Control of Infection in Hospital Wards

J Clin Pathol: first published as 10.1136/jcp.14.1.18 on 1 January 1961. Downloaded from J. clin. Path. (1961), 14, 18. Control of infection in hospital wards ROBERT BLOWERS Public Health Laboratory Service, Middlesbrough sviNopsis Some of the problems of ward management are reviewed. Methods suggested for dealing with them are probably not the ideals that should ultimately be attained but minimum standards to serve as immediate objectives. They concern indications for and methods of isolation, control of infection from staff, environmental contamination, and a few technical procedures. A new type of dressing towel for wounds is described. Infection acquired in a hospital ward may directly mind, the physician or surgeon must choose the cause disease; or it may create a symptomless methods that he will apply in his own wards. carrier. Efforts to control infection must concern There are, perhaps, four basic principles of ward both of these processes, because though a symptom- procedure for the control of infection: patients who less carrier himself suffers no immediate harm, he are especially liable to spread infection and those remains a source from which others may be more who are especially susceptible to it should not be seriously infected; moreover, he may re-infect him- accommodated in the same ward; the ward staff self if the organisms find their way from the site of should not themselves be dangerous sources or carriage to some more susceptible tissue. The success vectors of pathogenic organisms; the patients' copyright. of preventive measures must therefore be judged not inanimate environment should not become a only by their immediate effect on disease but also reservoir of pathogens; and ward techniques must by their control of carrier rates for pathogenic be those least liable to convey pathogens. For each organisms. of these principles, I make no attempt to define There are many ways by which bacteria may the ideals that are theoretically desirable. For the reach a patient, but none is necessarily more im- present it seems more useful to suggest the minimum portant than any of the others. So the value of standards we should try to reach. Nor can a review http://jcp.bmj.com/ many precautions that are now taken remains such as this cover all aspects of ward management. uncertain. The hope is sometimes expressed that Among the many important problems not considered with more detailed knowledge of the ways by which here are the pre-operative treatment ofskin, methods bacteria spread in a ward we may be able to con- for disposal of contaminated articles, and the centrate on only a few but vitally important pre- proper use of antibiotics. cautions, and to relax the many others that make our present system so tedious and so fallible. This hope ISOLATION AND SEGREGATION will be fulfilled only if bacteria behave themselves: on September 27, 2021 by guest. Protected if all species and all strains spread in the same way Here is a suggested list of infections for which at all times. There is no evidence that this is so and patients should be removed from an open ward. though some broad generalizations may be possible, They should also be moved when they are suffering categorical support or condemnation of any pre- from disorders making them particularly susceptible caution cannot be based on its success or failure on to infection, or when being treated with certain a particular occasion. Assessment of the value of drugs which enhance susceptibility to infection. precautions against infection is difficult for yet 1 THE ACUTE SPECIFIC FEVERS, e.g., measles, mumps, another reason. Gillespie, Alder, Ayliffe, Bradbeer, chickenpox, whooping-cough, scarlet fever (and and Wypkema (1959) found that several precautions, other streptococcal diseases), diphtheria. which by themselves had no discernible effect on infection rates, had a significant effect when applied 2 OPEN TUBERCULOSIS. together. Lack of effect from applying or with- 3 INTESTINAL INFECTIONS: (a) Shigella dysentery; drawing any one procedure must therefore be (b) Salmonella infections, i.e., typhoid and para- interpreted very cautiously. With these difficulties typhoid fevers, food poisoning, symptomless car- of interpretation and much conflicting evidence in riers; (c) E. coli enteritis of infants and symptomless 18 J Clin Pathol: first published as 10.1136/jcp.14.1.18 on 1 January 1961. Downloaded from Control of infection in hospital wards 19 carriers of locally pathogenic strains; (d) unexplained METHODS OF ISOLATION For the acute specific fevers diarrhoea. and intestinal infections the patient should be transferred to an infectious diseases hospital. For 4 STAPHYLOCOCCAL DISEASE. staphylococcal diseases needing surgical treatment 5 INCREASED SUSCEPTIBILITY TO INFECTION: (a) this is rarely practicable though when it is, full use Treatment with steroid drugs; (b) acute leukaemia, should be made of isolation hospitals, especially especially during treatment with marrow-toxic during a serious outbreak. The value of the various drugs; (c) agranulocytosis; (d) uraemia; (e) burns degrees of 'isolation' available in general hospitals and skin grafts. has not been defined and careful bacteriological studies are very much needed. Many of these indications are so obvious that no Barrier nursing in an open ward depends on justification is needed here. Of the others, staphy- eliminating infection by direct and indirect con- lococcal infections deserve special discussion. tact and may actually do this if an exceptionally It is remarkable that in many wards where high standard of nursing is assured. It cannot, elaborate precautions against staphylococcal in- however, prevent airborne infection though it is not fection are taken, little importance is attached to the yet certain how great a part this plays in the spread apparently obvious one of removing patients with of staphylococci in a ward. By studying the spread frank sepsis. Thus, patients who have been admitted of Staph. aureus from known infant carriers and with Staphylococcus aureus pneumonia, empyema, from one nurse, Wolinsky, Lipsitz, Mortimer, and osteomyelitis, breast and other abscesses, urinary Rammelkamp (1960) concluded that contact rather tract infection, and septic dermatitis are regularly than airborne spread accounted for almost all the treated in open wards alongside uninfected patients. infections. But individuals vary greatly in their Perhaps even more dangerous are those patients who powers of aerial dissemination of staphylococci became infected with staphylococci in hospital, (Hare and Thomas, 1956; Hare and Ridley, 1958; because the organisms involved are more often Eichenwald, Kotsevalov, and Fasso, 1960), and epidemic strains and resistant to antibiotics; in this studies of airborne spread will have to be made with copyright. category are patients suffering from Staph. auireus subjects who are known to be profuse 'dispersers' enterocolitis, septic burns, post-operative wound before final conclusions can be reached on the sepsis, and the various forms of neonatal sepsis. importance of this method of studying spread of When patients must be removed from an open infection. For all this, there are many examples of ward for any of these reasons more isolation accom- failure to control the spread of Staph. aureus by must barrier whether these are due to modation than is usual be provided, and until nursing, and, http://jcp.bmj.com/ it is available, some form of priority must be inadequacy of the system or failure to apply it devised. The very profuse discharge of organisms properly, it cannot be recommended as a reliable from patients with staphylococcal enterocolitis, method. pneumonia, septic dermatitis, and burns requires Isolation in a ward side-room is perhaps more that they should be isolated. For patients who have often successful but failures are many if the patient been infected in hospital and from whom organisms is simply moved into it and attended in the usual are discharging profusely the need for isolation is way by nurses who also have to deal with uninfected still more imperative. patients in the main ward. Side-ward isolation should on September 27, 2021 by guest. Protected It is sometimes objected, however, that isolating therefore always include the full ritual of barrier septic patients cannot be expected to control in- nursing as a safeguard against contact infection. fection while symptomless carriers of Staph. aureus Thus, all equipment needed for the patient is kept remain in the ward. This is probably true during a in the isolation room or is disinfected or destroyed major outbreak of sepsis caused by a highly virulent as soon as it is brought out; ward staff wear gowns organism, when it may indeed be necessary to (which are kept in the isolation area) and masks remove carriers of the epidemic strain, as well as when attending the patient and wash their hands the septic patients to break the chain of infection. before and after doing so. In non-epidemic times, however, most of the Isolation rooms for septic patients should be symptomless carriers harbour strains that seem to ventilated by simple exhaust fans discharging to the lack virulence or a high degree of transmissibility, outside so that air flows into them and not from and these patients can safely remain in a well- them to the main ward. For patients who are managed ward. But the organisms in actual lesions being isolated for protection against infection, air- have already proved their virulence and it seems flow in the opposite direction is theoretically needed unwise to give them an opportunity to prove their but a reasonable compromise is to switch off the powers of spread. exhaust fan and to rely on natural ventilation from J Clin Pathol: first published as 10.1136/jcp.14.1.18 on 1 January 1961. Downloaded from 20 Robert Blower-s an open window. The door of an isolation room inspection, wound dressing, or injection), with a should be kept closed.

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