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Future methods for control of nosocomial infection
Guest editorial
Future methods for control of nosocomial infection One hundred years ago virtually 100% of surgical patients acquired postoperative infection. In 1976, only 16% of surgical patients will acquire postoperative infection, and although this is better, it is not good enough. Numerically, more people will die in the United States in 1976 from hospitalassociated infections than died in the entire Vietnam War. We must be doing many things wrong. If we used our present microbiological knowledge, we could eliminate 70% of unnecessary nosocomial infections. Unfortunately, too few use this knowledge today, mainly because too few understand how to apply microbiology principles to practical and everyday hospital usage. Our future hospitals can be made less of a microbiological nightmare through education and certification of hospital personnel in selected principles of microbiology required to prevent cross infection and by using aerospace techniques and automation to confine those microbes that cannot be killed. Bertha Yanis Litsky, PhD, is research associate, department of environmental sciences, University of Massachusetts, Amherst. She is a consultant to the AORN Technical Standards Committee.
M
Hospitals have used less quality control measures than any other industry. Quality control cannot be practiced without standards or guidelines, and until several years ago, standards for hospital use were few in number. Today, however, both private groups and government agencies are establishing standards for quality control in health care. For example, the Association of Operating Room Nurses has a standards committee and has published six Standards of Technical and Aseptic Practice: Operating Room.' The Association for the Advancement of Medical Instrumentation (AAMI) has a committee on sterilization. Performance standards are being formulated for ethylene oxide and steam sterilizers. Guidelines have been set by the US Food and Drug Administration* and the AAMl 2 7g3subcommittee for the safe use of ethylene oxide. The AAMl Sterilization Committee also has a subcommittee on radiation sterilization and another on the evaluation of biological monitors. The Joint Commission on Accreditation of Hospitals 1976 standards have many recommendations for the central service department that will provide quality control and lead to better sterility assurance for items being prepared for use in operating rooms. With the passage of the medical device law, more controls, guidelines, and standards will be put on hospital equipment and patientcare items. The simplicity of the dynamic interplay between man, nature, and germs has disappeared. Nature made man with excellent barriers against outside invasion of microbes,
AORN Journal, August 1976, Vol24, No 2
295
but when microbes won, man died, usually at an early age. The simplicity has been destroyed by man trying to fool Mother Nature. A person who was unable to urinate died: today we break microbial barriers with a catheter. The patient will urinate but all too often will acquire a bladder infectionthat may lead to septicemia and death. Renal dialysis can be used, but hepatitis may be acquired. The skin is an excellent barrier to microbial invasion, but when surgery, fluids, or blood are required to sustain life, the barrier is broken and infection can result. Respiratory care is given, and all too often pneumonia sets in. Respirators can prolong breathing but not always what is known as life. Our equipment and electronic technology are advancing at a galloping pace, but the ability to control microbial murder by use of these inventions is lagging behind. We are experiencing future microbial shock. If we apply the selected principles of rnicrobiology that enable us to control micmbes that contact patients, the future hospitalassociated infection rate will greatly reduce. Control of hospital-acquired infection may require private rooms and isolation of all patients who enter the hospital. Laminar air flow curtains at the door of the patient’s room will separate him from the rest of the hospital. Such an air curtain can also be used at the door to the operating room. Barrier materials should be used for operating gowns and drapes. The patient might be transported from one area of the hospital to another on a transfer cart under a plastic bubble with a self-contained ventilation system. Microbiological principles should also be applied throughout the hospital. Scientific housekeeping and HEPA (high efficiency particulate air) filters are measures that can be taken. It might be possible to have a vaccine to protect all who enter the hospital from microbes. Both visitors and salesmen might wear exhaust suits. Use of antibiotics will come under stricter control. Hospitals will be designed to control infection. A hospital might be built in a circular design with each patient’s room being selfcontained with an outside entrance. The bed could be designed so it could be used as a bathtub as well as an operating or examination table. At arm’s length, the patient would
296
have a freezer with cooked food that could be prepared in the microwave oven in the room. The medical and nursing functions would be located in the core of the hospital. Some of these suggestions are more visionary than others, but they all may become part of hospital infection control in the future.
Bertha Yanis Litsky, PhD Notes 1. ”AORN standards OR wearing apparel, draping and gowning materials,” AORN Journal 21 (March 1975) 594; “AORN standards for OR sanitation,” AORN Journal 21 (June 1975) 1228; “Standards for sponge, needle, and instrument counts,” AORN Journai 23 (May 1976) 971; ”Standards for preoperative skin preparation of patient,” AORN Journal 23 (May 1976) 974; “Standards for surgical hand scrubs,” AORN Journal 23 (May 1976) 976; “Standards for inhospital packaging materia1,”AORN Journal 23 (May 1976) 980. 2. “FDA issues guidelines for ETO sterilization,“ Hosp&i/s 49 (Nov 16, 1975) 81. 3. Marie G Wisler, “Guidelines for use of ethylene oxide,” AORN Journal (June 1974) 1286-1295.
Nurses thanked for aid at Congress Carl N Freddy’s name may not be familiar to every OR nurse, but every one who attended Congress will remember the Parke-Davis area sales manager who suffered a ruptured esophagus at Congress. AORN members were asked for 6-negative blood; many donated blood and others indicated their availability. In a recent letter, Freddy reported that he was well on his way to recovery despite a subsequent bout with pneumonia. He wished to thank publicly all the nurses who donated blood with special thanks to the nurse, whose name he does not know, who gave emergency assistance to him at his hotel where he collapsed and “did much to save my life prior to being taken by ambulance to Mt Sinai.” Writes Freddy: “The response received from the nurses attending the AORN Convention was truly unbelievable and deeply appreciated. I know I owe my life to the nurses who responded so rapidly to my desperate need for blood.’’
AORN Journal, August 1976, Vol24, No 2
Future methods for control of nosocomial infection One hundred years ago virtually 100% of surgical patients acquired postoperative infection. In 1976, only 16% of surgical patients will acquire postoperative infection, and although this is better, it is not good enough. Numerically, more people will die in the United States in 1976 from hospitalassociated infections than died in the entire Vietnam War. We must be doing many things wrong. If we used our present microbiological knowledge, we could eliminate 70% of unnecessary nosocomial infections. Unfortunately, too few use this knowledge today, mainly because too few understand how to apply microbiology principles to practical and everyday hospital usage. Our future hospitals can be made less of a microbiological nightmare through education and certification of hospital personnel in selected principles of microbiology required to prevent cross infection and by using aerospace techniques and automation to confine those microbes that cannot be killed. Bertha Yanis Litsky, PhD, is research associate, department of environmental sciences, University of Massachusetts, Amherst. She is a consultant to the AORN Technical Standards Committee.
M
Hospitals have used less quality control measures than any other industry. Quality control cannot be practiced without standards or guidelines, and until several years ago, standards for hospital use were few in number. Today, however, both private groups and government agencies are establishing standards for quality control in health care. For example, the Association of Operating Room Nurses has a standards committee and has published six Standards of Technical and Aseptic Practice: Operating Room.' The Association for the Advancement of Medical Instrumentation (AAMI) has a committee on sterilization. Performance standards are being formulated for ethylene oxide and steam sterilizers. Guidelines have been set by the US Food and Drug Administration* and the AAMl 2 7g3subcommittee for the safe use of ethylene oxide. The AAMl Sterilization Committee also has a subcommittee on radiation sterilization and another on the evaluation of biological monitors. The Joint Commission on Accreditation of Hospitals 1976 standards have many recommendations for the central service department that will provide quality control and lead to better sterility assurance for items being prepared for use in operating rooms. With the passage of the medical device law, more controls, guidelines, and standards will be put on hospital equipment and patientcare items. The simplicity of the dynamic interplay between man, nature, and germs has disappeared. Nature made man with excellent barriers against outside invasion of microbes,
AORN Journal, August 1976, Vol24, No 2
295
but when microbes won, man died, usually at an early age. The simplicity has been destroyed by man trying to fool Mother Nature. A person who was unable to urinate died: today we break microbial barriers with a catheter. The patient will urinate but all too often will acquire a bladder infectionthat may lead to septicemia and death. Renal dialysis can be used, but hepatitis may be acquired. The skin is an excellent barrier to microbial invasion, but when surgery, fluids, or blood are required to sustain life, the barrier is broken and infection can result. Respiratory care is given, and all too often pneumonia sets in. Respirators can prolong breathing but not always what is known as life. Our equipment and electronic technology are advancing at a galloping pace, but the ability to control microbial murder by use of these inventions is lagging behind. We are experiencing future microbial shock. If we apply the selected principles of rnicrobiology that enable us to control micmbes that contact patients, the future hospitalassociated infection rate will greatly reduce. Control of hospital-acquired infection may require private rooms and isolation of all patients who enter the hospital. Laminar air flow curtains at the door of the patient’s room will separate him from the rest of the hospital. Such an air curtain can also be used at the door to the operating room. Barrier materials should be used for operating gowns and drapes. The patient might be transported from one area of the hospital to another on a transfer cart under a plastic bubble with a self-contained ventilation system. Microbiological principles should also be applied throughout the hospital. Scientific housekeeping and HEPA (high efficiency particulate air) filters are measures that can be taken. It might be possible to have a vaccine to protect all who enter the hospital from microbes. Both visitors and salesmen might wear exhaust suits. Use of antibiotics will come under stricter control. Hospitals will be designed to control infection. A hospital might be built in a circular design with each patient’s room being selfcontained with an outside entrance. The bed could be designed so it could be used as a bathtub as well as an operating or examination table. At arm’s length, the patient would
296
have a freezer with cooked food that could be prepared in the microwave oven in the room. The medical and nursing functions would be located in the core of the hospital. Some of these suggestions are more visionary than others, but they all may become part of hospital infection control in the future.
Bertha Yanis Litsky, PhD Notes 1. ”AORN standards OR wearing apparel, draping and gowning materials,” AORN Journal 21 (March 1975) 594; “AORN standards for OR sanitation,” AORN Journal 21 (June 1975) 1228; “Standards for sponge, needle, and instrument counts,” AORN Journai 23 (May 1976) 971; ”Standards for preoperative skin preparation of patient,” AORN Journal 23 (May 1976) 974; “Standards for surgical hand scrubs,” AORN Journal 23 (May 1976) 976; “Standards for inhospital packaging materia1,”AORN Journal 23 (May 1976) 980. 2. “FDA issues guidelines for ETO sterilization,“ Hosp&i/s 49 (Nov 16, 1975) 81. 3. Marie G Wisler, “Guidelines for use of ethylene oxide,” AORN Journal (June 1974) 1286-1295.
Nurses thanked for aid at Congress Carl N Freddy’s name may not be familiar to every OR nurse, but every one who attended Congress will remember the Parke-Davis area sales manager who suffered a ruptured esophagus at Congress. AORN members were asked for 6-negative blood; many donated blood and others indicated their availability. In a recent letter, Freddy reported that he was well on his way to recovery despite a subsequent bout with pneumonia. He wished to thank publicly all the nurses who donated blood with special thanks to the nurse, whose name he does not know, who gave emergency assistance to him at his hotel where he collapsed and “did much to save my life prior to being taken by ambulance to Mt Sinai.” Writes Freddy: “The response received from the nurses attending the AORN Convention was truly unbelievable and deeply appreciated. I know I owe my life to the nurses who responded so rapidly to my desperate need for blood.’’
AORN Journal, August 1976, Vol24, No 2