292

TIIE CONTROL OF INFECllONS IN HOSPITALS

TABLE C.3.187 METHODS USED FOR DISINFECTION OF GARBAGE CANS Exposure to flowing steam Wiped with chemical disinfectant Both Other (not specified) Total Not answered Not applicable

Number

Per cent of total

80 77 19

41.5 39.9 9.8 8.8

17

193

5

10

TABLE C.3.188 ARE ALL HOUSEKEEPING PERSONNEL TRAINED IN THE PRINCIPLES OF STRICT ASEPTIC TECHNIQUE? Yes No Total Not answered Not applicable

TABLE C.3 .189 IF NOT ALL HOUSEKEEPING PERSONNEL ARE TRAINED IN STRICT ASEPTIC TECHNIQUE, IS THE CLEANING OF ISO· LATION AREAS CARRIED OUT BY A SPECIALLY TRAINED DISINFECTION TEAM? Yes No Total Not answered Not applicable

TABLE C.3.190 HOSPITAL DEPARTMENT(S) RESPONSIBLE FOR TRAINING OF HOUSEKEEPING PERSONNEL Medical Nursing Housekeepini Nursin[r and ousekeeping Other not specified) Total Not answered Not applicable

103 81

184

56.0 44 .0

7 17

61 29 90

67.8 32.2

8 110

0

44

123 10 7 184 6 18

0 23.9 66.9 5.4 3 .8

APPENDIXC

Number TABLE

293

Per cent of total

C .3. 191

ARE MEMBERS OF THE ISOLATION TEAM REQUIRED TO WEAR MASKS AND GOWNS WHEN CLEANING ISOLATION AREAS?

155 15 170

Yes No Total Not answered Not applicable

TABLE

91.2 8 .8

15 23

C.3 . 192

ARE MASKS AND GOWNS CHANGED AFTER CLEANING EACH CONTAMINATED AREA?

159 4 163

Yes No Total Not answered Not applicable

TABLE

97.5 2 .5

17 28

C.3.193

ARE MOPHEADS, PAILS AND SOLUTIONS CHANGED AFTER CLEANING EACH CONTAMINATED AREA?

154 20 174

Yes No Total Not answered Not applicable

TABLE

88.5 11 .5

13 21

C.3.194

ARE ALL CLEANING DETERGENTS USED IN ISOLATION AREAS IMPREGNATED WITH A DISINFECTANT?

170 5 175

Yes No Total Not answered Not applicable TABLE

97.1 2.9

12 21

C. 3. 195

DISINFECTANT ADDED TO DETERGENT IN ISOLATION AREAS Air Kem Detergicide Dettol 2% D.R.X. Germicidal detergent

1 1 11 22

.6 .6 6 .4 12.7

294

THE CONTROL OF INFECITONS IN HOSPITALS

TABLE C.3.195 continued Hibitane 1:5000 Lysol 5% O'Gib Pine oil R2L Wellodyne Wescodyne Zephiran 1:1000 (in water solution) Other Total

Number

Per cent of total

1 21 2 1 1 2 36 3 70 172

.6 12.2 1.2 .6 .6 1.2 20.9 1.7 40 .7

12 24

Not answered Not applicable

TABLE C.3 .196 METHOD OF MOPPING USED FOR FLOORS OF ISOLATION AREAS

97 2 82 181

Wet Dry Both Total

53 .6 1.1 45 .3

6 21

Not answered Not applicable

TABLE C.3.197 IF DRY MOPPING IS CARRIED OUT, ARE MOPS TREATED WITH A DUST CONTROL SOLUTION?

80 12 92

Yes No Total

12 104

Not answered Not applicable

TABLE C.3.198 Is THE CLEANING SCHEDULE

87 .0 13 .0

OF ISOLATION AREAS

"STEPPED-UP"?

Yes No Total Not answered Not applicable

101 56 157 30 21

64.3 35 .7

APPENDIX

Number

C 295

Per cent of total

TABLE C.3.199 INTERVALS AT WHICH ISOLATION UNITS ARE MOPPED Twice daily Daily Less often than every two days Other (not specified) Total Not answered Not applicable

25 100 I

2 128

19.5 78 .1 .8 1.6

20 60

TABLE C.3 .200 ARE WINDOW CURTAINS USED IN ISOLATION AREAS? Yes No Total Not answered Not applicable

125 52 177

70 .6 29.4

10 21

TABLE C.3.201 INTERVALS AT WHICH WINDOW CURTAINS ARE CHANGED When room is vacated Not exceeding 3 weeks if patient stay prolonged Less often than once a month When room is vacated and not exceeding 3 weeks if patient stay is prolonged Other (not specified) Total Not answered Not applicable

114

2 2

89.8 1.6 1.6

4

3 .1 3 .9

5 127 9 72

TABLE C.3.202 INTERVALS AT WHICH GENERAL DUSTING OF FURNITURE, BEDFRAMES, WINDOWSILLS, CUPBOARDS, ETC. IS CARRIED OUT IN ISOLATION AREAS Twice daily Daily Every two days Less often than every two days Other (not specified) Total Not answered Not applicable

10 164 I

2 1 178 9 21

5.6 92 . 1 .6 I.I

.6

296

TIIE CONTROL OF INFECTIONS IN HOSPITALS

Number TABLE

Per cent of total

C.3.203

ARE WALLS, CEILINGS AND FLOORS COMPLETELY CLEANED AFTER EACH ROOM USE?

150 ~31 181

Yes No Total

17.1

7 20

Not answered Not applicable TABLE

82.9

C.3.204

JS THE ROOM OR AREA DISINFECTED BY AN AEROSOL SPRAY BEFORE CLEANING IS STARTED?

60

Yes No Total

114 174

14 20

Not answered Not applicable

C.3 .205 Is CONTAMINATED LINEN

34.5 65.5

TABLE

AUTOCLAVED BEFORE BEING SENT

TO THE LAUNDRY?

8 169 177

Yes No Total Not answered Not applicable

4.5 95.5

11

20

TABLE C.3.206 IF CONTAMINATED LINEN IS NOT AUTOCLAVED, IS IT PLACED IN A SPECIALLY MARKED CONTAINER?

165 3 168

Yes No Total Not answered Not applicable TABLE

Is

98.2 1.8

14 26

C.3.207

THE HOSPITAL EQUIPPED WITH ITS OWN LAUNDRY DEPARTMENT?

Yes No Total Not answered Not applicable

154 28 182 6 20

84.6 15.4

APPENDIX

Number

C 297

Per cent of total

TABLE C.3 .208 AREA IN WHICH CONTAMINATED LAUNDRY IS WASHED Commercial laundry Other hospital laundry Other (not specified) Total

17 8 2 27

Not answered Not applicable

7 174

63 . 0 29 . 6 7.4

TABLE C .3 .209 ARE ALL :MATTRESSES USED IN ISOLATION AREAS DISINFECTED ROUTINELY AFTER DISCHARGE OF PATIENT? Yes No Total Not answered Not applicable

174 6 180

96 . 7 3.3

8 20

TABLE C . 3.210 METHODS USED FOR DISINFECTION OF MATTRESSES Airing for specified time Autoclaving Cleaning of rubber or plastic mattress cover with a disinfectant Cleaning of mattress itself with a disinfectant Ethylene oxide gas Formaldehyde gas Ultraviolet radiation Airing and cleaning of mattress and/or cover with a disinfectant Other (not specified) Total Not answered Not applicable

7 3

1. 7

22 51 23 3 1

12.7 29.3 13.2 1. 7 .6

57 7 174

32.8 4 .0

4 .0

10 24

TABLE C . 3.211 AREA IN WHICH MATTRESSES ARE DISINFECTED In unit within hostital In unit outside of .ospital Other (not specified) Total Not answered Not applicable

159 14 3 176 9 23

90 . 3 8 .0 1. 7

298

THE CONTROL OF INFECTIONS IN HOSPITALS

Number

Per cent of total

162 15 177

91.5 8 .5

TABLE C.3.212 ARE ALL BLANKETS DISINFECTED ROUTINELY AFTER DISCHARGE OF PATIENT?

Yes

No Total Not answered Not applicable

11

20

TABLE C.3.213 METHODS USED FOR DISINFECTION OF BLANKETS USED IN ISOLATION AREAS Airing for specified time Use of formaldehyde gas Impregnation with a quaternary ammonium compound (e.g. Zephiran) Laundering slightly below boiling temperature Airing and laundering slightly below boiling temperature Other (not specified) Total Not answered Not applicable

13 2

8 .0 1.2

5 97

3 .1 59 .5

21 25 163

12 .9 15.3

12 33

TABLE C.3.214 AREA IN WHICH CONTAMINATED BLANKETS ARE DISINFECTED Within hospital Outside hospital Other (not specified) Total Not answered Not applicable

142 29 2 173

82 .1 16.8 1.1

9 26

TABLE C.3.215 ARE ALL PILLOWS DISINFECTED ROUTINELY AFTER DISCHARGE OF PATIENT?

Yes

No Total Not answered Not applicable

167 8 175 13 20

95.4 4.6

APPENDIX

TABLE C . 3.216 METHODS USED FOR DISINFECTION OF PILLOWS USED IN ISOLATION AREAS Airing for specified time Autoclaving Cleaning of rubber or plastic pillow cover with a disinfectant Cleaning of pillow itself with a disinfectant Ethylene oxide gas Formaldehyde gas Ultraviolet radiation Airing and cleaning of pillow and/or cover with a disinfectant Other (not specified) Total Not answered Not applicable TABLE C.3.217 AREA IN WHICH PILLOWS ARE DISINFECTED Within hospital Outside hospital Both Other (not specified) Total Not answered Not applicable TABLE C . 3.218 IS CONTAMINATED GARBAGE COLLECTED IN A SPECIALLY MARKED CONTAINER? Yes No Total Not answered Not applicable TABLE C.3.219 ARE NOSE AND/OR THROAT CULTURES TAKEN ROUTINELY ON HOUSEKEEPING PERSONNEL? Yes No Total Not answered Not applicable

C 299

Number

Per cent of total

14 3

8 .3 1.8

22 38 12 1 2

13.1 22.6 7.1 .6 1.2

48 28 168

28.6 16.7

12 28

148 20 4 2 174

85.1 11 . 5 2.3 1.1

10 24

163 15 178

91.6 8 .4

9 21

32 144 176 13 19

18.2 81.8

300

THE CONTROL OF INFECI'IONS IN HOSPITALS

Number

Per cent of total

TABLE C.3 . 220 Is THERE AN INFECTION CONTROL COMMITTEE IN YOUR HOSPITAL? Yes No Total Not answered Not applicable

89 87 176 13 19

50 . 6 49.4

TABLE C .3.221 IS THE EXECUTIVE OR HEAD HOUSEKEEPER A MEMBER OF THIS COMMITTEE? Yes No Total Not answered Not applicable

23 63 86 16 106

26 . 7 73 . 3

153 1 14

86.4 .6 7.9

5 4 177 10 21

2.8 2 .3

TABLE C . 3.222 PERSON TO WHOM THE EXECUTIVE HOUSEKEEPER IS DIRECTLY RESPONSIBLE Hospital administrator or his assistant Chief Bacteriologist Director of Nursing Both hospital administrator and Director of Nurses Other (not specified) Total Not answered Not applicable

C.4.

Section III : OPERATING ROOM TECHNIQUES

Number TABLE C.4.223 RELATIONSHIP OF OPERATING SUITE TO REST OF HOSPITAL On separate floor in hospital Closely associated with ward In area apart from ward Other (not specified) Total Not answered Not applicable

17 37 118 4 176 1 31

Per cent of total

9.7 21.0 67.0 2.3

APPENDIX

C 301

Number

Per cent of total

59 36 27 16 12 4 2 7 163

36 . 2 22.1 16 .6 9 .8 7.4 2.4 1.2 4.3

TABLE C.4.224 RA.no OF OPERATING ROOMS PER SURGICAL BEDS

1:15 1:20 1:30 1:40 1:50 1:80 1:100 Other (not specified) Total Not answered Not applicable

13 32

TABLE C.4.225 DO YOU CONSIDER YOUR OPERATING SUITE ADEQUATELY STAFFED?

Yes No Total

Not answered Not applicable

135 38 173

78.0 22 .0

4 31

TABLE C.4.226 Is THERE A SEPARATE OPERATING ROOM FOR CONTAMINATED CASES?

Yes No Total Not answered Not applicable

44

131 175

25.1 74.9

2 31

TABLE C . 4.227 IS THERE AN INFECTION CONTROL COMMITTEE IN YOUR HOSPITAL?

Yes No Total

Not answered Not applicable

94 80

174 3 31

54 .0 46 .0

302

THE CONTROL OF INFECTIONS IN HOSPITALS

Number TABLE

Per cent of total

C.4 .228

IS THE OPERATING ROOM SUPERVISOR A MEMBER OF THIS COMMITTEE?

34 64 98

Yes No Total

3 107

Not answered Not applicable TABLE

34 .7 65.3

C.4.229

ARE NOSE AND/OR THROAT CULTURES TAKEN ON OPERATING ROOM PERSONNEL ROUTINELY?

53 122 175

Yes No Total

2 31

Not answered Not applicable TABLE

C .4.230

ARE KNOWN CARRIERS OF Staphylococcus TO WORK IN THE OPERATING ROOM?

aureus PERMITTED

19 154 173

Yes No Total Not answered Not applicable TABLE

30 .3 69 .7

11.0 89 .0

4 31

C.4 .231

Is ANTIBIOTIC PROPHYLAXIS USED FOR CARRIERS OF

Staphylococcus aureus?

83 55 138

Yes No Total Not answered Not applicable TABLE

60.1 39 .9

36 34

C.4.232

Do SURGICAL PATIENTS RECEIVE PRE-OPERATIVE ANTIBIOTIC PROPHYLAXIS ROUTINELY? Yes No Total Not answered Not applicable

8 159 167 9 32

4.8 95.2

APPENDIX

Number

C 303

Per cent of total

TABLE C.4.233 ARE SCRUBBING TECHNIQUES STANDARDIZED AS FAR AS POSSIBLE?

Yes

No Total Not answered Not applicable

171

5

176

97.2 2 .8

1 31

TABLE C . 4 .234 Is EACH OPERATING ROOM PROVIDED WITH A SEPARATE SCRUB ROOM? Yes No Total Not answered Not applicable

60

114 174

34.5 65 . 5

3 31

TABLE C.4.235 LOCATION OF STERILIZING ROOM(S) SEPARATE FROM CENTRAL SUPPLY ROOM In operating room In small area of operating room Separate from operating room Combinations of the above Other (not specified) Total Not answered Not applicable

2 38

112 7

15 174

1.2 21.8

64.4 4 .0 8 .6

2 32

TABLE C.4.236 Is THE INSTRUMENT CLOSET LOCATED WITHIN THE OPERATING ROOM?

Yes

No Total Not answered Not applicable

82 91 173 3 32

47.4 52.6

9 52

5 .1 29.7

89

50.9

TABLE C . 4 .237 TYPE OF WALL FOUND IN OPERATING ROOM Rubber tile Painted plaster Both Other (not specified)

Total

Not answered Not applicable

25

175 2 31

14.3

304

'IllE CX>NTROL OF INFECTIONS IN HOSPITALS

Number

Per cent of total

TABLE C . 4 .238 TYPE OF FLOOR FOUND IN OPERATING ROOMS Asphalt tile Conductive vinyl Terrazzo Chipped marble Other (not specified) Total Not answered Not applicable

4 51 81 4 34 174

2.3 29.3 46 . 6 2 .3 19 . 5

3 31

TABLE C . 4.239 ARE WINDOWS LOCATED IN THE OPERATING ROOM PROPER? Yes No Total Not applicable

158 19 177

89 .3 10.7

31

TABLE C.4 .240 ARE WINDOWS LOCATED IN THE OPERATING ROOMS FLUSH WITH WALL SURFACES? Yes No Total Not answered Not applicable

42 116 158

26.6 73 . 4

1 49

TABLE C.4.241 ARE X-RAY VIEWING BOXES FLUSH WITH WALL SURFACES? Yes No Total Not answered Not applicable

92 67 159

57 . 9 42.1

6 43

TABLE C .4.242

Is THE HOSPITAL EQUIPPED WITH A VENTILATION PLANT? Yes No Total Not answered Not applicable

111 64 175 2 31

63 . 4 36.6

APPENDIX

TABLE C.4.243 IS THE HUMIDIFYING WATER .CULTURED ROUTINELY? Yes No Total Not answered Not applicable TABLE C.4.244 ARE AIR CONDITIONERS EVER USED IN OPERATING ROOMS? Yes No Total Not answered Not applicable TABLE C.4.245 ARE OPERATING ROOMS PRESSURIZED? Yes No Total Not answered Not applicable TABLE C.4.246 ARE CHEMICAL AEROSOLS OR ULTRAVIOLET RADIATION EVER USED IN OPERATING ROOMS TO CONTROL AIRBORNE INFECTIONS? Yes No Total Not answered Not applicable TABLE C.4.247 Is THE LAUNDRY CHUTE NEAR OR ADJACENT TO THE OPERATING SUITE? Yes No Total Not applicable

C 305

Number

Per cent of total

18

16 .4 83.6

92 110 9 89

69

106

175

39.4 60.6

1 32

41 128 169

24.3 75 .7

7 32

35 141 176

19.9 80.1

1 31

38 136

174

34

21.8 78.2

306

THE CONTROL OF INFECllONS IN HOSPITAI.S

Number TABLE

Per cent of total

C.4.248

IS THE LAUNDRY CHUTE SO DESIGNED AS TO PREVENT THE RETURN OF CHUTE AIR TO THE HOSPITAL?

23 13 36

Yes No Total Not answered Not applicable TABLE

63.9 36 .1

2 170

C.4 .249

ARE SURGICAL PATIENTS BROUGHT TO THE OPERATING ROOM BY WARD PERSONNEL?

85 91 176

Yes No Total Not answered Not applicable TABLE

48 .3 51.7

1

31

C.4.250

ARE CARRIAGES USED FOR TRANSPORTING SURGICAL PATIENTS PART OF THE WARD EQUIPMENT?

54 119

Yes No Total

173

Not answered Not applicable TABLE

ls

31.2 68 .8

3 32

C .4 .251

THE PATIENT TRANSFERRED TO THE-OPERATING TABLE IN THE OPERATING ROOM PROPER?

167 9 176

Yes No Total Not answered Not applicable TABLE

94.9 5.1

1 31

C.4.252

Do PATIENTS EVER WEAR MASKS WHEN ANAESTHESIA IS LOCAL?

Yes

No Total Not applicable

26 151 177 31

14 .7

85 .3

APPENDIXC

Number TABLE C .4.253 STANDARD SOLUTION(S) USED FOR SKIN PREPARATION OF THE OPERATIVE SITE IN THE OPERATING ROOM Alcohol 70% (propyl) Bichloride of mercury 1:500 Cetavlon 1:100 (in water solution) 2% Hexachlorophene liquid soap Merthiolate 1:1000 Zephiran 1:1000 (in water solution) Zephiran 1:1000 (in alcohol 70%) More than one solution indicated Other (not specified) Total Not applicable

TABLE C.4.254 Is SKIN PREPARATION TIMED? Yes No Total Not answered Not applicable TABLE C.4.255 TOTAL TIME REQUIRED FOR SKIN PREPARATION OF THE PATIENT 2 minutes 3 minutes 5 minutes Longer than 5 minutes Other (not specified) Total Not answered Not applicable

1 8 3 1 9 2 8 138 6 176

Per cent of total

.6 4 .5 1. 7 .6 5.1 1.2 4.5 78.4 3.4

32

45 130 175

25.7 74 . 3

2 31

6 15 14 9 2 46

13 . 0 32 . 6 30.4 19 . 6 4 .4

2 160

TABLE C.4.256 Is A TEN-MINUTE SCRUB REQUIRED BY ALL MEMBERS OF THE OPERATING TEAM? Yes No Total Not answered Not applicable

81 94 175 2 31

307

46.3 53.7

308

THE CONTROL OF INFECilONS IN HOSPITAU

Number

Per cent of total

TABLE C.4.257 TIME REQUIRED FOR SURGICAL SCRUB IF LESS THAN TEN MINUTES

4 minutes 5 minutes 6 minutes 8 minutes

Less than 4 minutes Other (not specified) Total Not answered Not applicable

7 38 15 20 6 8 94

7 .4

40 .4

16.0 21.3 6.4 8.5

3 111

TABLE C.4.258 SURGICAL SOAPS USED BY MEMBERS OF OPERATING ROOM TEAM Green soap Green soap with hexachlorophene 2% Hexachlorophene liquid soap pHisoHex Ordinary toilet soap More than one soap indicated Other (not specified) Total Not answered Not applicable

3 18 47 24 3 65 16 176

1. 7 10.2 26.7 13.6 1.7 37.0 9.1

1 31

TABLE C.4.259 ARE SCRUB SINKS EQUIPPED WITH SURGICAL TAPS? (i.e. TAPS OPERATED EITHER BY ELBOW, FOOT OR BOTH) Yes No Total Not answered Not applicable

173 2 175

98.9 1.1

2 31

TABLE C.4 .260 ARE SOAP SOLUTION DISPENSERS FOOT OPERATED? Yes No Total Not answered Not applicable

170 5 175 2 31

97.1 2.9

APPENDIX

Number

C 309

Per cent of total

TABLE C.4.261 ARE SOAP SOLUTIONS CULTURED ROUTINELY? Yes No Total Not answered Not applicable

18 151 169

10.7 89.3

8 31

TABLE C.4.262 ARE HANDS AND ARMS RINSED OR SWABBED WITH A DISINFECTANT SOLUTION AFTER SCRUBBING? Yes No Total Not applicable

18 159 177

10.2 89.8

31

TABLE C.4.263 DISINFECTANT USED FOR SWABBING HANDS AND ARMS AFTER SCRUBBING Alcohol 70% (ethyl) Alcohol 70% (propyl) Zephiran 1:1000 (m alcohol 70%) Zephiran 1:1000 (in water solution) Cetavlon .5% (in water solution) Hibitane .5% (in water solution) Other (not specified) Total Not applicable

5 5 2 2 1 1 4 20

25.0 25.0 10 .0 10.0 5.0 5.0 20.0

188

TABLE C .4.264 ARE PLASTIC APRONS WORN WHILE SCRUBBING? Yes No Total Not applicable

13 163 176

7.4 92.6

32

TABLE C .4.265

Is A COMPLETE SCRUB REQUIRED BETWEEN CASES IF GLOVES ARE REMOVED?

Yes No Total Not applicable

82 94 176 32

46.6 53.4

310

'lllE CONTROL OF INFECTIONS IN HOSPITALS

Number

Per cent of total

TABLE C.4 .266 LENGTH OF TIME REQUIRED FOR PARTIAL SCRUB

2 minutes 3 minutes 4 minutes 5 minutes

Longer than 5 minutes Other (not specified) Total Not answered Not applicable

15 49 18 20 3 4 109 1 98

13.8 45 .0 16 .5 18 .3 2.7 3 .7

21 155 176 32

11 .9 88.1

7 14

33 .3 66.7

TABLE C.4 .267

Is DISINFECTANT HAND CREAM USED REGULARLY BY OPERATING ROOM PERSONNEL?

Yes No Total Not applicable TABLE C.4.268 DISINFECTANT HAND CREAM USED BY SURGICAL PERSONNEL Dettol hand cream 2% Other (not specified) Total Not applicable

21

187

TABLE C.4 .269 TYPE OF MASK ROUTINELY WORN IN OPERATING ROOM Absorbent gauze Gauze mask with disposable filter and steel nose band Paper disposable Polyvinyl plastic deflection with disposable filter Absorbent gauze and disposable masks Other (not specified) Total Not applicable

145

82.9

9

5.1 .6

1 1

2 17 175 33

.6

1.1

9.7

TABLE C.4 .270 ARE MASKS WORN OVER BOTH NOSE AND MOUTH? Yes No Total Not applicable

175 0 175 33

100.0 0.0

APPENDIX

Number

C 311

Per cent of total

TABLE C.4.271 INTERVALS AT WHICH MASKS ARE CHANGED DURING SURGERY

Every hour Between cases After coughing and sneezing Not exceeding 2 hours if surgery is prolonged Twice daily Between cases and not exceeding 2 hours if surgery is prolonged Between cases and after coughing and sneezing Between cases and twice daily Other (not specified) Total Not answered Not applicable

4

106

5 2 8

7 23 2 17 174

2 .3 61.0 2 .9 1.1 4.6 4.0 13.2 1.1 9 .8

1 33

TABLE C.4 .272 Is OPERATING ROOM CLOTHING PERMITTED TO BE WORN OUTSIDE OF THE OPERATING SUITE?

Yes No Total Not applicable

112 63 175

64 .0 36 .0

33

TABLE C .4 .273 IF OPERATING ROOM CLOTHING IS PERMITTED TO BE WORN OUTSIDE OF THE OPERATING SUITE, IS CLOTHING PRO· TECTED BY A CLEAN COAT?

Yes No Total Not applicable

61 55 116

52 .6 47 . 4

92

TABLE C.4 .274 IF A CLEAN COAT IS NOT WORN OUTSIDE OF SURGICAL AREA TO PROTECT OPERATING ROOM CLOTHING, ARE PERSONNEL REQUIRED TO PUT ON FRESH CLOTHING BEFORE REENTERING THE OPERATING SUITE?

Yes No Total Not answered Not applicable

36 38

74

1 133

48.6 51.4

312

1HE CONTROL OF INFECTIONS IN HOSPITALS

Number TABLE

Per cent of total

C .4 .275

ARE SHOE COVERS OR OPERATING BOOTS WORN ROUTINELY?

136 40 176

Yes No Total Not applicable TABLE

77 .3 22.7

32

C.4.276

ARE SURGEONS' CHANGE ROOMS EQUIPPED WITH SHOWERS?

152 23 175

Yes No Total Not applicable TABLE

86 .9 13 .1

33

C.4.277

Do SHOWERS SEPARATE CHANGE ROOMS INTO CLEAN AND DIRTY AREAS?

27 123 150

Yes No Total Not answered Not applicable

TABLE

18.0 82 .0

2 56

C.4.278

DEPARTMENT(S) RESPONSIBLE FOR CLEANING OF OPERATING ROOM SUITES Housekeeping Nursing Both Total Not applicable

TABLE

12 18 147 177

6.8 10 .2 83.0

31

C.4.279

IF BOTH NURSING AND HOUSEKEEPING DEPARTMENTS SHARE THE CLEANING OF THE OPERATING SUITE, ARE THE CLEANING AREAS SO DEFINED THAT EACH DEPARTMENT IS AWARE OF ITS OWN RESPONSIBILITY? Yes No Total Not answered Not applicable

141 4 145 3

60

97 .2 2.8

APPENDIX

Number

C 313

Per cent of total

TABLE C.4.280 INTERVALS AT WHICH FLOORS OF OPERATING ROOMS ARE WET MOPPED

After each operation After each major operation Twice daily Daily After each operation and daily After each major operation and daily Other (not specified) Total Not applicable

101 30 6 25 6 2 7 177 31

57 .1 16 .9 3.4 14.1 3 4 1 1 4.0

14 98 7 15 6 8 24 172 4 32

8 1 57 0 4 1 8 .7 3.5 4 .6 14 .0

40 10 21

23.1 5.8 12.1 50.9 1.7 6.4

TABLE C .4 .281 INTERVALS AT WHICH OPERATING ROOM FLOORS ARE SCRUBBED

Twice daily Daily Twice weekly Weekly Every two weeks Less often than every two weeks Other (not specified) Total Not answered Not applicable TABLE C 4.282 INTERVALS AT WHICH FLOORS OF SCRUB ROOMS ARE WET MOPPED

After each operation After each major operation Twice daily Daily After each operation and daily Other (not specified) Total Not answered Not applicable

88

3

11

173 2 33

TABLE C.4.283 INTERVALS AT WHICH SCRUB AND ANESTHESIA ROOMS ARE SCRUBBED

After each major operation Daily Twice daily Twice weekly Weekly Every two weeks Other (not specified) Total Not answered Not applicable

10 97 10 4 12 5 24 162 10 36

6.2 59.9 6 .2 2 .4 7.4 3.1 14 .8

314

THE CONTROL OF INFECTIONS IN HOSPITALS

Number TABLE C .4 .284 INTERVALS AT WHICH LOWER WALLS ARE WASHED ROUTINELY Daily Every two days Weekly Monthly Other (not specified) Total Not applicable TABLE C.4 . 285 INTERVALS AT WHICH UPPER WALLS AND CEILINGS ARE WASHED ROUTINELY Twice weekly Weekly Every two weeks Monthly Every three months Every six months Other (not specified) Total Not answered Not applicable TABLE C .4 . 286 CLEANING SOLUTIONS USED IN SURGICAL Detergent and water Detergent and disinfectant Disinfectant and water Other (not specified) Total Not answered Not applicable

36 3 76 32 30

177

Per cent of total

20.3 1. 7 42.9

18.1 17.0

31

1

33 8 55 29 22 28

176

.6

18 .8 4.5

31.2 16 . 5 12 . 5 15 .9

1

31

AREA

TABLE C.4 .287 DISINFECTANT USED FOR CLEANING SURGICAL Dettol 2% Di-Crobe D.R.X. Germicidal detergent Hibitane 1:5000 Lysol 3% Lysol 5% Pine oil Wellodyne Wescodyne Zephiran 1:1000 More than one disinfectant used Other (not specified) Total Not answered Not applicable

19 97 48 8 172 5 31

11 .0 56.4 27 .9

4.7

AREA

7 3 34 1 6 7 1 4 43 1 9

27 143 12 53

4 .9

2.1

23 .8 .7

4 .2 4 .9

.7 2 .8 30 .0 .7 6.3 18 . 9

APPENDIX

Number

C 315

Per cent of total

TABLE C .4 .288 ARE HOUSEKEEPING PERSONNEL SPECIFICALLY ASSIGNED TO THE OPERATING SUITE?

Yes No Total Not answered Not applicable

114

59

173

65 .9 34.1

4

31

TABLE C .4.289 ARE ANESTHETISTS PERMITTED TO WEAR OPERATING ROOM CLOTHING WHEN~VISITING PATIENT.. 'AREAS?

Yes

No Total Not answered Not applicable

126 48 174 1 33

72.4 27.6

TABLE C.4.290 ARE ANESTHETISTS REQUIRED TO WEAR A CLEAN COAT OVER THEIR CLOTHING WHEN LEAVING SURGICAL AREA?

Yes No Total Not answered Not applicable

75 52

127

59.1

40.9

1

80

TABLE C .4 .291 IF A CLEAN COAT IS NOT REQUIRED, ARE ANESTHETISTS REQUIRED TO PUT ON FRESH CLOTHING BEFORE REENTERING OPERATING SUITE?

Yes

No Total Not answered Not applicable

42 37 79

53.2

46.8

2

127

TABLE C.4 .292 ARE ANESTHETISTS REQUIRED TO SCRUB BEFORE EACH OPERATION?

Yes No Total Not answered Not applicable

62 111 173 2

33

35 .8 64 .2

316

THE CONTROL OF INFECOONS IN HOSPITALS

Number TABLE C .4 .293 INTERVALS AT WHICH ANESTHESIA MACHINES ARE DISINFECTED After each operation Twice daily Daily Twice weekly Weekly After each operation and daily After each operation and weekly Other (not specified) Total Not answered Not applicable TABLE C.4.294 CHEMICAL DISINFECTANTS USED TO WIPE OFF ANESTHESIA MACHINES Alcohol 70% Detergent and water 2% Hexachlorophene liquid soap Hibitane .5% (in ethyl alcohol 70%) ~isoHex a~ and water Ze~ iran 1:1000 (in water solution) Ot er (not specified) Total Not answered Not applicable TABLE C.4.295 Is ETHYLENE OXIDE GAS EVER USED TO DISINFECT . ANESTHESIA MACHINES? Yes No Total Not answered Not applicable TABLE C .4 .296 METHOD OF DISINFECTION USED FOR ENDOTRACHEAL TUBES, AIRWAYS, ETC. Autoclaving Boiling Chemical disinfection Ethylene oxide vapor Washing with soap and water ..

69 2 83 1 7 1 1 4 168

Per cent of total

41.1 1.2 49.4 .6 .. 4.1 .6 .6 2.4 .

3 37

22 28 19 1 1 22 8 67 168

13 . 1 16 . 6 11 .3 .6 .6 13.1 4 .8 39 .9

3 37

0 165 165

0.0 100 . 0

7 36

15 7 51 2 36

8.6 4 .0 29.1 1.1 20 .6

APPENDIX

TABLE C.4.296 continued Autoclaving and chemical disinfection Autoclaving, chemical disinfection and washing with soap and water Autoclaving and washing with soap and water Chemical disinfection and washing with soap and water Other (not specified) Total Not applicable TABLE C.4.297 CHEMICAL USED FOR DISINFECTION OF AIRWAYS AND ENDOTRACHEAL TUBES Alcohol 70% (ethyl) Alcohol 70% (propyl) Cystan Detergicide 1: 1000 Green soap 2% Hexachlorophene liquid soap Lysol 2% Lysol 3% Lysol 5% pHisoHex Wescodyne Zephiran 1:1000 (in water solution) More than one solution Other (not specified) Total Not applicable TABLE C .4.298 ARE FACE MASKS DISINFECTED AFTER EACH USE? Yes No Total Not answered Not applicable TABLE C .4.299 IF NOT DISINFECTED, ARE FACE MASKS WASHED WITH SOAP AND WATER AFTER USE? Yes No Total Not applicable

C 317

Number

Per cent of total

7

4.0

4 9

2.3 5.1

33 11 175

18 .9 6.3

33

5 4

1

5 10 9 3 1 2 4 23 33 9 15 124

4 .0 3.2 .8 4 .0 8.1 7 .3 2.4 .8 1.6 3 .2 18.6 26 .6 7.3 12.1

84

76 95 171

44 .4 55 .6

2 35

102 3 105 103

97 . 1 2.9

318

THE CONTROL OF INFECllONS IN HOSPITALS

ADDITIONAL QUESTIONS Number

Per cent of total

125 47 172

72 .7 27.3

TABLE C.4.300 ARE CONDUCTIVE FLOORS USED THROUGHOUT OPERATING ROOM SUITE?

Yes No Total

4 32

Not answered Not applicable

TABLE C.4 .301 ARE "NO SMOKING" SIGNS PROMINENTLY DISPLAYED IN CORRIDORS OF OPERATING AND DELIVERY ROOMS?

Yes No Total

84

86 170

49 .4 50 .6

5

Not answered Not applicable

33

TABLE C.4.302 Is THERE YEAR ROUND

CONTROL OF TEMPERATURE AND

HUMIDITY?

95

Yes No Total

75 170

Not answered Not applicable

TABLE C .4.303 UsuAL TEMPERATURE 66-70°F 70-76°F 76-82°F Other (not specified) Total Not answered Not applicable

55 .9

44 .1

6

32

OF OPERATING ROOMS

16 102 31 17 166 8 34

9 .6 61.5 18.7 10.2

APPENDIX

Number

C 319

Per cent of total

TABLE C.4 .304 RELATIVE HUMIDITY OF OPERATING ROOMS

25-35% 35-45% 45-55% 55-65% 65% and over

Other (not specified) Total Not answered Not applicable

4

14 49 36 11 9

123

3.3 11.4 39.8 29.3 8.9 7 .3

43 42

TABLE C.4.305 NUMBER OF AIR CHANGES PER HOUR IN OPERATING ROOMS

8 10 12 15

16 10 20

Other (not specified) Total Not answered Not applicable

11

39 96

16 .7 10 .4 20.8 11.5 40 .6

64 48

TABLE C .4.306 ARE ELECTRIC SWITCHES (IN OPERATING ROOMS) EXPLOSIVE PROOF? Yes No Total Not answered Not applicable

TABLE C.4.307 ARE CONTACTING DEVICES, (e.g. DRAG CHAINS) INSTALLED ON MOVABLE EQUIPMENT IN THE ANESTHESIA AREA? Yes No Total Not answered Not applicable

152 22 174

87 .4 12.6

2 32

120 49 169 6 33

71.0 29 .0

320

TIIE CONTROL OF INFECTIONS IN HOSPITALS

Number TABLE

Per cent of total

C.4.308

ARE BREATHING BAGS, RUBBER TUBES AND MASKS, OF GOOD QUALITY CONDUCTING RUBBER?

173 1 174

Yes No Total Not answered Not applicable TABLE

Is

99.4 .6

2 32

C.4.309

OPERATING-ROOM FURNITURE, (e.g. INSTRUMENT TABLES, STOOLS, ETC.) OF STEEL, CHROME, OR CONDUCTIVE ALUMINUM CONSTRUCTION?

166 6 172

Yes No Total Not answered Not applicable TABLE

96.5 3.5

4 32

C .4.310

ARE WOOLLEN BLANKETS EXCLUDED FROM ANAESTHETIZING LOCATIONS?

172

Yes No Total

1

Not answered Not applicable TABLE

Is

173 2 33

99.4 .6

C.4.311

PLASTIC SHEETING EXCLUDED FROM ANAESTHETIZING LOCATIONS?

Yes

No

Total Not answered Not applicable TABLE

163 10 173 2 33

94.2 5.8

171 3

98.3 1.7

C .4.312

ARE OPERATING ROOM PERSONNEL REQUIRED TO WEAR COTTON UNIFORMS? Yes No Total Not answered Not applicable

174

2 32

APPENDIX

Number

C

321

Per cent of total

TABLE C.4.313 ARE OPERATING ROOM PERSONNEL REQUIRED TO WEAR CONDUCTIVE FOOTWEAR?

Yes No Total Not answered Not applicable

113 59 172

65.7 34 .3

4

32

TABLE C.4.314 ARE HOSIERY AND UNDERGARMENTS OF SYNTHETIC FABRICS (i.e. NYLON) PERMITTED TO BE WORN UNDER COTTON UNIFORMS?

Yes No Total Not answered Not applicable

131 41 172

76.2 23.8

4

32

TABLE C.4.315 ARE CONDUCTIVE MATTRESSES USED ON DELl\'ERY OR SURGICAL TABLES?

Yes No Total Not answered Not applicable

147 25 172

85.5 14.5

3

33

TABLE C.4.316 IF CONDUCTIVE MATTRESSES ARE NOT USED, ARE MATTRESSES COVERED WITH CONDUCTIVE RUBBERIZED SHEETING?

Yes No Total Not answered Not applicable

25

4

29

86 . 2 13.8

3

176

TABLE C.4 .317 ARE SEVERAL SMALL CARBON DIOXIDE EXTINGUISHERS LOCATED IN STRATEGIC AREAS OF OPERATING SUITE?

Yes No Total Not answered Not applicable

142 29 171 5 32

83 .0 17.0

322

TIIE CONTROL OF INFECTIONS IN HOSPITALS

Number

TABLE C .4 .318 ARE FLAMMABLE GERMICIDES

Per cent of total

USED FOR PRE-OPERATIVE

SKIN PREPARATION?

Yes No Total Not answered Not applicable

74

95

169 8 31

43 .8 56.2

D. Scoring of Selected Questions

D.l. Section I(A): NON-ISOLATION TECHNIQUES 0 .1.l.

TIIERMOMETER TECHNIQUE

.I Please check thermometer technique used: (a) Individual ( b) Non-individual (c) Both 0 .1.2.

) )

2 0 I

(

) )

I 0

( ( (

) ) )

0 2 I

( (

) )

I 0

( ( (

) ) )

2 0 I

(

) )

I 0

MEDICINE CUP TECHNIQUE

.I If glass or plastic medicine cups used, are they disinfected after each use? (a) Yes (b) No .2 If medicine cups are disinfected after each use, please check method used for disinfection: (a) Boiling ( b) Autoclaving ( c) Chemical disinfection 0.1.3.

)

URINAL TECHNIQl'E Are individual bedpans used? (a) Yes (b) No Please check method used in terminal disinfection of individual bedpans: (a) Autoclaving ( b) Free flowing steam ( i.e. bedpan sterilizer) ( c) Chemical disinfectant Are individual urinals used? (a) Yes (b) No Please check type of cover used for bedpans and urinals: (a) Cloth ( b) Disposable

(

BEDPAN AND

.I .2

.3 .4

(

( (

0 I

324

nm CONTROL OF INFEcnONS IN HOSPITALS

0.1.4

TECHNIQUE USED IN CARING FOR ENEMA EQUIPMENT

.I li "Fleet" enemas or equivalent are not used

D.1.5.

routinely, is complete enema equipment disinfected after each use? ( (a) Yes ( (b) No

) )

0

.2 Method of disinfection used for enema equipment: ( (a) Autoclaving ( (b) Boiling ( c) Chemical disinfection (

) ) )

2 0 1

.3 If "Fleet" enemas or equivalent are not used routinely by the Department of Radiology, is complete enema equipment disinfected after each use? ( (a) Yes (b) No (

) )

0

I

I

STERILE DRESSING TECHNIQUE

.1 Please check place where dressings are done: ( (a) Treatment room ( ( b) Dressing room ( (c) Ward ( ( d) All three

)

)

2 3 0

.2 Is provision made for clean and dirty dressing areas? ( (a) Yes ( (b) No

) )

0

) )

.3 Are dressing carts or carriages used routinely? (a) Yes (b) No

I

I

0

1

.4 Is there a separate dressing cart or carriage for

contaminated cases? (a) Yes (b) No

.5 Are masks worn while doing dressings? (a) Yes · (b) No .6 Are sterile gloves used when doing contaminated dressings? ( (a) Yes ( (b) No

1

) )

0

) )

0

1

1 0

APPENDIX

.7 Are contaminated instruments disinfected before being returned to Central Supply Room for sterilizing? (a) Yes ( (b) No (

) )

.8 Are contaminated dressings discarded in a special container? ( e.g. waxed bag, etc.) (a) Yes ( (b) No ( D.1.6.

D 325

1 0

1 0

WARD HOUSEKEEPING TECHNIQUES

.1 Please check which department is responsible for general cleaning of unit or ward: (a) Housekeeping • (b) Nursing (c) Both

) ) )

2

.2 Is the ward cleaning time arranged between the nurse in charge and the executive housekeeper? (a) Yes (b) No

) )

1 0

.3 Are cleaning solutions impregnated with a disinfectant? (a) Yes ( (b) No ( .4 Are individual blankets used? (a) Yes (b) No

( (

1

0

1

0

) )

1 0

) )

1 0

D.2. Section I(B): ISOLATION TECHNIQUES D.2.1.

GENERAL

.1 Are all cases of known staphylococcal infection isolated and treated as communicable? (a) Yes (b) No .2 Can the nurse in charge temporarily isolate suspected cases without a doctor's order? (a) Yes ( (b) No (

.3 Is there a formal program for interns on the principles of aseptic techniques? (a) Yes ( (b) No (

1 0

) )

1 0

326

THE CONTROL OF INFECTIONS IN HOSPITALS

.4 Please check type of isolation gown used: (a) Long sleeved ( b) Short sleeved

( (

)

)

0 I

) ) ) )

3 2 I 0

) )

I 0

)

2

) )

I 0

) )

)

2 0 I

.5 How often are gowns changed routinely? (a) ( b) (c) (d)

After each use After each shift Daily Less often than daily

( (

(

(

.6 Please check soap used for scrubbing: ( (a) Ordinary toilet soap ( (b) Green soap ( c) Soap or detergent with hexachlorophene ( added

D.2.2.

THERMOMETER TECHNIQUE

.I Are individual thermometers used? (a) Yes (b) No

( (

.2 Please check method of disinfection used for individual thermometers: (a) Concurrent ( (b) Terminal ( (c) Both ( D.2.3.

D.2.4.

FOOD MANAGEMENT AND MEDICATION TECHNIQUE

.I Are disposable dishes used? (a) Yes (b) No

( (

) )

I 0

.2 Are disposable medicine cups used? (a) Yes (b) No

( (

) )

I 0

.I Please check which department is responsible for cleaning of isolation unit: (a) Nursing ( ( b) Housekeeping ( (c) Both (

) ) )

0 I 2

.2 Please check method of mopping used for floors of patient areas: (a) Wet ( (b) Dry ( (c) Both (

) ) )

2 0 I

ISOLATION HOUSEKEEPING TECHNIQUE

3Z7

APPENDIXD

.3 Please check how often floors of patient areas are mopped: (a) Daily ( ( b) Every two days ( (c) Weekly ( ( d) Less often than weekly (

) ) ) )

3 2 1 0

.4 How often is general dusting of furniture, bed-

frames, windowsills, cupboards, etc., carried out? ( (a) Daily ( ( b) Evez two days ( (c) Wee y ( (d) Less often than weekly

3 2 1 0

.5 Please check type of dusting carried out: (a) Damp (b) Dry (c) Both

( ( (

) ) )

2 0 1

( (

) )

1 0

)

1 2

.6 Are cleaning detergents impregnated with a disinfectant? (a) Yes (b) No

.7 Are bedside utensils ( i.e. bedpans, wash basins,

emesis basins, etc.) sent to a central area for sterilization upon discharge of patient? ( (a) Yes ( (b) No

)

.8 Is contaminated linen placed in a specially marked laundry bag? (a) Yes (b) No

( (

1 0

.9 Please check kind of blanket used: ( (a) All wool ( (b) Wool plus synthetic fibre (e.g. nylon) ( c) Cellular cotton, terry towelling or terylene (

0 1 2

.10 Are all blankets disinfected routinely after discharge of patient? ( (a) Yes ( (b) No

1

) )

0

) )

1 0

.11 Are all pillows disinfected routinely after discharge of patient? (a) Yes (b) No

( (

3~

THE CONTBOL OF INFEGnONS IN HOSPITALS

D.3. Section II: HOUSEKEEPING TECHNIQUES D.3.1.

GENERAL HOUSEKEEPING TECHNIQUES

.1 Please check method of mopping used for floors of patient areas: (a) Wet ( (b) Dry ( (c) Both (

) ) )

2 0 1

.2 Are all cleaning detergents impregnated with a disinfectant? ( (a) Yes (b) No (

) )

1 0

.3 Are fresh mopheads issued daily? (a) Yes (b) ,No

( (

) )

1 0

.4 Are cleaning personnel assigned to specific hospital areas? (a) Yes ( ( (b) No

) )

1 0

.5 Please check how often patient areas are wet mopped: (a) (b) (c) (d)

(

Daily Every two days Weekly Less often than weekly

3 2 1 0

( ( (

.6 Are bathroom floors wet mopped daily? (a) Yes (b) No

( (

) )

1 0