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Dispensing surgical gloves onto the open surgical gown pack does not increase the bacterial contamination rate
Journal
of Hospital
Injection
(1994) 26, 293-296
SHORT
Dispensing gown
surgical gloves onto the open surgical pack does not increase the bacterial contamination rate K. C. Kong,
Orthopaedic
REPORT
Department,
M. Sheppard
and G. Serne
Mayday University Hospital, Surrey CR4 7YE, UK
Accepted for publication
28 January
Thornton
Heath,
1994
Summary:
In implant surgery air and surface contamination have become important factors in post-operative wound infection. We established the rate of contamination of surgical gown packs and found that dropping gloves onto the open gown pack prior to scrubbing had no effect on it. Ninety-six contact plates were used for this study, which was carried out during clean orthopaedic operations in one operating room. The overall rate of contamination was 65%. Most of the contaminants were skin commensals. The rate of contamination was 67% when gloves were dropped onto the gown pack compared with 63% when opened and presented to the scrubbed and gowned theatre staff. However this difference was statistically not significant. The high rate of contamination was probably due to the gown packs having been left opened for too long. This delay arose because each gown pack had three gowns and would have been avoided if single gown packs had been used.
Keywords: paedic
Surface surgery.
contamination;
operation
room;
wound
infection;
ortho-
Introduction
The use of implants and bone cement in orthopaedic surgery has led to an increased importance of skin organisms such as Staphylococcus epidermidis in bone and joint infections.’ The main sources of bacteria in the operating theatre are the people, that is, the staff and the patient.2 It is the surgical team that disperses most of the airborne bacteria from shedded skin scales.3 These bacteria-laden skin scales are deposited by gravity onto surfaces. An important aseptic practice to minimize surface contamination is to avoid crossing near to or over a sterile field,” but this practice is often ignored when it comes to dispensing sterile surgical gloves. A common practice is to open the outer glove wrap and then drop the gloves onto the gown pack before proceeding to scrub. Not only does the staff member cross his or her hands over the sterile gown
294
K. C. Kong et
al.
pack, but quite often the gloves will fall too close to the edge or slide down to the floor. This study was carried out to research the contamination rate of surgical gown packs and to look at the effect of this method of dispensing surgical gloves on the contamination of the gown pack. Material
and methods
Contact plates (Difco) were used to sample the inner surface of the gown wrap. This is a reliable and simple method of assessing surface contamination.’ This study was carried out consecutively in one theatre during clean orthopaedic procedures to minimize differences from the type of operation, theatre and staff. We did the study using our routine triple gown packs in order to minimize disturbance to theatre routine. After the surgical gown packs were opened the gloves were dispensed in two ways: Method 1: The gloves were opened and then dropped onto the open gown pack before the staff member proceeded to scrub. Method 2: After the gown pack was opened the staff member would scrub and put on the gown before the gloves were opened and presented to him or her. Each method was used alternately for each gown pack. Ninety-six gown packs were swabbed for this study. Swabs were taken by the first or third author or a designated theatre sister. Gloves were put on using a closed technique. After the gowns had been used the inner surface of the paper was swabbed with a contact plate. Five impressions were made in a standard pattern, such that an area of 50 cm* was sampled. The contact plates were incubated at 37°C in air with 5% CO2 for 48 h. The plates were inspected at 24 and 48 h. The presence of any bacterial colony was taken as a positive result and complete absence of growth was taken as negative. Bacteria were identified by colonial appearance and Gram stain. We did not perform duplicate cultures for anaerobes as we were looking at surface contamination by hand organisms such as coryneforms and coagulase negative staphylococci. The person carrying out bacteriological examination was blinded to the glove method. Six control contact plates were tested by opening them for 1 min in the theatre and then closing without making any impressions. Statistical tests of significance were carried out using the chi-square or Fisher Exact test if the sample size was small. A value of PcO.05 was considered significant. Results Overall, 65% (62 out of 96) of the contact plates were positive. Although the contamination rare was higher with method 1 (67%) when compared with
Dispensing
surgical
295
gloves
method 2 (63%), this difference was not significant (chi-square test, P>O*OS). The frequency distribution of the number of colony forming units (cfu) was similar (Figure 1) for both methods. Coagulase negative staphylococci were isolated in 61 instances, diphtheroids in 15, aerobic spore-bearers in 12 and pseudomonads in three. The species of pseudomonas was not determined. No Staphylococcus aureus or coliform organisms were isolated. AIt six contro1 plates were negative. Further investigations During the study we observed that the gown packs were left open for a considerable time before the surgeons used them. We then surveyed 30 operations and found that 60% of the gown packs were left opened for more than 20 min before they were used by the surgeon. It would seem reasonable to expect more surface contamination to occur the longer a gown pack had been left opened. We carried out a controlled study in the same theatre using 20 gown packs to find out the effect of time on the surface contamination rate. In group 1 10 gown packs were opened for 1 min and then cultures were made as before and in group 2 another 10 were left opened for 30 min before the cultures were taken. Group 2 had nine positive plates out of 10 while group 1 had four positive plates. This difference was significant (Fisher Exact Test, PzO.03). Discussion
We found that there was no difference in the rate of surface contamination between the two methods of dispensing gloves. The variation in the number of colony counts was similar between the two methods, indicating that
1
18 16
m 0
Method Method
1 2
4 2 0 Nil
Figure gloves.
1.
Frequency
distribution
1
2
3 No. of cfus
of number
of cfus
4
5 for
each
6 or > method
of dispensing
the
K. C. Kong
296
et al.
similar factors apart from the method of dispensing the gloves were operating during the study. The overall contamination rate was rather high. Most of the contaminants were skin organisms, confirming that skin scales were being deposited onto the open gown packs. The high rate of contamination may have been due to the high level of activity around the scrub area. We frequently observed the tendency for the scrubbed personnel to drip water onto the open gown pack when picking up sterile tissues to wipe their hands. This is supported by the three instances where pseudomonads were isolated. Another possible mechanism to explain the high contamination rate was the length of time the gown pack had been left open after the scrub nurse had used the first gown in the triple gown pack. This arose because the nurse had to scrub first to prepare and lay out the trolleys while the patient was being anaesthetized and positioned on the operating table. A considerable amount of time can be required to position the patient, particularly those with fractures of the neck of the femur and it is essential that the surgeon is actively involved in this procedure. This was confirmed by our supplementary investigation which revealed that 90% of the gown packs left open for half an hour became contaminated. While surface contamination is determined by many factors, one which can be altered is to avoid the use of multiple gown packs. If this sort of pack is to be used they should only be opened just before scrubbing and should be discarded if they have been left open for more than 10 min. Also, more care would seem to be required in allowing the hands to drip sufficiently dry before the gown is picked up to minimize contamination by this route. The authors would like to thank Dr Kelly, Consultant Nurse Bearpark and staff of theatre 6, Mayday Hospital this study.
Microbiologist, Sister for their co-operation
Stewart, in carrying
Staff out
References 1. Sanderson
PJ. The choice between prophylactic agents for orthopaedic surgery. J Hasp 1988; 11, Suppl. C: 57-67. Whyte W. The role of clothing and drapes in the operating room. J Hasp Infect 1988; 11, Suppl. C: 2-17. Hambraeus A, Laurel1 G. Protection of the patient in the operating suite. J Hasp Infect 1980; 1: 15-30. AORN Recommended Practices Committee. Recommended practices-Basic asptic technique. AORNJ 1987; 45: 784-789. Angelotti R, Wilson JF, Litsky W, Walter WG. Comparative evaluation of the cotton swab and Rodac methods for the recovery of Bacillus subtilis spore contamination from stainless steel surfaces. Health Lab Sci 1964; 1: 289-296.
Infect 2. 3. 4. 5.
of Hospital
Injection
(1994) 26, 293-296
SHORT
Dispensing gown
surgical gloves onto the open surgical pack does not increase the bacterial contamination rate K. C. Kong,
Orthopaedic
REPORT
Department,
M. Sheppard
and G. Serne
Mayday University Hospital, Surrey CR4 7YE, UK
Accepted for publication
28 January
Thornton
Heath,
1994
Summary:
In implant surgery air and surface contamination have become important factors in post-operative wound infection. We established the rate of contamination of surgical gown packs and found that dropping gloves onto the open gown pack prior to scrubbing had no effect on it. Ninety-six contact plates were used for this study, which was carried out during clean orthopaedic operations in one operating room. The overall rate of contamination was 65%. Most of the contaminants were skin commensals. The rate of contamination was 67% when gloves were dropped onto the gown pack compared with 63% when opened and presented to the scrubbed and gowned theatre staff. However this difference was statistically not significant. The high rate of contamination was probably due to the gown packs having been left opened for too long. This delay arose because each gown pack had three gowns and would have been avoided if single gown packs had been used.
Keywords: paedic
Surface surgery.
contamination;
operation
room;
wound
infection;
ortho-
Introduction
The use of implants and bone cement in orthopaedic surgery has led to an increased importance of skin organisms such as Staphylococcus epidermidis in bone and joint infections.’ The main sources of bacteria in the operating theatre are the people, that is, the staff and the patient.2 It is the surgical team that disperses most of the airborne bacteria from shedded skin scales.3 These bacteria-laden skin scales are deposited by gravity onto surfaces. An important aseptic practice to minimize surface contamination is to avoid crossing near to or over a sterile field,” but this practice is often ignored when it comes to dispensing sterile surgical gloves. A common practice is to open the outer glove wrap and then drop the gloves onto the gown pack before proceeding to scrub. Not only does the staff member cross his or her hands over the sterile gown
294
K. C. Kong et
al.
pack, but quite often the gloves will fall too close to the edge or slide down to the floor. This study was carried out to research the contamination rate of surgical gown packs and to look at the effect of this method of dispensing surgical gloves on the contamination of the gown pack. Material
and methods
Contact plates (Difco) were used to sample the inner surface of the gown wrap. This is a reliable and simple method of assessing surface contamination.’ This study was carried out consecutively in one theatre during clean orthopaedic procedures to minimize differences from the type of operation, theatre and staff. We did the study using our routine triple gown packs in order to minimize disturbance to theatre routine. After the surgical gown packs were opened the gloves were dispensed in two ways: Method 1: The gloves were opened and then dropped onto the open gown pack before the staff member proceeded to scrub. Method 2: After the gown pack was opened the staff member would scrub and put on the gown before the gloves were opened and presented to him or her. Each method was used alternately for each gown pack. Ninety-six gown packs were swabbed for this study. Swabs were taken by the first or third author or a designated theatre sister. Gloves were put on using a closed technique. After the gowns had been used the inner surface of the paper was swabbed with a contact plate. Five impressions were made in a standard pattern, such that an area of 50 cm* was sampled. The contact plates were incubated at 37°C in air with 5% CO2 for 48 h. The plates were inspected at 24 and 48 h. The presence of any bacterial colony was taken as a positive result and complete absence of growth was taken as negative. Bacteria were identified by colonial appearance and Gram stain. We did not perform duplicate cultures for anaerobes as we were looking at surface contamination by hand organisms such as coryneforms and coagulase negative staphylococci. The person carrying out bacteriological examination was blinded to the glove method. Six control contact plates were tested by opening them for 1 min in the theatre and then closing without making any impressions. Statistical tests of significance were carried out using the chi-square or Fisher Exact test if the sample size was small. A value of PcO.05 was considered significant. Results Overall, 65% (62 out of 96) of the contact plates were positive. Although the contamination rare was higher with method 1 (67%) when compared with
Dispensing
surgical
295
gloves
method 2 (63%), this difference was not significant (chi-square test, P>O*OS). The frequency distribution of the number of colony forming units (cfu) was similar (Figure 1) for both methods. Coagulase negative staphylococci were isolated in 61 instances, diphtheroids in 15, aerobic spore-bearers in 12 and pseudomonads in three. The species of pseudomonas was not determined. No Staphylococcus aureus or coliform organisms were isolated. AIt six contro1 plates were negative. Further investigations During the study we observed that the gown packs were left open for a considerable time before the surgeons used them. We then surveyed 30 operations and found that 60% of the gown packs were left opened for more than 20 min before they were used by the surgeon. It would seem reasonable to expect more surface contamination to occur the longer a gown pack had been left opened. We carried out a controlled study in the same theatre using 20 gown packs to find out the effect of time on the surface contamination rate. In group 1 10 gown packs were opened for 1 min and then cultures were made as before and in group 2 another 10 were left opened for 30 min before the cultures were taken. Group 2 had nine positive plates out of 10 while group 1 had four positive plates. This difference was significant (Fisher Exact Test, PzO.03). Discussion
We found that there was no difference in the rate of surface contamination between the two methods of dispensing gloves. The variation in the number of colony counts was similar between the two methods, indicating that
1
18 16
m 0
Method Method
1 2
4 2 0 Nil
Figure gloves.
1.
Frequency
distribution
1
2
3 No. of cfus
of number
of cfus
4
5 for
each
6 or > method
of dispensing
the
K. C. Kong
296
et al.
similar factors apart from the method of dispensing the gloves were operating during the study. The overall contamination rate was rather high. Most of the contaminants were skin organisms, confirming that skin scales were being deposited onto the open gown packs. The high rate of contamination may have been due to the high level of activity around the scrub area. We frequently observed the tendency for the scrubbed personnel to drip water onto the open gown pack when picking up sterile tissues to wipe their hands. This is supported by the three instances where pseudomonads were isolated. Another possible mechanism to explain the high contamination rate was the length of time the gown pack had been left open after the scrub nurse had used the first gown in the triple gown pack. This arose because the nurse had to scrub first to prepare and lay out the trolleys while the patient was being anaesthetized and positioned on the operating table. A considerable amount of time can be required to position the patient, particularly those with fractures of the neck of the femur and it is essential that the surgeon is actively involved in this procedure. This was confirmed by our supplementary investigation which revealed that 90% of the gown packs left open for half an hour became contaminated. While surface contamination is determined by many factors, one which can be altered is to avoid the use of multiple gown packs. If this sort of pack is to be used they should only be opened just before scrubbing and should be discarded if they have been left open for more than 10 min. Also, more care would seem to be required in allowing the hands to drip sufficiently dry before the gown is picked up to minimize contamination by this route. The authors would like to thank Dr Kelly, Consultant Nurse Bearpark and staff of theatre 6, Mayday Hospital this study.
Microbiologist, Sister for their co-operation
Stewart, in carrying
Staff out
References 1. Sanderson
PJ. The choice between prophylactic agents for orthopaedic surgery. J Hasp 1988; 11, Suppl. C: 57-67. Whyte W. The role of clothing and drapes in the operating room. J Hasp Infect 1988; 11, Suppl. C: 2-17. Hambraeus A, Laurel1 G. Protection of the patient in the operating suite. J Hasp Infect 1980; 1: 15-30. AORN Recommended Practices Committee. Recommended practices-Basic asptic technique. AORNJ 1987; 45: 784-789. Angelotti R, Wilson JF, Litsky W, Walter WG. Comparative evaluation of the cotton swab and Rodac methods for the recovery of Bacillus subtilis spore contamination from stainless steel surfaces. Health Lab Sci 1964; 1: 289-296.
Infect 2. 3. 4. 5.