«FICHA TÉCNICA Título Segurança e Higiene Ocupacionais - SHO 2012 - Livro de Resumos Autores/Editores Arezes, P., Baptista, J.S., Barroso, M.P., ...»
Occupational Safety and Hygiene - SHO 2012 - Book of Abstracts
Arezes, P., Baptista, J.S., Barroso, M.P., Carneiro, P., Cordeiro, P., Costa, N., Melo, R., Miguel, A.S., Perestrelo, G.P.
Portuguese Society of Occupational Safety and Hygiene (SPOSHO)
Linkprint Gráfica, Lda. - Vila Nova de Gaia
Cover Design and Pagination
978-972-99504-8-3 Legal Deposit 304920/10 Edition 400 copies
FICHA TÉCNICATítulo Segurança e Higiene Ocupacionais - SHO 2012 - Livro de Resumos Autores/Editores Arezes, P., Baptista, J.S., Barroso, M.P., Carneiro, P., Cordeiro, P., Costa, N., Melo, R., Miguel, A.S., Perestrelo, G.P.
Editora Sociedade Portuguesa de Segurança e Higiene Ocupacionais (SPOSHO) Impressão e Acabamentos Linkprint Gráfica, Lda. - Vila Nova de Gaia Data Fevereiro de 2012 Design da capa e edição Manuela Fernandes ISBN 978-972-99504-8-3 Depósito Legal 304920/10 Tiragem 400 exemplares This edition is published by the Portuguese Society of Occupational Safety and Hygiene - SPOSHO, 2012.
Portuguese National Library Cataloguing in Publication Data Occupational Safety and Hygiene - SHO2012 edited by Arezes, P., Baptista, J.S., Barroso, M.P., Carneiro, P., Cordeiro, P., Costa, N., Melo, R., Miguel, A.S., Perestrelo, G.P.
Includes biographical references and index.
1. Safety. 2. Hygiene. 3. Industrial. 4. Ergonomics. 5. Occupational.
Publisher: Sociedade Portuguesa de Segurança e HigieneOcupacionais (SPOSHO) Occupational Safety Hygiene SHO Series Publisher Prefix: 972-99504 Book in 1 volume, 506 pages This book contains information obtained from authentic sources.
Reasonable efforts have been made to publish reliable data information, but the authors, as well as the publisher, cannot assume responsibility for the validity of all materials or for the consequences of their use.
Neither this book nor any part may be reproduced or transmitted in any form or by any means, electronic or physical, including photocopying, microfilming, and recording, or by any information storage or retrieval system, without prior permission in writing from the SPOSHO Direction Board.
All rights reserved. Authorization to photocopy items for internal or personal use may be granted by SPOSHO.
Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation, without intent to infringe.
SPOSHODPS, Campus de Azurém 4800 – 058 Guimarães, Portugal Visit SPOSHO on line in http://www.sposho.pt © 2012 by SPOSHO ISBN 978-972-99504-8-3 Organizing Committee Chairman A. Sérgio Miguel Universidade do Minho Secretary Pedro Arezes Universidade do Minho Members Gonçalo Perestrelo SMGP J. Santos Baptista FEUP Mónica Barroso Universidade do Minho Nélson Costa Universidade do Minho Patrício Cordeiro Universidade do Minho Paula Carneiro Universidade do Minho Rui Melo Universidade Técnica de Lisboa International Scientific Committee
1. INTRODUCTION Experts in infection control are often asked about issues related to the use of scrubs and clean air suits in the operating room (OR). So far there is no clear explanation or mandatory obligation why the surgical team has to wear clean air suits or scrub suits in the operating rooms (OR´s) and more importantly, what are the main differences between these two type of clothing. There is a general perception that the two are equal or very similar.
So, what are clean air and scrub suits? Where did the concept and employ originate? Are they necessary from an infection control point of view, are they an useful resources of preventing or controlling transmission of infection?
The clean air suits are considered a Class I medical devices according to the definition and classification rules of the consolidated EU directive 93/42/EC as amended by 2007/47/EC and the scrub suits don´t have any regulation for their use in any hospital area.
Routes of infection are contact or airborne. In the last case, dispersed human skin particles are often carriers of infection.
A healthy individual can disperse to the air approximately 5000 bacteria-carrying skin particles per minute during walking and males disperse more than females. The particles are 5 µm to 60 µm in size and the average number of aerobic and anaerobic bacteria carried is estimated to be about 5 per skin particle. The airborne particles contaminate the surgical site directly by sedimentation or indirectly by first setting on instruments or other items that are then brought into contact with the surgical wound. Fabrics with interstices larger than 80 µm do little to prevent the dispersal of skin scales.
This article seeks to highlight the most relevant information of this products and try to define the benefits of using them for preventing airborne disposal from the surgical staff, reducing the risk of infection.
This issue is more important now, because in the next year the European Commission will release a norm, specifically for clean air suits. The clean air suits are used mostly in the Scandinavian countries and are not very spread in other European countries or over the world. As a result, will this norm influence the use of clean air suits or perhaps increase the consumption of this product in Europe, turning it as an obligatory item in the OR such as the surgical gowns and drapes? Will there be any reference regarding the scrub suits?
2. CLEAN AIR SUITS The clean air suits are considered a Class I medical devices according to the definition and classification rules of the MDD 93/42/EEC.
The definition of clean air suit is "a suit intended and shown to minimize contamination of the operating wound by the wearer´s skin scales carrying infective agents via the operating room air thereby reducing the risk of wound infection".
EN 13795-1 (2002) - "Surgical drapes, gowns and clean air suits, used as medical devices for patients, clinical staff and equipment - general requirements for manufacturers, processors and products (Part 1)", EN 13795-2 (2004) - "Surgical drapes, gowns and clean air suits, used as medical devices for patients, clinical staff and equipment - test methods (Part 2)" and EN 13795-3 (2006) - "Surgical drapes, gowns and clean air suits, used as medical devices for patients, clinical staff and equipment - performance requirements and performance levels (Part 3)" identifies the relevant characteristics of clean air suits, specifies test methods for evaluating the identified characteristics and sets performance requirements for finished products (Table 1). In addition this standard sets requirements for manufacturing and for processing and specifies information to be supplied by the manufacturer. Unlike the gown usually worn in the operation room, the clean air suit is designed to reduce the operating room air contamination by personnel. Performance requirements apply for all product areas of clean air suits and should be used in addition to surgical gowns and not as a substitute.
This standards were revised this year to an unique standard (pr EN 13795, 2010) and the clean air suits appear, but will emerge soon in an entirely new standard for this type of products, "Clean air suits, used as medical devices for clinical
staff - General requirements for manufacturers, processors and products, test methods, performance requirements and performance levels". This document will supersede those parts of prEN 13795 (2010) that deal with clean air suits.
The conception of the clean air suit should be sufficient to enclose the dispersed bacteria-carrying particles in the suit and not dispersed through the openings of the suit at the neckline, sleeves, waist, leg and boot openings. So, this part has to be closed, preferably by cuffs. If a clean air suit with a wide neckline is used, the gap should be closed by wearing a hood that covers all uncovered body parts (Figure 1 and 2). If the clean air suit is a two piece ensemble (shirt and trousers), the shirt has to be put into the trousers.
Figure 1 – Single-Use Clean air suit from Mölnlycke Health Care Figure 2 – Reusable Clean air suit from Lojigma Int.
Following studies demonstrated that a reduction in airborne bacteria arising from the perineum, thighs and feet could be accomplished by using specially designed trouserlike garment that was sealed at the feet and waist and made from tightly woven fabrics that restricted the dissemination of skin particles.
The correlation between a low surgical wound infection rate and a high microbiological air cleanliness during the operation has been demonstrated in total joint replacement operations (Lidwell et al, 1983) and hip or knee-joint replacement (Lidwell et al, 1984). The ultraclean air conditions have been shown to be obtained either using special ventilation systems or special clean air suits by Bergman et al, 1985 and Blomgren et al, 1990.
Clean air suits to reduce dispersal of bacteria carrying skin particles from the human body out into the air and the effectiveness has been established by Verkala et al, 1998 and Blomgren et al, 1990.
The test of a clean air suit is quite expensive, because it´s important to do the test in a dispersal chamber (very expensive) or in an OR with laminar vertical system.
3. SCRUB SUITS The definition of scrub suit is quite wide-ranging. Outside the OR, scrubs have been adopted as a replacement for the more traditional uniform worn by healthcare staff. Inside the OR, it´s used under the surgical gown and frequently denominated as "pajamas" that consists of pants and shirt.
Since the turn of the XX century, clothing known as surgical scrub suits has been worn by health care workers in the OR.
Today, a wide variety of this type of suits is being used for many applications in healthcare also outside the OR (Belkin, 1997), but scrub suits don´t have any regulation for their use in any hospital area. Thsi should be viewed as a uniform over which a sterile gown is worn. The use of scrubs began in the OR around 1900 and was preceded by the surgical cap and gown (Doberneck, Kleinman, 1984). The word scrub was derived from the practice of surgical staff who scrubbed their hands before performing surgery or assisting in surgical procedures. The first mention of scrubs was published in the final of the XIX century stating that it is safer and better that all should put on a complete change of costume rather than simply put a sterilised coat and pair of trousers over the ordinary clothing as has been recommended by the German school.
In the late 1950s of the XX century, concern for the level of airborne contamination comes out as possible influence on the occurrence of surgical wound infection (Belkin, 1997). It had already been demonstrated that dissemination of skin bacteria occurred as a result of friction between areas of heavy skin colonisation and that many more bacteria were liberated by movement involving the lower extremities (Bernard et al, 1965).
A scrub development later took place that included changes in the color, design and materials of which they were made and also expanded outside the OR to other healthcare facilities (Figure 3 and 4).
Figure 3 – Single Use Scrub suit from Mölnlycke Health Care Figure 4 - Reusable Scrub Suit from Lojigma Int. Lda.
3.1 Scrub suits in the OR The Association of Operating Room Nurses (AORN) suggests that scrubs in the OR promote high level cleanliness and hygiene within the practice setting. Further it recommends that all scrub attire should be placed in appropriately designed containers for washing or disposal, depending if it is a single-use or a reusable scrub and should not be hung or put in a locker for wearing in another time (AORN, 1995).
Traditional scubs are generally not made of a barrier type, liquid resistant material and therefore may not provide adequate protection, but on the other hand if it´s used under the surgical gown the protection has to be guaranteed by the gown and not by the scrub suit, so the use of scub suits is tightly related with the prevention of infection.
OR gowns with front and sleeves made of material that is resistant to liquid penetration reduces the risk of transfer of bacteria between patients in the operating theatre via scrub suits (Hoborn, 2005).
4. FINAL REMARKS No scientific data support the practice of using scrub suits as a means for preventing transmission of infection, but on the other site we have a vast amount of studies regarding the effectiveness of clean air suits. However this won´t invalidate the use of scrub suits, just validating that this type of studies has to be done.
In the next future the Textile Engineering Department of the University of Minho and an enterprise interested in this study, between comparison of scrub suit and clean air suit with the same fabrics (nonwoven, when single-use and micropolyester if reprocessed and reused afterwoods) will be done, testing the same performance measurements. Perhaps this comparison bring more explicitness. Also the cost-effectiveness, since the scrub suits are less expensive than the clean air suits, is an important issue for the healthcare system in the different countries, when it guarantee the same prevention of infection. Cost deliberation include purchase price, maintenance and management.
At last, the scrub suits are certainly more effective as the use of normal under-wear beneath the surgical gown and the obligation to use this suits under the gowns is undoubtedly a positive attitude of the hospital administrations.
5. REFERENCES Association of Operating Room Nurses - AORN (1995). Recommended practices for surgical attire. Standards and recommended practices. AORN, 141-142.
Belkin, N. L. (1997). Use of scrubs and related apparel in health care facilities. American Journal of Infection Control, 25, 401-404.
Bergman, B. R., Hoborn, J., Nachemson, A. L. (1985). Patient Draping and Staff Clothing in the Operating Theatre: A microbiological study. Scandinavian Journal of Infection Disease, 17, 421-426.
Bernard, B. R., Speers Jr, R., O´Grady, F. W., Shooter, R. A. (1965). Airborne bacterial contamination-investigation of human sources. Archives of Surgery, 91, 530.