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Operating Room Sanitation
OPERATING ROOM SANITATION David R. Peck The problem of controlling and eliminating cross infection in hospitals is a subject that has been receiving more and more attention in medical literature, particularly as it relates to the operating room, where contamination can occur most readily and where the patient is sensitive to infection. Attempts to control infection are not new. Although modern infection control dates from the time of Lord Lister, modern methods are foreshadowed by farsighted programs that crop up from the pages of history. For example, we learn that Aristotle advised Alexander the Great to have his armies boil their drinking water and to bury all human excreta. Evidently, the philosopher had some insight into the sources of bacterial contamination. Modern infection control through the use of chemicals seems to date from 1839; that is the year in which we have the first record of iodine compounds being used for the treatment of wounds. For over a century it has been recognized that the beslt method for destroying microbial life is heat or steam under pressure. Of course, this method is not always practical or even possible, especially when the material to be sterilized consists of specialized instruments, furniture, or whole rooms. Consequently, hospitals turn to chemical disinfectants for such purposes. R. Peck received his B.S. degree from New York University and attended graduate courses at David
Massachusetts Institute of Technology. He is director of the Professional Division at West Chemical Products, Inc. Mr. Peck has been with the company since 1956.
February 1968
Although many chemicals have good germicidal properties, these are not all that is required to recommend a product for hospital use, since, if a disinfectant is to destroy a germ cell, it must make full contact with that cell. It is here that many disinfectants fall down. Especially in operating room environments, the bacteria may be encased in oil, fat or proteinaceous materials such as blood or pus, and so shielded from chemical action. As a result, a thorough cleaning to remove all such deposits muslt precede disinfectionor, if possible, be carried out in one step along with the disinfection. The last option can take place if the germicide also has detergent properties.
CHOOSING A CHEMICAL DISINFECTANT The selection of a general purpose disinfectant that will both clean and disinfect, and will also kill the widest possible range of bacteria and viruses, has always been a problem to personnel engaged in hospital purchasing. It is a particularly vexing problem to professional people; they, more than all others, are able to see just how little real information there is on the microbiological and toxicological properties of the various commercial disinfectants. The problem is made all the more complex when you consider that there are around 7,000 different formulations on the market. In choosing a chemical disinfectant for the operating room, the purchaser should look for one that will perform all the functions required in OR disinfection:
1) It should be easy to use, requiring little
47
special training for the nurses or housekeepers who will be applying it. 2) It should be safe to handle and use, nontoxic with no annoying or noxious odors. 3) The disinfectant should be stable, not losing its germicidal properties or changing its characteristics in storage. 4) It should be non-selective, killing the largest number of organisms possible. 5) It should be readily available and economical to use, preferably obtained and stored in concentrated form and used in dilution. 6) There should be some method of determining quickly when the bactericidal properties are depleted, since the presence of proteins and other organic materials tend to diminish the strength of any germicide. 7 ) There should be independent laboratory proofs of its efficiency, and it should be registered with pertinent government agencies. 8) It should have detergent properties so that it can penetrate through oily or proteinaceous material to kill protected bacteria. Of all the germicidal compounds available today, the ones that fulfill these qualifications most completely are those that contain “tamed iodine.” An abundance of published information on the history of iodine and on research into its properties supports its appropriateness for hospital, and especially OR disinfection. Iodine liberating germicides are chemiand iodocally referred to as “iodophor~,~’ phors in which iodine is complexed with nonionic synthetic detergents are called “tamed iodines.” The usual characteristics of a tamed iodine are high bactericidal activity through contact killing rather than through inhibiting factors, and a reduction in vapor pressure and odor. Tamed iodines are readily and easily diluted and are unaffected by ordinary water hardness. Tamed iodine solutions have a unique distinction of indicating their own germicidal activity by color. When used in recommended
48
dilutions, the solutions have a rich amber color, which fades as the iodine complex acts to kill organisms. As long as the color remains, the user can be sure the germicidal effect will be there. Research has shown that tamed iodine compounds are exceptionally effective against the widest spectrum of microorganisms, such as viruses, spores and a variety of bacteria, including TB, staphlococcus, streptococcus, and pseudomonas aeruginosa. Because of this broad range of effectiveness, they have been designated non-selective germicides, in direct contrast to some chemical agents that are selective in their killing power. One notable advantage of tamed iodines is that they are non-irritating, non-staining and non-toxic when used according to the manufacturer’s recommendations. In recent years hospital personnel have become more and more familiar with iodine complexes as dislinfectants for the operating room, where they have been found to give maximum germicidal protection to both patients and staff. The mode of operation that has been found most effective in the OR requires the use of a solution containing 75-150 ppm of titratable iodine. This is obtained by dissolving 18-36 cc of iodophor in a gallon of water. Following surgical procedure, all inanimate objects in the operating room-table, kick pails, instrument tables, walls, etc.should be disinfected by washing down with this tamed iodine solution. Since a major source of airborne bacteria arises from foot traffic on contaminated floors, the floor should also be disinfected by flooding with the solution, then picking it up in a wet pickup vacuum. Tamed iodine will not alter the conductivity of special flooring, and the elimination of bacteria on the floor, contained in excreta and dust, results in a great decrease in airborne bacteria. All instruments that have been contaminated during the operation should be placed in
AORN Journal
a basin full of solution for transportation to the cleaning sink, where they should be cleansed with a scrub brush in a fresh batch of solution prior to autoclaving. All removable non-autoclavable materials should be washed and disinfected in solution, rinsed out and then subjected to the ordinary hospital procedure for continued disinfection. This procedure, which has been found to be the most effective for the sanitation of the
operating room, is receiving wider and wider acceptance in hospitals. Its advantages include the fact that it is easy to put into effect and requires no fresh training of nurses or housekeeping personnel. Best of all, it assures physicians and hospital administration that the most advanced and effective chemical germicides are at work to eliminate all possible causes, of infection in the most sensitive area of the hospital.
PHOTOS IMPROVE ORTHOTIC FITTZNGS Seeking to improve orthotic fitting and patient services, The Institute for the Crippled and Disabled, in N e w I’ork City, is currently testing two supplemental fitting procedures. One is to routinely photograph trauma or congenital anomaly o f upper extremities; the other is the use of a multiple adjustment fitting device. Motivation to explore these areas was stimulated b y a need to enhance communications between orthotist and fabricating benchmen. It was felt that the methods of representation embodied in the standard measuring chart and tracings could be improved upon and that greater insight to unique conditions could be given to the orthotic craftsman who did not have the advantage of on-site perspective or the orthotist.
To this end, routine use of a Polaroid camera was established. W h e n used with close-up or portrait attachment, with black and white or color film, a usefully large image was obtained, upon which were drawn, with contrasting colored felt tip pens, the details of special brace requirements. For situations not amenable to standard tracing techniques, this was a substantial improvement.
I t is not unusual to take several photos from as many angles as would yield useful detailed information. The orthotist is now able to provide the benchman with a fitting-room view of the orthophaxis need, as seen by the orthotist. To further increase fitting accuracy, a multi-adjustment forearm fitting-room device was designed, prototyped, and is now undergoing preliminary testing. Only a screwdriver is needed to make adjustments, which allow the palmar width to be increased from 3%’’ to 444”; the palmar-dorsal thickness from to 2%’’; and the palmar angle can be altered 45 degrees to the right or left. The dorsal bar hinges open upon release o f a thumbscrew enabling easy application and removal. Other facilities are provided for unique demands.
lw
Once the fitting device has been adjusted to the patient, it is sent to the orthotic department, together with the marked photographs, tracings, measuring charts, prescription orders, etc. T h e addition of photos and fitting device not only provides more exacting details to the benchman, but they also tend to reduce the number o f patient’s clinical fitting visits.
INSTITUTE FOR
February 1968
THE
FRANKA. MOTT VOCATIONAL TESTDEVELOPER CRIPPLED A N D DISABLED, NEWYORKCITY
49
Massachusetts Institute of Technology. He is director of the Professional Division at West Chemical Products, Inc. Mr. Peck has been with the company since 1956.
February 1968
Although many chemicals have good germicidal properties, these are not all that is required to recommend a product for hospital use, since, if a disinfectant is to destroy a germ cell, it must make full contact with that cell. It is here that many disinfectants fall down. Especially in operating room environments, the bacteria may be encased in oil, fat or proteinaceous materials such as blood or pus, and so shielded from chemical action. As a result, a thorough cleaning to remove all such deposits muslt precede disinfectionor, if possible, be carried out in one step along with the disinfection. The last option can take place if the germicide also has detergent properties.
CHOOSING A CHEMICAL DISINFECTANT The selection of a general purpose disinfectant that will both clean and disinfect, and will also kill the widest possible range of bacteria and viruses, has always been a problem to personnel engaged in hospital purchasing. It is a particularly vexing problem to professional people; they, more than all others, are able to see just how little real information there is on the microbiological and toxicological properties of the various commercial disinfectants. The problem is made all the more complex when you consider that there are around 7,000 different formulations on the market. In choosing a chemical disinfectant for the operating room, the purchaser should look for one that will perform all the functions required in OR disinfection:
1) It should be easy to use, requiring little
47
special training for the nurses or housekeepers who will be applying it. 2) It should be safe to handle and use, nontoxic with no annoying or noxious odors. 3) The disinfectant should be stable, not losing its germicidal properties or changing its characteristics in storage. 4) It should be non-selective, killing the largest number of organisms possible. 5) It should be readily available and economical to use, preferably obtained and stored in concentrated form and used in dilution. 6) There should be some method of determining quickly when the bactericidal properties are depleted, since the presence of proteins and other organic materials tend to diminish the strength of any germicide. 7 ) There should be independent laboratory proofs of its efficiency, and it should be registered with pertinent government agencies. 8) It should have detergent properties so that it can penetrate through oily or proteinaceous material to kill protected bacteria. Of all the germicidal compounds available today, the ones that fulfill these qualifications most completely are those that contain “tamed iodine.” An abundance of published information on the history of iodine and on research into its properties supports its appropriateness for hospital, and especially OR disinfection. Iodine liberating germicides are chemiand iodocally referred to as “iodophor~,~’ phors in which iodine is complexed with nonionic synthetic detergents are called “tamed iodines.” The usual characteristics of a tamed iodine are high bactericidal activity through contact killing rather than through inhibiting factors, and a reduction in vapor pressure and odor. Tamed iodines are readily and easily diluted and are unaffected by ordinary water hardness. Tamed iodine solutions have a unique distinction of indicating their own germicidal activity by color. When used in recommended
48
dilutions, the solutions have a rich amber color, which fades as the iodine complex acts to kill organisms. As long as the color remains, the user can be sure the germicidal effect will be there. Research has shown that tamed iodine compounds are exceptionally effective against the widest spectrum of microorganisms, such as viruses, spores and a variety of bacteria, including TB, staphlococcus, streptococcus, and pseudomonas aeruginosa. Because of this broad range of effectiveness, they have been designated non-selective germicides, in direct contrast to some chemical agents that are selective in their killing power. One notable advantage of tamed iodines is that they are non-irritating, non-staining and non-toxic when used according to the manufacturer’s recommendations. In recent years hospital personnel have become more and more familiar with iodine complexes as dislinfectants for the operating room, where they have been found to give maximum germicidal protection to both patients and staff. The mode of operation that has been found most effective in the OR requires the use of a solution containing 75-150 ppm of titratable iodine. This is obtained by dissolving 18-36 cc of iodophor in a gallon of water. Following surgical procedure, all inanimate objects in the operating room-table, kick pails, instrument tables, walls, etc.should be disinfected by washing down with this tamed iodine solution. Since a major source of airborne bacteria arises from foot traffic on contaminated floors, the floor should also be disinfected by flooding with the solution, then picking it up in a wet pickup vacuum. Tamed iodine will not alter the conductivity of special flooring, and the elimination of bacteria on the floor, contained in excreta and dust, results in a great decrease in airborne bacteria. All instruments that have been contaminated during the operation should be placed in
AORN Journal
a basin full of solution for transportation to the cleaning sink, where they should be cleansed with a scrub brush in a fresh batch of solution prior to autoclaving. All removable non-autoclavable materials should be washed and disinfected in solution, rinsed out and then subjected to the ordinary hospital procedure for continued disinfection. This procedure, which has been found to be the most effective for the sanitation of the
operating room, is receiving wider and wider acceptance in hospitals. Its advantages include the fact that it is easy to put into effect and requires no fresh training of nurses or housekeeping personnel. Best of all, it assures physicians and hospital administration that the most advanced and effective chemical germicides are at work to eliminate all possible causes, of infection in the most sensitive area of the hospital.
PHOTOS IMPROVE ORTHOTIC FITTZNGS Seeking to improve orthotic fitting and patient services, The Institute for the Crippled and Disabled, in N e w I’ork City, is currently testing two supplemental fitting procedures. One is to routinely photograph trauma or congenital anomaly o f upper extremities; the other is the use of a multiple adjustment fitting device. Motivation to explore these areas was stimulated b y a need to enhance communications between orthotist and fabricating benchmen. It was felt that the methods of representation embodied in the standard measuring chart and tracings could be improved upon and that greater insight to unique conditions could be given to the orthotic craftsman who did not have the advantage of on-site perspective or the orthotist.
To this end, routine use of a Polaroid camera was established. W h e n used with close-up or portrait attachment, with black and white or color film, a usefully large image was obtained, upon which were drawn, with contrasting colored felt tip pens, the details of special brace requirements. For situations not amenable to standard tracing techniques, this was a substantial improvement.
I t is not unusual to take several photos from as many angles as would yield useful detailed information. The orthotist is now able to provide the benchman with a fitting-room view of the orthophaxis need, as seen by the orthotist. To further increase fitting accuracy, a multi-adjustment forearm fitting-room device was designed, prototyped, and is now undergoing preliminary testing. Only a screwdriver is needed to make adjustments, which allow the palmar width to be increased from 3%’’ to 444”; the palmar-dorsal thickness from to 2%’’; and the palmar angle can be altered 45 degrees to the right or left. The dorsal bar hinges open upon release o f a thumbscrew enabling easy application and removal. Other facilities are provided for unique demands.
lw
Once the fitting device has been adjusted to the patient, it is sent to the orthotic department, together with the marked photographs, tracings, measuring charts, prescription orders, etc. T h e addition of photos and fitting device not only provides more exacting details to the benchman, but they also tend to reduce the number o f patient’s clinical fitting visits.
INSTITUTE FOR
February 1968
THE
FRANKA. MOTT VOCATIONAL TESTDEVELOPER CRIPPLED A N D DISABLED, NEWYORKCITY
49