J. clin. Path. (1961), 14, 18.

Control of infection in hospital wardsROBERT BLOWERS

Public Health Laboratory Service, Middlesbrough

sviNopsis Some of the problems of ward management are reviewed. Methods suggested for dealingwith them are probably not the ideals that should ultimately be attained but minimum standards toserve as immediate objectives. They concern indications for and methods of isolation, control ofinfection from staff, environmental contamination, and a few technical procedures. A new type ofdressing towel for wounds is described.

Infection acquired in a hospital ward may directlycause disease; or it may create a symptomlesscarrier. Efforts to control infection must concernboth of these processes, because though a symptom-less carrier himself suffers no immediate harm, heremains a source from which others may be moreseriously infected; moreover, he may re-infect him-self if the organisms find their way from the site ofcarriage to some more susceptible tissue. The successof preventive measures must therefore be judged notonly by their immediate effect on disease but alsoby their control of carrier rates for pathogenicorganisms.There are many ways by which bacteria may

reach a patient, but none is necessarily more im-portant than any of the others. So the value ofmany precautions that are now taken remainsuncertain. The hope is sometimes expressed thatwith more detailed knowledge of the ways by whichbacteria spread in a ward we may be able to con-centrate on only a few but vitally important pre-cautions, and to relax the many others that make ourpresent system so tedious and so fallible. This hopewill be fulfilled only if bacteria behave themselves:if all species and all strains spread in the same wayat all times. There is no evidence that this is so andthough some broad generalizations may be possible,categorical support or condemnation of any pre-caution cannot be based on its success or failure ona particular occasion. Assessment of the value ofprecautions against infection is difficult for yetanother reason. Gillespie, Alder, Ayliffe, Bradbeer,and Wypkema (1959) found that several precautions,which by themselves had no discernible effect oninfection rates, had a significant effect when appliedtogether. Lack of effect from applying or with-drawing any one procedure must therefore beinterpreted very cautiously. With these difficultiesof interpretation and much conflicting evidence in

mind, the physician or surgeon must choose themethods that he will apply in his own wards.There are, perhaps, four basic principles of ward

procedure for the control of infection: patients whoare especially liable to spread infection and thosewho are especially susceptible to it should not beaccommodated in the same ward; the ward staffshould not themselves be dangerous sources orvectors of pathogenic organisms; the patients'inanimate environment should not become areservoir of pathogens; and ward techniques mustbe those least liable to convey pathogens. For eachof these principles, I make no attempt to definethe ideals that are theoretically desirable. For thepresent it seems more useful to suggest the minimumstandards we should try to reach. Nor can a reviewsuch as this cover all aspects of ward management.Among the many important problems not consideredhere are the pre-operative treatment of skin, methodsfor disposal of contaminated articles, and theproper use of antibiotics.

ISOLATION AND SEGREGATION

Here is a suggested list of infections for whichpatients should be removed from an open ward.They should also be moved when they are sufferingfrom disorders making them particularly susceptibleto infection, or when being treated with certaindrugs which enhance susceptibility to infection.1 THE ACUTE SPECIFIC FEVERS, e.g., measles, mumps,chickenpox, whooping-cough, scarlet fever (andother streptococcal diseases), diphtheria.2 OPEN TUBERCULOSIS.

3 INTESTINAL INFECTIONS: (a) Shigella dysentery;(b) Salmonella infections, i.e., typhoid and para-typhoid fevers, food poisoning, symptomless car-riers; (c) E. coli enteritis of infants and symptomless

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carriers of locally pathogenic strains; (d) unexplaineddiarrhoea.

4 STAPHYLOCOCCAL DISEASE.

5 INCREASED SUSCEPTIBILITY TO INFECTION: (a)

Treatment with steroid drugs; (b) acute leukaemia,especially during treatment with marrow-toxicdrugs; (c) agranulocytosis; (d) uraemia; (e) burnsand skin grafts.

Many of these indications are so obvious that no

justification is needed here. Of the others, staphy-lococcal infections deserve special discussion.

It is remarkable that in many wards whereelaborate precautions against staphylococcal in-fection are taken, little importance is attached to theapparently obvious one of removing patients withfrank sepsis. Thus, patients who have been admittedwith Staphylococcus aureus pneumonia, empyema,osteomyelitis, breast and other abscesses, urinarytract infection, and septic dermatitis are regularlytreated in open wards alongside uninfected patients.Perhaps even more dangerous are those patients whobecame infected with staphylococci in hospital,because the organisms involved are more oftenepidemic strains and resistant to antibiotics; in thiscategory are patients suffering from Staph. auireus

enterocolitis, septic burns, post-operative woundsepsis, and the various forms of neonatal sepsis.When patients must be removed from an open

ward for any of these reasons more isolation accom-modation than is usual must be provided, and untilit is available, some form of priority must bedevised. The very profuse discharge of organismsfrom patients with staphylococcal enterocolitis,pneumonia, septic dermatitis, and burns requiresthat they should be isolated. For patients who havebeen infected in hospital and from whom organismsare discharging profusely the need for isolation isstill more imperative.

It is sometimes objected, however, that isolatingseptic patients cannot be expected to control in-fection while symptomless carriers of Staph. aureus

remain in the ward. This is probably true during a

major outbreak of sepsis caused by a highly virulentorganism, when it may indeed be necessary toremove carriers of the epidemic strain, as well asthe septic patients to break the chain of infection.In non-epidemic times, however, most of thesymptomless carriers harbour strains that seem tolack virulence or a high degree of transmissibility,and these patients can safely remain in a well-managed ward. But the organisms in actual lesionshave already proved their virulence and it seems

unwise to give them an opportunity to prove theirpowers of spread.

METHODS OF ISOLATION For the acute specific feversand intestinal infections the patient should betransferred to an infectious diseases hospital. Forstaphylococcal diseases needing surgical treatmentthis is rarely practicable though when it is, full useshould be made of isolation hospitals, especiallyduring a serious outbreak. The value of the variousdegrees of 'isolation' available in general hospitalshas not been defined and careful bacteriologicalstudies are very much needed.

Barrier nursing in an open ward depends oneliminating infection by direct and indirect con-tact and may actually do this if an exceptionallyhigh standard of nursing is assured. It cannot,however, prevent airborne infection though it is notyet certain how great a part this plays in the spreadof staphylococci in a ward. By studying the spreadof Staph. aureus from known infant carriers andfrom one nurse, Wolinsky, Lipsitz, Mortimer, andRammelkamp (1960) concluded that contact ratherthan airborne spread accounted for almost all theinfections. But individuals vary greatly in theirpowers of aerial dissemination of staphylococci(Hare and Thomas, 1956; Hare and Ridley, 1958;Eichenwald, Kotsevalov, and Fasso, 1960), andstudies of airborne spread will have to be made withsubjects who are known to be profuse 'dispersers'before final conclusions can be reached on theimportance of this method of studying spread ofinfection. For all this, there are many examples offailure to control the spread of Staph. aureus bybarrier nursing, and, whether these are due toinadequacy of the system or failure to apply itproperly, it cannot be recommended as a reliablemethod.

Isolation in a ward side-room is perhaps moreoften successful but failures are many if the patientis simply moved into it and attended in the usualway by nurses who also have to deal with uninfectedpatients in the main ward. Side-ward isolation shouldtherefore always include the full ritual of barriernursing as a safeguard against contact infection.Thus, all equipment needed for the patient is keptin the isolation room or is disinfected or destroyedas soon as it is brought out; ward staff wear gowns(which are kept in the isolation area) and maskswhen attending the patient and wash their handsbefore and after doing so.

Isolation rooms for septic patients should beventilated by simple exhaust fans discharging to theoutside so that air flows into them and not fromthem to the main ward. For patients who arebeing isolated for protection against infection, air-flow in the opposite direction is theoretically neededbut a reasonable compromise is to switch off theexhaust fan and to rely on natural ventilation from

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an open window. The door of an isolation roomshould be kept closed.

Full isolation requires nurses who do not attenduninfected patients, and a separate room for eachpatient in a building set away from the general wards.Isolation units such as this are not part of the usualhospital design in Britain but they have some-times been improvised during an emergency and,remaining in use afterwards, have shown theirvalue by apparently limiting the spread of infectionfrom occasional septic patients during non-epidemictimes.Only recently has the number of isolation rooms

required for the control of infection become thesubject of quantitative study. Results of currentstudies are not yet available but it seems likely thatat least 30% of surgical and 15% of medical bedswill be required. In most British hospitals suchgenerous isolation facilities are not yet available anduntil they are, anything approaching full control ofstaphylococcal infection will be difficult.

Segregation During an outbreak of sepsis whenthere are more patients for isolation than there arerooms to put them in, an acceptable substitute forisolation is segregation, whereby infected patientsare collected together in a special ward. This doesnot, of course, prevent them from re-infecting eachother and it is a method that can only be accepted ifthere is no possibility of proper isolation. It is,however, infinitely preferable to leaving the septicand clean patients together in the same ward.

PREVENTION OF INFECTION FROM WARD STAFF

INFECTIOUS DISEASES Members of the hospital staffwho remain on duty with even minor infections maybe more dangerous than patients suffering fromserious infective conditions. Nurses and doctors,perhaps from a mistaken sense of duty, often con-tinue to attend patients while suffering from a sorethroat, undiagnosed diarrhoea, purulent dischargefrom nose or ear, or staphylococcal sepsis such asgeneralized furunculosis, boils, styes, paronychia,and septic cuts or burns. Nurses are sometimesdiscouraged from reporting sick for these 'trivial'reasons and many doctors believe that their servicesare too valuable for them to hand over to a colleaguefor a few days. It is not easy to lay down generalrules for behaviour of staff during minor illness orsepsis but the minimum requirements (apart fromthe obvious ones) should be:

Completely off duty for diarrhoea until provedbacteriologically safe, sore throat; one large dis-charging staphylococcal lesion; generalized furuncu-losis with several discharging lesions.Not to assist at any aseptic procedure (e.g., wound

inspection, wound dressing, or injection), with adischarging lesion on any part of the body; anyseptic lesion, whether discharging or not, on thehand or forearm.

SYMPTOMLESS CARRIERS The routine seeking andexclusion from duty of all carriers of pathogenicorganisms amongst ward staff is impracticable andprobably not necessary. As with the patients,however, it may be needed during an outbreak dueto a clearly recognizable organism. Carriers ofStaph. aureus are detected by swabbing the anteriornares. Phage typing should be used to identify theepidemic strain and antibiotic sensitivity patternsare sometimes useful for more rapid but partialidentification. Clearance of the carrier state is oftendifficult but treatment that sometimes succeeds isthe thrice-daily application of neomycin-chlor-hexidine cream' to the noses of carriers for 10 days.In addition when washing and bathing they shouldregularly use toilet soap2 or cream3 containinghexachlorophene or tetrachlorsalicylanilide4. Per-sistent skin carriage is often controlled by thepermanent use, both on and off duty, of these soapseven though carriage by the nose remains un-controlled.

MECHANICAL CONVEYANCE OF ORGANISMS BY WARDSTAFF Contamination of hands, and spread fromthem, can be reduced by applying these rules:Use forceps or rubber gloves for all wound

dressings and examinations and for handlingdrainage tubes, tracheal tubes, catheters, and otherheavily contaminated objects.Wash the hands before and after any procedure

for which gloves, forceps, or sterilized equipmentare used; after changing an infant's napkin ordressing the umbilicus; after rounds of temperaturetaking, bedmaking, or bedpans; after any item ofservice for a patient who is (or should be) isolated;after defaecation and before and after each spell ofward duty.For all these purposes a 'surgical scrub' probably

has no advantage over thoroughly washing the handswith soap and water and drying them on a cleantowel. Conveyance of pathogens is reduced if thesoap contains hexachlorophene (Lowbury andLilly, 1960). Automatic roller-towel dispensers andgood-quality paper towels are both satisfactory andshould replace the communal towel. It may some-times be preferable to use a sterile towel but whenthis is not done drying the hands on a clean butunsterilized towel is safer than leaving them wet.I Naseptin cream (Imperial Chemical Industries Ltd.).2Derl (Roberts Windsor Ltd.); Cidal (Bibby Ltd.).3Phisohex (Bayer Products Ltd.).'Breeze (Crosfields (C.W.G.) Ltd.).

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Clothing The aprons and dresses of nursesattending infected patients, especially children whomust often be lifted and carried, are sometimesheavily contaminated after only one day's wearing(Potter and Blowers, unpublished observations in a

burns unit). Thus there seems some justification fora one-piece uniform, changed daily, instead of theusual daily clean apron and a dress that is worn fora week. Besides its possible bacteriological advan-tages, this means one less item of laundry eachweek than does the older system.Cotton gowns offer only incomplete protection

against contamination in either direction but theyseem to be of some value (Cook, Parrish, andShooter, 1958) so they should be worn over theuniform at least during wound dressings andduring attention to patients in isolation. Im-pervious plastic gowns, disinfected by wiping with ahypochlorite solution containing 1% availablechlorine1, give better protection and seem preferableto cotton gowns for barrier nursing and isolationtechniques.

CONTROL OF ENVIRONMENTAL CONTAMINATION

For many years, and especially in the last few,bacteriologists have been busy discovering inanimatereservoirs of pathogenic organisms in hospitalswalls, floors, ceilings, and furniture; bed-clothes,curtains, and crockery; and the air-while methodsfor disinfecting them have been increasing the costand complexity of ward management. Theseactivities should certainly not be discouraged,because the discovery of reservoirs and the in-vention of methods for disinfecting them areessential preliminaries to the full study of suchorganisms. It cannot be denied that disinfection ofthe whole environment is essential when there hasbeen known heavy contamination with dangerousorganisms. The need for frequent and energeticenvironmental decontamination at other times isless certain. Theoretically, it should reduce therisk of infection at any time, but whether or notit does so significantly has not been conclusivelyshown. Unfortunately, clear evidence on thispoint is not easy to obtain because, as has alreadybeen pointed out, the complexity of bacterialspread makes the evaluation of each pathway verydifficult. Enthusiasts for particular methods will nodoubt continue to apply them but it is hoped thatthey will accept responsibility for the steady, eventhough laborious, collection of evidence to supporttheir views, rather than becoming tedious crusadersfor unproven causes.

I For example, Chloros (Imperial Chemical Industries Ltd.) diluted Iin 10, wiped on and left to dry.

My purpose here is not to enumerate all the dis-infection procedures that might do some good, butto suggest, in the light of available evidence thoughwithout quoting it all in detail, minimum standardsfor environmental hygiene in hospital wards. Stillhigher standards may be desirable but those sug-gested are by no means universal and should serveas reasonable targets for the next few years.

WALLS, FLOORS, CEILINGS, AND FURNITURE Thenumber of pathogens on these surfaces can be keptlow by applying high standards of domestic cleanli-ness. This means that floors should be washed eachmorning, and dust and fluff should be taken upby vacuum cleaner after bed-making rounds. Forroutine purposes, mopping with very hot water, atnot less than 70°C. (160°F.), and a syntheticdetergent is sufficient. The routine use of disin-fectants for washing floors gives little better resultsand most of those cheap enough for the purposecause a persistent and unpleasant smell. Bacteriamay multiply profusely in dirty mops and bucketsof water if these are left for several hours. Aftereach use the bucket and mop should therefore berinsed with boiling water.Broom-sweeping often raises as much dust as it

collects, and slit-sampling shows an enormousincrease in the number of airborne organisms whileit is going on. This can be reduced by oiling thefloors but the process is only really satisfactory forwood and not for modem non-absorbent floors.The best solution is to discard brooms and usevacuum cleaners. Built-in suction points have someadvantages but are expensive to install and are lessconvenient than portable electric machines. Else-where in this issue, Dr. Bate discusses the types ofmachine that are safe for use in hospital (page32).

Walls and ceilings cannot conveniently be cleanedas often as floors; nor does this seem necessarybecause dust collects on them more slowly and isless often disturbed from them than from floors.Perhaps a reasonable rule to follow here is that theyshould never be visibly dirty. The washing methodsalready described for floors should therefore beapplied often enough to ensure this. It is a disturbingthought that there are still hospitals where even thisstandard is not reached.Ledges, furniture, and beds should be dusted

daily with a damp cloth.These are the routine methods. If, however, an

isolation room has been occupied by a patientsuffering from infectious disease (and this includesstaphylococcal sepsis) specific decontamination isneeded. The whole room may be treated by sealingit, spraying water to increase humidity, then

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generating formaldehyde and leaving the roomclosed for six hours. For each 1,000 cu. ft. of roomspace, 5 oz. (150 g.) potassium permanganate isadded to 10 oz. (280 ml.) of formalin. Sulphurdioxide is ineffective. A satisfactory and often moreconvenient method is to wash all surfaces, furniture,and the bed with hypochlorite solution (see footnoteon page 21) to which has been added some householddetergent.

If a septic patient has been barrier-nursed in anopen ward, it may suffice to wipe over the bed andbedside furniture in this way. But if a large wardhas been closed because of widespread sepsis itshould not be re-opened until the whole room hasbeen disinfected by one of these methods.

SCREENS AND CURTAINS Separate pull-round cur-tains for each bed in an open ward harbour moredust than a few sets of portable screens. Theirsocial advantages are so great, however, that itseems unjustifiable to condemn them on theoreticaland unevaluated bacteriological grounds. It isarbitrarily suggested that the curtains be removedand disinfected each month, when the overheadrails and runners should also be damp-dusted.Cotton curtains should be of colour-fast material sothat they may be laundered, and thus disinfected byboiling. Plastic materials have the theoreticaladvantage that they can be wiped with a disinfectantin situ or in a ward annexe; but this occupies moreof the ward staff's time than removing cottoncurtains and sending them to the laundry, so isoften postponed for long periods. Thompson andWebb (1960) describe fibre-glass curtains whichcan be washed at high temperature in the laundryor may be dipped in a disinfectant in the wardannexes and re-hung almost immediately.

BEDDING There is no doubt that bed-clothes canbecome heavily contaminated with pathogenicorganisms from a patient's lesions or from sites ofsymptomless carriage. Sheets are adequately dis-infected by the boiling they normally get duringlaundering; but hospital blankets are rarely washed,and then only by a low-temperature process whichneither removes nor destroys bacteria. It is arguedthat contaminated blankets, carrying organismsfrom a long succession of patients in each bed, maydirectly infect a new occupant, that organismsscattered from them into the air during bed makingmay help to maintain high nasal carrier rates ofstaphylococci derived from septic lesions; and thathospital beds should therefore be equipped withdisinfected blankets for each new occupant. Thetheoretical advantages of this are clear, but there areconflicting reports of its actual value. These are

perhaps summarized by the experiences of Gillespieet al. (1959) and Gillespie, Simpson, and Tozer(1958) who found that regular blanket disinfectionas the only new precaution had no detectableinfluence on Staph. aureus sepsis or carrier rates,but when applied with other precautions appearedto play a part in their control.Whether or not this fairly expensive routine is

wholly justified on bacteriological grounds, apartfrom its obvious aesthetic desirability, remains tobe shown. In the meantime, the following routineis suggested as a minimum standard:

(1) Sheets should be laundered at least weeklyand whenever a bed is vacated.

(2) Blankets, mattresses, and pillows should bedisinfected (a) every three months; (b) whenevervisibly soiled; (c) after use by any infected patientwho has been isolated or should have been isolatedaccording to the indications already given; (d) afteruse by every patient during an outbreak that hasresisted the routine precautions; (e) before re-opening a ward that has been closed because ofinfection.Woollen blankets may be disinfected by washing

them at the usual low temperature and using adetergent combined with a quaternary ammoniumor other suitable disinfectant substance'. It wasonce hoped that incorporation of the disinfectantin the last rinse instead of the washing stage wouldconfer self-disinfecting properties on the blankets.But though fibres from blankets so treated causezones of inhibition on a culture plate seeded withstaphylococci, there is no appreciable killing oforganisms in the blanket itself during use, presum-ably because the disinfectant does not act when dry.Woollen blankets may also be disinfected by high-temperature washing provided this is just belowboiling point (British Launderers' Research Asso-ciation and International Wool Secretariat, 1959).This causes no more damage to the blankets thanthe low-temperature wash but woollen blankets willstand only about 60 washes in any case, so dis-infecting them regularly must always be fairlyexpensive. Cotton cellular or terry-towelling blanketsare easily disinfected by washing at boiling point orjust below and will stand several hundred suchtreatments (Blowers, Potter, and Wallace, 1957).For pillows and mattresses enclosed in plasticcovers, it is usually sufficient to wipe the covers withhypochlorite solution.

CROCKERY This should be washed, or rinsed afterwashing, in water at 60°C. (140°F.).I For example, Vantropol BQ (Imperial Chemical Industries Ltd.);Hytox (Domestos Ltd.); Steravol (Laporte Ltd.); Comprox-panacide(B.P. Detergents Ltd.).

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NURSERY EQUIPMENT

The procedures already given are obviously ap-plicable in nurseries but three pieces of equipmenton which many babies are successively placed eachday need special attention. Nursery baths (andindeed baths in all wards) should be disinfectedafter each use by the effective method of Boycott(1956). One to two gallons of very hot water are

run into the bath; I fl. oz. of undiluted hypo-chlorite solution and enough domestic detergentfor effective cleaning is added to it and the bath isthoroughly mopped with this mixture. The pans ofthe baby scales should be wiped after each use with a

non-irritant disinfectant such as chlorhexidinel.This can be properly done only if metal or plasticpans replace the widely-used wicker ones. The tableson which babies are placed for changing their nap-kins or other attention should be similarly treatedand covered by a freshly laundered towel for eachbaby. But the risk of cross-infection is reduced if asmany as possible of these tasks are done with thebabies in their own cots.One other procedure of vital importance in the

prevention of nursery epidemics is the preparationand bottling of feeds for the babies. This should bedone by a nurse who does not handle the babies andin a department set aside and equipped for thepurpose. Suitable equipment and recommendedmethods cannot be fully discussed here and thereader is referred to the detailed recommendationsof Perkins (1956).

THE AIR There is yet no conclusive evidence of theimportance of airborne infection in wards. Directinfection by this route of properly covered surgicalwounds seems unlikely, but staphylococcal infectionof the respiratory tract causing pneumonia or

symptomless nasal carriage seem real possibilities.Plenum ventilation with a high exchange rate as

used in operation theatres would reduce the numberof airborne organisms but the cost of applying it toa whole hospital would be enormous. Recircula-tion ventilation of wards, with filtration to remove

bacteria, is less expensive but its effect on infectionis not known. Recirculation systems withoutfiltration and serving a whole hospital may actuallyassist the spread of infection between wards.Hudson, Sanger, and Sproul (1959) suggest

treating the air and entire ward contents with a

long-acting disinfectant, bis (n-tributyl) tin oxide.This reduces the number of airborne organisms byabout four-fifths but the effect on infection is notyet known.1 Hibitane (Imperial Chemical Industries Ltd.); 0-5°% alcoholicsolution or the I % obstetric cream are both effective for scale pans.

The most recently proposed method (Elek andFleming, 1960) is to spray the ward with a newsynthetic penicillinase-resistant penicillin. This mustsurely remain experimental until the properties ofthe drug have been more fully studied. Before it canbe contemplated as a routine measure, much moremust be known about its effect in creating orselecting resistant strains, in leaving the way openfor serious Gram-negative and Candida infections,and in causing human sensitivity. At present, there-fore, control of airborne infection in wards muststill depend on preventing dissemination oforganisms by isolation and by other techniquesalready recommended.

SPECIAL TECHNIQUES

Of the many special ward techniques that giveopportunity for infection, only two will be discussedhere: wound dressings and continuous drainagemethods.

WOUND DRESSINGS Techniques for wound dressingsmust allow no opportunity for infection to orfrom the wound by direct or indirect contact.Reliable methods for a dresser and assistant or foran unassisted dresser are described in a Ministryof Health report (1959) so are not given in detailhere. The number of ward sisters and sister tutorswho have neither seen nor heard of this publicationis remarkable. Because the importance of trainingnurses in the control of infection is so great thisdeficiency should be put right.The setting of dressing trolleys is simplified and

thus made safer by using individual dressing packs,disposable gallipots, and disposable paper bags fordirty dressings.One further improvement in dressing technique

is now available, namely, the use of water-repellentdressing towels. The usual dressing towels are water-absorbent so that wet instruments placed on themmay be contaminated when the water soaks throughto an unsterile table top beneath (Fig. 1). It is some-times necessary to put a towel over the bedclothesaround the wound and though instruments shouldnot be placed on this, they sometimes are, when therisk of contamination is even greater. Some types ofdisposable paper dressing towels are even moreabsorbent than cotton so may increase rather thanreduce, as is claimed, the risk of infection. Cottonfabrics of the Ventile1 type do not allow water tosoak through it unless it is very hot. These materialsare being successfully used for the sleeves of sur-geons' gowns to prevent skin organisms passingthrough to the wound when the sleeves are wetted,I Messrs. John Southworth & Sons Ltd., Clitheroe, Lancashire.

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FIG. 1. Wet forceps on an ordinary cotton dressing towel.The water soaks through to the underlying surface, fromwhich the instrument may then be contaminated.

as they often are during an operation. A more recentapplication is to use Ventile fabrics for dressingtowels to reduce the risk of contamination fromunderlying surfaces. Drops of water remaining on aVentile dressing-towel without soaking through areshown in Fig. 2.

Wound Dressing Rooms The value of speciallyventilated wound dressing rooms has been clearlyshown by Bourdillon and Colebrook (1946) and byLowbury (1954). For patients in open wards allwounds, whether infected or clean, should thereforebe done in a specially equipped and ventilateddressing-room. For patients already in isolation,however, the dressing should be done in the isolationroom unless it is so complicated that the specialfacilities of the dressing-room are essential.A dressing-room that is used for septic work soon

becomes a concentration area for pathogenicorganisms unless it is thoroughly cleaned after everysession of dressings and unless it is specially ven-tilated. Positive-pressure ventilation, as recom-mended by Bourdillon and Colebrook, preventscontamination of clean wounds with airborneorganisms from the wards. For a dressing-room thatis often used for septic wounds and closely com-municates with a ward, however, this may causeheavy contamination of the ward so a balancedventilation system with input and extraction fans ofequal capacity is preferable. A rapid turnover ofair is needed and for rooms of up to 2,000 cu. ft.,a ventilation rate of 650 cu. ft. per minute will clearheavy aerial contamination in about 10 minutes.It is rarely possible to equip dressing-rooms withthe complicated and expensive ventilation plant ofthe type used in operating theatres. A simple andinexpensive plant suitable for dressing-rooms is

FIG. 2. Wet forceps ont a Ventile cotton dressing towel.Water remains as globules whichi neither wet the surfacenor pass through the material.

described by Williams, Blowers, Garrod, andShooter (1960).

CONTINUOUS SUCTION APPARATUS Surgery of theurinary tract is complicated by post-operative in-fection perhaps more often than any other type ofsurgery. Most of this infection depends on commonbut avoidable faults of indwelling catheter drainagesystems. Pyrah, Goldie, Parsons, and Raper (1955)and Miller, Gillespie, Linton, Slade, and Mitchell(1958, 1960) show that post-operative urinary sepsisis all but eliminated by using closed drainage appa-ratus. In many wards, any urine drainage systemusing a bunged bottle is accepted as a closed one butthis is far from being so. Miller and his colleaguesshowed that even temporary disconnexion of the sys-tem for bladder irrigation or for some other reasonallowed infection to occur as often as did an opendrainage system. Their apparatus, which is stronglyrecommended, includes an irrigation attachment thatcan be used without breaking the closed system.Failure to sterilize an already infected bladder isoften due to its constant reinfection by organismsthat ascend from the accumulated urine in thebottle. This is prevented by putting 100 ml. offormalin in the bottle.Drainage from the thoracic cavity, too, often

allows infection unless a closed system is used. Forthis, however, a disinfectant cannot be put in thebottle because it may be aspirated into the chestduring coughing. Contamination of the fluid shouldbe prevented by a cottonwool plug in the air outlettube and by changing the bottles with the asepticcare of a surgical operation.I am grateful to Dr. Stanley Wray and Mr. WilliamBound for their help with the photographs.

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REFERENCES

Blowers, R., Potter, J., and Wallace, K. R. (1957). Lancet, 1, 629.Bourdillon, R. B., and Colebrook, L. (1946). Ibid., 1, 561 and

601.Boycott, J. A. (1956). Ibid., 2, 678.British Launderers' Research Association and International Wool

Secretariat (1959). High Temperature Laundering of WoollenHospital Blankets. London.

Cook, Josephine, Parrish, J. A., and Shooter, R. A. (1958). Brit.med. J., 1, 74.

Eichenwald, H. F., Kotsevalov, Olga, and Fasso, Lois A. (1960).Amer. J. Dis. Child., 100, 161.

Elek, S. D., and Fleming, P. C. (1960). Lancet, 2, 569.Gillespie, W. A., Alder, V. G., Ayliffe, G. A. J., Bradbeer, J. W., and

Wypkema, W. (1959). Ibid., 2, 781.Simpson, K., and Tozer, Rosemary C. (1958). Ibid., 2, 1075.

Hare, R., and Ridley, M. (1958). Brit. med. J., 1, 69.-, and Thomas, C. G. A. (1956). Ibid., 2, 840.

Hudson, P. B., Sanger, G., and Sproul, Edith E. (1959). J. Amer. med.Ass., 169, 1549.

Lowbury, E. J. L. (1954). Lancet, 1, 292., and Lilly, H. A. (1960). Brit. med. J., 1, 1445.

Miller, A., Gillespie, W. A., Linton, K. B., Slade, N., and Mitchell,J. P. (1958). Lancet, 2, 608.Linton, K. B., Gillespie, W. A., Slade, N., and Mitchell, J. P.(1960). Ibid., 1, 310.

Ministry of Health (1959). Central Health Services Council Report:Staphylococcal Infections in Hospitals. H.M.S.O., London.

Perkins, J. J. (1956). Principles and Methods of Sterilization.Thomas, Springfield, Illinois.

Pyrah, L. N., Goldie, W., Parsons, F. M., and Raper, F. P. (1955).Lancet, 2, 314.

Thompson, K. S., and Webb, Mary J. (1960). Ibid., 1, 286.Williams, R. E. O., Blowers, R., Garrod, L. P., and Shooter, R. A.

(1960). Hospital Infection. Lloyd-Luke, London.Wolinsky, E., Lipsitz, P. J., Mortimer, E. A. Jr., and Rammelkamp,

C. H. Jr. (1960). Lancet, 2, 620.

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