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CROSS-INFECTION ITS CONTROL IN AN ORTHOPÆDIC HOSPITAL BY MEANS OF A CUBICLED ISOLATION WARD
1228
Special
Articles
ITS CONTROL IN AN ORTHOPÆDIC HOSPITAL BY MEANS OF A CUBICLED ISOLATION WARD
C. H. LACK M.B. Sydney HONORARY CONSULTANT PATHOLOGIST, READER IN UNIVERSITY OF LONDON
BACTERIOLOGY,
A. G. TOWERS M.B., B.Sc. Lond. LECTURER, DEPARTMENT
OF PATHOLOGY
F. HARWOOD STEVENSON M.D. Lond., M.R.C.P. CONSULTANT PHYSICIAN
Royal National Orthopœdic Hospital, Stanmore, Middlesex, and the Institute of Orthopœdics
From the
IN 1948 we had only open 25-bed wards without rooms for dressings, the aspiration of abscesses, removal of stitches and so forth. No attempt was made to separate clean surgical cases from suppurating cases. Epidemiological studies showed that many postoperative infections were due to our hos-
are
available. Procedures for Wound Dressings
Everyone entering room to
attend
examine
a
a
to or
patient,
or
in when
are
exposed,
coats, roll and don a up sleeves, and plastic apron paper must remove
other
changes, enough crossinfection persisted to convince us that isolaFig. I-A room in the cubicled hut. tion of infection was Each has french windows. necessary. An isolation ward of 17 rooms (fig. 1) was constructed from an existing open ward. After two years some assessment of its value can be made. The principles underlying the plan of the isolation unit were: (1) the risk of microbic spread between rooms must be low and (2) the isolation of patients should not mean too great a deprivation of amenities. The plans ensured that almost everything required by a patient is kept in his room. Double doors give on to a fine-weather solarium for beds. The rooms open off a central six-foot corridoor and are partitioned with hardboard on a wood frame. The shock-absorbing cushion seating for all posts, the use of soundabsorbing materials, and low ceilings have much reduced noise and echo. Corridor light cannot shine into the rooms; fanlights above the french doors give Fig. 2-The built-in furniture light and ventilation. which forms the wall between each room and the corridor. The top horizontal cupboard takes the individual bedpans into or out of the room and stores them for use.
portable telephone
wounds
"
and
blankets, bactericidally treated. Food comes from the general kitchen with no separate utensils. Library books and a
coming
pital staphylococci. Dressing-rooms were then provided, a notouch " dressing technique was enforced, and dry sweeping was abolished; but, in spite these
are
’
CROSS-INFECTION
of
painted in different colours. Floors are of ’. Acrotyle The wall between corridor and room is made up of cupboards and drawers (fig. 2) for clothes, bedpan and urinal, washbowl and toilet articles, and spare blankets. The bedpan is in a hatch opening from both corridor and room (fig. 3). An extensible bed-lamp gives light for reading or for dressings. Wash basins have elbow taps. Patients use boilable cotton boards
The Furnishing of the Isolation Rooms Walls and built-in cup-
face-mask. The trolley has on it sterilised Fig. 3-The corridor of the cubicled nylon packs of dresshut showing through-the-wall cupings and paper enveboard for patient’s own bedpan lopes with sterilised and urine bottle. instruments. After bed clothes and old dressings have been removed, the nylon film wrapping of the pack is opened and serves as a sterile trolley-cover for instruments and bowls. Paper bags stuck to the trolley receive soiled dressings for the ward’s electric incinerator. Instruments after use are placed in chlorocresol. Plastic aprons are put into 0-1% chlorhexidine (’Hibitane’) and are later dried by hot-air fan, thus retaining a surface antiseptic. Paper stretcher-sheets are used for internal transport of septic patients and for the X-ray tables to reduce possible contamination. Walls and floors are washed with cetrimide and chlorhexidine ’Savlon’ solution ; and cleaned with a vacuum cleaner which has a filter pad in the exhaust. Attitude of Patients to Isolation Contentment with the greater comfort and privacy usually succeeds any reluctance to be isolated; the
Fig.4-Plastic aprons drip-drying under hot-air fan after soaking in chlorhexidine
0 t%.
continuance of education for children and occupational therapy are helpful, but young children may be less happy.
1229
Attitude of Staff to Isolation The enthusiasm of nurses and domestic staff and the appreciation of the advantages by the medical staff have produced an efficient unit. Fear of danger from infection has been allayed among the untrained staff.
Routine in the Period of this Report Infected sites
were
swabbed
weekly. Sensitivities of
gram-positive pathogens were checked to penicillin, streptomycin, chloramphenicol, and chlortetracycline and to
other
drugs
if in
use
by the patient. Local antibiotic
sensitivities if required (neomycin, bacitracin, polymyxin).
description of every lesion with the amount of discharge, &c., was recorded weekly. The principles of chemotherapy accepted by the medical staff committee were: penicillin never to be used alone; two antibiotics in combination always to be used both for general and local treatment; these, if possible to be of proven value against the infection and to prevent crossresistance adequately. Visitors are allowed to enter only one room. A modified " barrier technique ", with gowning of medical and other staff, is used for septic patients in the general wards if the A full
isolation ward is full. Patients with intercurrent sepsis, boils, &c., ferred, if possible, before the lesions discharge.
are
trans-
Bacteriological Investigations The investigations carried out between September, 1959, and December, 1960, covered the patients, the staff and their clothes, and the rooms and their contents. The Patients Weekly nasal swabbing of 27 patients over two months showed no characteristic patterns of Staphylococcus pyogenes, or correlation with their wound infections, and no evidence of nasal carriage of epidemic types.
Staff on the Unit Fortnightly nasal swabbing
The
of nurses and domestic helpers revealed among 7 permanent members 1 recurrent triplyresistant Staph. pyogenes carrier of no known phage-type and other variable transient carriers. Of the 40 other changing staff in the period (14 in all at any one time), about a quarter were positive each fortnight. Re-swabbing the positives four days later showed that 90% had either lost or replaced their staphylococcus with types which had no particular relation to the patients’ organisms and it also showed that there were very few persistent carriers; nasal carriage therefore caused no anxiety in the ward.
Fingerprints From September, 1959,
February, 1960, 5 x 27 right-hand prints taken from three staff nurses after completing a dressing, and before immersing the hand in the routine bowl of 0-1% chlorhexidine, were recorded and no Staph. pyogenes were isolated. During March and April, 1960, Staph. pyogenes was to
recovered three times from 1 member of the staff, and once each from 3 other members of the staff. Since April, 1960, scanty Staph. pyogenes were recovered twice from many fingerprint checks.
Plastic Aprons After use the plastic aprons are soaked in 0-1 % chlorhexidine, hung to dry (fig. 4), and then assumed " clean ". Six of those swabbed each week up to March, 1960, grew no Staph. pyogenes. During March and April, 1960, Staph. pyogenes was recovered
eight occasions from the aprons. The supply of permit one hour’s soaking resulted in no more positive cultures of Staph. pyogenes or Escherichia coli in any on
more aprons to
weekly test.
The results of tests on 216 aprons were: No growth Aerobic Esch.coli Proteus
spore-bearers ..............
..............
Coagulase-negative staphylococci Coagulase-positive staphylococci........
......
162 34 3 1 8 8
After each dressing, the nurse sponges her own apron and her hands with 0-1% chlorhexidine and then-does the next dressing without further washing. Twenty-five aprons checked between dressings before being wiped, showed no growth from twenty-two, aerobic spore-bearers from two, and Staph. pyogenes from one. Since April, 1960, the wall behind the " clean " apron rail has been regularly wiped with 0-1% chlorhexidine and has grown
no
pathogens.
Uniforms Uniforms
covered by aprons were examined by impressthree months’ period; they are changed 1-3 times plate during a week. Non-pathogens were always grown but a fully sensitive Staph. pyogenes was grown once only from a dress that had been worn four days. not
a
Rooms, Furniture, &c. All
rooms were
swabbed for 3 ft. above the "
dusting
line, both before and six weeks after the half-yearly painters’ wash-down. The only Staph. pyogenes (obtained on one occasion before the
wash-down) was from the room of a man with secondarily infected, widespread exfoliative dermatitis. Sister’s Office The telephone, walls, radiators, cupboards, and desk in this much-used room were checked on numbers of occasions, and Staph. pyogenes were never found. Books In October, 1959, many books and papers from 4 patients (3 chronic osteomyelitis, 1 secondarily infected tuberculous sinus) were swabbed 4 times during one week. Only aerobic spore-bearers were found and consequently we allow our patients full library facilities.
Wastepaper Bins in Each Room These are plastic with hinged lids,
and paper-bag liners, and receive wastepaper, banana skins, cigarette ends, &c. The bags are burnt, and the bins wiped daily with savlon. From 34 swab examinations, no Staph. pyogenes were recovered.
Vacuum Cleaner Domestic cylinder type is used; no sweeping is done in the ward. The emerging filtered air, checked monthly, showed a rise of colony count from 12-24 over twelve months, on a plate held one foot from the air exit for fifteen seconds. One fully sensitive Staph. pyogenes was once grown; otherwise only aerobic spore-bearers. The filter is now changed quarterly.
Curtains These
are
nylon throughout.
’
Blankets Six cotton blankets, impregnated at the laundry with a blend of chloro-substituted phenol with alkyl-phenolic esters, gave a very satisfactory colony-count over 18 days after normal bed use. Six woollen blankets showed a slow colony-count rise per sq. cm., but even after three weeks’ use there were many less in treated than in untreated blankets. In April, 1960, impress-plates from seventeen cotton topblankets in use gave satisfactorily low counts with scanty, fully sensitive Staph. pyogenes from 4 only. In September, 1960, treated cotton top-blankets, impressplated weekly in the 17 rooms, gave a mixed organism count of four colonies per sq. cm., except in two in which the count was doubled in the fourth week. Staph. pyogenes were only obtained 7 times from 119 plates; all but one fully sensitive. Self-sterilisation of blankets up to four weeks seems more
1230 successful than Williams (1960) found: he reported that " none of the disinfectant processes seems able to make the blankets sufficiently self-sterilising ". We now re-launder blankets after four weeks, or on discharge of a patient.
It is clear from our investigations that no spread occurs from room to room of any one staphylococcus. During 1960, we isolated 7 phage-type 80 or 52A/80 staphylococci (1-9%) but the staff did not become carriers nor were adjoining patients’ wounds infected. In 1959, 70% of Staph. pyogenes isolated were penicillin-sensitive; in 1960, the proportion was still high at 62%. Bradley and Meynell (1961) reported 10% phage-type 80 and 21% penicillinsensitive for hospital inpatients in Birmingham. We are fortunate, with all wards on one storey, well spread out, and 450 ft. above sea level; initial contamination of the air must be lower than in a city hospital. We admit cases of acute and chronic osteomyelitis and secondarily infected skeletal tuberculosis but, because ours is a specialised hospital, we do not take in abdominal cases or patients with
sepsis was proved to come from an endogenous source. Staphylococcal colonisation may be saprophytic and irrelevant. A new sensitivity pattern should be confirmed by re-swabbing before change of chemotherapy, especially if the latter is based upon operation material. There is a clear difference between infection and infestation, but the latter may have a conNo
TABLE
case
of postoperative
II-INCIDENCE
OF
POSTOPERATIVE
SEPSIS
IN
THE HOSPITAL
staphylococcal pneumonia. Staphylococci in
the
Hospital
swabbing produced 333 swabs for Staph. pyogenes from 1128 patients and staff. positive The organism was sensitive to antibiotics in 81 of the staff and 122 of the patients. It was resistant to penicillin in 58 In 1959
mass
nasal
TABLE I-THE SENSITIVITY OF STAPHYLOCOCCI FROM INTERCURRENT IN PATIENTS AND STAFF LESIONS STYES, SEPTIC FINGERS,
&C.)
(BOILS,
siderable public health relevance. Antibiotics should be given when likely to prove helpful.
only
Our enviable penicillin sensitive and P+S+C+A+ staphylococci percentage rate is associated with a policy of two-drug chemotherapy for general or local treatment. The surface antibiotics used are as a rule not the same as the ones employed systemically. Table II gives full details over the period in question. The 1961:
following
are our
figures, for the hospital, in
Staphylococcal sepsis-rate after clean operations was 1 02%. Penicillin-sensitive staphylococci were responsible in 71%. Intercurrent lesions with fully sensitive staphylococci in patients, 65 %. Intercurrent lesions with fully sensitive staphylococci in staff, 82%.
implants to wound infection Of 21 patients with deep postoperative sepsis, 14 had
Relationship
of the staff and 72 of the patients. In all, the organisms sensitive to chlorhexidine and neomycin ointment (’ Naseptin ’), but applied twice daily it failed to lower the carrier-rate in patients and staff in two wards. The use of naseptin more often is difficult, and, as in our experience nasal carriage is hardly ever a source of autoinfection, we do not attempt it. were
Patients, resident staff, and non-resident staff each number about 350. Inpatients with boils, styes, &c., are removed to the isolation ward, if possible before pus discharges. Members of the staff with such a lesion are put off work without full sickness certification. The intake to the ward for the year was 157 patients. Direct admissions....
Transferred from other wards atStanmore .. Infected operation wounds
26 12 11 5 1 1 1
Staphylococcal cystitis.. Infected dermatitis Chronic bone infection (osteomyelitis, tubercu..
losis, &c.)
from town branch...... Staphylococcal enteritis from town branch Chronic bone infection.. Plastic surgery Others...... ....
3 1 24 7 14 49
45 6
....
Plastic surgery patients
Postoperative
a
clean operation site.
"
means
sometimes
Summary
our
infection, superficial
or
responsible ?
Infection in relation to implants can appear clinically months or years later, suggesting that bacterasmia is the etiology. Blacklock’s (1957) investigations of tuberculous infection of penicillin injection sites may be relevant. Of course operations involving metallic implants frequently take longer with increase in the theatre infection-rate.
tions of
108 "
(1) Do metallic ions impair host defence mechanisms or in growth of microbes ? (2) Is the infection always due to primary lodgement at operation or is a bacterxmia subsequent to the operation any other way facilitate the
This paper records our results in an orthopardic hospital after two years’ experience of the segregation of septic cases by means of a cubicled isolation ward. We have been guided throughout by constant bacteriological examination of the patients’ wounds, their clothing, the staff and their clothing, and the contents of rooms. We have employed combined antibiotic therapy and by making rigid defini-
Postoperative
..
metallic implants. Deep postoperative infection is said to be more prevalent where foreign material has been implanted. This high incidence of infection raises issues:
49
108
Boils, septic fingers, &c... Pressure sores .... Infected trauma.... Infected closed hsematoma
of metallic
deep,
of
sepsis we patients early.
have
Full cooperation of the possible. The committee
detected, segregated, and treated
surgeons
responsible has made this work project consisted of the
involved in the
1231 three authors and the following: J. N. Wilson, F.R.C.S. ; C. W. Manning, F.R.C.S. ; Miss M. E. Sands (matron); Sister M. Elms (ward sister); B. Spence, F.R.C.S., R. S. Cowie, F.R.C.S., and A. H. G. Murley, F.R.C.S. (successive senior surgical officers); Dr. B. Higgins (medical registrar); and Dr. J. Scales. The willing cooperation of nursing, domestic, and other staff in the ward, and the vigilance of the junior medical staff and sisters in early reporting and investigation of possible sepsis, have been vital. We are also grateful to the laboratory staff who carry a very considerable extra load. One of us (A. G. T.) is in receipt of a grant from the Ministry of Health. We also wish to acknowledge the gift from Imperial Chemical Industries Ltd. of a supply of ’Naseptin ’. REFERENCES
Blacklock, J. W. S. (1957) Proc. R. Soc. Med. 50, 61. Bradley, J., Meynell, M. J. (1961) J. clin. Path. 14, 94. Williams, R. E. O. (1960) Annu. Rev. Microbiol. 14, 61.
Mills law, which expanded Federal grants towards funds for old people unable to pay medical expenses, has been accepted by 38 States and is being considered by others. They believe it to be pernicious because: It excludes the large minority not covered by Social Security. Most of these are groups-such as the doctors themselveswho do not wish to take part in the scheme, but many would be really needy. It does not cover anyone under sixty-five and would destroy private insurance schemes that do. People who do not need benefits would draw them at the expense of the workers who are paying Social-Security contri-
butions. The benefits would be often inadequate. The length of a is limited, and the patient would pay part of the
hospital stay cost.
MEDICARE FROM A CORRESPONDENT IN THE UNITED STATES
PROBABLY most people in the United States who need care get it sooner or later; but many may delay treatment for financial reasons, and many more seeking use up their small life-savings to pay for a severe or chronic illness. Bills running into tens of thousands of dollars over a year or two are not unknown; even a fairly minor fracture may cost several hundreds, for twenty, thirty, or more dollars a day for a hospital bed is only a start to the expense. As medicine becomes more complex, it becomes more and more costly to cure a patient (or to diagnose an incurable lesion). Even the most affluent society has its poor, and many of the poor are old, retired people, who need medical care more often than the young. The Administration’s proposals for financing medical care for people over sixty-five have been incorporated in the King-Anderson Bill, which is to go before Congress
medical
again this year.1 The Bill provides
for payment of hospital charges (after the day) for up to 120 days a year, together with partial payment for laboratory tests and home-nursing, outpatient, and nursing-home care. It does not pay doctors’ or surgeons’ fees. The money is to come from Social Security funds, which are raised by contributions from employees and employers, much like the British National Insurance scheme; but not everyone is covered by Social Security, and the Bill would provide only
first$9
a
for those who
are.
President Kennedy has swung his present great personal popularity into the campaign to get his programme through Congress. Addressing a rally in New York on May 20, he said that the Bill was not for those
"who haven’t got a cent, but for those who saved or worked-then get hit ". Repudiating the objection that the Bill would sap the American quality of self-reliance, he said that nothing could destroy self-reliance more than the burden of massive medical bills passed on from patients to other generations. Mr. Kennedy’s speech was nationally televised, and next day the American Medical Association bought half an hour of national network time to put its case. Dr. E. R. Annis, chairman of the A.M.A. speakers’ bureau, claimed that most doctors opposed the King-Anderson Bill, even though they might be financially better off if it were enacted. The A.M.A. hold that the bill is both unnecessary and pernicious. They believe it to be unnecessary because 53% of the over-sixty-fives are already covered by some prepayment plan, and, according to actuarial estimates, 70-80% will be by 1970; and because the Kerr1.
Lancet, 1961, i, 440.
The Government would get
foot in the hospitals. For to decide whether a patient was still eligible for treatment after 30 days. Paper work would be increased. a
instance, review committees would have
Dr. Annis warned his audience that the Administration’s ultimate aim was something like the health service in Britain, where more and more people were buying insurance for medical care outside the State scheme. The A.M.A. believe that the older Americans should finance their medical care through the private insurance schemes, such as Blue Cross (whose benefits are usually similar to those of the King-Anderson Bill, though even more restricted) and the welfare schemes of the States, counties, and towns. The Kerr-Mills plan authorises the Federal Government to reimburse a State for half the cost of its scheme for medical care to the aged, the rest of the money coming from State and local taxes. Some States have taken no action: in those that have, the benefits vary. One of the most liberal schemes is that of Massachusetts, which provides unlimited free hospital and medical and surgical care, and appliances-e.g., glassesbut only for people over sixty-five who can pass a fairly stringent means test. The old person’s total assets must not exceed $2000 ($3000 if his spouse is alive), and a child must contribute to his parents’ medical expenses if his income exceeds a rather low level which depends on the size of his
family.
Proponents of the King-Anderson Bill point out that this means test excludes people not far above the poverty level. Not only would the new Bill cover them but it would preserve the dignity of all old people because it would be financed out of their own contributions and would apply no means test. The A.M.A. are probably right in claiming the support of a majority of doctors, but a sizeable minority favours the King-Anderson Bill, though often with reservations. Many feel that it is in catastrophic long-term illnesses that people need financial protection, rather than in the comparatively short hospital-stay covered by the Bill-in other words, that the Bill gives insufficient cover or the wrong cover. A spot poll which I took at a private hospital and a State hospital a mile apart from each other showed that 3/11 of the doctors in private practice and 1°/13 of the State-employed doctors would vote for the KingAnderson Bill. But whether it will be passed, at least in the present Congress, depends less on the views of the doctors, the old people, or the contributors to Social Security, than on the views of the twenty-five members of the ways and means committee of the House of Representatives ; for without their approval it is hard (though not impossible) for any Bill to be enacted.
Special
Articles
ITS CONTROL IN AN ORTHOPÆDIC HOSPITAL BY MEANS OF A CUBICLED ISOLATION WARD
C. H. LACK M.B. Sydney HONORARY CONSULTANT PATHOLOGIST, READER IN UNIVERSITY OF LONDON
BACTERIOLOGY,
A. G. TOWERS M.B., B.Sc. Lond. LECTURER, DEPARTMENT
OF PATHOLOGY
F. HARWOOD STEVENSON M.D. Lond., M.R.C.P. CONSULTANT PHYSICIAN
Royal National Orthopœdic Hospital, Stanmore, Middlesex, and the Institute of Orthopœdics
From the
IN 1948 we had only open 25-bed wards without rooms for dressings, the aspiration of abscesses, removal of stitches and so forth. No attempt was made to separate clean surgical cases from suppurating cases. Epidemiological studies showed that many postoperative infections were due to our hos-
are
available. Procedures for Wound Dressings
Everyone entering room to
attend
examine
a
a
to or
patient,
or
in when
are
exposed,
coats, roll and don a up sleeves, and plastic apron paper must remove
other
changes, enough crossinfection persisted to convince us that isolaFig. I-A room in the cubicled hut. tion of infection was Each has french windows. necessary. An isolation ward of 17 rooms (fig. 1) was constructed from an existing open ward. After two years some assessment of its value can be made. The principles underlying the plan of the isolation unit were: (1) the risk of microbic spread between rooms must be low and (2) the isolation of patients should not mean too great a deprivation of amenities. The plans ensured that almost everything required by a patient is kept in his room. Double doors give on to a fine-weather solarium for beds. The rooms open off a central six-foot corridoor and are partitioned with hardboard on a wood frame. The shock-absorbing cushion seating for all posts, the use of soundabsorbing materials, and low ceilings have much reduced noise and echo. Corridor light cannot shine into the rooms; fanlights above the french doors give Fig. 2-The built-in furniture light and ventilation. which forms the wall between each room and the corridor. The top horizontal cupboard takes the individual bedpans into or out of the room and stores them for use.
portable telephone
wounds
"
and
blankets, bactericidally treated. Food comes from the general kitchen with no separate utensils. Library books and a
coming
pital staphylococci. Dressing-rooms were then provided, a notouch " dressing technique was enforced, and dry sweeping was abolished; but, in spite these
are
’
CROSS-INFECTION
of
painted in different colours. Floors are of ’. Acrotyle The wall between corridor and room is made up of cupboards and drawers (fig. 2) for clothes, bedpan and urinal, washbowl and toilet articles, and spare blankets. The bedpan is in a hatch opening from both corridor and room (fig. 3). An extensible bed-lamp gives light for reading or for dressings. Wash basins have elbow taps. Patients use boilable cotton boards
The Furnishing of the Isolation Rooms Walls and built-in cup-
face-mask. The trolley has on it sterilised Fig. 3-The corridor of the cubicled nylon packs of dresshut showing through-the-wall cupings and paper enveboard for patient’s own bedpan lopes with sterilised and urine bottle. instruments. After bed clothes and old dressings have been removed, the nylon film wrapping of the pack is opened and serves as a sterile trolley-cover for instruments and bowls. Paper bags stuck to the trolley receive soiled dressings for the ward’s electric incinerator. Instruments after use are placed in chlorocresol. Plastic aprons are put into 0-1% chlorhexidine (’Hibitane’) and are later dried by hot-air fan, thus retaining a surface antiseptic. Paper stretcher-sheets are used for internal transport of septic patients and for the X-ray tables to reduce possible contamination. Walls and floors are washed with cetrimide and chlorhexidine ’Savlon’ solution ; and cleaned with a vacuum cleaner which has a filter pad in the exhaust. Attitude of Patients to Isolation Contentment with the greater comfort and privacy usually succeeds any reluctance to be isolated; the
Fig.4-Plastic aprons drip-drying under hot-air fan after soaking in chlorhexidine
0 t%.
continuance of education for children and occupational therapy are helpful, but young children may be less happy.
1229
Attitude of Staff to Isolation The enthusiasm of nurses and domestic staff and the appreciation of the advantages by the medical staff have produced an efficient unit. Fear of danger from infection has been allayed among the untrained staff.
Routine in the Period of this Report Infected sites
were
swabbed
weekly. Sensitivities of
gram-positive pathogens were checked to penicillin, streptomycin, chloramphenicol, and chlortetracycline and to
other
drugs
if in
use
by the patient. Local antibiotic
sensitivities if required (neomycin, bacitracin, polymyxin).
description of every lesion with the amount of discharge, &c., was recorded weekly. The principles of chemotherapy accepted by the medical staff committee were: penicillin never to be used alone; two antibiotics in combination always to be used both for general and local treatment; these, if possible to be of proven value against the infection and to prevent crossresistance adequately. Visitors are allowed to enter only one room. A modified " barrier technique ", with gowning of medical and other staff, is used for septic patients in the general wards if the A full
isolation ward is full. Patients with intercurrent sepsis, boils, &c., ferred, if possible, before the lesions discharge.
are
trans-
Bacteriological Investigations The investigations carried out between September, 1959, and December, 1960, covered the patients, the staff and their clothes, and the rooms and their contents. The Patients Weekly nasal swabbing of 27 patients over two months showed no characteristic patterns of Staphylococcus pyogenes, or correlation with their wound infections, and no evidence of nasal carriage of epidemic types.
Staff on the Unit Fortnightly nasal swabbing
The
of nurses and domestic helpers revealed among 7 permanent members 1 recurrent triplyresistant Staph. pyogenes carrier of no known phage-type and other variable transient carriers. Of the 40 other changing staff in the period (14 in all at any one time), about a quarter were positive each fortnight. Re-swabbing the positives four days later showed that 90% had either lost or replaced their staphylococcus with types which had no particular relation to the patients’ organisms and it also showed that there were very few persistent carriers; nasal carriage therefore caused no anxiety in the ward.
Fingerprints From September, 1959,
February, 1960, 5 x 27 right-hand prints taken from three staff nurses after completing a dressing, and before immersing the hand in the routine bowl of 0-1% chlorhexidine, were recorded and no Staph. pyogenes were isolated. During March and April, 1960, Staph. pyogenes was to
recovered three times from 1 member of the staff, and once each from 3 other members of the staff. Since April, 1960, scanty Staph. pyogenes were recovered twice from many fingerprint checks.
Plastic Aprons After use the plastic aprons are soaked in 0-1 % chlorhexidine, hung to dry (fig. 4), and then assumed " clean ". Six of those swabbed each week up to March, 1960, grew no Staph. pyogenes. During March and April, 1960, Staph. pyogenes was recovered
eight occasions from the aprons. The supply of permit one hour’s soaking resulted in no more positive cultures of Staph. pyogenes or Escherichia coli in any on
more aprons to
weekly test.
The results of tests on 216 aprons were: No growth Aerobic Esch.coli Proteus
spore-bearers ..............
..............
Coagulase-negative staphylococci Coagulase-positive staphylococci........
......
162 34 3 1 8 8
After each dressing, the nurse sponges her own apron and her hands with 0-1% chlorhexidine and then-does the next dressing without further washing. Twenty-five aprons checked between dressings before being wiped, showed no growth from twenty-two, aerobic spore-bearers from two, and Staph. pyogenes from one. Since April, 1960, the wall behind the " clean " apron rail has been regularly wiped with 0-1% chlorhexidine and has grown
no
pathogens.
Uniforms Uniforms
covered by aprons were examined by impressthree months’ period; they are changed 1-3 times plate during a week. Non-pathogens were always grown but a fully sensitive Staph. pyogenes was grown once only from a dress that had been worn four days. not
a
Rooms, Furniture, &c. All
rooms were
swabbed for 3 ft. above the "
dusting
line, both before and six weeks after the half-yearly painters’ wash-down. The only Staph. pyogenes (obtained on one occasion before the
wash-down) was from the room of a man with secondarily infected, widespread exfoliative dermatitis. Sister’s Office The telephone, walls, radiators, cupboards, and desk in this much-used room were checked on numbers of occasions, and Staph. pyogenes were never found. Books In October, 1959, many books and papers from 4 patients (3 chronic osteomyelitis, 1 secondarily infected tuberculous sinus) were swabbed 4 times during one week. Only aerobic spore-bearers were found and consequently we allow our patients full library facilities.
Wastepaper Bins in Each Room These are plastic with hinged lids,
and paper-bag liners, and receive wastepaper, banana skins, cigarette ends, &c. The bags are burnt, and the bins wiped daily with savlon. From 34 swab examinations, no Staph. pyogenes were recovered.
Vacuum Cleaner Domestic cylinder type is used; no sweeping is done in the ward. The emerging filtered air, checked monthly, showed a rise of colony count from 12-24 over twelve months, on a plate held one foot from the air exit for fifteen seconds. One fully sensitive Staph. pyogenes was once grown; otherwise only aerobic spore-bearers. The filter is now changed quarterly.
Curtains These
are
nylon throughout.
’
Blankets Six cotton blankets, impregnated at the laundry with a blend of chloro-substituted phenol with alkyl-phenolic esters, gave a very satisfactory colony-count over 18 days after normal bed use. Six woollen blankets showed a slow colony-count rise per sq. cm., but even after three weeks’ use there were many less in treated than in untreated blankets. In April, 1960, impress-plates from seventeen cotton topblankets in use gave satisfactorily low counts with scanty, fully sensitive Staph. pyogenes from 4 only. In September, 1960, treated cotton top-blankets, impressplated weekly in the 17 rooms, gave a mixed organism count of four colonies per sq. cm., except in two in which the count was doubled in the fourth week. Staph. pyogenes were only obtained 7 times from 119 plates; all but one fully sensitive. Self-sterilisation of blankets up to four weeks seems more
1230 successful than Williams (1960) found: he reported that " none of the disinfectant processes seems able to make the blankets sufficiently self-sterilising ". We now re-launder blankets after four weeks, or on discharge of a patient.
It is clear from our investigations that no spread occurs from room to room of any one staphylococcus. During 1960, we isolated 7 phage-type 80 or 52A/80 staphylococci (1-9%) but the staff did not become carriers nor were adjoining patients’ wounds infected. In 1959, 70% of Staph. pyogenes isolated were penicillin-sensitive; in 1960, the proportion was still high at 62%. Bradley and Meynell (1961) reported 10% phage-type 80 and 21% penicillinsensitive for hospital inpatients in Birmingham. We are fortunate, with all wards on one storey, well spread out, and 450 ft. above sea level; initial contamination of the air must be lower than in a city hospital. We admit cases of acute and chronic osteomyelitis and secondarily infected skeletal tuberculosis but, because ours is a specialised hospital, we do not take in abdominal cases or patients with
sepsis was proved to come from an endogenous source. Staphylococcal colonisation may be saprophytic and irrelevant. A new sensitivity pattern should be confirmed by re-swabbing before change of chemotherapy, especially if the latter is based upon operation material. There is a clear difference between infection and infestation, but the latter may have a conNo
TABLE
case
of postoperative
II-INCIDENCE
OF
POSTOPERATIVE
SEPSIS
IN
THE HOSPITAL
staphylococcal pneumonia. Staphylococci in
the
Hospital
swabbing produced 333 swabs for Staph. pyogenes from 1128 patients and staff. positive The organism was sensitive to antibiotics in 81 of the staff and 122 of the patients. It was resistant to penicillin in 58 In 1959
mass
nasal
TABLE I-THE SENSITIVITY OF STAPHYLOCOCCI FROM INTERCURRENT IN PATIENTS AND STAFF LESIONS STYES, SEPTIC FINGERS,
&C.)
(BOILS,
siderable public health relevance. Antibiotics should be given when likely to prove helpful.
only
Our enviable penicillin sensitive and P+S+C+A+ staphylococci percentage rate is associated with a policy of two-drug chemotherapy for general or local treatment. The surface antibiotics used are as a rule not the same as the ones employed systemically. Table II gives full details over the period in question. The 1961:
following
are our
figures, for the hospital, in
Staphylococcal sepsis-rate after clean operations was 1 02%. Penicillin-sensitive staphylococci were responsible in 71%. Intercurrent lesions with fully sensitive staphylococci in patients, 65 %. Intercurrent lesions with fully sensitive staphylococci in staff, 82%.
implants to wound infection Of 21 patients with deep postoperative sepsis, 14 had
Relationship
of the staff and 72 of the patients. In all, the organisms sensitive to chlorhexidine and neomycin ointment (’ Naseptin ’), but applied twice daily it failed to lower the carrier-rate in patients and staff in two wards. The use of naseptin more often is difficult, and, as in our experience nasal carriage is hardly ever a source of autoinfection, we do not attempt it. were
Patients, resident staff, and non-resident staff each number about 350. Inpatients with boils, styes, &c., are removed to the isolation ward, if possible before pus discharges. Members of the staff with such a lesion are put off work without full sickness certification. The intake to the ward for the year was 157 patients. Direct admissions....
Transferred from other wards atStanmore .. Infected operation wounds
26 12 11 5 1 1 1
Staphylococcal cystitis.. Infected dermatitis Chronic bone infection (osteomyelitis, tubercu..
losis, &c.)
from town branch...... Staphylococcal enteritis from town branch Chronic bone infection.. Plastic surgery Others...... ....
3 1 24 7 14 49
45 6
....
Plastic surgery patients
Postoperative
a
clean operation site.
"
means
sometimes
Summary
our
infection, superficial
or
responsible ?
Infection in relation to implants can appear clinically months or years later, suggesting that bacterasmia is the etiology. Blacklock’s (1957) investigations of tuberculous infection of penicillin injection sites may be relevant. Of course operations involving metallic implants frequently take longer with increase in the theatre infection-rate.
tions of
108 "
(1) Do metallic ions impair host defence mechanisms or in growth of microbes ? (2) Is the infection always due to primary lodgement at operation or is a bacterxmia subsequent to the operation any other way facilitate the
This paper records our results in an orthopardic hospital after two years’ experience of the segregation of septic cases by means of a cubicled isolation ward. We have been guided throughout by constant bacteriological examination of the patients’ wounds, their clothing, the staff and their clothing, and the contents of rooms. We have employed combined antibiotic therapy and by making rigid defini-
Postoperative
..
metallic implants. Deep postoperative infection is said to be more prevalent where foreign material has been implanted. This high incidence of infection raises issues:
49
108
Boils, septic fingers, &c... Pressure sores .... Infected trauma.... Infected closed hsematoma
of metallic
deep,
of
sepsis we patients early.
have
Full cooperation of the possible. The committee
detected, segregated, and treated
surgeons
responsible has made this work project consisted of the
involved in the
1231 three authors and the following: J. N. Wilson, F.R.C.S. ; C. W. Manning, F.R.C.S. ; Miss M. E. Sands (matron); Sister M. Elms (ward sister); B. Spence, F.R.C.S., R. S. Cowie, F.R.C.S., and A. H. G. Murley, F.R.C.S. (successive senior surgical officers); Dr. B. Higgins (medical registrar); and Dr. J. Scales. The willing cooperation of nursing, domestic, and other staff in the ward, and the vigilance of the junior medical staff and sisters in early reporting and investigation of possible sepsis, have been vital. We are also grateful to the laboratory staff who carry a very considerable extra load. One of us (A. G. T.) is in receipt of a grant from the Ministry of Health. We also wish to acknowledge the gift from Imperial Chemical Industries Ltd. of a supply of ’Naseptin ’. REFERENCES
Blacklock, J. W. S. (1957) Proc. R. Soc. Med. 50, 61. Bradley, J., Meynell, M. J. (1961) J. clin. Path. 14, 94. Williams, R. E. O. (1960) Annu. Rev. Microbiol. 14, 61.
Mills law, which expanded Federal grants towards funds for old people unable to pay medical expenses, has been accepted by 38 States and is being considered by others. They believe it to be pernicious because: It excludes the large minority not covered by Social Security. Most of these are groups-such as the doctors themselveswho do not wish to take part in the scheme, but many would be really needy. It does not cover anyone under sixty-five and would destroy private insurance schemes that do. People who do not need benefits would draw them at the expense of the workers who are paying Social-Security contri-
butions. The benefits would be often inadequate. The length of a is limited, and the patient would pay part of the
hospital stay cost.
MEDICARE FROM A CORRESPONDENT IN THE UNITED STATES
PROBABLY most people in the United States who need care get it sooner or later; but many may delay treatment for financial reasons, and many more seeking use up their small life-savings to pay for a severe or chronic illness. Bills running into tens of thousands of dollars over a year or two are not unknown; even a fairly minor fracture may cost several hundreds, for twenty, thirty, or more dollars a day for a hospital bed is only a start to the expense. As medicine becomes more complex, it becomes more and more costly to cure a patient (or to diagnose an incurable lesion). Even the most affluent society has its poor, and many of the poor are old, retired people, who need medical care more often than the young. The Administration’s proposals for financing medical care for people over sixty-five have been incorporated in the King-Anderson Bill, which is to go before Congress
medical
again this year.1 The Bill provides
for payment of hospital charges (after the day) for up to 120 days a year, together with partial payment for laboratory tests and home-nursing, outpatient, and nursing-home care. It does not pay doctors’ or surgeons’ fees. The money is to come from Social Security funds, which are raised by contributions from employees and employers, much like the British National Insurance scheme; but not everyone is covered by Social Security, and the Bill would provide only
first$9
a
for those who
are.
President Kennedy has swung his present great personal popularity into the campaign to get his programme through Congress. Addressing a rally in New York on May 20, he said that the Bill was not for those
"who haven’t got a cent, but for those who saved or worked-then get hit ". Repudiating the objection that the Bill would sap the American quality of self-reliance, he said that nothing could destroy self-reliance more than the burden of massive medical bills passed on from patients to other generations. Mr. Kennedy’s speech was nationally televised, and next day the American Medical Association bought half an hour of national network time to put its case. Dr. E. R. Annis, chairman of the A.M.A. speakers’ bureau, claimed that most doctors opposed the King-Anderson Bill, even though they might be financially better off if it were enacted. The A.M.A. hold that the bill is both unnecessary and pernicious. They believe it to be unnecessary because 53% of the over-sixty-fives are already covered by some prepayment plan, and, according to actuarial estimates, 70-80% will be by 1970; and because the Kerr1.
Lancet, 1961, i, 440.
The Government would get
foot in the hospitals. For to decide whether a patient was still eligible for treatment after 30 days. Paper work would be increased. a
instance, review committees would have
Dr. Annis warned his audience that the Administration’s ultimate aim was something like the health service in Britain, where more and more people were buying insurance for medical care outside the State scheme. The A.M.A. believe that the older Americans should finance their medical care through the private insurance schemes, such as Blue Cross (whose benefits are usually similar to those of the King-Anderson Bill, though even more restricted) and the welfare schemes of the States, counties, and towns. The Kerr-Mills plan authorises the Federal Government to reimburse a State for half the cost of its scheme for medical care to the aged, the rest of the money coming from State and local taxes. Some States have taken no action: in those that have, the benefits vary. One of the most liberal schemes is that of Massachusetts, which provides unlimited free hospital and medical and surgical care, and appliances-e.g., glassesbut only for people over sixty-five who can pass a fairly stringent means test. The old person’s total assets must not exceed $2000 ($3000 if his spouse is alive), and a child must contribute to his parents’ medical expenses if his income exceeds a rather low level which depends on the size of his
family.
Proponents of the King-Anderson Bill point out that this means test excludes people not far above the poverty level. Not only would the new Bill cover them but it would preserve the dignity of all old people because it would be financed out of their own contributions and would apply no means test. The A.M.A. are probably right in claiming the support of a majority of doctors, but a sizeable minority favours the King-Anderson Bill, though often with reservations. Many feel that it is in catastrophic long-term illnesses that people need financial protection, rather than in the comparatively short hospital-stay covered by the Bill-in other words, that the Bill gives insufficient cover or the wrong cover. A spot poll which I took at a private hospital and a State hospital a mile apart from each other showed that 3/11 of the doctors in private practice and 1°/13 of the State-employed doctors would vote for the KingAnderson Bill. But whether it will be passed, at least in the present Congress, depends less on the views of the doctors, the old people, or the contributors to Social Security, than on the views of the twenty-five members of the ways and means committee of the House of Representatives ; for without their approval it is hard (though not impossible) for any Bill to be enacted.