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Dear all,
An additional quote for the discussion – “there is nothing common about
common sense” Sue Greig
This is interesting discussion and I agree with several of the comments
made including Matthias that highlights the absence of evidence is no
excuse for bad practice.
Having looked at this issue now for several years in a variety of settings
– the evidence is scarce if you are looking for rationale on the exact
question of where and when to wear operating theatre scrubs. Sometimes it
is good to think outside the box and never forget a common sense approach.
Some of the variables I have had to contend ( that may provide food for
thought for others) with include:
Where governance sits on this issue – do they support and actively
participate in enforcing policy and procedures that the organisation
endorses? even in the absence of strong evidence
Why is the organisation using scrubs at all – they are expensive and not
part of the PPE required as part of infection prevention or workplace
health and safety however, they are historically seen as part of the
required attire to enter the restricted environment of operating theatres.
This environment is special and this is in part created by environmental
controls, identified risks for workforce and patients, the need for
asepsis, public perceptions and habits.
Who owns the scrubs – do they belong to the organisation or to the staff
and what are the requirements for wearing them in the organisation,
outside the organisation, to and from work? Consider co-located
organisations
How laundering is managed – by the organisation or by the staff – How
important is it that this is known and if it is seen as important how is
this controlled and monitored?
Where are clean scrubs stored in the organisation – often in theatre
change rooms they are located adjacent to toilets on open racks or
shelving, even with frequent use they still can be exposed to
contamination from air and hands.
What are the limitations or boundaries applied to wearing scrubs outside
the theatre/procedural setting – this varies from organisation to
organisation depending on scope of services provided and layout of the
buildings and placement of the services in the buildings. Is it OK to go
from rooms (or theatres in another organisation) via the carpark and then
straight in to the operating theatre? if the answer is no – what are you
going to do about it
Are scrubs just a uniform? Who wears the uniform? – surgeon, theatre
nurses, anaesthetists, orderlies, and what additional apparel do they wear
to protect the patient in the special environment? Often an anaesthetist
will wear nothing additional even for procedures that require aseptic
technique.
And so on……
Good luck,
Regards,
Sue
Sue Greig
Senior Project Officer
Australian Commission on Safety and Quality in Health Care
GPO Box 5480 Sydney NSW 2001 | Level 7, 1 Oxford Street, Darlinghurst NSW
2010
( direct (02) 9126 3565 | ( switchboard (02) 9126 3600 | 6 (02) 9126 3613
|
Email sue.greig@safetyandquality.gov.au | http://www.safetyandquality.gov.au
Cath Murphy
Sent by: ACIPC Infexion Connexion
04/03/2013 05:16 PM
Please respond to
ACIPC Infexion Connexion
To
AICALIST@AICALIST.ORG.AU
cc
Subject
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
Of Matthias Maiwald (KKH)
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
Of Fiona Randall
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 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
Of Toni Schouten
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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