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THE INFECTION CONTROL SISTER HER ROLE IN A LARGE HOSPITAL
1321
Special
has been created in the Exeter group of hospitals. Our sister, however, appears to have rather different duties.
Articles
SURGICAL WOUND SURVEY
THE INFECTION CONTROL SISTER HER ROLE IN A LARGE HOSPITAL
NEVILLE C. DAVIS M.B.
GEORGE FIELDING
Sydney,
F.R.C.S., F.R.A.C.S.
M.B. Queensland, F.R.C.S., F.R.A.C.S.
VISITING SURGEON
SURGICAL SUPERVISOR
FRANK GARLICK
A. RAO Calcutta, M.R.C.P.E., Dp.Bact., M.C.P.A.
M.S.
Queensland,
M.B.
F.R.C.S., F.R.A.C.S. FORMERLY SURGICAL SUPERVISOR
*
MEDICAL BACTERIOLOGIST
PRINCESS ALEXANDRA HOSPITAL, BRISBANE, QUEENSLAND, AUSTRALIA
IN 1959
a
Joint Hospitals Infection Committee
was
formed in Brisbane, representing the medical staff of the Brisbane General Hospital (1022 acute beds) and of the Princess Alexandra Hospital (830 acute beds). But, such a committee, though it meets every few months to discuss matters of mutual concern, cannot deal with the day-to-day problems of individual hospitals. Accordingly, in 1960, an infection control subcommittee was formed for the Princess Alexandra Hospital. The members of this subcommittee soon found that they could give only a small part of their time to the problem, and they came to the conclusion that control of infection within a hospital should, if possible, be vested in one person devoted entirely to this-work. As Williams et al.l have said, the key to the administrative control of infection is the appointment of an efficient Control of Infection Office". Probably the most suitable person would be a medical bacteriologist, but none was available in Brisbane. Through the help of the Department of Health and Home Affairs, a survey of infection in the hospital at that time was made by a pathologist, with a nursing sister and a bacteriological technician. The results showed that a sister concerned with the detailed control of infection could be of tremendous value. Accordingly, we pressed for the appointment of a full-time Infection Control Sister (i.c.s.), and one was appointed to the Princess Alexandra Hospital in October, 1962. As she works under the control of the director of the department of pathology, she is not in the general nursing pool of the hospital, and can give her entire time to the control of infection. The infection control subcommittee of the hospital has three members-a representative of the visiting surgical staff, the surgical supervisor, and the medical bacteriologist. It is independent of the Joint Hospitals Infection Committee and is under the administrative control of the medical superintendent of the Princess Alexandra Hospital. It meets every two weeks for an hour, usually over lunch, to receive reports and make policy decisions. The LC.S. does not attend these meetings, but she submits reports and makes suggestions. This arrangement is preferred so that matters concerning medical staff can be discussed by the subcommittee without restriction or embarrassment. The l.c.s. has an office next to, and works in close liaison with, the bacteriologist, with whom she may communicate several times daily if need be. Since the appointment of the i.c.s.- at the Princess Alexandra Hospital, we have noted that a similar position "
* Present address: Christian Medical College, Vellore, South India. 1.
Williams, R. E. O., Blowers, R., Garrod,
L.
P., Shooter,
Infection: Causes and Prevention. London, 1960.
R. A.
Hospital
The i.c.s. follows the course of every operation wound, both while the patient is in hospital and also after he has left. She is thus able to furnish, every month, a complete surgical wound survey, which provides a continuing record of the incidence of infection. She personally inspects all postoperative wounds after the first dressing has been removed. If the patient is seriously ill she arranges with the treatment nurse to be present when the wound has to be dressed. Once a week the i.c.s. holds a follow-up clinic in the outpatient department, for patients discharged after operation.
Any patient who cannot attend is sent a questionnaire inquiring into the state of the wound. Some wound infection, it is found, is not apparent until the patient has left hospital. Preoperative Classification of Wounds Operations are classified beforehand as (A) clean and (B) potentially infected. In general, an operation in which the gastrointestinal tract is opened, or in which pus is found, is
potentially infected. Postoperative Classification of Wounds After operation, wounds are classified as (I) absolutely clean, (ii) intermediate (red flush, stitch abscess, haematoma), and (III) discharging pus.t Bacteriology Material collected from the wound is bacteriologically examined. In addition, a nasal swab is taken from all patients undergoing operations included in the survey. This is to determine the nasal carriage rate of Staphylococcus aureus. Williams et al.1 have shown that wound infection with Staph. aureus is five times commoner in patients who have staphylococci in their noses. Though our experience suggests that postoperative wound sepsis is by no means entirely due to Staph. aureus, we think that nasal swabbing can help to reduce cross-infection in the hospital. Technique classified
as
Swabs moistened with nutrient broth are used for collection, and the nasal swabs are cultured both on nutrient media and on selective media for Staph. aureus. Swabs from wounds are cultured both aerobically and anaerobically, and bacterial species are identified. This surgical wound survey continues throughout the year, and the bacteriology for it is performed by the i.c.s. herself. This means that the regular staff of the bacteriology department is not overburdened with work on hospital infection. SUPERVISION AND INSTRUCTION IN ASEPTIC
TECHNIQUES
important function of the i.c.s. is the supervision of aseptic techniques. She visits the surgical wards each day and has ample opportunity to see that dressings are being done correctly. Our hospital uses an aseptic technique and trolley A very
slightly modified from the Medical Research Council’s recommendations. It might be thought that friction would arise between the i.c.s. and the sister in charge of the ward; but the ward sister is usually so busy that she welcomes a system whereby she is relieved of supervising dressing techniques. If the i.c.s. notices any irregularities in the ward, she can correct them on the spot. If they persist, the i.c.s. reports them to the subcommittee. This in turn advises the superintendent, who can issue appropriate instructions. The i.c.s. also teaches and supervises new sisters and nurses who may be unfamiliar with dressing techniques. ,
STERILISATION
The
examines sterilisation procedures throughout the hospital, including the operating-theatres, outpatient depart2. Gardner, A. M. N., Stamp, M., Bowgen, J. A., Moore, B. Lancet, 1962, ii, 710.
t
i.c.s.
An addendum to this paper shows a typical wound survey for a month. Multigraphed copies may be had from The Lancet, 7, Adam Street, Adelphi, London, W.C.2.
1322 ment, and wards.
All sterilisers were checked originally by and intermittent checks are made regularly. When a her, steriliser is found to be inefficient, the i.c.s. informs the sister in charge and declares the steriliser temporarily unfit for use. In the central sterilising department of the hospital the contents and size of each variety of pack are standardised. At first, individual sterility tests for each variety of pack were carried out. Since then, tests for sterility have been made at suitable intervals using the thermophilic spore test. EPIDEMIOLOGICAL INVESTIGATIONS
Staphylococci in the Nose To determine the prevalence of nasal Staph. aureus in the operating-theatre personnel, all medical, nursing, and technical staff and wardsmen in the theatre were swabbed by the i.c.s. The main object was to pick out the persistent nasal carriers and then to render them non-carriers by means of neomycin and chlorhexidine nasal
cream.
Investigation of Cross-infection When a case of gas-gangrene occurred in a surgical ward, the bacteriologist, with the help of the i.c.s., isolated the organism from many articles in the ward. This made the nurses more aware of potential sources of cross-infection and much readier to join in attaining higher standards of hygiene.
Sterility of Operating-theatre Water-supply This is checked regularly by the i.c.s. CLINICAL TRIALS
In
a
teaching hospital,
any method introduced to reduce
hospital infection should be tested by properly conducted clinical trials. Here the i.c.s. has a very important part to play. At present we are determining the effect of local chemotherapy on the incidence of wound infection and the LC.S. is recording the data. MISCELLANEOUS DUTIES
Throughout the hospital the presence of the i.c.s. has created an interest in infection and cross-infection. This interest is increased by suitable posters. The subcommittee decides on their content, and the i.c.s. arranges for their display at suitable strategic points. SUMMARY AND CONCLUSIONS
In
infection control sister can Each month she can a complete list of wound infections, including those apparent only after the patient has left hospital. She can easily be trained to do the routine bacteriology associated with hospital infection. She looks exactly like an ordinary nursing sister, and can walk in and out of wards without attracting attention. In this way, she is in a good position to see that aseptic techniques are being carried out. She can also undertake the teaching and supervising of dressing procedures to new sisters and nurses who may be unfamiliar with the techniques. She regularly checks sterilisation procedures in all parts of the hospital and reports any defects. She can do the detailed work arising from epidemiological surveys and clinical trials. Finally, her very presence in the wards and in the theatre is a reminder of the problems of hospital infection. It is a pleasure to acknowledge the wisdom of the Department of Health and Home Affairs of Queensland in making possible the a
perform compile
major hospital
an
many useful functions.
appointment of a full-time infection control sister at the Princess Alexandra, Hospital. The Department cooperated originally by allowing Dr. J. Tonge, director of the Laboratory of Microbiology and Pathology, Sister S. Hillard, S.R.N., and Miss Y. Battey, B.sc., to undertake the initial investigation into the incidence of hospital infection at the hospital. It was the outstanding ability and qualities of Sister Hillard which impressed us so much that it became obvious that we should seek a permanent l.c.s. The Joint Hospitals Infection Committee helped us by recommending such an appointment to the Director General of Health. Sister N. Wernigk, S.R.N., holds the appointment of l.c.s., and we wish to record our sincere thanks to her for carrying out her duties so efficiently and conscientiously.
Very Special
Articles
LOOKING BACKWARDS FROM 1975 We are fortunate in being able to publish, twelve years before its delivery, the following message from an official of the Federal Government of the United States on the 200th anniversary of the First Continental Congress. This message, we understand, does not necessarily reflect the policies or positions of the U.S. Public Health Service as at
As
present constituted.—ED. L.
Surgeon General of the U.S. Welfare Service, I
report that the most notable event of 1975 has been revival of an essential birth-rate after the disastrous drop in fertility which followed commercial introduction of a cola drink, called SafeTea, with properties which not only repressed ovulation but also prevented infection. Aphrodisiac and euphoric effects of the beverage assured its popularity. The drop in the tide of population, welcomed at first, was marred by economic events. Shocked by the bankruptcy of old-line beverage manufacturers who lacked the magic formula, the economy faltered. It sagged with an abrupt halt in construction of housing, although nothing suffered so much as the dairy industry, already hard hit by radioactivity. Food and drug regulations were invoked to restrict the sale of SafeTea and, with cooperation from the World Health Organisation, its distribution was prohibited internationally. To be sure, the popular appeal of SafeTea continues, and bootlegging persists despite firm methods of law enforcement. But a strong program of public education, supported by the Maternity League, headed by leading figures in the world of finance, is restoring the recommended level of 2.01 children per family. Another significant event has been agreement of the major Nuclear Powers, including Egypt, the People’s Republic of China, Israel, Argentina, and Sarawak, to refrain from further testing of nuclear devices, except under favorable circumstances, so as to retard progressive contamination of the environment. In this connection, the Agricultural Research Service has succeeded in obtaining milk of minimum radioactivity from cows raised under glass and watered and fed from decontaminating ionexchange tubes. The consequent spur to the construction industry for putting pastures under glass also helped to revive the sagging economy and reduced the Federal unemployment total to 10 million. Thanks to the pioneer efforts of the air-conditioning industry, every American citizen now eats, sleeps, and works under circumstances where he breathes only filtered air and drinks only treated water. For outdoor workers, the headgear for breathing is proving reasonably satisfactory, thanks to the development of clothing prepared originally for Space travel. All Americans, consequently, are now reasonably secure from internal radiation and from toxic chemicals except for the contaminants that continue to penetrate the food-processing systems. In another five years we shall also have reduced the hazards associated with the filtering mechanisms. The population is also well protected from external radiation, in view of the shielding program, so that the hazard is significant only for those who spend much time out of doors. The increased morbidity and mortality of those occupationally exposed to outdoor radiation, however, is being offset by our success
in
restoring fertility-rates.
As to the matter of
Special
has been created in the Exeter group of hospitals. Our sister, however, appears to have rather different duties.
Articles
SURGICAL WOUND SURVEY
THE INFECTION CONTROL SISTER HER ROLE IN A LARGE HOSPITAL
NEVILLE C. DAVIS M.B.
GEORGE FIELDING
Sydney,
F.R.C.S., F.R.A.C.S.
M.B. Queensland, F.R.C.S., F.R.A.C.S.
VISITING SURGEON
SURGICAL SUPERVISOR
FRANK GARLICK
A. RAO Calcutta, M.R.C.P.E., Dp.Bact., M.C.P.A.
M.S.
Queensland,
M.B.
F.R.C.S., F.R.A.C.S. FORMERLY SURGICAL SUPERVISOR
*
MEDICAL BACTERIOLOGIST
PRINCESS ALEXANDRA HOSPITAL, BRISBANE, QUEENSLAND, AUSTRALIA
IN 1959
a
Joint Hospitals Infection Committee
was
formed in Brisbane, representing the medical staff of the Brisbane General Hospital (1022 acute beds) and of the Princess Alexandra Hospital (830 acute beds). But, such a committee, though it meets every few months to discuss matters of mutual concern, cannot deal with the day-to-day problems of individual hospitals. Accordingly, in 1960, an infection control subcommittee was formed for the Princess Alexandra Hospital. The members of this subcommittee soon found that they could give only a small part of their time to the problem, and they came to the conclusion that control of infection within a hospital should, if possible, be vested in one person devoted entirely to this-work. As Williams et al.l have said, the key to the administrative control of infection is the appointment of an efficient Control of Infection Office". Probably the most suitable person would be a medical bacteriologist, but none was available in Brisbane. Through the help of the Department of Health and Home Affairs, a survey of infection in the hospital at that time was made by a pathologist, with a nursing sister and a bacteriological technician. The results showed that a sister concerned with the detailed control of infection could be of tremendous value. Accordingly, we pressed for the appointment of a full-time Infection Control Sister (i.c.s.), and one was appointed to the Princess Alexandra Hospital in October, 1962. As she works under the control of the director of the department of pathology, she is not in the general nursing pool of the hospital, and can give her entire time to the control of infection. The infection control subcommittee of the hospital has three members-a representative of the visiting surgical staff, the surgical supervisor, and the medical bacteriologist. It is independent of the Joint Hospitals Infection Committee and is under the administrative control of the medical superintendent of the Princess Alexandra Hospital. It meets every two weeks for an hour, usually over lunch, to receive reports and make policy decisions. The LC.S. does not attend these meetings, but she submits reports and makes suggestions. This arrangement is preferred so that matters concerning medical staff can be discussed by the subcommittee without restriction or embarrassment. The l.c.s. has an office next to, and works in close liaison with, the bacteriologist, with whom she may communicate several times daily if need be. Since the appointment of the i.c.s.- at the Princess Alexandra Hospital, we have noted that a similar position "
* Present address: Christian Medical College, Vellore, South India. 1.
Williams, R. E. O., Blowers, R., Garrod,
L.
P., Shooter,
Infection: Causes and Prevention. London, 1960.
R. A.
Hospital
The i.c.s. follows the course of every operation wound, both while the patient is in hospital and also after he has left. She is thus able to furnish, every month, a complete surgical wound survey, which provides a continuing record of the incidence of infection. She personally inspects all postoperative wounds after the first dressing has been removed. If the patient is seriously ill she arranges with the treatment nurse to be present when the wound has to be dressed. Once a week the i.c.s. holds a follow-up clinic in the outpatient department, for patients discharged after operation.
Any patient who cannot attend is sent a questionnaire inquiring into the state of the wound. Some wound infection, it is found, is not apparent until the patient has left hospital. Preoperative Classification of Wounds Operations are classified beforehand as (A) clean and (B) potentially infected. In general, an operation in which the gastrointestinal tract is opened, or in which pus is found, is
potentially infected. Postoperative Classification of Wounds After operation, wounds are classified as (I) absolutely clean, (ii) intermediate (red flush, stitch abscess, haematoma), and (III) discharging pus.t Bacteriology Material collected from the wound is bacteriologically examined. In addition, a nasal swab is taken from all patients undergoing operations included in the survey. This is to determine the nasal carriage rate of Staphylococcus aureus. Williams et al.1 have shown that wound infection with Staph. aureus is five times commoner in patients who have staphylococci in their noses. Though our experience suggests that postoperative wound sepsis is by no means entirely due to Staph. aureus, we think that nasal swabbing can help to reduce cross-infection in the hospital. Technique classified
as
Swabs moistened with nutrient broth are used for collection, and the nasal swabs are cultured both on nutrient media and on selective media for Staph. aureus. Swabs from wounds are cultured both aerobically and anaerobically, and bacterial species are identified. This surgical wound survey continues throughout the year, and the bacteriology for it is performed by the i.c.s. herself. This means that the regular staff of the bacteriology department is not overburdened with work on hospital infection. SUPERVISION AND INSTRUCTION IN ASEPTIC
TECHNIQUES
important function of the i.c.s. is the supervision of aseptic techniques. She visits the surgical wards each day and has ample opportunity to see that dressings are being done correctly. Our hospital uses an aseptic technique and trolley A very
slightly modified from the Medical Research Council’s recommendations. It might be thought that friction would arise between the i.c.s. and the sister in charge of the ward; but the ward sister is usually so busy that she welcomes a system whereby she is relieved of supervising dressing techniques. If the i.c.s. notices any irregularities in the ward, she can correct them on the spot. If they persist, the i.c.s. reports them to the subcommittee. This in turn advises the superintendent, who can issue appropriate instructions. The i.c.s. also teaches and supervises new sisters and nurses who may be unfamiliar with dressing techniques. ,
STERILISATION
The
examines sterilisation procedures throughout the hospital, including the operating-theatres, outpatient depart2. Gardner, A. M. N., Stamp, M., Bowgen, J. A., Moore, B. Lancet, 1962, ii, 710.
t
i.c.s.
An addendum to this paper shows a typical wound survey for a month. Multigraphed copies may be had from The Lancet, 7, Adam Street, Adelphi, London, W.C.2.
1322 ment, and wards.
All sterilisers were checked originally by and intermittent checks are made regularly. When a her, steriliser is found to be inefficient, the i.c.s. informs the sister in charge and declares the steriliser temporarily unfit for use. In the central sterilising department of the hospital the contents and size of each variety of pack are standardised. At first, individual sterility tests for each variety of pack were carried out. Since then, tests for sterility have been made at suitable intervals using the thermophilic spore test. EPIDEMIOLOGICAL INVESTIGATIONS
Staphylococci in the Nose To determine the prevalence of nasal Staph. aureus in the operating-theatre personnel, all medical, nursing, and technical staff and wardsmen in the theatre were swabbed by the i.c.s. The main object was to pick out the persistent nasal carriers and then to render them non-carriers by means of neomycin and chlorhexidine nasal
cream.
Investigation of Cross-infection When a case of gas-gangrene occurred in a surgical ward, the bacteriologist, with the help of the i.c.s., isolated the organism from many articles in the ward. This made the nurses more aware of potential sources of cross-infection and much readier to join in attaining higher standards of hygiene.
Sterility of Operating-theatre Water-supply This is checked regularly by the i.c.s. CLINICAL TRIALS
In
a
teaching hospital,
any method introduced to reduce
hospital infection should be tested by properly conducted clinical trials. Here the i.c.s. has a very important part to play. At present we are determining the effect of local chemotherapy on the incidence of wound infection and the LC.S. is recording the data. MISCELLANEOUS DUTIES
Throughout the hospital the presence of the i.c.s. has created an interest in infection and cross-infection. This interest is increased by suitable posters. The subcommittee decides on their content, and the i.c.s. arranges for their display at suitable strategic points. SUMMARY AND CONCLUSIONS
In
infection control sister can Each month she can a complete list of wound infections, including those apparent only after the patient has left hospital. She can easily be trained to do the routine bacteriology associated with hospital infection. She looks exactly like an ordinary nursing sister, and can walk in and out of wards without attracting attention. In this way, she is in a good position to see that aseptic techniques are being carried out. She can also undertake the teaching and supervising of dressing procedures to new sisters and nurses who may be unfamiliar with the techniques. She regularly checks sterilisation procedures in all parts of the hospital and reports any defects. She can do the detailed work arising from epidemiological surveys and clinical trials. Finally, her very presence in the wards and in the theatre is a reminder of the problems of hospital infection. It is a pleasure to acknowledge the wisdom of the Department of Health and Home Affairs of Queensland in making possible the a
perform compile
major hospital
an
many useful functions.
appointment of a full-time infection control sister at the Princess Alexandra, Hospital. The Department cooperated originally by allowing Dr. J. Tonge, director of the Laboratory of Microbiology and Pathology, Sister S. Hillard, S.R.N., and Miss Y. Battey, B.sc., to undertake the initial investigation into the incidence of hospital infection at the hospital. It was the outstanding ability and qualities of Sister Hillard which impressed us so much that it became obvious that we should seek a permanent l.c.s. The Joint Hospitals Infection Committee helped us by recommending such an appointment to the Director General of Health. Sister N. Wernigk, S.R.N., holds the appointment of l.c.s., and we wish to record our sincere thanks to her for carrying out her duties so efficiently and conscientiously.
Very Special
Articles
LOOKING BACKWARDS FROM 1975 We are fortunate in being able to publish, twelve years before its delivery, the following message from an official of the Federal Government of the United States on the 200th anniversary of the First Continental Congress. This message, we understand, does not necessarily reflect the policies or positions of the U.S. Public Health Service as at
As
present constituted.—ED. L.
Surgeon General of the U.S. Welfare Service, I
report that the most notable event of 1975 has been revival of an essential birth-rate after the disastrous drop in fertility which followed commercial introduction of a cola drink, called SafeTea, with properties which not only repressed ovulation but also prevented infection. Aphrodisiac and euphoric effects of the beverage assured its popularity. The drop in the tide of population, welcomed at first, was marred by economic events. Shocked by the bankruptcy of old-line beverage manufacturers who lacked the magic formula, the economy faltered. It sagged with an abrupt halt in construction of housing, although nothing suffered so much as the dairy industry, already hard hit by radioactivity. Food and drug regulations were invoked to restrict the sale of SafeTea and, with cooperation from the World Health Organisation, its distribution was prohibited internationally. To be sure, the popular appeal of SafeTea continues, and bootlegging persists despite firm methods of law enforcement. But a strong program of public education, supported by the Maternity League, headed by leading figures in the world of finance, is restoring the recommended level of 2.01 children per family. Another significant event has been agreement of the major Nuclear Powers, including Egypt, the People’s Republic of China, Israel, Argentina, and Sarawak, to refrain from further testing of nuclear devices, except under favorable circumstances, so as to retard progressive contamination of the environment. In this connection, the Agricultural Research Service has succeeded in obtaining milk of minimum radioactivity from cows raised under glass and watered and fed from decontaminating ionexchange tubes. The consequent spur to the construction industry for putting pastures under glass also helped to revive the sagging economy and reduced the Federal unemployment total to 10 million. Thanks to the pioneer efforts of the air-conditioning industry, every American citizen now eats, sleeps, and works under circumstances where he breathes only filtered air and drinks only treated water. For outdoor workers, the headgear for breathing is proving reasonably satisfactory, thanks to the development of clothing prepared originally for Space travel. All Americans, consequently, are now reasonably secure from internal radiation and from toxic chemicals except for the contaminants that continue to penetrate the food-processing systems. In another five years we shall also have reduced the hazards associated with the filtering mechanisms. The population is also well protected from external radiation, in view of the shielding program, so that the hazard is significant only for those who spend much time out of doors. The increased morbidity and mortality of those occupationally exposed to outdoor radiation, however, is being offset by our success
in
restoring fertility-rates.
As to the matter of