[...] [Animation of nurse putting newborn in a neonatal crib] [...] [Nursery Sepsis] [Presented by: The American Academy of Pediatrics] [With the cooperation of the: American Hospital Association, American Medical Association] [American Nurses Association,National League of Nursing] [Developed by the CommitteeOn the Fetus and Newborn] [Special Consultants:] [Warren E. Wheeler, M.D.,Paul A. Harper, M.D.] [Benjamin M. Kagan, M.D.,Samuel Spector, M.D.] [...] [This film, one of a series dealing with the problem of the control of infection,] [was made possible as a professional service through the cooperation] [and support of Johnson and Johnson] [...] [Baby in a nursery crib] [Narrator:] The time? Spring 1954. [...] The setting? A large university hospital. [...] Nursery problems werenicely under control. In general, recommendednursery practices were being followedwith good results. The days of catastrophicepidemic diarrhea were in the past. [...] There were the usualnumber of varied disorders, but by and large, nurserysepsis was under control. [...] So it seemed. [...] In August, the hospitalbegan to readmit mothers with breast abscesses. At a children'shospital across town, they began to realize thata number of babies born at the university hospital were developing pustules after theywent home. True, an occasional pustulehad been seen in the nursery during the precedingmonths, but most infants were sent out into thecommunity without suspicion. The dark cloudsof an epidemic had been rolling up, unrecognized. [...] That was in August. Nothing had preparedthe hospital staff for what occurred in September. [...] September, 26 cases ofstaphylococcal skin pustules developed in the hospital. [Graphic statistical chart] Another 10 casesdeveloped after discharge. 20 nursing mothersdeveloped breast abscesses. Finally, a baby developeda staphylococcal pneumonia and died. Another bassinet had beenemptied by nursery sepsis. [Orderly removes deceased newborn] [...] [Several nurses in a meeting] It was a time for re-evaluation. [...] Practices were reviewedto make sure they met recommended standards. [Hospital care of newborn infant's manual] Individual techniqueswere checked. [Nurse washing hands] [...] Cleaning and laundrytechniques were studied. [Worker cleaning equipment] [...] The baby's generalcare was reviewed. [Nurse cleans the newborn] There were no major errors inthe way the nursery was run. [...] Infant's lesions werecultured, as were the breast abscesses of mothers. In all cases, phage-typing revealed that it was the strainof staphylococcus soon to becomecelebrated as 80/81. [Lab work] Hospital personnel were culturedto detect healthy carriers of this strain. There were seven-- allmembers of the nursery staff. [Staff members, silent] [Staff enters nursery] One of the nurseries was turnedinto an isolation nursery for infants with skinlesions, without effect. [...] [Nurse examines the newborn baby] Another technique, newat the time, was tried, that of bathing with a solutioncontaining hexachlorophene. [Cotton dipped into glass jar] This stopped thedevelopment of skin lesions while babies remainedin the nursery, but many of thesesame babies continued to become nasal carriers--and many of these developed pustules later,after they had been sent home. This, too, was notthe entire solution. It was decided withgrave misgivings to give an appropriateantibiotic. This prevented babiesfrom becoming colonized with the epidemic strain. It was only then that theepidemic came to an end. This epidemic, andthose that followed, made us aware that our nurseryproblems were not solved. [Baby fed bottle] [Silent] Before this time, ourmost troublesome epidemics were with diseases ofthe intestinal tract. The normal intestinalflora of the newborn infant is usually acquiredfrom his mother. Happily, these intestinalbacteria from the mother are usually not very virulent,and she passes on to the baby some degree of immunity as well. [On-screen graphics] Mothers therefore,are rarely the source of nursery epidemics. [...] Other bacteria, such asAlcaligenes, Pseudomonas, Flavobacteria, and colonor paracolon bacilli are soil and water bacteria, andmay abound in the environment. Though not commonly consideredparticularly pathogenic, certain unusual strainsof these bacteria are virulent and may posea real threat, especially to the premature ordistressed infant. Such babies arelikely to receive more manipulationand more contact with incubators andother equipment. It is not surprisingthat poor housekeeping is sometimes followed bysepsis and even epidemics, since newborn infants haveno protective immunity to these bacteria. [On-screen graphics] Viruses are another cause ofdisease among the newborn, but one about whichlittle is yet known. It is probably personnel who areresponsible for transmission. Our only defenseagainst the spread of viral infection at presentis good aseptic technique. [On-screen graphics] Today our emphasis hasshifted from enteric pathogens to those of therespiratory tract, principally staphylococci. The reservoir ofbacteria is usually here in the nursery personnel,or even occasionally, delivery room personnel. The infant may beinfected directly. But even when the source canbe traced to the environment, the ultimate source is likelyto be in the nursery personnel. [On-screen graphics] It is possible to runan immaculate nursery, to observe everyrecommended practice, and still to have an epidemic. The perpetrator isusually found to be the carrier of an unusuallyvirulent strain of organisms. This is the mostdifficult problem in the management of nurseries,and one about which we know perhaps the least. [...] The nasopharynx of adisseminating carrier may produce enough staphylococcito keep a nursery teeming, and yet the carrier may showno symptoms of infection. [Graphic of sinus area] [...] Asymptomatic carriersare frequently discovered only afteran epidemic starts the search for the source. [Baby tucked in] More dangerous is the carrierwith even a small lesion. The person with anexposed furuncle can be identifiedand controlled. It is the personwith a concealed one who can be dangerous ifhe fails to report it. [Man with a bandageon his neck] [Petri dish] Bacteriologicalstudies of persons with staphylococcal lesionshave yielded sobering data. [Petri Dish] [On-screen graphic] Such carriers arelikely to shed bacteria not only from theirlesion and nasopharynx, but also from their hair,hands, perineum, and clothes. [On-screen graphic animation] The dangerous carrierwith an open lesion should obviously bebarred from the nursery until the infection has cleared. The same is true forthe person with diarrhea or the one withrespiratory infection. The hospital hasthe responsibility to assure thesepeople that there will be no financial penaltyfor becoming a carrier or for reportingillnesses promptly. However, a healthycarrier of staph should not bebarred unless it can be shown that she is a carrierof the identical strain as those causinglesions in babies. [...] [On-screen animation] As an example, during the courseof a study in one nursery, it was found that sevennurses were permanent carriers of a certain strain of staph. Despite this, duringthe study, no infants even became colonized. [On-screen graphics] There were also seven permanentcarriers of another strain. Although a total of68 infants became colonized by this strain,they developed no lesions as a result. As one strain didnot cause disease, and the other didnot transfer readily, neither group had to beremoved from the nursery. [On-screen graphics] Fortunately, many carriers,even of pathogenic strains, are transient carriers. If removed from exposureto infected infants, they will usuallybecome negative in a few days or weeks, and may safely work inthe nursery again. [On-screen graphics] [...] Detection of disseminatingcarriers before an epidemic is an unsolved problem. Culturing is valuablefor research, but is not practicalas a routine. Without further identificationby phage typing, it should not be usedto exclude carriers of coagulase-positive staph. [Laboratory technician working] [...] However, an employee healthservice can be of great value. One situation isin the detection of beta-hemolytic streptococciwhen persons are returning from a respiratory illness. [...] Culture of stools cangive useful information when personnel returnafter a diarrheal illness. [Laboratory technician working] [...] And certainly, it is ofvalue to detect traditionally epidemic strains in thosewho transfer from adult wards or have worked recentlyin other hospitals. [Individual being tested] [...] Though an undiscovered carriercan cause an epidemic despite every asepticsafeguard for the baby, we cannot neglectthe safeguards. [...] Each time, before enteringthe nursery of course, a sterilized scrubdress or a gown should be put on by everyone. It usually does notneed to be changed more than once a shift unless itbecomes soiled handling a baby. [...] There is one thing we have notconsidered in this picture. [On-screen animation] The scrub dress may besterilized, but underneath, the person mustbe clean herself. Cleanliness is possibleonly with a morning shower. [On-screen animation] Cleanliness is possibleonly with clean underwear. Where it is possibleto shower and change to clean underclothes at thehospital, it is even better. [On-screen animation] [On-screen animation dissolves to nurse] Bodily cleanliness isespecially important because the skirt is ideallydesigned to scatter bacteria. [Nurse dressing] Although trousersare somewhat better designed to contain bacteria,the need for cleanliness applies equally to the male. Physicians who comein to examine a baby, or other persons who comeinto the nursery briefly, must wear a cap anda long-sleeved gown. [Physician donning a hospital gown] [Nurse hands baby off to Physician] [Physician lays baby on exam table] They should also weara mask, which will not be used long enoughto become a greater hazard than a safeguard. Ordinary gauze masks, whenworn for extended periods, become loaded with bacteria. [...] This, of course, is whythey are not worn routinely by nurses on duty. [Nurse washes hands] Hands are traditionallyconsidered the most frequent offendersin transmitting disease to the newborn. Although they must be washedthoroughly between each baby, they need special carewhen entering the nursery. [Nurse washes hands] Nails should be keptshort and be kept clean. [Nurse utilizing tool to clean nails] Nail polish should not beworn, as cracked polish affords a harbor for bacteria. [Cleaning hands... dispensing soap] Detergents containinghexachlorophene have certain advantagesover plain soap. However, they donot remove bacteria by the simple act ofcovering the skin. Carrying away soil is the mostimportant feature of washing. In any case, whether thecleansing agent is detergent or soap, use enough of it. [Intense hand cleansing] Although this is nota surgical scrub, it is important to wash allsides of the hands and fingers. [Intense hand cleansing] Since washing shouldinclude the wrists and arms, the need for shortsleeves is apparent. [Washing forearm] Rinse thoroughly. Use paper towels for drying. We must consider handsgrossly contaminated unless washed just beforea baby is to be handled. But looking at it selfishly,it is quite as important to protect ourselves frombeing contaminated by a baby as it is to protect thebaby in the next bassinet. [Diaper is put on the baby] [Silent] [On-screen graphic] We have been emphasizingthe role of personnel in transmitting organismsto the infant directly. Let us consider the role ofthe environment in complicating the spread of infection. [On-screen animation] For instance, a colonizednurse scatters organisms onto the floor. [On-screen animation] They are scuffed into theair, where in the fallout, they colonize an infant. They contaminate a blanket,scatter to the floor and into the air, where theyinfect another infant, who transfers the organisms to theoxygen apparatus, from which it feeds back to another infant. This is the web ofcross-infection. The growingconcentration creates a self-perpetuatingseptic environment. [On-screen animation] We can decontaminatethis environment as meticulously andas often as we please, but as long as reservoirs existto reinfect the environment, the best care and housekeepingcan't solve the basic problem. [On-screen animation] One of our problems thenis to be aware of all the potential reservoirs. Each baby is, himself,part of the environment of the other babies in his unit. [Nurse dips swab with antiseptic] [...] His umbilicus is onepotentially dangerous reservoir of bacteria. An antiseptic solution maybe painted on the cord stump and out over thesurrounding skin. This is done immediately afterbirth and daily thereafter. [Nurse swabbing umbilicus] [Silent] There is no such easy solutionfor suppressing bacteria in the respiratory tract. Perhaps the mostfrequent reservoir of all. Precise air sampling testshave been made recently, showing that many babiesthough asymptomatic, are carriers of staph. [Air sampling device] The majority, fortunately, havea low index of infectivity. [...] However, the tests have shownthat epidemic respiratory virus infections convert others intohighly infectious infants. These so-called "cloudbabies," are literally surrounded by acloud of organisms which will causemassive contamination of a whole nursery,and can set the stage for an explosive epidemic. [Particle animation around baby's face] Unfortunately, a carrierbaby isn't conveniently surrounded by a paintedcloud such as this. Detecting him in routinenursery operation, like detectingthe carrier nurse, is one of the unsolvedproblems of nursery management. [Baby crying] [Nursery] The physical planof a nursery can be important in howorganisms spread. In this large nursery, bacteriafrom one cloud baby or carrier would have a widefield of operation. Certainly, nonursery room should have more than 12 infants. [...] Obviously, in smallernurseries such as this, where fewer areexposed to infection, fewer can be infected. [Nurse caring for baby] [Nursery floorplan graphic] Where circumstancespermit, the cohort plan can reduce the chance ofcross-infection still further. Small groups of babies, forinstance, those born each day, are cared for in separaterooms, each with its own nurses and equipment. [On-screen animation] Not until onegroup is discharged do new infants occupy the room. This plan preventsexposure of each infant to a constantlychanging population. It is an admirable planwhere circumstances make it practical. [On-screen animation] [Baby visiting mother] There is still lessexposure, of course, where the infant rooms inconstantly, and doesn't exchange bacteriawith his peers at all. [Mother holding her baby] The one plan to reducecolonization which does not present drawbacksto any hospital is not to prolong theinfant's hospital stay. [Parents departing hospital] [...] [On-screen graphic] One typical study has shownhow the percentage of babies colonized with staphincreases with each day of hospitalization. On the first day,3 percent were colonized. [On-screen animation] The next day, 5 percent. Then 7 percent, 9 percent, 20 percent. [On-screen animation] The number of rosesteadily until of those who stayed in the nursery for10 days, 43 percent were colonized. [On-screen graphic] [Baby handed to mother in car] The moral is clear. [Nurse closes door, mother say's thank-you very much] [On-screen graphic] Much can be done to preventa self-perpetuating septic environment bygood housekeeping. The aim is toprevent concentration of bacteria in such dosesthat they cause infection. [On-screen animation] [Hospital hallway floor] One of the requirements iscleaning and dust control. Methods of cleaningfloors should be reviewed to make sure thatdust and bacteria are not just being redistributed. [Cotton mop head] [Wet mop device] Wet vacuuming is far superior,and should be substituted for mops wherever possible. [Wet mop device] [Gowned worker wiping counter] Other horizontalsurfaces and equipment should be cleaned daily witha cloth treated with detergent germicide, and at a timewhen fewest infants are in the nursery. A certain amount ofdust is inevitable when a nursery iscleaned only once a day. It can be kept to a minimumby a proper ventilation, where the system produces 12 changesof filtered air per hour. [Air filtration ceiling vent] Aside from the problemof dust control, there is the problem of keepingclean those articles which contact the baby. After discharge, everycorner and every inch of his bassinet andcrib unit should be taken out into the workarea and cleaned carefully with antiseptic solution. [Gowned worker wiping crib unit] And, of course, the terminalcare given to bassinets is doubly needed for incubators. Here particularly, we should notbecome so concerned with staph that we neglect thebreeding grounds of water andsoil bacteria. [Gowned worker cleaning incubator] [...] One Representative studyof organisms recovered from various water sources,humidifiers, distilled water, and mist generators revealedsome shocking figures. The number of bacteriaper milliliter ran from a meanof 850 to 14,850. [On-screen graphic] The type of organism was noted,and the number of sources from which they were recovered. [On-screen graphic] [Type of organism and number of sources] [Silent] [Type of organism and number of sources] [Worker unscrewing glass container] Other studies haveimplicated oxygen equipment just as seriously where ithasn't been cleaned regularly or the water has beenallowed to stand. Although we do not thinkof some of these organisms as being particularlypathogenic, oxygen apparatus and humidifyingwater, when neglected, are especially congenialhomes for breeding massive reservoirs of bacteria. [Worker scrubbing equipment in sink] Some kinds andparts of equipment can be sterilizedwithout difficulty. [Laboratory sterilizer] Others are designed to giveaccess for thorough cleaning. [...] Older models presentmore difficulty and will needfrequent disassembly for thorough disinfection. [Worker removes machine component] [...] This is the depositthat had collected on an incubator whichhad not been disassembled for some time. [Wiping down a component] Whatever the difficulty, we mustkeep these devices immaculate. [Wiping down a component] [Waste can] Soiled linens can also grosslycontaminate the environment. Soiled diapers mustbe kept in a closed can, separate from soiledclothing and bed linen, until ready to beremoved from the nursery. [Items transferred to hamper bag] Soiled linens should bepicked up at least twice a day and should be set outside,so the person collecting them need not come into the nursery. [Worker transfers bag to sanitation staff] They should betaken to the laundry without beingremoved from the bag. [Sanitation staff receives bag] [Gowned laundry worker] Diapers should bewashed separately from the other soiledfabrics, and both should be kept separate fromthe rest of the hospital linen. [Laundry sorted] [Hospital laundry facility] Laundering is not enough. Infants' linensand diapers should be sterilized before reuse. [Worker operates machine] [Nurse changes diaper] Disposable sterile diapersare another solution to this potentially hazardoussource of cross-infection, and might well be used. [Nurse changes diaper] [Silent] [Nurse changes diaper] [Weight scale] Another potentialsource of trouble is equipment used in common. Scales must be freshlycovered for each infant. [Weight scale] [Nurse transfers baby to scale] Small tissues can be used toprevent contaminating the scale when making adjustments. [Adjusting scale] [Nurse cleaning baby] Each baby should have hisown individual articles. [Supply drawer] [Baby being transferred] Whenever an infant istaken to its mother, he should go in his ownbassinet or carefully wrapped in the nurse's arms,never in a common carrier. [Baby being transferred] [Graphic animation] These are some of theelements that can weave the web of cross-infection. It is a web that constantlythreatens every nursery, and is all the more threateningbecause it cannot be seen. [Graphic animation] We see only the result-- the infected baby. [Graphic animation] And even then, inthe case of staph, the infection is morelikely to become apparent only after the babyis home, where it becomes a hazard to its family. [Graphic animation] The hazard also extendsto the community. The well-run nursery willhave a positive program of following up casesfor several weeks because evidence ofan epidemic is often first seen in the community. The unseen web ofcross-infection is complex and elusive. It is affected by ourpersonal techniques. Our housekeeping. Our nursery practices. Our willingness to absentourselves when ill. Our baby care. By the innumerable waysin which we manage ourselves and our environment. It is everyone's responsibility. Each of us must beconstantly on guard. [Hospital staff] The goal is worth the effort. [...] [The End] [A Churchill Wexler Film Production] [This film can only sketch in the broad outlines of nursery sepsis.] [For detail, we refer you to your Infection Committee and to] [the recommendations of theAmerican Academy of Pediatrics.] [...]