- Email: [email protected]
Effects of patching on sterilization of surgical textiles
he development of nonwoven, disposable surgical gowns, drapes, and wrappers has generated a controversy in the hospital supply industry, which has spread to the OR nursing profession and hospital central service managers. Some advocate the continued use of woven, reusable fabrics, while others think that the nonwoven products are superior. The controversy is based on the ability of OR textiles t o meet three criteria: 0 Ability to be sterilized. Steam or ethylene oxide must be able to penetrate the material to permit complete sterilization of the textile and items and devices included in the pack. Barrier properties. The materials must act as an absolute barrier to microorganisms and dust particles. Wrappers must be resistant to moisture and mechanical injury, such as tearing or puncturing, to maintain sterile integrity of the pack’s interior after removal from the sterilizer. Economy. The per-unit cost of each item must be as low as possible. Disposables have been advocated because, after their initial cost, there is no further expenditure for laundry, patching, and repair. On the other hand, reusables cost more initially, but with each use, the per-unit cost decreases. If the fabrics are torn or punctured during their use, however, they lose their barrier quality, their life expectancy is shortened, and their economic advantage is diminished. To extend the life of woven fabrics and minimize replacement cost, holes are repaired with heat-sealed fabric patches. Do these patches interfere with sterilization? What is the maximum number of patches that may be used to repair a punctured or torn fabric, and where should they be placed? Current guidelines are based more on feelings about safety and esthetics than on scientific data.
T
Effects of patching on sterilization of surgical textiles V W Greene Gwen M Borlaug Evan Nelson
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1249
Moore suggests no more than five patches for a ten-inch square area.l Ryan simply warns that patches should be “extremely limited in number.”2 The only empirical data we could find is the work by Palmer, who covered two 54 x 54 inch wrappers with 300 heat-sealed patches and found no adverse effect on routine ~terilization.~ These guidelines are inconsistent. There a r e no d a t a to document a threshold level of patching below which sterility is achieved and above which it is impeded. In response to this, a Patching Task Force was organized in 1979with representatives from the Textile Rental Service Association, the Association of Operating Room Nurses, the American Society for Hospital Central Service Personnel, and the Association for Practitioners in Infection Contr01.~This
group listed the following questions that could be examined in a controlled research study: 1. Is the patched portion of a drape or wrapper penetrated by steam and, therefore, able to be sterilized? 2. Is the patched portion of a drape or wrapper penetrated by ethylene oxide (EO) and, therefore, able t o be sterilized? 3. Is there a limit to the percent of exposed surface area that can be covered by patching material and still permit the item to be sterilized? 4. Is there a maximum size of patch? Should several small patches be used to cover five separate holes that are close together, or could one larger patch be used? 5. What happens if two layers of patching are used, as might be the case if a large three-corner tear is
V W Greene, PhD, is professor of public health and microbiology, University of Minnesota, Minneapolis. He has a BSAfrom the University of Manitoba and a master’s degree and PhD from the University of Minnesota.
Health. He has a BS from the University of New Mexico, Albuquerque, and an M P H from the University of Minnesota School of Public Health.
Gwen M Borlaug, M P H , is assistant director,
Division of Chemistry, lab services section, North Dakota State Department of Health, Bismarck, ND. She has a BS from North Dakota State University, Fargo, and an M P H from the University of Minnesota. Evan Nelson, MPH, is a project assistant, University of Minnesota School of Public
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Acknowledgments The authors would like to express their appreciation to the 3 M Company, St Paul, for providing the ATTEST Biological Indicators. The help of their colleagues at the University of Minnesota, Myron Karki, Carol Freudenstein, Don Vesley and Mary Halbert, was invaluable. The project was funded by a research grant from the Textile Rental Services Association of America, Hallandale, Fla.
AORN Journat, June 1981,Vo133, No 7
mended with two patches? If the material is double-layered 140thread count, will EO and steam penetrate four layers of patches? 6. Does the mucilage from steam- or gas-indicator tape interfere with subsequent resterilization if it is not removed prior to reprocessing? In J a n u a r y 1980, the task force awarded a contract to the University of Minnesota to conduct a research study on the effects of patching on the sterilization of surgical textiles. Rationale and methodology The first objective was t o compare the sterilizability of unpatched packs to packs t h a t were either wrapped in patched fabrics or t h a t contained patched fabrics. Three types of textiles from different manufacturers, representative of commercially available fabrics, were used (Table 1). One was a 180-thread-count blend of 50% polyester/50 % combed cotton; another was a 280-thread-count combed Pima cotton fabric with a water-repellent finish; the third was the conventional 140-threadcount carded cotton muslin. In preliminary trials, 1x 1inch heat-sealed thermal patches were used, but 3 x 3 inch patches were used in most other trials. The patches used on each type of fabric were similar t o the material being patched, ie, 140-thread-count patches were used on 140-thread-count material. Patching was done with a heat-
Trial and results Phase one: Worst possible cases 0 steam penetration 0 pack composition 0 effect o f patched wrappers Phase two: Threshold test packs 0 packs designed for study Phase three: Sterility during storage
Table 1
Textile and patch identify 180-thread-countblend of 50% polyester/50%combed cotton B and C 280-thread-countcombed Pima cotton with water-repellentfinish D and E 140-thread-countcarded cotton muslin. Materials were patched with like fabrics.
A
~~
~
~
sealing patching machine (Thermopress Model HP-4AUL). The patches were applied at a temperature of 210 C (410 F) and a pressure of 55 psi for ten seconds. The second objective was to relate our experimental findings as closely as possible to hospital practice. The packs were all sterilized in the University Hospitals Central Service Department by central service personnel. AMSCO equipment was used, and all three common hospital sterilizing approaches were evaluated: gravity displacement steam, prevacuum high-temperatureshort-time steam, and ethylene oxide. Gravity displacement cycles were 121 C (250 F) for 30 minutes; prevacuum cycles were 132 C (270 F) for 4 minutes; EO cycles were 1.75 hours followed by 12 hours of aeration. In many of the trials, we simulated a “worst possible case,” and the packs were steam sterilized lying flat. In the final trials, the packs were steam sterilized on edge. The sterilizers never had less than two packs or more than ten packs per load. All textiles were laundered according t o the routine procedures used by the University Hospitals laundry. Textiles used in the preliminary studies were not laundered prior to testing, but all textiles used in the final trials had been laundered one to three times. To monitor sterility, we used a battery of five t o ten ATTEST (3M Co) indicators per pack. Steam sterilization
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trials (both gravity displacement and prevacuum) used Bacillus stearothermophilus spores incubated at 56 C (133 F) for 48 hours. EO trials were monitored with Bacillus subtilis spores incubated at 40 C (104 F) for 48 hours. The five to ten ATTEST indicators were uniformly spaced and stratified throughout the pack to permit estimation of the geometric penetration of sterilizing gas. This was to avoid the statistical objections to biological indicator interpretation when only one indicator is used per pack or load. We could express our sterilization outcome as a probability per pack (ranging from 0110 to 10110).If there were any positive units (viable spores) in a pack, we could identify the approximate location of any barriers that impeded gas penetration. The study developed through several phases. In the first phase, we deliberately deviated from good hospital practice to create some “worst possible cases.” We wanted to see if anything would interfere with fabric sterilization and if so, whether patches added markedly to such interference. We experimented with a variety of pack compositions and arrangements to see whether the sterilization outcome of patched fabrics could be predicted theoretically. The final experiments of the preliminary phase determined the absolute proportion of wrapper surface that could be patched and still permit sterilization. In the second phase, we developed a so-called “threshold pack”-one i n which small manipulations in number of patches would result in predictable sterilization failures. This type of pack included a l l t h e different textiles selected for the study. These packs were used in a series of experiments to answer t h e questions about types of patches and numbers of patches that would be permissible in practice. The final phase studied t h e ability of
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patched fabrics to maintain sterility during storage. Some of our packs would not have been accepted by a good central service (CS)manager because of marginal weight and bulk characteristics. Furthermore, in many of our experiments we used gravity displacement steam sterilizers and placed the packs flat on their sides, even though this did not conform to accepted practice. If patched packs, lying flat in a gravity displacement steam sterilizer could be sterilized, prevacuum and EO sterilizers should also sterilize them. Trials and results Worstpossible cases: Steam penetration. Since no one knew how patches affected steam penetration, or whether heatsealed patches interfered with sterilizability, initial experiments were directed specifically at this question. In a test of steam penetration, test packs were assembled consisting of five type A sheets (54 x 72 inch, two ply) with 800 patches (1 x 1 inch) distributed uniformly on one side of each sheet (about 20% of the total surface area). Each sheet was folded onto itself five times (32 double layers of fabric), and the folded sheets were stacked on top of each other. The contents were wrapped in a type B wrapper (45x 72 inch, single ply) patched with 650 patches (20% of surface area). Ten ATTEST indicators were distributed in a vertical row throughout the center of the pack. Control packs were identically constructed except the sheets and wrappers were unpatched. Test packs and matched control packs, lying flat on their sides, were sterilized in gravity displacement and prevacuum steam sterilizers. Results of these trials are shown in Table 2. Gravity displacement sterilization was significantly hindered by heatsealed patches, at least when 20% of the pack and wrapper surfaces were
AORN Journal, June 1981, Vol33, No 7
Table 2 Worst possible cases Wrappers and contents heavily patched and folded and steam sterilized flat Location and incidence of positive indic tors in pack Gravity Prevacuum steam steam displacement + +
+ + + + + + +
Patched test pack
I
I I
+ +
+ + + +
-
+ + + + + + +
-
-
811 0
6110
811 0
0110
011 0
0110
patched and the packs were flat. Between 60% and 80% of the indicators remained positive, and their location suggested impedance of steam penetration beyond the first few inches of the pack periphery. The unpatched control packs could be sterilized under these conditions. No difficulty was experienced in sterilizing either patched or unpatched fabrics i n a prevacuum sterilizer. It appeared that the steam could not permeate by force of gravity alone the layers of fabrics with many steam impermeable sites within the time we used. The patched wrapper itself did not impede steam penetration, through the
~
I
I
0110
0110
top or bottom; rather the pack contents and arrangement seemed to determine the sterilizability of the interior. Worst possible cases: Pack composition and arrangement. The next step was to verify the hypothesis that pack composition and arrangement contributed to sterilization failure of patched fabrics. A series of packs was constructed, using patched and unpatched sheets i n the same pack. All of the packs, of the same approximate size and weight, were wrapped in patched wrappers (20% of surface area). The only difference was the relative positions of patched and unpatched folded sheets in the interior of the packs, ie, their poten-
AORN Journal, June 1981, Vol33, No 7
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tial cumulative impedance to easy steam penetration. Results are shown in Table 3. The greater the number of patched textiles in a given pack and the more layers of patched textiles next to each other, the greater the impediment to steam penetration. We only verified what every CS manager and OR nurse knows: Enough layers of impervious material will interfere with downward passage of steam in a gravity sterilizer. It can be shown mathematically (and demonstrated with transparent models of our packs) that 32 layers of fabric with 2Wo of each layer randomly covered with heat-sealed patches superimposed on each other will provide a nearly 100% occluded surface. When several of these barriers are stacked onto each other, the pack provides a formidable handicap to internal sterilization. Worst possible cases: Effect ofpatched wrappers. Next, a series of experiments tested the permissible limits of patching pack wrappers. The pack contents were 24 folded huckaback towels, which preliminary tests showed would not inter-
fere with steam penetration even when lying flat in a gravity displacement sterilizer. Several different types of wrappers were patched with 3 x 3 inch patches over 0% to 100% of the surface area. All of the different combinations were sterilized in the gravity displacement sterilizer, the prevacuum system, or with EO. Results of this test are shown in Table 4. Wrappers with as much as 20% of their surfaces occluded by heat-sealed patches did not interfere with sterilization by any method. Of greater significance was the observation that in the prevacuum and EO sterilizers, even 100% patching did not impede penetration of the germicidal gases. In the gravity displacement steam sterilizer, however, 100% patched surfaces yielded mostly sterilization failures. Threshold testpacks. Once the sterilization impediments of patches had been verified by the worst possible cases, we tried to design a reproducible packsterilization trial that could answer the questions about the type and number of patches and the types of fabrics used in hospital practice. We used a mixture of
Table 3 Effect of pack composition and location of patched fabrics
Module 1 Module 2 Module 3 Module 4 Module 5 Module 6 Module 7
Composition
Arrangement*
Positive indicators
3 patched and 2 unpatched 2 patched and 3 unpatched
P-u-P-u-P
8/10
P-u-u-u-P u-u-P-u-u u-u-u-u-u P-P-P-P-P P-P-u-P-P u-P-P-u-u
8110 011 0 011 0 8110 7110 8110
1 patched and 4 unpatched 0 patched and 5 unpatched 5 patched and 0 unpatched 4 patched and 1 unpatched 2 Datched and 3 unpatched
"U-type A sheet folded on itself five times. P-type A sheet with 800 patches on one side (20% of surface folded five times). Wrapper-type B sheet with 20% of surface patched.
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Table 4 Worst possible cases: Effect of patching wrappers on sterilizability when steam sterilized lying flat Positive indicators Percent of surface patched Wrapper: A*
Gravity steam displacement
Prevacuum steam
Ethylene oxide
011 0 0110 0110 016
0110
0110 Oil 0 011 0 016
011 0 Oil 0 0110 016
6/10 011 0 Oil 0
011 0 011 0 011 0
0% 10% 20% 100%
Content: 24 huckabacks double folded Wrapper: B
0%
011 0
10% 20% 100%
Content: 24 huckabacks double folded Wrapper: E*
0%
011 0
10% 20%
%O 011 0 011 0
Content: 24 huckabacks double folded *The two-ply wrappers were patched on both sides. patched folded sheets and folded huckaback towels. These were called “threshold packs” because they permitted a quantitative determination of sterility success and failure. These threshold packs would permit observation of subtle effects that could result from the use of fabrics with different porosities and with different surface areas occluded. The threshold pack consisted of 24 huckaback towels, each folded two times, to yield 96 layers. On the top and bottom was one sheet folded five times with 20% of its surface covered with the 3 x 3 inch patches. The whole pack was
I
0110 Oil 0 016
wrapped in a patched wrapper (2Wo of surface area) of the same fabric type as the inside sheets. Ten indicators were uniformly distributed through the center of the pack. The method of constructing these threshold packs is shown in Figure 1.The average weight of a pack was 8 to 10 lbs; the size was about 15 x 10 x 8 inches. Twenty-two trials compared patched test packs made with the three different textiles and unpatched controls made with the same fabrics. The results (Table 5) indicate that the interaction between textile and patch affected sterilizability. The effect was subtle and
AORN Journal, June 1981,Val 33, No 7
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1
4
2
5
3
6
Fig 1. Assembling test threshold packs. 1. Laundered textiles prior to assembling. From left to right: Fabric A, 6,C, D, E with 20% of surfaces patched. 2. Folding the outer patched textiles. First fold yields two layers. Reduction is from 72 x 54 to 36 x 54. 3. Third fold yields eight layers. The original 72 x 54 sheet is reduced to 18 x 27.
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4. Fourth fold yields 16layers and size is 18 x 14. Note ATTESTS taped to interior. 5. Final fold yields a textile approximately 9 x 13. Note ATTEST. 6. Adding 24 huckaback towels with ATTESTS distributed through interior.
AORN Journal, June 1981,V o l 3 3 , No 7
7
8
9
7. Content of threshold pack prior to
wrapping. Note the position of the patches randomly distributed over 20% of surface. 8. After wrapping. 9. Appearance of the packs prior to sterilizing.
would be hard to detect unless a sensitive monitoring system (like ten ATTESTS) was used. But the potential consequences are important. In particular, packs made with patched textile A (two ply, 180-thread-count) and textile E (two ply, 140-thread-count)were difficult to sterilize by gravity steam. Significantly, t h e s a m e textiles, u n patched, were not problems. Four series of threshold packs, prepared with all the fabrics under study, were tested again to see whether the position of the pack in the gravity displacement steam sterilizer was responsible for the sterility misses. Results are shown in Table 6. It is evident that the combined effects of tightly woven fabrics, plus manyfolded, multipatched contents, plus multipatched wrappers, plus gravity displacement steam sterilization can be overcome by good sterilizing practices, ie, positioning the packs on edge in the sterilizer. This is significant. We had already consistently shown t h a t the prevacuum and EO sterilizers would sterilize any of our worst possible cases. Now we were able to show that it was possible to achieve sterility of patched fabrics, even in a gravity displacement sterilizer . Effect of patching on sterility during storage. In the last experiment, standard test packs were prepared, with patched wrappers, two patched folded sheets, and 24 huckaback towels. Before t h e packs were wrapped, five small stainless steel rings were taped to the textiles near the indicators. The packs were sterilized i n a prevacuum sterilizer and then stored for two weeks in the laboratory work area on open shelves. They were opened carefully, b u t without aseptic precautions such a s gloves or masks. As soon as the packs were opened, 15 Rodac impressions were taken from the interior surface of
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Table 5 Threshold packs (sterilized in gravity displacement steam sterilizer lying flat)
Patched test packs
Unpatched control packs
Wrapper: A-P 6/10; 0110; 0110; 8/10
Wrapper A-P
Content: 2 A-P-F 24 H
0110
Content: 5 A-U-F
Wrapper: 6-P
Wrapper 6-P 0110; 0110: 0110
Oil 0
Content: 2 B-P-F 24 H Wrapper: C-P Content: 2 C-P-F 24 H
Content: 5 6-U-F
I
I
0110; 0110
I
Wrapper: D-P
Wrapper c-p Content 5 C-U-F
I
I
0110; Oil0
Wrapper D-P 0110: 2110
011 0: 0110
Content: 5 D-U-F
Content: 2 D-P-F 24 H Wrapper: E-P
Wrapper E-P 1/10; 0110; 8/10
Content: 2 E-P-F 24 H
0110; 0110
Content: 5 E-U-F
Legend: Textiles-A, B, C, D, E (see Table 1) P-20% of surface patched U-Unpatched F-Folded on itself 5 times (32 fabric layers) H-Huckaback towels, each folded twice
the wrapper (three each from five different locations). The steel rings were removed with sterile forceps and inoculated into trypticase soy broth, and the ATTESTS were removed, crushed, and incubated. There were no positive results. Although this is a simplified sterility test, it would have shown any significant failure to maintain sterility.
Discussion All trials in which sterility was not achieved showed that they all occurred when 0 sterilization was done in a gravity 1258
displacement steam sterilizer the packs were placed flat in the sterilizer 0 the packs contained multiple folds of patched fabrics superimposed on each other, or the outer wrappers were completely (100%) occluded with heat-sealed patches. This means fabrics can be patched for reuse, and the patching will not interfere with their ability to be sterilized. It also means that patched fabrics are different, and that certain precautions must be observed during their sterilization. These precautions are:
AORN Journal, June 1981, Vo133, No 7
posed on each other. 2. If EO or prevacuum sterilizers are used, manufacturers instructions should be followed. Patched wrappers and patched, folded textiles did not significantly inhibit sterilization i n prevacuum or EO sterilizers. The only problems encountered were in gravity displacement steam sterilizers and only when we deliberately contrived a pack difficult to sterilize.
1. If a gravity displacement steam sterilizer is used, the packs should be placed in the sterilizer on edge 0 be wrapped in a textile that does not have more than 20% of its surface area occluded by heatsealed patches be constructed loosely to permit easy steam penetration not contain more than 32 layers of patched textiles superim-
Table 6 Threshold pack positioning in gravity steam displacement sterilizer ~
~
Incidence and location of positive indicators Sterilized flat
Sterilized on edge
Wrapper: A-P Content: 2 A-P-F 24 H
Wrapper: B-P Content: 2 B-P-F 24 H
+ + +
315
-
Wrapper: C-P Content: 2 C-P-F 24 H
Wrapper: D-P Content: 2 D-P-F 24 H
+ + + + + + + + +
+ + + +
415
-
515
+ +
215
-
415
+
1 I5
-
-
-
Wrapper: E-P Content: 2 E-P-F 24 H
Legend: Textile: A, B, C, D, E (see Table 1) P-20% patched F-Folded on itself 5 times H-Huckaback towels folded twice
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In prevacuum and EO sterilizers, the preliminary vacuum cycle removes all air from the pack. When steam or EO is introduced, there is very little resistance to penetration. The gases permeate every incremental space and pass through any unoccluded pore to fill the vacuum. Even our 100% patched wrappers permitted steam and EO to enter, probably through the same packaging gaps that permitted the air to be removed. On the other hand, in a gravity displacement steam sterilizer, t h e steam enters the pack like a piston, pushing the colder, drier air ahead of it as it passes downward through the pack. If the only impediment is a wrapper with 20%of its surface occluded, the steam enters through the 809'0 of the unoccluded surface. On the other hand, the patched, multifolded textiles in the threshold packs provided some significant barriers to steam trying to move downward through a pack. A fabric whose surface is 20% occluded will provide 80% unoccluded surface unfolded, but each fold increases the probability that an occluding patch will cover some of the previously unoccluded surface. Five folds, which yield 32 layers of patched fabric resting on each other, will provide little space for direct downward passage of steam. Instead, the steam will be forced sideways until it finds an unoccluded space that will permit its downward path. It is possible to calculate the geometry and dynamics of this situation, but so many other factors enter into the equation, like tightness of weave, tightness of folding, and space between folds, that it is easier to resolve the issue the way we did-in t h e steri1izer . Despite the theoretical barriers to sterilization, even packs constructed completely of multilayered, multipatched textiles could be sterilized. Theory predicted, and the lab results
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verified, that patches should provide no difficulty as long as the contents of the packs are permeable to steam.
Conclusions On the basis of a six month-study, which involved a statistically controlled evaluation of more than 150 surgical packs, a variety of textiles from a number of suppliers, three different sterilizing treatments, and more than a thousand biological indicators, we can respond to the questions asked by the task force. 1 and 2. The patched portion of a drape or wrapper is not penetrated by steam or EO, but it is sterilized in the same way as other nonpermeable items (glass, rubber, and plastic). 3. The limit t o the percent of exposed surface area that can be patched depends on the mode of sterilizing, the positioning of the pack in the sterilizer, and the number of layers of patched fabric included in the pack and wrapper. As a general rule, for the worst possible condition-gravity displacement steam sterilizing-the surface area occluded should be less than 20%. 4. There seemed to be no difference to sterilizability whether 1 x 1 inch patches or 3 x 3 inch patches were used. The decisions should be made on the basis of appearance and ease of fabric handling characteristics. 5 . Four, three, two, or one layer of patches on the same fabric do not affect sterilizability or permeability. The critical factor is the amount of nonoccluded surface left after patching and folding. In prevacuum and EO sterilizers, even this factor is not important. 6. There did not seem to be any problem from tape adhesive residual. The experiments with fabrics used over and over yielded similar results to new ones that had not been covered with tape. An import.ant find is t h a t our monitoring approach, using five or ten ATTESTS arranged vertically, can be
AORN Journal, June 1981,Yo1 33, No 7
easily employed in any hospital. Any central services manager or operating room supervisor can evaluate fabrics suggested for use, p a t c h e d o r unpatched, w i t h o u t t h e need o f statisticians, engineers, o r bacteriologists. Variations involved in a study such as t h i s one are so great that we would hesit a t e t o establish a standard based o n only these data. But any o f these tasks can be repeated, if necessary several times, by anyone in any hospital, and a satisfactory system can be certified as appropriate for an institution.
Notes 1. M J Moore, “Guidelines for woven fabrics established by Michigan hospitals,” Newsletter of the American Society for Hospital Central Service Personnel 13 (April 1979). 2. J H Palmer, “Tests convince central laundry to use heat seal patched reusables,” American Laundry Digest (Jan 15, 1979). 3. Peggy Ryan, “Basics of packaging,” AORN Journal 21 (May 1975) 1091. 4. The members of the Patching Task Force were: Stuart Case, Nathan Beikin, Peter Lipprnan, Bruce Johnson, Jan Schultz (AORN),Edward Hedrick (APIC), and Myron Karki (ASHCSP).
Michigan nurses strike for professional autonomy Frustrated by more than seven months of negotiations with university officials about issues such as overwork and lack of professional autonomy, registered nurses at the University of Michigan hospitals in Ann Arbor walked off the job April 8. Margo Barron, RN, chairman of the University of Michigan Professional Nurse Council, said more than 800 RNs were on strike in its seventh day, and more were joining the picket lines everyday. The nurses’ contract expired Sept 30, 1980, and they extended it week by week as they met with the university administration45 times to try to resolve their differences. The bargaining group of 1,100 RNs is organized under the Michigan Nurses’ Association. A nursing shortage “reflective of the national nursing shortage but more severe” is a major problem, observed Sandy Wilson, RN, a senior staff nurse in the OR at University Hospital. The shortage has led to inadequate staffing, undesirable schedules, excessive overtime, and even more turnover. Wilson traced the problems to a hospital reorganization in 1975, which abolished a central authority for nursing. Nurses had no one person who could make decisions about their problems. Hospital management took steps to alleviate the shortage, but Wilson believes
these were ineffective because nursing had no focus for decision making. “The nursing shortage continued, and morale dropped,” she said. “The nurses were overworked and believed no one in hospital management understood their position. Some believed management was more interested in keeping beds open than in nurses’ concern for providing patient care.“ Other concerns she listed were incomplete academic preparation to meet work demands, both for new graduates and nurses in leadership positions; lack of formal communication between clinical areas and the chief of nursing; and inadequate coordination between nursing service and the school of nursing, despite their interdependence. “More and more people were realizing that the university’s problems were not only in nursing service but in the whole organization,” Wilson said. Finding the university unresponsiveto their proposals for professional practice and limiting and reorganizing the workload, the group voted overwhelmingly to strike.
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T
Effects of patching on sterilization of surgical textiles V W Greene Gwen M Borlaug Evan Nelson
AORN Journal, June 1981, Vol33, No 7
1249
Moore suggests no more than five patches for a ten-inch square area.l Ryan simply warns that patches should be “extremely limited in number.”2 The only empirical data we could find is the work by Palmer, who covered two 54 x 54 inch wrappers with 300 heat-sealed patches and found no adverse effect on routine ~terilization.~ These guidelines are inconsistent. There a r e no d a t a to document a threshold level of patching below which sterility is achieved and above which it is impeded. In response to this, a Patching Task Force was organized in 1979with representatives from the Textile Rental Service Association, the Association of Operating Room Nurses, the American Society for Hospital Central Service Personnel, and the Association for Practitioners in Infection Contr01.~This
group listed the following questions that could be examined in a controlled research study: 1. Is the patched portion of a drape or wrapper penetrated by steam and, therefore, able to be sterilized? 2. Is the patched portion of a drape or wrapper penetrated by ethylene oxide (EO) and, therefore, able t o be sterilized? 3. Is there a limit to the percent of exposed surface area that can be covered by patching material and still permit the item to be sterilized? 4. Is there a maximum size of patch? Should several small patches be used to cover five separate holes that are close together, or could one larger patch be used? 5. What happens if two layers of patching are used, as might be the case if a large three-corner tear is
V W Greene, PhD, is professor of public health and microbiology, University of Minnesota, Minneapolis. He has a BSAfrom the University of Manitoba and a master’s degree and PhD from the University of Minnesota.
Health. He has a BS from the University of New Mexico, Albuquerque, and an M P H from the University of Minnesota School of Public Health.
Gwen M Borlaug, M P H , is assistant director,
Division of Chemistry, lab services section, North Dakota State Department of Health, Bismarck, ND. She has a BS from North Dakota State University, Fargo, and an M P H from the University of Minnesota. Evan Nelson, MPH, is a project assistant, University of Minnesota School of Public
1250
Acknowledgments The authors would like to express their appreciation to the 3 M Company, St Paul, for providing the ATTEST Biological Indicators. The help of their colleagues at the University of Minnesota, Myron Karki, Carol Freudenstein, Don Vesley and Mary Halbert, was invaluable. The project was funded by a research grant from the Textile Rental Services Association of America, Hallandale, Fla.
AORN Journat, June 1981,Vo133, No 7
mended with two patches? If the material is double-layered 140thread count, will EO and steam penetrate four layers of patches? 6. Does the mucilage from steam- or gas-indicator tape interfere with subsequent resterilization if it is not removed prior to reprocessing? In J a n u a r y 1980, the task force awarded a contract to the University of Minnesota to conduct a research study on the effects of patching on the sterilization of surgical textiles. Rationale and methodology The first objective was t o compare the sterilizability of unpatched packs to packs t h a t were either wrapped in patched fabrics or t h a t contained patched fabrics. Three types of textiles from different manufacturers, representative of commercially available fabrics, were used (Table 1). One was a 180-thread-count blend of 50% polyester/50 % combed cotton; another was a 280-thread-count combed Pima cotton fabric with a water-repellent finish; the third was the conventional 140-threadcount carded cotton muslin. In preliminary trials, 1x 1inch heat-sealed thermal patches were used, but 3 x 3 inch patches were used in most other trials. The patches used on each type of fabric were similar t o the material being patched, ie, 140-thread-count patches were used on 140-thread-count material. Patching was done with a heat-
Trial and results Phase one: Worst possible cases 0 steam penetration 0 pack composition 0 effect o f patched wrappers Phase two: Threshold test packs 0 packs designed for study Phase three: Sterility during storage
Table 1
Textile and patch identify 180-thread-countblend of 50% polyester/50%combed cotton B and C 280-thread-countcombed Pima cotton with water-repellentfinish D and E 140-thread-countcarded cotton muslin. Materials were patched with like fabrics.
A
~~
~
~
sealing patching machine (Thermopress Model HP-4AUL). The patches were applied at a temperature of 210 C (410 F) and a pressure of 55 psi for ten seconds. The second objective was to relate our experimental findings as closely as possible to hospital practice. The packs were all sterilized in the University Hospitals Central Service Department by central service personnel. AMSCO equipment was used, and all three common hospital sterilizing approaches were evaluated: gravity displacement steam, prevacuum high-temperatureshort-time steam, and ethylene oxide. Gravity displacement cycles were 121 C (250 F) for 30 minutes; prevacuum cycles were 132 C (270 F) for 4 minutes; EO cycles were 1.75 hours followed by 12 hours of aeration. In many of the trials, we simulated a “worst possible case,” and the packs were steam sterilized lying flat. In the final trials, the packs were steam sterilized on edge. The sterilizers never had less than two packs or more than ten packs per load. All textiles were laundered according t o the routine procedures used by the University Hospitals laundry. Textiles used in the preliminary studies were not laundered prior to testing, but all textiles used in the final trials had been laundered one to three times. To monitor sterility, we used a battery of five t o ten ATTEST (3M Co) indicators per pack. Steam sterilization
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trials (both gravity displacement and prevacuum) used Bacillus stearothermophilus spores incubated at 56 C (133 F) for 48 hours. EO trials were monitored with Bacillus subtilis spores incubated at 40 C (104 F) for 48 hours. The five to ten ATTEST indicators were uniformly spaced and stratified throughout the pack to permit estimation of the geometric penetration of sterilizing gas. This was to avoid the statistical objections to biological indicator interpretation when only one indicator is used per pack or load. We could express our sterilization outcome as a probability per pack (ranging from 0110 to 10110).If there were any positive units (viable spores) in a pack, we could identify the approximate location of any barriers that impeded gas penetration. The study developed through several phases. In the first phase, we deliberately deviated from good hospital practice to create some “worst possible cases.” We wanted to see if anything would interfere with fabric sterilization and if so, whether patches added markedly to such interference. We experimented with a variety of pack compositions and arrangements to see whether the sterilization outcome of patched fabrics could be predicted theoretically. The final experiments of the preliminary phase determined the absolute proportion of wrapper surface that could be patched and still permit sterilization. In the second phase, we developed a so-called “threshold pack”-one i n which small manipulations in number of patches would result in predictable sterilization failures. This type of pack included a l l t h e different textiles selected for the study. These packs were used in a series of experiments to answer t h e questions about types of patches and numbers of patches that would be permissible in practice. The final phase studied t h e ability of
1252
patched fabrics to maintain sterility during storage. Some of our packs would not have been accepted by a good central service (CS)manager because of marginal weight and bulk characteristics. Furthermore, in many of our experiments we used gravity displacement steam sterilizers and placed the packs flat on their sides, even though this did not conform to accepted practice. If patched packs, lying flat in a gravity displacement steam sterilizer could be sterilized, prevacuum and EO sterilizers should also sterilize them. Trials and results Worstpossible cases: Steam penetration. Since no one knew how patches affected steam penetration, or whether heatsealed patches interfered with sterilizability, initial experiments were directed specifically at this question. In a test of steam penetration, test packs were assembled consisting of five type A sheets (54 x 72 inch, two ply) with 800 patches (1 x 1 inch) distributed uniformly on one side of each sheet (about 20% of the total surface area). Each sheet was folded onto itself five times (32 double layers of fabric), and the folded sheets were stacked on top of each other. The contents were wrapped in a type B wrapper (45x 72 inch, single ply) patched with 650 patches (20% of surface area). Ten ATTEST indicators were distributed in a vertical row throughout the center of the pack. Control packs were identically constructed except the sheets and wrappers were unpatched. Test packs and matched control packs, lying flat on their sides, were sterilized in gravity displacement and prevacuum steam sterilizers. Results of these trials are shown in Table 2. Gravity displacement sterilization was significantly hindered by heatsealed patches, at least when 20% of the pack and wrapper surfaces were
AORN Journal, June 1981, Vol33, No 7
Table 2 Worst possible cases Wrappers and contents heavily patched and folded and steam sterilized flat Location and incidence of positive indic tors in pack Gravity Prevacuum steam steam displacement + +
+ + + + + + +
Patched test pack
I
I I
+ +
+ + + +
-
+ + + + + + +
-
-
811 0
6110
811 0
0110
011 0
0110
patched and the packs were flat. Between 60% and 80% of the indicators remained positive, and their location suggested impedance of steam penetration beyond the first few inches of the pack periphery. The unpatched control packs could be sterilized under these conditions. No difficulty was experienced in sterilizing either patched or unpatched fabrics i n a prevacuum sterilizer. It appeared that the steam could not permeate by force of gravity alone the layers of fabrics with many steam impermeable sites within the time we used. The patched wrapper itself did not impede steam penetration, through the
~
I
I
0110
0110
top or bottom; rather the pack contents and arrangement seemed to determine the sterilizability of the interior. Worst possible cases: Pack composition and arrangement. The next step was to verify the hypothesis that pack composition and arrangement contributed to sterilization failure of patched fabrics. A series of packs was constructed, using patched and unpatched sheets i n the same pack. All of the packs, of the same approximate size and weight, were wrapped in patched wrappers (20% of surface area). The only difference was the relative positions of patched and unpatched folded sheets in the interior of the packs, ie, their poten-
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tial cumulative impedance to easy steam penetration. Results are shown in Table 3. The greater the number of patched textiles in a given pack and the more layers of patched textiles next to each other, the greater the impediment to steam penetration. We only verified what every CS manager and OR nurse knows: Enough layers of impervious material will interfere with downward passage of steam in a gravity sterilizer. It can be shown mathematically (and demonstrated with transparent models of our packs) that 32 layers of fabric with 2Wo of each layer randomly covered with heat-sealed patches superimposed on each other will provide a nearly 100% occluded surface. When several of these barriers are stacked onto each other, the pack provides a formidable handicap to internal sterilization. Worst possible cases: Effect ofpatched wrappers. Next, a series of experiments tested the permissible limits of patching pack wrappers. The pack contents were 24 folded huckaback towels, which preliminary tests showed would not inter-
fere with steam penetration even when lying flat in a gravity displacement sterilizer. Several different types of wrappers were patched with 3 x 3 inch patches over 0% to 100% of the surface area. All of the different combinations were sterilized in the gravity displacement sterilizer, the prevacuum system, or with EO. Results of this test are shown in Table 4. Wrappers with as much as 20% of their surfaces occluded by heat-sealed patches did not interfere with sterilization by any method. Of greater significance was the observation that in the prevacuum and EO sterilizers, even 100% patching did not impede penetration of the germicidal gases. In the gravity displacement steam sterilizer, however, 100% patched surfaces yielded mostly sterilization failures. Threshold testpacks. Once the sterilization impediments of patches had been verified by the worst possible cases, we tried to design a reproducible packsterilization trial that could answer the questions about the type and number of patches and the types of fabrics used in hospital practice. We used a mixture of
Table 3 Effect of pack composition and location of patched fabrics
Module 1 Module 2 Module 3 Module 4 Module 5 Module 6 Module 7
Composition
Arrangement*
Positive indicators
3 patched and 2 unpatched 2 patched and 3 unpatched
P-u-P-u-P
8/10
P-u-u-u-P u-u-P-u-u u-u-u-u-u P-P-P-P-P P-P-u-P-P u-P-P-u-u
8110 011 0 011 0 8110 7110 8110
1 patched and 4 unpatched 0 patched and 5 unpatched 5 patched and 0 unpatched 4 patched and 1 unpatched 2 Datched and 3 unpatched
"U-type A sheet folded on itself five times. P-type A sheet with 800 patches on one side (20% of surface folded five times). Wrapper-type B sheet with 20% of surface patched.
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Table 4 Worst possible cases: Effect of patching wrappers on sterilizability when steam sterilized lying flat Positive indicators Percent of surface patched Wrapper: A*
Gravity steam displacement
Prevacuum steam
Ethylene oxide
011 0 0110 0110 016
0110
0110 Oil 0 011 0 016
011 0 Oil 0 0110 016
6/10 011 0 Oil 0
011 0 011 0 011 0
0% 10% 20% 100%
Content: 24 huckabacks double folded Wrapper: B
0%
011 0
10% 20% 100%
Content: 24 huckabacks double folded Wrapper: E*
0%
011 0
10% 20%
%O 011 0 011 0
Content: 24 huckabacks double folded *The two-ply wrappers were patched on both sides. patched folded sheets and folded huckaback towels. These were called “threshold packs” because they permitted a quantitative determination of sterility success and failure. These threshold packs would permit observation of subtle effects that could result from the use of fabrics with different porosities and with different surface areas occluded. The threshold pack consisted of 24 huckaback towels, each folded two times, to yield 96 layers. On the top and bottom was one sheet folded five times with 20% of its surface covered with the 3 x 3 inch patches. The whole pack was
I
0110 Oil 0 016
wrapped in a patched wrapper (2Wo of surface area) of the same fabric type as the inside sheets. Ten indicators were uniformly distributed through the center of the pack. The method of constructing these threshold packs is shown in Figure 1.The average weight of a pack was 8 to 10 lbs; the size was about 15 x 10 x 8 inches. Twenty-two trials compared patched test packs made with the three different textiles and unpatched controls made with the same fabrics. The results (Table 5) indicate that the interaction between textile and patch affected sterilizability. The effect was subtle and
AORN Journal, June 1981,Val 33, No 7
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1
4
2
5
3
6
Fig 1. Assembling test threshold packs. 1. Laundered textiles prior to assembling. From left to right: Fabric A, 6,C, D, E with 20% of surfaces patched. 2. Folding the outer patched textiles. First fold yields two layers. Reduction is from 72 x 54 to 36 x 54. 3. Third fold yields eight layers. The original 72 x 54 sheet is reduced to 18 x 27.
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4. Fourth fold yields 16layers and size is 18 x 14. Note ATTESTS taped to interior. 5. Final fold yields a textile approximately 9 x 13. Note ATTEST. 6. Adding 24 huckaback towels with ATTESTS distributed through interior.
AORN Journal, June 1981,V o l 3 3 , No 7
7
8
9
7. Content of threshold pack prior to
wrapping. Note the position of the patches randomly distributed over 20% of surface. 8. After wrapping. 9. Appearance of the packs prior to sterilizing.
would be hard to detect unless a sensitive monitoring system (like ten ATTESTS) was used. But the potential consequences are important. In particular, packs made with patched textile A (two ply, 180-thread-count) and textile E (two ply, 140-thread-count)were difficult to sterilize by gravity steam. Significantly, t h e s a m e textiles, u n patched, were not problems. Four series of threshold packs, prepared with all the fabrics under study, were tested again to see whether the position of the pack in the gravity displacement steam sterilizer was responsible for the sterility misses. Results are shown in Table 6. It is evident that the combined effects of tightly woven fabrics, plus manyfolded, multipatched contents, plus multipatched wrappers, plus gravity displacement steam sterilization can be overcome by good sterilizing practices, ie, positioning the packs on edge in the sterilizer. This is significant. We had already consistently shown t h a t the prevacuum and EO sterilizers would sterilize any of our worst possible cases. Now we were able to show that it was possible to achieve sterility of patched fabrics, even in a gravity displacement sterilizer . Effect of patching on sterility during storage. In the last experiment, standard test packs were prepared, with patched wrappers, two patched folded sheets, and 24 huckaback towels. Before t h e packs were wrapped, five small stainless steel rings were taped to the textiles near the indicators. The packs were sterilized i n a prevacuum sterilizer and then stored for two weeks in the laboratory work area on open shelves. They were opened carefully, b u t without aseptic precautions such a s gloves or masks. As soon as the packs were opened, 15 Rodac impressions were taken from the interior surface of
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Table 5 Threshold packs (sterilized in gravity displacement steam sterilizer lying flat)
Patched test packs
Unpatched control packs
Wrapper: A-P 6/10; 0110; 0110; 8/10
Wrapper A-P
Content: 2 A-P-F 24 H
0110
Content: 5 A-U-F
Wrapper: 6-P
Wrapper 6-P 0110; 0110: 0110
Oil 0
Content: 2 B-P-F 24 H Wrapper: C-P Content: 2 C-P-F 24 H
Content: 5 6-U-F
I
I
0110; 0110
I
Wrapper: D-P
Wrapper c-p Content 5 C-U-F
I
I
0110; Oil0
Wrapper D-P 0110: 2110
011 0: 0110
Content: 5 D-U-F
Content: 2 D-P-F 24 H Wrapper: E-P
Wrapper E-P 1/10; 0110; 8/10
Content: 2 E-P-F 24 H
0110; 0110
Content: 5 E-U-F
Legend: Textiles-A, B, C, D, E (see Table 1) P-20% of surface patched U-Unpatched F-Folded on itself 5 times (32 fabric layers) H-Huckaback towels, each folded twice
the wrapper (three each from five different locations). The steel rings were removed with sterile forceps and inoculated into trypticase soy broth, and the ATTESTS were removed, crushed, and incubated. There were no positive results. Although this is a simplified sterility test, it would have shown any significant failure to maintain sterility.
Discussion All trials in which sterility was not achieved showed that they all occurred when 0 sterilization was done in a gravity 1258
displacement steam sterilizer the packs were placed flat in the sterilizer 0 the packs contained multiple folds of patched fabrics superimposed on each other, or the outer wrappers were completely (100%) occluded with heat-sealed patches. This means fabrics can be patched for reuse, and the patching will not interfere with their ability to be sterilized. It also means that patched fabrics are different, and that certain precautions must be observed during their sterilization. These precautions are:
AORN Journal, June 1981, Vo133, No 7
posed on each other. 2. If EO or prevacuum sterilizers are used, manufacturers instructions should be followed. Patched wrappers and patched, folded textiles did not significantly inhibit sterilization i n prevacuum or EO sterilizers. The only problems encountered were in gravity displacement steam sterilizers and only when we deliberately contrived a pack difficult to sterilize.
1. If a gravity displacement steam sterilizer is used, the packs should be placed in the sterilizer on edge 0 be wrapped in a textile that does not have more than 20% of its surface area occluded by heatsealed patches be constructed loosely to permit easy steam penetration not contain more than 32 layers of patched textiles superim-
Table 6 Threshold pack positioning in gravity steam displacement sterilizer ~
~
Incidence and location of positive indicators Sterilized flat
Sterilized on edge
Wrapper: A-P Content: 2 A-P-F 24 H
Wrapper: B-P Content: 2 B-P-F 24 H
+ + +
315
-
Wrapper: C-P Content: 2 C-P-F 24 H
Wrapper: D-P Content: 2 D-P-F 24 H
+ + + + + + + + +
+ + + +
415
-
515
+ +
215
-
415
+
1 I5
-
-
-
Wrapper: E-P Content: 2 E-P-F 24 H
Legend: Textile: A, B, C, D, E (see Table 1) P-20% patched F-Folded on itself 5 times H-Huckaback towels folded twice
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In prevacuum and EO sterilizers, the preliminary vacuum cycle removes all air from the pack. When steam or EO is introduced, there is very little resistance to penetration. The gases permeate every incremental space and pass through any unoccluded pore to fill the vacuum. Even our 100% patched wrappers permitted steam and EO to enter, probably through the same packaging gaps that permitted the air to be removed. On the other hand, in a gravity displacement steam sterilizer, t h e steam enters the pack like a piston, pushing the colder, drier air ahead of it as it passes downward through the pack. If the only impediment is a wrapper with 20%of its surface occluded, the steam enters through the 809'0 of the unoccluded surface. On the other hand, the patched, multifolded textiles in the threshold packs provided some significant barriers to steam trying to move downward through a pack. A fabric whose surface is 20% occluded will provide 80% unoccluded surface unfolded, but each fold increases the probability that an occluding patch will cover some of the previously unoccluded surface. Five folds, which yield 32 layers of patched fabric resting on each other, will provide little space for direct downward passage of steam. Instead, the steam will be forced sideways until it finds an unoccluded space that will permit its downward path. It is possible to calculate the geometry and dynamics of this situation, but so many other factors enter into the equation, like tightness of weave, tightness of folding, and space between folds, that it is easier to resolve the issue the way we did-in t h e steri1izer . Despite the theoretical barriers to sterilization, even packs constructed completely of multilayered, multipatched textiles could be sterilized. Theory predicted, and the lab results
1260
verified, that patches should provide no difficulty as long as the contents of the packs are permeable to steam.
Conclusions On the basis of a six month-study, which involved a statistically controlled evaluation of more than 150 surgical packs, a variety of textiles from a number of suppliers, three different sterilizing treatments, and more than a thousand biological indicators, we can respond to the questions asked by the task force. 1 and 2. The patched portion of a drape or wrapper is not penetrated by steam or EO, but it is sterilized in the same way as other nonpermeable items (glass, rubber, and plastic). 3. The limit t o the percent of exposed surface area that can be patched depends on the mode of sterilizing, the positioning of the pack in the sterilizer, and the number of layers of patched fabric included in the pack and wrapper. As a general rule, for the worst possible condition-gravity displacement steam sterilizing-the surface area occluded should be less than 20%. 4. There seemed to be no difference to sterilizability whether 1 x 1 inch patches or 3 x 3 inch patches were used. The decisions should be made on the basis of appearance and ease of fabric handling characteristics. 5 . Four, three, two, or one layer of patches on the same fabric do not affect sterilizability or permeability. The critical factor is the amount of nonoccluded surface left after patching and folding. In prevacuum and EO sterilizers, even this factor is not important. 6. There did not seem to be any problem from tape adhesive residual. The experiments with fabrics used over and over yielded similar results to new ones that had not been covered with tape. An import.ant find is t h a t our monitoring approach, using five or ten ATTESTS arranged vertically, can be
AORN Journal, June 1981,Yo1 33, No 7
easily employed in any hospital. Any central services manager or operating room supervisor can evaluate fabrics suggested for use, p a t c h e d o r unpatched, w i t h o u t t h e need o f statisticians, engineers, o r bacteriologists. Variations involved in a study such as t h i s one are so great that we would hesit a t e t o establish a standard based o n only these data. But any o f these tasks can be repeated, if necessary several times, by anyone in any hospital, and a satisfactory system can be certified as appropriate for an institution.
Notes 1. M J Moore, “Guidelines for woven fabrics established by Michigan hospitals,” Newsletter of the American Society for Hospital Central Service Personnel 13 (April 1979). 2. J H Palmer, “Tests convince central laundry to use heat seal patched reusables,” American Laundry Digest (Jan 15, 1979). 3. Peggy Ryan, “Basics of packaging,” AORN Journal 21 (May 1975) 1091. 4. The members of the Patching Task Force were: Stuart Case, Nathan Beikin, Peter Lipprnan, Bruce Johnson, Jan Schultz (AORN),Edward Hedrick (APIC), and Myron Karki (ASHCSP).
Michigan nurses strike for professional autonomy Frustrated by more than seven months of negotiations with university officials about issues such as overwork and lack of professional autonomy, registered nurses at the University of Michigan hospitals in Ann Arbor walked off the job April 8. Margo Barron, RN, chairman of the University of Michigan Professional Nurse Council, said more than 800 RNs were on strike in its seventh day, and more were joining the picket lines everyday. The nurses’ contract expired Sept 30, 1980, and they extended it week by week as they met with the university administration45 times to try to resolve their differences. The bargaining group of 1,100 RNs is organized under the Michigan Nurses’ Association. A nursing shortage “reflective of the national nursing shortage but more severe” is a major problem, observed Sandy Wilson, RN, a senior staff nurse in the OR at University Hospital. The shortage has led to inadequate staffing, undesirable schedules, excessive overtime, and even more turnover. Wilson traced the problems to a hospital reorganization in 1975, which abolished a central authority for nursing. Nurses had no one person who could make decisions about their problems. Hospital management took steps to alleviate the shortage, but Wilson believes
these were ineffective because nursing had no focus for decision making. “The nursing shortage continued, and morale dropped,” she said. “The nurses were overworked and believed no one in hospital management understood their position. Some believed management was more interested in keeping beds open than in nurses’ concern for providing patient care.“ Other concerns she listed were incomplete academic preparation to meet work demands, both for new graduates and nurses in leadership positions; lack of formal communication between clinical areas and the chief of nursing; and inadequate coordination between nursing service and the school of nursing, despite their interdependence. “More and more people were realizing that the university’s problems were not only in nursing service but in the whole organization,” Wilson said. Finding the university unresponsiveto their proposals for professional practice and limiting and reorganizing the workload, the group voted overwhelmingly to strike.
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