- Email: [email protected]
Break Scrub to Take That Phone Call?
Accepted Manuscript Break Scrub to Take That Phone Call? Abigail Schirmer, bs, Courtney Swan, bs, Steven J. Hughes, md, FACS, Terrie Vasilopoulos, phd, Monika Oli, phd, Sana Chaudhry, Nikolaus Gravenstein, md, Chris Giordano, md PII:
S1072-7515(18)30178-9
DOI:
10.1016/j.jamcollsurg.2018.03.002
Reference:
ACS 9081
To appear in:
Journal of the American College of Surgeons
Received Date: 8 February 2018 Revised Date:
22 February 2018
Accepted Date: 1 March 2018
Please cite this article as: Schirmer A, Swan C, Hughes SJ, Vasilopoulos T, Oli M, Chaudhry S, Gravenstein N, Giordano C, Break Scrub to Take That Phone Call?, Journal of the American College of Surgeons (2018), doi: 10.1016/j.jamcollsurg.2018.03.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1 Break Scrub to Take That Phone Call? Abigail Schirmer, BSa Courtney Swan, BS,a Steven J Hughes, MD, FACSb Terrie Vasilopoulos, a c c a a PHD, Monika Oli, PHD, Sana Chaudhry, Nikolaus Gravenstein, MD, Chris Giordano, MD a
Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL Department of Surgery, University of Florida College of Medicine, Gainesville, FL c Department of Microbiology & Cell Science, University of Florida, Gainesville FL
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Correspondence address: Chris Giordano, MD, Department Of Anesthesiology University Of Florida College Of Medicine 1600 SW Archer Road PO Box 100-0254 Gainesville FL 32610-0254 email: [email protected]
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Disclosure Information: Nothing to disclose.
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Running title: Break Scrub to Take That Phone Call?
ACCEPTED MANUSCRIPT 2
BACKGROUND: The American College of Surgeons reports that 60% of the hundreds of thousands of surgical site infections occurring annually are preventable. The practice of surgeons
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taking phone calls while remaining sterile in the operating field is often accomplished by
interposing a sterile disposable towel between the phone and their glove. After completing the call, surgeons resume operating. The purpose of our study is to test the conceptual idea of
surgeon through a sterile disposable towel.
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whether bacteria transmit from an inanimate object, such as a telephone, to the gloves of a
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STUDY DESIGN: GloGerm™, a UV light-enhanced particle powder sized to mimic bacteria, was placed on an inanimate surface and held with a sterile disposable OR towel covering a sterile surgical glove. The glove was then inspected for GloGerm™ using a UV light. Additionally, 18 operating room telephones were cultured and then held with a Sterile Disposable OR Towel
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(Medline Industries Inc., Northfield, IL) covering a sterile surgical glove. The surgical gloves were then cultured to determine if bacteria had transmitted from the telephone through the towel and onto the sterile glove.
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RESULTS: The GloGerm™ powder readily transmitted through the towel to the gloves. Median CFU on the cultured telephones for the 17 samples was 10, ranging from 1 to 35 CFUs. Of these
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17 samples, 47% had transmission from the telephone to the glove, which was significantly greater than 0% (95% CI: 26%-69%, p < 0.001). CONCLUSIONS: Sterile disposable OR towels do not provide an effective barrier between bacteria present on operating room telephones and the otherwise sterile gloves of a surgeon.
Keywords: sterile field, sterile towel, cross contamination, potential infection, patient safety
ACCEPTED MANUSCRIPT 3 Abbreviations:
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SSI = surgical site infection CFU/mL = colony forming units per milliliter PCR = polymerase chain reaction TSA = tryptic soy agar
ACCEPTED MANUSCRIPT 4 INTRODUCTION A major goal for improving the quality of care and safety of surgical patients is reducing the incidence of surgical site infections (SSIs). The American College of Surgeons and the Surgical
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Infection Society state that there are still hundreds of thousands of SSIs annually in the United States, 60% of which are considered to be preventable.1,2 Factors known to influence SSIs include surgical technique, prophylactic antibiotic timing and dose, extent of endogenous
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contamination of the wound at surgery, preoperative skin antisepsis, duration of operation,
operating room environment, patient temperature, and organisms shed by the operating room
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team.1,3 Patient-related factors such as history of smoking, diabetes, obesity,
immunosuppression, preoperative albumin levels of <3.5 mg/dL, and total bilirubin >1.0 mg/dL are also considered SSI risk factors.1
The presence and quantity of microorganisms on inanimate objects is well established.4
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Depending on the inanimate object’s location and surface type, bacterial contamination ranges from 102 to 106 colony forming units (CFUs) of bacteria that can be cultured per milliliter (CFU/mL) of culture medium.5 The ability of a microorganism to survive on an inanimate object
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contributes to its virulence and likelihood of transmission.6,7 Common pathogens can persist on fomites and can then serve as a vector for cross-contamination in the absence of effective
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sanitation procedures.7 Kramer et al. found that both gram-positive bacteria (Enterococcus spp., Staphylococcus aureus, and Streptococcus pyogenes) and gram-negative species (Acinetobacter spp., Escherichia coli, Klebsiella spp., Pseudomonas aeruginosa, Serratia marcescens, and Shigella spp.) can survive on inanimate surfaces for months.7 Neely et al. reported that “Staphylococci and Enterococci spp can survive for days to months, even after drying, on commonly used hospital fabrics and plastic.”6 The surivival capability of these prevalent
ACCEPTED MANUSCRIPT 5 pathogenic bacterial species warrants concern for their presence in the operating room setting. There is a positive correlation between the concentration of bacterial contaminants on an object and the frequency of human contact with that object. This elevates the the potential for infection
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from frequently handled and less regularly cleaned surfaces found in operating rooms such as telephones.8-11
The World Health Organization (WHO) outlined the necessary sanitation procedures in
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the operating theater. Included in their procedures are cleaning all horizontal surfaces and surgical items every morning and between procedures.5 However, they advise a complete
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cleaning of the operating room area, including all annexes such as dressing rooms, technical rooms, and cupboards, only once a week.3 In general, to decrease pathogens on inanimate objects and to improve patient safety, hospitals have implemented routine sanitation measures such as the use of disposable surgical caps, but these measures often are not effective.12 A collaborative
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effort between several Texas hospitals questioned infection control practices and their relevance in the prevention of SSIs. The authors suggested that it is the evidence-based infection control practices pertaining to perioperative care of patient skin, wound hygiene, and transparent SSI
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display that have had the greatest influence on SSIs.13 The recent concern and study regarding microbial shedding from once-acceptable operating room protective headwear prompts us to
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question another common practice.12 Can an operating room telephone, touched by a surgeon holding an interposed sterile towel, serve as reservoir and vector for potentially pathogenic microbes? A surgeon may use a sterile towel to hold the telephone and speak to a pathologist or consultant. Because telephone recievers and cell phones are not directly involved in patient care, cleaning and sanitation measures may not be routinely or reliably implemented.
ACCEPTED MANUSCRIPT 6 The purpose of this study is to assess if surgical glove sterility is preserved after handling a contaminated dry object (telephone receiver) with a sterile towel interposed, as is a commonly observed practice. Based on the frequency of witnessing these intraoperative phone
that the sterile blue towel would maintain surgical sterility.
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conversations and in the absence of any reports of telephone-mediated SSIs, we hypothesized
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METHODS IRB approval was not required. We began by qualitatively determining if pathogenic bacterial species were present on four randomly selected operating room telephone recievers. We
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then qualitatively assessed if non-pathogenic GloGerm™ powder (GloGerm™ Company, Moab, UT), UV light-enhanced particles that were the same average size as bacteria would transmit through Sterile Disposable Surgical OR Towels (Medline Industries Inc., Northfield, IL). These Sterile Disposable Surgical OR Towels are woven with dimensions of 46 by 19 square inches, equating to a thread count of 874, and each towel is made with 55 g of cotton thread (Heidi,
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Medline Customer Service, telephone call, personal communication, October 05, 2017). An in situ method was developed to test if the bacteria present on operating room telephones would
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transmit through a Sterile Disposable Surgical OR Towel onto sterile surgical gloves. Qualititative: Polymerase Chain Reaction (PCR) Assessment of Bacterial Species Present
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Samples were collected in the middle of the day and after room turnover for culture from four operating room telephones. Outer surfaces were swabbed with sterile saline-soaked swabs dipped and plated on tryptic soy agar (TSA) plates. The plates were incubated for 24 hours at 37°C and cultured colonies were isolated. PCR was performed for each colony of unique morphology to determine bacterial species present on these randomly selected, frequently handled telephone receiver handpieces in between operating room cases in the middle of the day in a busy tertiary care operating room suite.
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Qualitative: Transmission of GloGerm™ Powder Through Sterile Disposable Surgical OR Towels
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Approximately 3 g of Glo Germ powder was spread on a plastic surface that served as a proxy for a telephone reciever. GloGerm™ powder has particles that are the same size as microbes (0.5-4.0 µm in diameter) and thus they qualitatively replicate transmissibility of bacterial species
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through the towels. Individual GloGerm™ particles are visible with UV light.The GloGerm™ powder was spread flat so that no visible elevations or clumping formed. With a new sterile pair
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of gloves, the Sterile Disposable Surgical OR Towel was laid on top of the “contaminated surface,” which was then held with a gloved hand for 30 seconds and then illuminated with UV light to identify the presence or absence of GloGerm™ powder on the sterile glove. Three repetitions of this procedure, with three individual Sterile Disposable Surgical OR Towels, were
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performed.
In Situ Assessment of Bacterial Transmission Through Sterile Disposable Surgical OR Towels
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By rolling Rodac TSA plates on the back surface of operating room landline telephone recievers where the operator’s palm would make contact with the telephone handset, the quantity
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of bacteria was determined. This in situ experiment was performed on 18 different operating room telephones between cases. Sterile gloves were then draped with a Sterile Disposable Surgical OR Towel and then an operating room telephone receiver was held for 30 seconds (Figure 1A). The gloves were then cultured onto a TSA plate and the Rodac and TSA plates were incubated for 72 hours.
ACCEPTED MANUSCRIPT 8 Negative controls of the sterile gloves, Sterile Disposable Surgical OR Towels, and sterile saline were obtained to rule out any results that could occur from contamination. Statistical Analysis
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Analyses were run in JMP Pro 13 (SAS Institutue, Inc., Cary, NC). CFUs were
summarized and bacterial transmission was coded as any colonies on the glove versus no
colonies. A one-sample test was run to assess if the percent of gloves with tramission was greater
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than 0 (note: this one-sample test cannot have the hypothesized null proportion = 0, thus the null proportion was set to 0.01%). In addition, the 95% confidence interval was calulated for the
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percent of gloves with a positive transmission. p < 0.05 was considered statistically significant. RESULTS
Qualititative PCR Assessment of Bacterial Species Present
To confirm that inamimate objects in an operating room harbor microorganisms,
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telephone recievers were sampled. On three of four operating room telephone recievers cultured, Micrococcus luteus, Staphylococcus epidermidis, Microbacterium insulae, Actiniomyces, Staphylococcus pasteuri, and an unclassified species were found. One telephone’s cultures did
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not yield any bacterial species.
Qualitative Transmission of GloGerm™ Powder Through Sterile Disposable Surgical OR
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Towels
GloGerm™ powder was macroscopically visible with UV illumination on all gloves after
touching a contaminated plastic surface (Figure 2). Quantitative In Situ Assessment of Bacterial Transmission Through Sterile Disposable Surgical OR Towels
ACCEPTED MANUSCRIPT 9 The action of handling a telephone receiver through a sterile dry towel to maintain the sterile field was simulated in a mock operative environment (Figure 1A). Due to an outlier value for one telephone that did not show bacterial growth at baseline, only 17 samples were included
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for statistical analysis. Median CFU on the telephones for these 17 samples was 10, ranging from 1 to 35 CFUs. Of these 17 samples, 47% had transmission from the telephone to the glove, which was significantly greater than 0% (95% CI: 26%-69%, p < 0.001). Negative controls for sterile
were not due to contamination (results not shown).
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DISCUSSION
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gloves, Sterile Disposable Surgical OR Towels, and sterile saline confirmed that these results
In this conceptual study, we demonstrated for the first time that sSterile Disposable Surgical OR Towels, often used by many surgeons to hold or adjust a non-sterile object (e.g. telephone, headlamp, loupes) while within a sterile field during surgery, are an ineffective barrier
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for reliably maintaining surgical sterility. Based on the common occurrence of this practice, we believed that no organisms would transfer through the towels, but our results disproved this hypothesis. Our data support the concern that inanimate objects such as operating room
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telephones harbor bacteria despite structured and regulated efforts to decontaminate these surfaces. Subsequently, we demonstrated the plausibility of bacterial translocation by using
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GloGerm™ powder to elucidate the porosity of the towels. Finally, we showed that dry sterile gloves became readily contaminated with bacteria when attempting to preserve glove sterility by using a sterile towel to hold an operating room telephone. Our data demonstrate that the practice of handling a potentially contaminated surface with only a sterile towel is not a best practice and should be reconsidered as we have demonstrated that it readily compromises glove sterility.
ACCEPTED MANUSCRIPT 10 Previous studies on perioperative textiles focus primarily on the protective characteristics of surgical gowns and drapes.14-16 This literature focuses on liquid permeability, bacterial colonization, and environmental sustainability regarding single- or multiple-use fabrics.17-20 We
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were unable to find any studies that evaluate the protective microbial barrier capability of dry sterile operating room towels. The Sterile Disposable OR Towel used in our study, is visibly permeable to the naked eye (Figure 1B).
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Some limitations should be considered. Our study does not prove that handling a
contaminated object using a sterile towel will lead to a SSI. It simply demonstrates that bacterial
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pathogens readily transmit through these sterile towels onto gloves. The in situ nature of the methods leads to inconsistent bacterial species and CFU measurements for each particular investigative repetition. The inconsistency of bacterial load may appear to limit the reproduciblility of our results, but they do reflect a real world clinical environment sampling.
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Furthermore, we did not assess cellular telephones, which are not included in institutional cleaning practices, but are frequently used by surgeons in a similar manner to that of an operating room telephone. Additionally, there were institutional limitations, including only
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testing the sterile disposable surgical OR towels rather than Deluxe or Non-Woven Medline Brand options, as they are not used in our institution. This study was also limited to the material
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of towel tested, providing conceptual evidence of transmission for one particular towel material and type rather than every available option on the market today. CONCLUSION
Bacterial pathogens readily transmit through a sterile cotton towel material.
Intraoperative practices where telephones, headgear, and loupes are adjusted by a surgeon using an interposed towel without changing gloves afterward should be reconsidered. Operating room
ACCEPTED MANUSCRIPT 11 towels made of different material or thread count may behave a lower risk of bacterial translocation. However, based upon our results, it is worth recognizing the potential
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object brings to the sterile field safety and thus the patient.
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contamination threat the common practice of holding a phone or other inanimate nonsterile
ACCEPTED MANUSCRIPT 12 REFERENCES 1. Ban KA, Minei JP, Laronga C. American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. J Am Coll Surg 2017;224:59–74.
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2. Anderson D, Podgorny K, Berríos-Torres S. Strategies to prevent surgical site infections in acute care hospitals: 2014 Update. Infect Control Hospital Epidemiol 2014;35:605–627. 3. World Health Organization. Prevention of hospital-acquired infections: A practical guide,
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2nd edition. Department of Communicable Disease, Surveillance and Response, 2002. 4. Chukwudozie Onuoha S, Fatokun K. Bacterial contamination and public health risk
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associated with the use of banks’ automated teller machines (ATMs) in Ebonyi State, Nigeria. Am J Public Health Res 2014;2:46–50.
5. World Health Organization. WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care Is Safer Care: Tranmission of pathogens by
29, 2018.
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hands. Available at https://www.ncbi.nlm.nih.gov/books/NBK144014/. Accessed January
6. Neely AN, Maley MP. Survival of enterococci and staphylococci on hospital fabrics and
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plastic. J Clin Microbiol 2000;38:724–726. 7. Kramer A, Schwebke I, Kampf G. How long do nosocomial pathogens persist on inanimate
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surfaces? A systematic review. BMC Infect Dis 2006;6:130. 8. Boyce J, Potter-Bynoe G, Chenevert C, King T. Environmental contamination due to Methicillin-resistant Staphylococcus aureus possible infection control implications. Infect Control Hospital Epidemiol 1997;18:622–627. 9. Chao Foong Y, Green M, Zargari A. Mobile phones as a potential vehicle of infection in a hospital setting. J Occup Environ Hyg 2015;12:D232–235.
ACCEPTED MANUSCRIPT 13 10. Brady RR, Hunt AC, Visvanathan A. Mobile phone technology and hospitalized patients: a cross-sectional surveillance study of bacterial colonization, and patient opinions and behaviors. Clin Microbiol Infect 2011;17:830–835.
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11. Pathare NA, Asogan H, Tejani S. Prevalance of methicillin resistant Staphylococcus aureus [MRSA] colonization or carriage amoung health-care workers. J Infect Public Health 2016;9:571–576.
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12. Markel TA, Gormley T, Greeley D. Hats off: a study of different operating room headgear assessed by environmental quality indicators. J Am Coll Surg 2017;225:573–581.
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13. Davis CH, Kao LS, Fleming JB. Multi-institution analysis of infection control practices identifies the subset associated with best surgical site infection performance: a Texas Alliance for Surgical Quality Collaborative project. J Am Coll Surg J Am Coll Surg. 2017 Aug 16. pii: S1072-7515(17)31665-4.
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14. McCullough EA. Methods for determining the barrier efficacy of surgical gowns. Am J Infect Control 1993;21:368–374.
15. Blom A, Estela C, Bowker K. The passage of bacteria through surgical drapes. Ann R Coll
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Surg Engl. 2000;82:405–407.
16. Mitchell A, Spencer M, Edmiston C Jr. Role of healthcare apparel and other healthcare
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textiles in the transmission of pathogens: a review of the literature. J Hosp Infect 2015;90:285–292.
17. Leonas KK, Jinkins RS. The relationship of selected fabric characteristics and the barrier effectiveness of surgical gown fabrics. Am J Infect Control 1997;25:16–23.
ACCEPTED MANUSCRIPT 14 18. OverCash M. A comparison of reusable and disposable perioperative textiles: sustainability state-of-the-art 2012. Anesth Analg 2012;114:1055–1066. Review. Erratum in: Anesth Analg 2012;115:733.
care. Infect Control Hosp Epidemiol 2001;22:248–257.
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19. Rutala WA, Weber DJ. A review of single-use and reusable gowns and drapes in health
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materials. Am J Infect Control 2004;32:27–30.
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20. Takashima M, Shirai F, Sageshima M. Distinctive bacteria-binding property of cloth
ACCEPTED MANUSCRIPT 15 Figure Legends
Figure 1. (A) Surgeon holding a non-sterile phone with a Sterile Disposable Surgical OR
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Towels. (B) The visibly porous material of the Sterile Disposable Surgical OR Towels.
Figure 2. GloGerm™ powder transmits through a Sterile Disposable Surgical OR Towel to
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sterile gloves.
ACCEPTED MANUSCRIPT 16 Precis The practice of surgeons taking phone calls while remaining sterile in the operating field is often attempted by interposing a sterile disposable towel between the phone and the surgeon’s glove.
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Sterile disposable operating room towels do not provide an effective barrier between bacteria on
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operating room telephones and the otherwise sterile gloves of a surgeon.
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ACCEPTED MANUSCRIPT
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ACCEPTED MANUSCRIPT
S1072-7515(18)30178-9
DOI:
10.1016/j.jamcollsurg.2018.03.002
Reference:
ACS 9081
To appear in:
Journal of the American College of Surgeons
Received Date: 8 February 2018 Revised Date:
22 February 2018
Accepted Date: 1 March 2018
Please cite this article as: Schirmer A, Swan C, Hughes SJ, Vasilopoulos T, Oli M, Chaudhry S, Gravenstein N, Giordano C, Break Scrub to Take That Phone Call?, Journal of the American College of Surgeons (2018), doi: 10.1016/j.jamcollsurg.2018.03.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1 Break Scrub to Take That Phone Call? Abigail Schirmer, BSa Courtney Swan, BS,a Steven J Hughes, MD, FACSb Terrie Vasilopoulos, a c c a a PHD, Monika Oli, PHD, Sana Chaudhry, Nikolaus Gravenstein, MD, Chris Giordano, MD a
Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL Department of Surgery, University of Florida College of Medicine, Gainesville, FL c Department of Microbiology & Cell Science, University of Florida, Gainesville FL
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Correspondence address: Chris Giordano, MD, Department Of Anesthesiology University Of Florida College Of Medicine 1600 SW Archer Road PO Box 100-0254 Gainesville FL 32610-0254 email: [email protected]
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Disclosure Information: Nothing to disclose.
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Running title: Break Scrub to Take That Phone Call?
ACCEPTED MANUSCRIPT 2
BACKGROUND: The American College of Surgeons reports that 60% of the hundreds of thousands of surgical site infections occurring annually are preventable. The practice of surgeons
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taking phone calls while remaining sterile in the operating field is often accomplished by
interposing a sterile disposable towel between the phone and their glove. After completing the call, surgeons resume operating. The purpose of our study is to test the conceptual idea of
surgeon through a sterile disposable towel.
SC
whether bacteria transmit from an inanimate object, such as a telephone, to the gloves of a
M AN U
STUDY DESIGN: GloGerm™, a UV light-enhanced particle powder sized to mimic bacteria, was placed on an inanimate surface and held with a sterile disposable OR towel covering a sterile surgical glove. The glove was then inspected for GloGerm™ using a UV light. Additionally, 18 operating room telephones were cultured and then held with a Sterile Disposable OR Towel
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(Medline Industries Inc., Northfield, IL) covering a sterile surgical glove. The surgical gloves were then cultured to determine if bacteria had transmitted from the telephone through the towel and onto the sterile glove.
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RESULTS: The GloGerm™ powder readily transmitted through the towel to the gloves. Median CFU on the cultured telephones for the 17 samples was 10, ranging from 1 to 35 CFUs. Of these
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17 samples, 47% had transmission from the telephone to the glove, which was significantly greater than 0% (95% CI: 26%-69%, p < 0.001). CONCLUSIONS: Sterile disposable OR towels do not provide an effective barrier between bacteria present on operating room telephones and the otherwise sterile gloves of a surgeon.
Keywords: sterile field, sterile towel, cross contamination, potential infection, patient safety
ACCEPTED MANUSCRIPT 3 Abbreviations:
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SSI = surgical site infection CFU/mL = colony forming units per milliliter PCR = polymerase chain reaction TSA = tryptic soy agar
ACCEPTED MANUSCRIPT 4 INTRODUCTION A major goal for improving the quality of care and safety of surgical patients is reducing the incidence of surgical site infections (SSIs). The American College of Surgeons and the Surgical
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Infection Society state that there are still hundreds of thousands of SSIs annually in the United States, 60% of which are considered to be preventable.1,2 Factors known to influence SSIs include surgical technique, prophylactic antibiotic timing and dose, extent of endogenous
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contamination of the wound at surgery, preoperative skin antisepsis, duration of operation,
operating room environment, patient temperature, and organisms shed by the operating room
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team.1,3 Patient-related factors such as history of smoking, diabetes, obesity,
immunosuppression, preoperative albumin levels of <3.5 mg/dL, and total bilirubin >1.0 mg/dL are also considered SSI risk factors.1
The presence and quantity of microorganisms on inanimate objects is well established.4
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Depending on the inanimate object’s location and surface type, bacterial contamination ranges from 102 to 106 colony forming units (CFUs) of bacteria that can be cultured per milliliter (CFU/mL) of culture medium.5 The ability of a microorganism to survive on an inanimate object
EP
contributes to its virulence and likelihood of transmission.6,7 Common pathogens can persist on fomites and can then serve as a vector for cross-contamination in the absence of effective
AC C
sanitation procedures.7 Kramer et al. found that both gram-positive bacteria (Enterococcus spp., Staphylococcus aureus, and Streptococcus pyogenes) and gram-negative species (Acinetobacter spp., Escherichia coli, Klebsiella spp., Pseudomonas aeruginosa, Serratia marcescens, and Shigella spp.) can survive on inanimate surfaces for months.7 Neely et al. reported that “Staphylococci and Enterococci spp can survive for days to months, even after drying, on commonly used hospital fabrics and plastic.”6 The surivival capability of these prevalent
ACCEPTED MANUSCRIPT 5 pathogenic bacterial species warrants concern for their presence in the operating room setting. There is a positive correlation between the concentration of bacterial contaminants on an object and the frequency of human contact with that object. This elevates the the potential for infection
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from frequently handled and less regularly cleaned surfaces found in operating rooms such as telephones.8-11
The World Health Organization (WHO) outlined the necessary sanitation procedures in
SC
the operating theater. Included in their procedures are cleaning all horizontal surfaces and surgical items every morning and between procedures.5 However, they advise a complete
M AN U
cleaning of the operating room area, including all annexes such as dressing rooms, technical rooms, and cupboards, only once a week.3 In general, to decrease pathogens on inanimate objects and to improve patient safety, hospitals have implemented routine sanitation measures such as the use of disposable surgical caps, but these measures often are not effective.12 A collaborative
TE D
effort between several Texas hospitals questioned infection control practices and their relevance in the prevention of SSIs. The authors suggested that it is the evidence-based infection control practices pertaining to perioperative care of patient skin, wound hygiene, and transparent SSI
EP
display that have had the greatest influence on SSIs.13 The recent concern and study regarding microbial shedding from once-acceptable operating room protective headwear prompts us to
AC C
question another common practice.12 Can an operating room telephone, touched by a surgeon holding an interposed sterile towel, serve as reservoir and vector for potentially pathogenic microbes? A surgeon may use a sterile towel to hold the telephone and speak to a pathologist or consultant. Because telephone recievers and cell phones are not directly involved in patient care, cleaning and sanitation measures may not be routinely or reliably implemented.
ACCEPTED MANUSCRIPT 6 The purpose of this study is to assess if surgical glove sterility is preserved after handling a contaminated dry object (telephone receiver) with a sterile towel interposed, as is a commonly observed practice. Based on the frequency of witnessing these intraoperative phone
that the sterile blue towel would maintain surgical sterility.
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conversations and in the absence of any reports of telephone-mediated SSIs, we hypothesized
SC
METHODS IRB approval was not required. We began by qualitatively determining if pathogenic bacterial species were present on four randomly selected operating room telephone recievers. We
M AN U
then qualitatively assessed if non-pathogenic GloGerm™ powder (GloGerm™ Company, Moab, UT), UV light-enhanced particles that were the same average size as bacteria would transmit through Sterile Disposable Surgical OR Towels (Medline Industries Inc., Northfield, IL). These Sterile Disposable Surgical OR Towels are woven with dimensions of 46 by 19 square inches, equating to a thread count of 874, and each towel is made with 55 g of cotton thread (Heidi,
TE D
Medline Customer Service, telephone call, personal communication, October 05, 2017). An in situ method was developed to test if the bacteria present on operating room telephones would
EP
transmit through a Sterile Disposable Surgical OR Towel onto sterile surgical gloves. Qualititative: Polymerase Chain Reaction (PCR) Assessment of Bacterial Species Present
AC C
Samples were collected in the middle of the day and after room turnover for culture from four operating room telephones. Outer surfaces were swabbed with sterile saline-soaked swabs dipped and plated on tryptic soy agar (TSA) plates. The plates were incubated for 24 hours at 37°C and cultured colonies were isolated. PCR was performed for each colony of unique morphology to determine bacterial species present on these randomly selected, frequently handled telephone receiver handpieces in between operating room cases in the middle of the day in a busy tertiary care operating room suite.
ACCEPTED MANUSCRIPT 7
Qualitative: Transmission of GloGerm™ Powder Through Sterile Disposable Surgical OR Towels
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Approximately 3 g of Glo Germ powder was spread on a plastic surface that served as a proxy for a telephone reciever. GloGerm™ powder has particles that are the same size as microbes (0.5-4.0 µm in diameter) and thus they qualitatively replicate transmissibility of bacterial species
SC
through the towels. Individual GloGerm™ particles are visible with UV light.The GloGerm™ powder was spread flat so that no visible elevations or clumping formed. With a new sterile pair
M AN U
of gloves, the Sterile Disposable Surgical OR Towel was laid on top of the “contaminated surface,” which was then held with a gloved hand for 30 seconds and then illuminated with UV light to identify the presence or absence of GloGerm™ powder on the sterile glove. Three repetitions of this procedure, with three individual Sterile Disposable Surgical OR Towels, were
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performed.
In Situ Assessment of Bacterial Transmission Through Sterile Disposable Surgical OR Towels
EP
By rolling Rodac TSA plates on the back surface of operating room landline telephone recievers where the operator’s palm would make contact with the telephone handset, the quantity
AC C
of bacteria was determined. This in situ experiment was performed on 18 different operating room telephones between cases. Sterile gloves were then draped with a Sterile Disposable Surgical OR Towel and then an operating room telephone receiver was held for 30 seconds (Figure 1A). The gloves were then cultured onto a TSA plate and the Rodac and TSA plates were incubated for 72 hours.
ACCEPTED MANUSCRIPT 8 Negative controls of the sterile gloves, Sterile Disposable Surgical OR Towels, and sterile saline were obtained to rule out any results that could occur from contamination. Statistical Analysis
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Analyses were run in JMP Pro 13 (SAS Institutue, Inc., Cary, NC). CFUs were
summarized and bacterial transmission was coded as any colonies on the glove versus no
colonies. A one-sample test was run to assess if the percent of gloves with tramission was greater
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than 0 (note: this one-sample test cannot have the hypothesized null proportion = 0, thus the null proportion was set to 0.01%). In addition, the 95% confidence interval was calulated for the
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percent of gloves with a positive transmission. p < 0.05 was considered statistically significant. RESULTS
Qualititative PCR Assessment of Bacterial Species Present
To confirm that inamimate objects in an operating room harbor microorganisms,
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telephone recievers were sampled. On three of four operating room telephone recievers cultured, Micrococcus luteus, Staphylococcus epidermidis, Microbacterium insulae, Actiniomyces, Staphylococcus pasteuri, and an unclassified species were found. One telephone’s cultures did
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not yield any bacterial species.
Qualitative Transmission of GloGerm™ Powder Through Sterile Disposable Surgical OR
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GloGerm™ powder was macroscopically visible with UV illumination on all gloves after
touching a contaminated plastic surface (Figure 2). Quantitative In Situ Assessment of Bacterial Transmission Through Sterile Disposable Surgical OR Towels
ACCEPTED MANUSCRIPT 9 The action of handling a telephone receiver through a sterile dry towel to maintain the sterile field was simulated in a mock operative environment (Figure 1A). Due to an outlier value for one telephone that did not show bacterial growth at baseline, only 17 samples were included
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for statistical analysis. Median CFU on the telephones for these 17 samples was 10, ranging from 1 to 35 CFUs. Of these 17 samples, 47% had transmission from the telephone to the glove, which was significantly greater than 0% (95% CI: 26%-69%, p < 0.001). Negative controls for sterile
were not due to contamination (results not shown).
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DISCUSSION
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gloves, Sterile Disposable Surgical OR Towels, and sterile saline confirmed that these results
In this conceptual study, we demonstrated for the first time that sSterile Disposable Surgical OR Towels, often used by many surgeons to hold or adjust a non-sterile object (e.g. telephone, headlamp, loupes) while within a sterile field during surgery, are an ineffective barrier
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for reliably maintaining surgical sterility. Based on the common occurrence of this practice, we believed that no organisms would transfer through the towels, but our results disproved this hypothesis. Our data support the concern that inanimate objects such as operating room
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telephones harbor bacteria despite structured and regulated efforts to decontaminate these surfaces. Subsequently, we demonstrated the plausibility of bacterial translocation by using
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GloGerm™ powder to elucidate the porosity of the towels. Finally, we showed that dry sterile gloves became readily contaminated with bacteria when attempting to preserve glove sterility by using a sterile towel to hold an operating room telephone. Our data demonstrate that the practice of handling a potentially contaminated surface with only a sterile towel is not a best practice and should be reconsidered as we have demonstrated that it readily compromises glove sterility.
ACCEPTED MANUSCRIPT 10 Previous studies on perioperative textiles focus primarily on the protective characteristics of surgical gowns and drapes.14-16 This literature focuses on liquid permeability, bacterial colonization, and environmental sustainability regarding single- or multiple-use fabrics.17-20 We
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were unable to find any studies that evaluate the protective microbial barrier capability of dry sterile operating room towels. The Sterile Disposable OR Towel used in our study, is visibly permeable to the naked eye (Figure 1B).
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Some limitations should be considered. Our study does not prove that handling a
contaminated object using a sterile towel will lead to a SSI. It simply demonstrates that bacterial
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pathogens readily transmit through these sterile towels onto gloves. The in situ nature of the methods leads to inconsistent bacterial species and CFU measurements for each particular investigative repetition. The inconsistency of bacterial load may appear to limit the reproduciblility of our results, but they do reflect a real world clinical environment sampling.
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Furthermore, we did not assess cellular telephones, which are not included in institutional cleaning practices, but are frequently used by surgeons in a similar manner to that of an operating room telephone. Additionally, there were institutional limitations, including only
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testing the sterile disposable surgical OR towels rather than Deluxe or Non-Woven Medline Brand options, as they are not used in our institution. This study was also limited to the material
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of towel tested, providing conceptual evidence of transmission for one particular towel material and type rather than every available option on the market today. CONCLUSION
Bacterial pathogens readily transmit through a sterile cotton towel material.
Intraoperative practices where telephones, headgear, and loupes are adjusted by a surgeon using an interposed towel without changing gloves afterward should be reconsidered. Operating room
ACCEPTED MANUSCRIPT 11 towels made of different material or thread count may behave a lower risk of bacterial translocation. However, based upon our results, it is worth recognizing the potential
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object brings to the sterile field safety and thus the patient.
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contamination threat the common practice of holding a phone or other inanimate nonsterile
ACCEPTED MANUSCRIPT 12 REFERENCES 1. Ban KA, Minei JP, Laronga C. American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. J Am Coll Surg 2017;224:59–74.
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2. Anderson D, Podgorny K, Berríos-Torres S. Strategies to prevent surgical site infections in acute care hospitals: 2014 Update. Infect Control Hospital Epidemiol 2014;35:605–627. 3. World Health Organization. Prevention of hospital-acquired infections: A practical guide,
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2nd edition. Department of Communicable Disease, Surveillance and Response, 2002. 4. Chukwudozie Onuoha S, Fatokun K. Bacterial contamination and public health risk
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associated with the use of banks’ automated teller machines (ATMs) in Ebonyi State, Nigeria. Am J Public Health Res 2014;2:46–50.
5. World Health Organization. WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care Is Safer Care: Tranmission of pathogens by
29, 2018.
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hands. Available at https://www.ncbi.nlm.nih.gov/books/NBK144014/. Accessed January
6. Neely AN, Maley MP. Survival of enterococci and staphylococci on hospital fabrics and
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plastic. J Clin Microbiol 2000;38:724–726. 7. Kramer A, Schwebke I, Kampf G. How long do nosocomial pathogens persist on inanimate
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surfaces? A systematic review. BMC Infect Dis 2006;6:130. 8. Boyce J, Potter-Bynoe G, Chenevert C, King T. Environmental contamination due to Methicillin-resistant Staphylococcus aureus possible infection control implications. Infect Control Hospital Epidemiol 1997;18:622–627. 9. Chao Foong Y, Green M, Zargari A. Mobile phones as a potential vehicle of infection in a hospital setting. J Occup Environ Hyg 2015;12:D232–235.
ACCEPTED MANUSCRIPT 13 10. Brady RR, Hunt AC, Visvanathan A. Mobile phone technology and hospitalized patients: a cross-sectional surveillance study of bacterial colonization, and patient opinions and behaviors. Clin Microbiol Infect 2011;17:830–835.
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11. Pathare NA, Asogan H, Tejani S. Prevalance of methicillin resistant Staphylococcus aureus [MRSA] colonization or carriage amoung health-care workers. J Infect Public Health 2016;9:571–576.
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12. Markel TA, Gormley T, Greeley D. Hats off: a study of different operating room headgear assessed by environmental quality indicators. J Am Coll Surg 2017;225:573–581.
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13. Davis CH, Kao LS, Fleming JB. Multi-institution analysis of infection control practices identifies the subset associated with best surgical site infection performance: a Texas Alliance for Surgical Quality Collaborative project. J Am Coll Surg J Am Coll Surg. 2017 Aug 16. pii: S1072-7515(17)31665-4.
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14. McCullough EA. Methods for determining the barrier efficacy of surgical gowns. Am J Infect Control 1993;21:368–374.
15. Blom A, Estela C, Bowker K. The passage of bacteria through surgical drapes. Ann R Coll
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Surg Engl. 2000;82:405–407.
16. Mitchell A, Spencer M, Edmiston C Jr. Role of healthcare apparel and other healthcare
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textiles in the transmission of pathogens: a review of the literature. J Hosp Infect 2015;90:285–292.
17. Leonas KK, Jinkins RS. The relationship of selected fabric characteristics and the barrier effectiveness of surgical gown fabrics. Am J Infect Control 1997;25:16–23.
ACCEPTED MANUSCRIPT 14 18. OverCash M. A comparison of reusable and disposable perioperative textiles: sustainability state-of-the-art 2012. Anesth Analg 2012;114:1055–1066. Review. Erratum in: Anesth Analg 2012;115:733.
care. Infect Control Hosp Epidemiol 2001;22:248–257.
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19. Rutala WA, Weber DJ. A review of single-use and reusable gowns and drapes in health
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materials. Am J Infect Control 2004;32:27–30.
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20. Takashima M, Shirai F, Sageshima M. Distinctive bacteria-binding property of cloth
ACCEPTED MANUSCRIPT 15 Figure Legends
Figure 1. (A) Surgeon holding a non-sterile phone with a Sterile Disposable Surgical OR
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Towels. (B) The visibly porous material of the Sterile Disposable Surgical OR Towels.
Figure 2. GloGerm™ powder transmits through a Sterile Disposable Surgical OR Towel to
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sterile gloves.
ACCEPTED MANUSCRIPT 16 Precis The practice of surgeons taking phone calls while remaining sterile in the operating field is often attempted by interposing a sterile disposable towel between the phone and the surgeon’s glove.
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Sterile disposable operating room towels do not provide an effective barrier between bacteria on
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operating room telephones and the otherwise sterile gloves of a surgeon.
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