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. discharging lesion on any part of the body; any Full isolation requires nurses who do not attend septic lesion, whether discharging or not, on the uninfected patients, and a separate room for each hand or forearm. patient in a building set away from the general wards. Isolation units such as this are not part of the usual SYMPTOMLESS CARRIERS The routine seeking and hospital design in Britain but they have some- exclusion from duty of all carriers of pathogenic times been improvised during an emergency and, organisms amongst ward staff is impracticable and remaining in use afterwards, have shown their probably not necessary. As with the patients, value by apparently limiting the spread of infection however, it may be needed during an outbreak due from occasional septic patients during non-epidemic to a clearly recognizable organism. Carriers of times. Staph. aureus are detected by swabbing the anterior Only recently has the number of isolation rooms nares. Phage typing should be used to identify the required for the control of infection become the epidemic strain and antibiotic sensitivity patterns subject of quantitative study. Results of current are sometimes useful for more rapid but partial studies are not yet available but it seems likely that identification. Clearance of the carrier state is often at least 30% of surgical and 15% of medical beds difficult but treatment that sometimes succeeds is will be required. In most British hospitals such the thrice-daily application of neomycin-chlor- generous isolation facilities are not yet available and hexidine cream' to the noses of carriers for 10 days. until they are, anything approaching full control of In addition when washing and bathing they should staphylococcal infection will be difficult. regularly use toilet soap2 or cream3 containing Segregation During an outbreak of sepsis when hexachlorophene or tetrachlorsalicylanilide4. Per- there are more patients for isolation than there are sistent skin carriage is often controlled by the rooms to put them in, an acceptable substitute for permanent use, both on and off duty, of these soaps even though carriage by the nose remains un- isolation is segregation, whereby infected patients copyright. are collected together in a special ward. This does controlled. not, of course, prevent them from re-infecting each other and it is a method that can only be accepted if MECHANICAL CONVEYANCE OF ORGANISMS BY WARD there is no possibility of proper isolation. It is, STAFF Contamination of hands, and spread from however, infinitely preferable to leaving the septic them, can be reduced by applying these rules: and clean patients together in the same ward. Use forceps or rubber gloves for all wound dressings and examinations and for handling drainage tubes, tracheal tubes, catheters, and other http://jcp.bmj.com/ PREVENTION OF INFECTION FROM WARD STAFF heavily contaminated objects. INFECTIOUS DISEASES Members of the hospital staff Wash the hands before and after any procedure who remain on duty with even minor infections may for which gloves, forceps, or sterilized equipment be more dangerous than patients suffering from are used; after changing an infant's napkin or serious infective conditions. Nurses and doctors, dressing the umbilicus; after rounds of temperature perhaps from a mistaken sense of duty, often con- taking, bedmaking, or bedpans; after any item of tinue to attend patients while suffering from a sore service for a patient who is (or should be) isolated; on September 27, 2021 by guest. Protected throat, undiagnosed diarrhoea, purulent discharge after defaecation and before and after each spell of from nose or ear, or staphylococcal sepsis such as ward duty. generalized furunculosis, boils, styes, paronychia, For all these purposes a 'surgical scrub' probably and septic cuts or burns. Nurses are sometimes has no advantage over thoroughly washing the hands discouraged from reporting sick for these 'trivial' with soap and water and drying them on a clean and doctors believe that their services towel. Conveyance of pathogens is reduced if the reasons many soap contains hexachlorophene (Lowbury and are too valuable for them to hand over to a colleague and for a few days. It is not easy to lay down general Lilly, 1960). Automatic roller-towel dispensers rules for behaviour of staff during minor illness or good-quality paper towels are both satisfactory and sepsis but the minimum requirements (apart from should replace the communal towel. It may some- the obvious ones) should be: times be preferable to use a sterile towel but when for until this is not done drying the hands on a clean but Completely off duty diarrhoea proved than them wet. bacteriologically safe, sore throat; one large dis- unsterilized towel is safer leaving charging staphylococcal lesion; generalized furuncu- I Naseptin cream (Imperial Chemical Industries Ltd.). 2Derl (Roberts Windsor Ltd.); Cidal (Bibby Ltd.). losis with several discharging lesions. 3Phisohex (Bayer Products Ltd.). Not to assist at any aseptic procedure (e.g., wound 'Breeze (Crosfields (C.W.G.) Ltd.). J Clin Pathol: first published as 10.1136/jcp.14.1.18 on 1 January 1961. Downloaded from

Control ofinfection in hospital wards 21

Clothing The aprons and dresses of nurses My purpose here is not to enumerate all the dis- attending infected patients, especially children who infection procedures that might do some good, but must often be lifted and carried, are sometimes to suggest, in the light of available evidence though heavily contaminated after only one day's wearing without quoting it all in detail, minimum standards (Potter and Blowers, unpublished observations in a for environmental hygiene in hospital wards. Still burns unit). Thus there seems some justification for higher standards may be desirable but those sug- a one-piece uniform, changed daily, instead of the gested are by no means universal and should serve usual daily clean apron and a dress that is worn for as reasonable targets for the next few years. a week. Besides its possible bacteriological advan- tages, this means one less item of laundry each WALLS, FLOORS, CEILINGS, AND FURNITURE The week than does the older system. number of pathogens on these surfaces can be kept Cotton gowns offer only incomplete protection low by applying high standards of domestic cleanli- against contamination in either direction but they ness. This means that floors should be washed each seem to be of some value (Cook, Parrish, and morning, and dust and fluff should be taken up Shooter, 1958) so they should be worn over the by vacuum cleaner after bed-making rounds. For uniform at least during wound dressings and routine purposes, mopping with very hot water, at during attention to patients in isolation. Im- not less than 70°C. (160°F.), and a synthetic pervious plastic gowns, disinfected by wiping with a detergent is sufficient. The routine use of disin- hypochlorite solution containing 1% available fectants for washing floors gives little better results chlorine1, give better protection and seem preferable and most of those cheap enough for the purpose to cotton gowns for barrier nursing and isolation cause a persistent and unpleasant smell. Bacteria techniques. may multiply profusely in dirty mops and buckets of water if these are left for several hours. After CONTROL OF ENVIRONMENTAL CONTAMINATION each use the bucket and mop should therefore be rinsed with boiling water. For many years, and especially in the last few, Broom-sweeping often raises as much dust as it copyright. bacteriologists have been busy discovering inanimate collects, and slit-sampling shows an enormous reservoirs of pathogenic organisms in hospitals increase in the number of airborne organisms while walls, floors, ceilings, and furniture; bed-clothes, it is going on. This can be reduced by oiling the curtains, and crockery; and the air-while methods floors but the process is only really satisfactory for for disinfecting them have been increasing the cost wood and not for modem non-absorbent floors. and complexity of ward management. These The best solution is to discard brooms and use activities should certainly not be discouraged, vacuum cleaners. Built-in suction points have some http://jcp.bmj.com/ because the discovery of reservoirs and the in- advantages but are expensive to install and are less vention of methods for disinfecting them are convenient than portable electric machines. Else- essential preliminaries to the full study of such where in this issue, Dr. Bate discusses the types of organisms. It cannot be denied that disinfection of machine that are safe for use in hospital (page the whole environment is essential when there has 32). been known heavy contamination with dangerous Walls and ceilings cannot conveniently be cleaned organisms. The need for frequent and energetic as often as floors; nor does this seem necessary on September 27, 2021 by guest. Protected environmental decontamination at other times is because dust collects on them more slowly and is less certain. Theoretically, it should reduce the less often disturbed from them than from floors. risk of infection at any time, but whether or not Perhaps a reasonable rule to follow here is that they it does so significantly has not been conclusively should never be visibly dirty. The washing methods shown. Unfortunately, clear evidence on this already described for floors should therefore be point is not easy to obtain because, as has already applied often enough to ensure this. It is a disturbing been pointed out, the complexity of bacterial thought that there are still hospitals where even this spread makes the evaluation of each pathway very standard is not reached. difficult. Enthusiasts for particular methods will no Ledges, furniture, and beds should be dusted doubt continue to apply them but it is hoped that daily with a damp cloth. they will accept responsibility for the steady, even These are the routine methods. If, however, an though laborious, collection of evidence to support isolation room has been occupied by a patient their views, rather than becoming tedious crusaders suffering from infectious disease (and this includes for unproven causes. staphylococcal sepsis) specific decontamination is I For example, Chloros (Imperial Chemical Industries Ltd.) diluted I needed. The whole room may be treated by sealing in 10, wiped on and left to dry. it, spraying water to increase humidity, then J Clin Pathol: first published as 10.1136/jcp.14.1.18 on 1 January 1961. Downloaded from

22 Robert Blowers generating formaldehyde and leaving the room perhaps summarized by the experiences of Gillespie closed for six hours. For each 1,000 cu. ft. of room et al. (1959) and Gillespie, Simpson, and Tozer space, 5 oz. (150 g.) potassium permanganate is (1958) who found that regular blanket disinfection added to 10 oz. (280 ml.) of formalin. Sulphur as the only new precaution had no detectable dioxide is ineffective. A satisfactory and often more influence on Staph. aureus sepsis or carrier rates, convenient method is to wash all surfaces, furniture, but when applied with other precautions appeared and the bed with hypochlorite solution (see footnote to play a part in their control. on page 21) to which has been added some household Whether or not this fairly expensive routine is detergent. wholly justified on bacteriological grounds, apart If a septic patient has been barrier-nursed in an from its obvious aesthetic desirability, remains to open ward, it may suffice to wipe over the bed and be shown. In the meantime, the following routine bedside furniture in this way. But if a large ward is suggested as a minimum standard: has been closed because of widespread sepsis it (1) Sheets should be laundered at least weekly should not be re-opened until the whole room has and whenever a bed is vacated. been disinfected by one of these methods. (2) Blankets, mattresses, and pillows should be disinfected (a) every three months; (b) whenever SCREENS AND CURTAINS Separate pull-round cur- visibly soiled; (c) after use by any infected patient tains for each bed in an open ward harbour more who has been isolated or should have been isolated dust than a few sets of portable screens. Their according to the indications already given; (d) after social advantages are so great, however, that it use by every patient during an outbreak that has seems unjustifiable to condemn them on theoretical resisted the routine precautions; (e) before re- and unevaluated bacteriological grounds. It is opening a ward that has been closed because of arbitrarily suggested that the curtains be removed infection. and disinfected each month, when the overhead Woollen blankets may be disinfected by washing rails and runners should also be damp-dusted. them at the usual low temperature and using a Cotton curtains should be of colour-fast material so detergent combined with a quaternary ammoniumcopyright. that they may be laundered, and thus disinfected by or other suitable disinfectant substance'. It was boiling. Plastic materials have the theoretical once hoped that incorporation of the disinfectant advantage that they can be wiped with a disinfectant in the last rinse instead of the washing stage would in situ or in a ward annexe; but this occupies more confer self-disinfecting properties on the blankets. of the ward staff's time than removing cotton But though fibres from blankets so treated cause curtains and sending them to the laundry, so is zones of inhibition on a culture plate seeded with often postponed for long periods. Thompson and staphylococci, there is no appreciable killing of http://jcp.bmj.com/ Webb (1960) describe fibre-glass curtains which organisms in the blanket itself during use, presum- can be washed at high temperature in the laundry ably because the disinfectant does not act when dry. or may be dipped in a disinfectant in the ward Woollen blankets may also be disinfected by high- annexes and re-hung almost immediately. temperature washing provided this is just below boiling point (British Launderers' Research Asso- BEDDING There is no doubt that bed-clothes can ciation and International Wool Secretariat, 1959). become heavily contaminated with pathogenic This causes no more damage to the blankets than on September 27, 2021 by guest. Protected organisms from a patient's lesions or from sites of the low-temperature wash but woollen blankets will symptomless carriage. Sheets are adequately dis- stand only about 60 washes in any case, so dis- infected by the boiling they normally get during infecting them regularly must always be fairly laundering; but hospital blankets are rarely washed, expensive. Cotton cellular or terry-towelling blankets and then only by a low-temperature process which are easily disinfected by washing at boiling point or neither removes nor destroys bacteria. It is argued just below and will stand several hundred such that contaminated blankets, carrying organisms treatments (Blowers, Potter, and Wallace, 1957). from a long succession of patients in each bed, may For pillows and mattresses enclosed in plastic directly infect a new occupant, that organisms covers, it is usually sufficient to wipe the covers with scattered from them into the air during bed making hypochlorite solution. may help to maintain high nasal carrier rates of staphylococci derived from septic lesions; and that CROCKERY This should be washed, or rinsed after hospital beds should therefore be equipped with washing, in water at 60°C. (140°F.). blankets for each new occupant. The disinfected I For example, Vantropol BQ (Imperial Chemical Industries Ltd.); theoretical advantages of this are clear, but there are Hytox (Domestos Ltd.); Steravol (Laporte Ltd.); Comprox-panacide conflicting reports of its actual value. These are (B.P. Detergents Ltd.). J Clin Pathol: first published as 10.1136/jcp.14.1.18 on 1 January 1961. Downloaded from

Control of infection in hospital wards 23

NURSERY EQUIPMENT The most recently proposed method (Elek and Fleming, 1960) is to spray the ward with a new The procedures already given are obviously ap- synthetic penicillinase-resistant penicillin. This must plicable in nurseries but three pieces of equipment surely remain experimental until the properties of on which many babies are successively placed each the drug have been more fully studied. Before it can day need special attention. Nursery baths (and be contemplated as a routine measure, much more indeed baths in all wards) should be disinfected must be known about its effect in creating or after each use by the effective method of Boycott selecting resistant strains, in leaving the way open (1956). One to two gallons of very hot water are for serious Gram-negative and Candida infections, run into the bath; I fl. oz. of undiluted hypo- and in causing human sensitivity. At present, there- chlorite solution and enough domestic detergent fore, control of airborne infection in wards must for effective cleaning is added to it and the bath is still depend on preventing dissemination of thoroughly mopped with this mixture. The pans of organisms by isolation and by other techniques the baby scales should be wiped after each use with a already recommended. non-irritant disinfectant such as chlorhexidinel. This can be properly done only if metal or plastic SPECIAL TECHNIQUES pans replace the widely-used wicker ones. The tables on which babies are placed for changing their nap- Of the many special ward techniques that give kins or other attention should be similarly treated opportunity for infection, only two will be discussed and covered by a freshly laundered towel for each here: wound dressings and continuous drainage baby. But the risk of cross-infection is reduced if as methods. many as possible of these tasks are done with the babies in their own cots. WOUND DRESSINGS Techniques for wound dressings One other procedure of vital importance in the must allow no opportunity for infection to or prevention of nursery epidemics is the preparation from the wound by direct or indirect contact. and bottling of feeds for the babies. This should be Reliable methods for a dresser and assistant or for copyright. done by a nurse who does not handle the babies and an unassisted dresser are described in a Ministry in a department set aside and equipped for the of Health report (1959) so are not given in detail purpose. Suitable equipment and recommended here. The number of ward sisters and sister tutors methods cannot be fully discussed here and the who have neither seen nor heard of this publication reader is referred to the detailed recommendations is remarkable. Because the importance of training of Perkins (1956). nurses in the control of infection is so great this deficiency should be put right. http://jcp.bmj.com/ THE AIR There is yet no conclusive evidence of the The setting of dressing trolleys is simplified and importance of airborne infection in wards. Direct thus made safer by using individual dressing packs, infection by this route of properly covered surgical disposable gallipots, and disposable paper bags for wounds seems unlikely, but staphylococcal infection dirty dressings. of the respiratory tract causing pneumonia or One further improvement in dressing technique symptomless nasal carriage seem real possibilities. is now available, namely, the use of water-repellent Plenum ventilation with a high exchange rate as dressing towels. The usual dressing towels are water- on September 27, 2021 by guest. Protected used in operation theatres would reduce the number absorbent so that wet instruments placed on them of airborne organisms but the cost of applying it to may be contaminated when the water soaks through a whole hospital would be enormous. Recircula- to an unsterile table top beneath (Fig. 1). It is some- tion ventilation of wards, with filtration to remove times necessary to put a towel over the bedclothes bacteria, is less expensive but its effect on infection around the wound and though instruments should is not known. Recirculation systems without not be placed on this, they sometimes are, when the filtration and serving a whole hospital may actually risk of contamination is even greater. Some types of assist the spread of infection between wards. disposable paper dressing towels are even more Hudson, Sanger, and Sproul (1959) suggest absorbent than cotton so may increase rather than treating the air and entire ward contents with a reduce, as is claimed, the risk of infection. Cotton long-acting disinfectant, bis (n-tributyl) tin oxide. fabrics of the Ventile1 type do not allow water to This reduces the number of airborne organisms by soak through it unless it is very hot. These materials about four-fifths but the effect on infection is not are being successfully used for the sleeves of sur- yet known. geons' gowns to prevent skin organisms passing through to the wound when the sleeves are wetted, 1 Hibitane (Imperial Chemical Industries Ltd.); 0-5°% alcoholic solution or the I % obstetric cream are both effective for scale pans. I Messrs. John Southworth & Sons Ltd., Clitheroe, Lancashire. J Clin Pathol: first published as 10.1136/jcp.14.1.18 on 1 January 1961. 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24 Robert Blowers

FIG. 1. Wetforceps on an ordinary cotton dressing towel. FIG. 2. Wet forceps ont a Ventile cotton dressing towel. The water soaks through to the underlying surface, from Water remains as globules whichi neither wet the surface which the instrument may then be contaminated. nor pass through the material. as they often are during an operation. A more recent described by Williams, Blowers, Garrod, and application is to use Ventile fabrics for dressing Shooter (1960). towels to reduce the risk of contamination from underlying surfaces. Drops of water remaining on a CONTINUOUS SUCTION APPARATUS Surgery of the Ventile dressing-towel without soaking through are urinary tract is complicated by post-operative in- shown in Fig. 2. fection perhaps more often than any other type ofcopyright. Wound Dressing Rooms The value of specially surgery. Most of this infection depends on common ventilated wound dressing rooms has been clearly but avoidable faults of indwelling catheter drainage shown by Bourdillon and Colebrook (1946) and by systems. Pyrah, Goldie, Parsons, and Raper (1955) Lowbury (1954). For patients in open wards all and Miller, Gillespie, Linton, Slade, and Mitchell wounds, whether infected or clean, should therefore (1958, 1960) show that post-operative urinary sepsis be done in a specially equipped and ventilated is all but eliminated by using closed drainage appa- dressing-room. For patients already in isolation, ratus. In many wards, any urine drainage system http://jcp.bmj.com/ however, the dressing should be done in the isolation using a bunged bottle is accepted as a closed one but room unless it is so complicated that the special this is far from being so. Miller and his colleagues facilities of the dressing-room are essential. showed that even temporary disconnexion of the sys- A dressing-room that is used for septic work soon tem for bladder irrigation or for some other reason becomes a concentration area for pathogenic allowed infection to occur as often as did an open organisms unless it is thoroughly cleaned after every drainage system. Their apparatus, which is strongly session of dressings and unless it is specially ven- recommended, includes an irrigation attachment that on September 27, 2021 by guest. Protected tilated. Positive-pressure ventilation, as recom- can be used without breaking the closed system. mended by Bourdillon and Colebrook, prevents Failure to sterilize an already infected bladder is contamination of clean wounds with airborne often due to its constant reinfection by organisms organisms from the wards. For a dressing-room that that ascend from the accumulated urine in the is often used for septic wounds and closely com- bottle. This is prevented by putting 100 ml. of municates with a ward, however, this may cause formalin in the bottle. heavy contamination of the ward so a balanced Drainage from the thoracic cavity, too, often ventilation system with input and extraction fans of allows infection unless a closed system is used. For equal capacity is preferable. A rapid turnover of this, however, a disinfectant cannot be put in the air is needed and for rooms of up to 2,000 cu. ft., bottle because it may be aspirated into the chest a ventilation rate of 650 cu. ft. per minute will clear during coughing. Contamination of the fluid should heavy aerial contamination in about 10 minutes. be prevented by a cottonwool plug in the air outlet It is rarely possible to equip dressing-rooms with tube and by changing the bottles with the aseptic the complicated and expensive ventilation plant of care of a surgical operation. the type used in operating theatres. A simple and I am grateful to Dr. Stanley Wray and Mr. William inexpensive plant suitable for dressing-rooms is Bound for their help with the photographs. J Clin Pathol: first published as 10.1136/jcp.14.1.18 on 1 January 1961. Downloaded from

Control of infection in hospital wards 25

REFERENCES Hudson, P. B., Sanger, G., and Sproul, Edith E. (1959). J. Amer. med. Ass., 169, 1549. Blowers, R., Potter, J., and Wallace, K. R. (1957). Lancet, 1, 629. Lowbury, E. J. L. (1954). Lancet, 1, 292. Bourdillon, R. B., and Colebrook, L. (1946). Ibid., 1, 561 and , and Lilly, H. A. (1960). Brit. med. J., 1, 1445. 601. Miller, A., Gillespie, W. A., Linton, K. B., Slade, N., and Mitchell, Boycott, J. A. (1956). Ibid., 2, 678. J. P. (1958). Lancet, 2, 608. British Launderers' Research Association and International Wool Linton, K. B., Gillespie, W. A., Slade, N., and Mitchell, J. P. Secretariat (1959). High Temperature Laundering of Woollen (1960). Ibid., 1, 310. Hospital Blankets. London. Ministry of Health (1959). Central Health Services Council Report: Cook, Josephine, Parrish, J. A., and Shooter, R. A. (1958). Brit. Staphylococcal Infections in Hospitals. H.M.S.O., London. med. J., 1, 74. Perkins, J. J. (1956). Principles and Methods of Sterilization. Eichenwald, H. F., Kotsevalov, Olga, and Fasso, Lois A. (1960). Thomas, Springfield, Illinois. Amer. J. Dis. Child., 100, 161. Pyrah, L. N., Goldie, W., Parsons, F. M., and Raper, F. P. (1955). Elek, S. D., and Fleming, P. C. (1960). Lancet, 2, 569. Lancet, 2, 314. Gillespie, W. A., Alder, V. G., Ayliffe, G. A. J., Bradbeer, J. W., and Thompson, K. S., and Webb, Mary J. (1960). Ibid., 1, 286. Wypkema, W. (1959). Ibid., 2, 781. Williams, R. E. O., Blowers, R., Garrod, L. P., and Shooter, R. A. Simpson, K., and Tozer, Rosemary C. (1958). Ibid., 2, 1075. (1960). Hospital Infection. Lloyd-Luke, London. Hare, R., and Ridley, M. (1958). Brit. med. J., 1, 69. Wolinsky, E., Lipsitz, P. J., Mortimer, E. A. Jr., and Rammelkamp, -, and Thomas, C. G. A. (1956). Ibid., 2, 840. C. H. Jr. (1960). Lancet, 2, 620. copyright. http://jcp.bmj.com/ on September 27, 2021 by guest. Protected