Annals of Burns and Fire Disasters - vol. XII - n° 4 - December 1999

TRENDS AND STRATEGIES FOR INFECTION CONTROL IN A NEW BURNS CENTRE

Melandri D, Morri M, Polverelli M, Pierleoni M, Arcangeli F, Landi G.

Division of Dermatology and Burns Centre, M. Bufalini Hospital, Cesena, Italy

SUMMARY. Despite the significant advances made in the last 40 years in the treatment of burn patients, infections continue to represent a serious complication of burn injuries and a stimulating challenge for medical staff. The general arrangement of a new burns centre in Cesena was carefully planned in order to achieve a significant reduction in the risk of infection and to keep the microbial environment to a minimum. Special architectural structures were used to achieve satisfactory isolation from the external environment. There are separate entrances for burn unit staff, patients, equipment, and visitors. Air-handling systems have been installed, with a larninar airflow room and the choice of multiple centralized air-conditioning units for patients, staff, and the operating theatre. All rooms are provided with a bath in order to minimize the risk of cross-infection, which is traditionally associated with hydrotherapy. For the same reason, all rooms have an anteroom that functions as a further filter area for the staff. Microbiological checks are carried out on a frequent basis both on air samples and on surface swabs in order to monitor the level of microbial contamination inside the unit.

Introduction

The environment of a Burns Centre cannot be made completely germ-free and for that reason infection continues to be a serious risk for severely burned patients. The new Burns Centre in Cesena, Italy, is adjacent to the Dermatological Division but it is organized as a completely autonomous unit. Covering an area of 700 square metres, it is twice as large as the previous centre and well isolated from the external environment (Fig. 1).

Fig. 1 - Plan of the Cesena Burns Centre.

The purpose of this paper is to focus on the principles that were followed in the planning this new Burns Centre in order to prevent the spread of infection. In particular, we intended to verify whether microbial control of the environment is an effective measure in this respect.

Material
We evaluated the architectural structure and the facilities employed in our Burn Unit in relation to the microbial contamination of the environment. Microbiological tests were carried out on a frequent basis on air samples and surface swabs in order to monitor contamination levels in the unit and to identify the pathogens most frequently involved (bacteria and fungi).

Results
The data collected indicate a decreased amount of environmental microbial contamination and a possible reduction in the number of infections in the burn patients investigated.

Discussion
Access to the Burn Unit is through four distinct entrances for staff, patients, equipment, and visitors.
Staff enter through a filter area that is separate from the equipment entrance. They wear clean uniforms, disposable surgical masks, caps, and shoe-covers. While in the Unit, staff remain in contact with the outside world by telephone, interphone, and TV. Whenever they leave the Unit, they must change their uniform, mask, and cap.
Visitors enter by way of a corridor that runs round the external side of the patient area: they can see the patients through wide windows and talk to them over the intercom.
Newly admitted patients enter the Burns Unit through the emergency room (Fig. 2), which is a specific filter area provided with first-aid equipment and a bath for use when immediate bathing is required.
The patient area consists of four rooms for intensive care, each with an electrically articulated thermostatic airflow bed, laminar air flow, and a toilet. There is a dedicated bath-tub in each of the four intensive care rooms in order to minimize the risk of cross-infection that is frequently associated with hydrotherapy (Fig. 3). In the patient area there are two other rooms for sub-intensive care equipped with two beds and a toilet.

Fig. 2 - Emergency room Fig. 3 - Patient area

Each room is equipped with an extensively glazed anteroom provided with sterile equipment and a sink. This functions as a further filter area: before entering the room to perform the daily dressings, staff put on a sterile jacket and a pair of gloves that they remove before leaving the anteroom.
The Burns Centre has an internal surgical area to permit complete treatment of the patient inside the Centre (Fig. 4). The purpose of this is to prevent the risk of contamination and infection involved when a patient is taken out of the Centre. The operating theatre has a sterile air-conditioning unit of its own, laminar flow, and a sterilization area.

Fig. 4 - Surgical area

Multiple centralized air-conditioning units guarantee different conditions of temperature, humidity, and positive air pressure for the different areas of the Burns Unit. The operating theatre and the patient area also have laminar low-speed air flow. The whole air-handling system mobilizes 15,000 cubic metres of air per hour, with a complete air exchange every three minutes in the operating theatre, every four in the intensive care rooms, and every twelve in the remaining areas of the Centre.
The air-handling system filters are replaced whenever an abnormal rate of environmental microbial contamination is registered (Fig. 5).

Fig. 5 - Environmental microbial monitoring

We did this on a recent occasion and subsequent checks showed a significant reduction in air microbial contamination. It may therefore be advisable to replace filters more frequently than recommended by the manufacturers. The use of disposable items could be another appropriate measure to adopt if disinfection procedures in reusable articles (e.g. sponges and towels for cleansing) do not produce adequate results.

Conclusion
To keep microbial contamination of the environment at low level, it is important that a Burn Centre's architectural structure should be carefully planned and that strict environmental monitoring of pathogens should be regularly performed. We follow recommended schedules and protocols but it is wise to adjust these if necessary on the basis of actual experience and set up fresh ones. In our Burns Centre we have succeeded in reducing the amount of microbial contamination in the environment and possibly therefore also in our patients. Whether this will improve their prognosis as well has yet to be determined.

RESUME. Malgré les progrès significatifs réalisés dans les derniers quarante ans dans le traitement des patients brûlés, les infections continuent à représenter une grave complication des lésions et une stimulation pour le personnel médical. Pour réduire en manière significative le risque des infections et pour maintenir aux valeurs minimales les niveaux microbiens de l'environnement, les Auteurs ont projeté selon des critères particuliers l'arrangement général d'un nouveau Centre des Brûlés à Césène en Italie. Ils ont employé des structures architecturales spécifiques pour réaliser un isolement efficace de l'environnement externe. Il y a des entrées séparées pour le personnel du Centre, les patients, le matériel et les visiteurs. Le Centre possède des systèmes d'aération, avec une salle de circulation laminaire de l'air et un choix d'unités centralisées multiples de climatisation pour les patients, le personnel et la salle d'opération. Pour minimiser le risque des infections croisées, associées traditionellement à la technique de l'hydrothérapie, toutes les chambres sont dotées d'un bain. Pour la même raison toutes les chambres ont une antichambre qui agit comme zone ultérieure de filtration pour le personnel. Des contrôles microbiologiques sont effectués fréquemment, soit sur les échantillons d'air soit sur les tampons des surfaces brûlées, pour contrôler le niveau de la contamination microbienne dans le Centre.

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