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Author:
Cath Murphy
Email:
cath@INFECTIONCONTROLPLUS.COM.AU
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We recently posted on our Facebook Page https://www.facebook.com/infectioncontrolplus a recently taken image from a large public hospital in Australia depicting this exact scenario. The comments raised by respondents make curious reading and they come from practitioners from multiple disciplines across the globe and at various stages of chronologic and professional maturity. They make for interesting viewing. I have been dismayed my entire life to know this is a worldwide malpractice. Perhaps yet another sign of the decay of the well needed sense of asepsis?
Cheers
Cath
Cathryn Murphy PhD
Executive Director
Infection Control Plus Pty Ltd
http://www.infectioncontrolplus.com.au
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Dear Colleagues,
To use a famous quote:
“Absence of evidence is not evidence of absence”.
http://en.wikipedia.org/wiki/Argument_from_ignorance
and another one: “Those who cannot remember the past are condemned to repeat it” (George Santayana).
What I am trying to say is that the question of whether or not to wear theatre clothing, and in which circumstances, is — in my opinion — more complex than to say “there is no evidence for it” or vice versa, “there is evidence for doing it in a particular way”.
Some of it boils down to what we want to accept as evidence — is it only evidence from randomized clinical trials with surgical infection rates as the outcome (for which there are none in theatre clothing — so we would not find any evidence), or is it evidence from microbiology, historical/anecdotal sources, combined with “what makes sense”? If we were to accept only high-quality evidence from RCTs, we would have no basis for many everyday clinical decisions that otherwise make perfect sense (think of the famous parachute article in the 2003 Christmas edition of BMJ). In the absence of good-quality evidence from clinical trials, some answers may come from other sources and include scientific reasoning, common sense and sociological issues (e.g. institutional identity and public perception, as pointed out by Paul Smollen).
It is for some of these reasons that some of the analyses in the HIS document (Woodhead et al. 2002) — while it is overall a reasonable document and a laudable approach to query the issues — lack a little depth to fully address these issues (they also point out social and/or theatre discipline issues).
Things started in the 19th century, around Lister’s time. Senior surgeons often took pride in how dirty, blood- and pus-splattered their gowns were, because this was viewed as a status symbol. (Not sure, is wearing scrubs in cafeterias also a kind of status symbol?). In the late 19th and early 20th century, the principle of aseptic surgery was introduced (including scrubs, gowns, sterile field, etc.) and then refined during the first half of the 20th century. Note that by about the 1970s, the infection rates for clean surgery (classified as clean) were already quite similar to what they are today. Advancements came mostly from the other categories (clean-contaminated and higher).
The microbiological rationale for wearing dedicated operating theatre clothing, i.e. scrubs, comes from the fact that when freshly-laundered clothing is put on, this clothing acquires the wearer’s (and to a lesser extent the environment’s) microorganisms, and this bacterial burden increases over the time of wearing. This is thought to be in principle very similar for street clothing and scrubs, and what happens is that over time, the microorganisms on the clothing reach a saturated state and then the wearer disperses these microorganisms into the environment around her/him, although this also depends on how tightly woven the garments are (scrubs are more tightly woven, so lesser shedding). This is called the “cloud phenomenon”, and someone who has published on this in recent times is Robert (“Bob”) Sherertz from the USA. The acquisition and dispersal of microorganisms includes pathogens like Staph. aureus (also MRSA) in those who are colonised. That means, what the wearing of fresh scrub suits effectively does is to set the “clock” of microorganism acquisition and dispersal back to zero each time a new suit is put on. The consequence is that if there is an institutional scrub-wearing policy, then the institution has some control over this microorganism acquisition and dispersal, whereas if people can wear street clothes or re-use old scrubs, then there is no institutional control over this biological process. (People may come in with several-days-old street clothing or just put the scrubs in the locker for re-use if the process is not controlled). Much of this research dates back to about the 1950s and 1960s, before the advent of evidence-based medicine, and therefore information in the very recent literature is scarce. (I need to credit my colleague Andreas Widmer from Switzerland for bringing my attention to this microbiological rationale — a quote from Andreas is “what’s the point of having clean HEPA-filtered OT air when the clothing makes the bacteria airborne?”).
A publication by Bob Sherertz is here:
Bischoff WE, Tucker BK, Wallis ML, Reboussin BA, Pfaller MA, Hayden FG, Sherertz RJ. Preventing the airborne spread of Staphylococcus aureus by persons with the common cold: effect of surgical scrubs, gowns, and masks. Infect Control Hosp Epidemiol. 2007 Oct;28(10):1148-54.
http://www.ncbi.nlm.nih.gov/pubmed/17828691
While the above provides a clear rationale (I can’t call it evidence) for wearing dedicated scrubs in OT and for having an institutional OT attire policy, the rationale for changing when leaving OT and for putting on fresh scrubs when reentering, or alternatively for putting on cover gowns, is less clear. The microbial contamination between scrubs dedicated to the OT and scrubs worn outside the OT is generally not very different from each other. However, one study from the 1980s found that the microbial burden on scrubs was less when covergowns were worn outside the OT or when fresh scrubs were put on while reentering, while there was more contamination when no covergowns were worn, or when scrubs were just put in lockers and worn again after a lunch break:
Copp G, Mailhot CB, Zalar M, Slezak L, Copp AJ. Covergowns and the control of operating room contamination. Nurs Res. 1986 Sep-Oct;35(5):263-8.
http://www.ncbi.nlm.nih.gov/pubmed/3529043
Also to consider is the image of professionality and the professional image of healthcare staff on patients and the general public (see Paul Smollen’s comment).
Another issue to consider is the inadvertent contamination of scrubs with blood and body fluids (staff may have individually different perception as to when they regard scrubs as contaminated) and any potential infection risk to food/drink consumption areas, although I am not aware of any good literature on this.
Another interesting article is here:
Wright SN, Gerry JS, Busowski MT, Klochko AY, McNulty SG, Brown SA, Sieger BE, Ken Michaels P, Wallace MR. Gordonia bronchialis sternal wound infection in 3 patients following open heart surgery: intraoperative transmission from a healthcare worker. Infect Control Hosp Epidemiol. 2012 Dec;33(12):1238-41.
http://www.ncbi.nlm.nih.gov/pubmed/23143362
This is a recent case cluster of G. bronchialis sternal wound infections after cardiac surgery in the USA that was traced to contaminated scrub suits by a nurse anaesthetist. This was traced back (most likely) to home laundering of the scrub suits (a practice that is apparently still done at some institutions in the USA) with a badly-maintained, contaminated washing machine. That means, contaminated scrub suits definitely have the potential to cause surgical site infections.
Again, I am not claiming to have conclusive evidence here, but the above may be some food for thought.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387
An “oldie but a goodie” is the Hospital Infectioin Society working party report on “behaviours and rituals in the operating theatre” this was published in the journal of hospital infection quite a number of years ago now.
http://www.his.org.uk/_db/_documents/Rituals-02.pdf The working party reviewed all of the available evidence at the time and made recommendations based on the level of evidence available. Theatre attire, scrubs, overgowns & overshoes are addressed in this document.
Overgowns are not necessary outside the operating theatre. Scrubs must be changed as soon as there is any blood/body fluid contamination regardless of whether staff are remaining in the OT suite or leaving to go to the cafe.
I recommend a quick literature search of Pubmed for the latest literature/evidence on this subject.
Fiona Randall
CNC Infection Prevention & Control
Wesley Mission Brisbane.
On Fri, Mar 1, 2013 at 2:40 PM, Paul Smollen <Paul.Smollen@cec.health.nsw.gov.au> wrote:
Toni,
I do enjoy this chestnut. While it is a public perception, facilities and us at the Ministry receive multiple complaints from visitors about this issues. One of the complaints we get is that the public see them in the gowns in the cafe and are worried they are going off to operate on their family member. This alone could convince your OT staff against the practice.
The problems lies with no valid evidence. This comment may open a can of worms….. but I find this should be a two way street and if OT staff want to walk around a hospital and outside and do all normal activities in their scrubs, then they should allow people to walk into an OT in street clothes. I really see no difference. While we are concerned with levels of evidence about scrubs outside an OT what level of evidence is there about wearing scrubs inside an OT? The scrubs are usually kept on open shelves in open change rooms with toilets and showers nearby.
I do know of facilities that have a lunch ordering system with their cafe and the food is delivered there. This may be an option you could explore.
Good luck with it all.
Paul Smollen
Project Manager, Healthcare Associated Infections (HAI)
Clinical Excellence Commission | Level 14/227 Elizabeth Street, Sydney NSW 2000
T: (02) 9269 5586 |F: (02) 9269 5599 | E: Paul.Smollen@cec.health.nsw.gov.au
http://www.cec.health.nsw.gov.au
Dear All,
The issue of where you can and cannot wear operating theatre attire (blues) has arisen at our facilities – again.
I would be interested to know if your facilities/organisations allow theatre staff to eat and drink in the on-site cafeteria if they have clean blues that are covered.
Food is not supplied to the OT; staff are permitted to collect food from the on-site cafeteria if in clean blues that are covered; there is a tea room but it is said that it can be over crowded at peak times.
The public perseption (and complaints received) says that they should not be allowed to eat and drink there.
What valid evidence is there and what do others do or say to back up that they should not eat and drink in on-site cafeterias (if at all).
Look forward t your comments.
Regards, Toni.
Toni Schouten CICP
Clinica Quality Manager
Sydney Local Health District
toni.schouten@sswahs.nsw.gov.au
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