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THE BED ISOLATION OF CASES OFINFECTIOUS DISEASE.

BY C. R U N D L E, M.D. LOND.,MEDICAL SUPERINTENDENT, CIrY HOSPITAL, FAZAKERLEY, LIVERPOOL ;

AND

A. H. G. BURTON, M.D. LOND.,SENIOR RESIDENT MEDICAL OFFICER, CITY HOSPITAL, FAZAKERLEY,

LIVERPOOL.

IT is the practice to admit to the Fazakerley City Hospitalpatients suffering from the infectious illnesses commonlyadmitted to hospitals of this character. In addition to scarletfever, diphtheria, and typhoid fever, there are during thegreater part of the year under treatment at one time cases oferysipelas, puerperal fever, measles, chicken-pox, and in-fantile diarrhoea. To these may be added a variety ofconditions admitted under a mistaken diagnosis, the natureof which will be familiar to those who have been responsiblefor the administration of large fever hospitals. In addition,60 beds are set aside for the sanatorium treatment of

consumptives. There is in all accommodation for 520patients.The requirements of modern methods of nursing, the

separation of acute patients from those more convalescent,the isolation of those suffering from septic complications,and the large proportion of patients admitted under the

whether nursing on lines of strict surgical asepsis mightsafely take the place of the structural methods hitherto

adopted.The principles of the bed isolation of cases of infectiousdisease have been observed for a number of years under the

system of "barrier" isolation, but the practice of this

system has been reserved in the majority of instances for theseparation of different types of the same disease. By thismethod, for example, septic types of scarlet fever have beeneffectively isolated from types of a less severe character, andchildren have been separated from their fellows during theincubation period of a secondary infectious disease to whichthey have been exposed. No investigations have hithertobeen made on a scale sufficiently extensive to be of value tosuggest how far these same principles might be safely utilisedin the separation of patients suffering from a variety ofdifferent specific infectious diseases.The ward pavilion used for the purpose of this work has

male and female wards separated by an entrance hall, kitchen,pantry, and linen cupboard (see figure). The female ward hasa roofed verandah at the south end, the sanitary offices beingplaced at the side, while the male ward has its lavatoryaccommodation at the extreme north end. The beds are

arranged on the ordinary plan with a window between eachbed. The air-space in cubic feet per patient is 2100.Opening out of each ward of the pavilion is a small observa-tion ward with an inspection window to each from the kitchen;that on the female side is of the usual type accommodating

heading of Other Diseases," make it impossible to reserve toeach variety of infection a pavilion for the purpose of thatinfection only, the structural and administrative cost would beobviously prohibitive. As an alternative to a strict limitation of the number of diseases admitted for treatment, witha corresponding restriction in the utility of the hospital, thefollowing systems have been practised in various institu-tions whereby patients suffering from different infectionsmay be brought administratively under the control of a

limited number of nurses : (1) Treatment in separate roomsopening on to a common duty room-i.e., the system ofisolation nests; (2) the glass cubicle system ; and (3) thesystem of bed isolation whereby patients suffering fromdifferent infectious diseases are treated in the same wardunder the same nurses, measures of strict asepsis alone

being relied upon for the prevention of cross infection.The results obtained from a somewhat extensive trial ofthis last system made during the years 1910 and 1911 at theCity Hospital, Fazakerley, form the subject of this paper.The necessary administrative and economic disadvantages

attached to the system of isolation by separate wards need notbe noticed here ; structural changes in many directions havebeen made with a view of minimising these difficulties, and theglass cubicle system may be regarded as the most recent attemptto provide a physical obstacle to the transmission of infec-tions at a reasonable administrative cost. This method,although of great value, has limitations (apart from initialcost of construction), which have been readily admitted bythose who have had experience of its use, and the object ofthe investigation made at this hospital has been to show

one bed and a cot and has an outside door. On the male sidethe isolation ward has been converted into an anaestheticroom; it holds one bed and opens into a large and well-appointed operating theatre. The remaining appointmentsof the ward require no further description, being of the usualtype found in isolation hospitals.The diseases which are admitted to the ward are as

follows : (1) All cases of puerperal fever and erysipelas, andmost cases of pertussis, rubella, and varicella ; (2) all casesnotified as suffering from an infectious disease, but found onadmission to have no infectious condition ; (3) cases in whichthe diagnosis is doubtful and observation is necessary, suchas " query " scarlet fever or diphtheria cases ; (4) cases fromother wards in the hospital requiring operative treatment inwhich the after-treatment may be prolonged ; (5) convalescentcases of diphtheria or measles when the wards receivingthese patients are pressed by a sudden rise in the incidenceof the disease ; (6) cases of epidemic diarrhoea when theseare few in number. The method of isolating these various

diseases in one ward has been, in brief, the observation ofstrict cleanliness after examining or attending to a patientwith a primary infectious disease or suspected to be sufferingfrom such.The hospital has had the advantage of possessing a highly

trained sister in charge of the ward pavilion with specialsurgical and fever experience, who has supervised the wardssince their inception. Each ward, male and female, is incharge, under the sister, of a general hospital-trained nursewith some fever experience ; one probationer is also allocatedto each ward. The night staff consists of two nurses, one of

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whom has frequently had three years’ general training. Thewards are consequently well staffed both as regards thenumber and the qualifications of the nurses in charge. Eachcase of puerperal fever is placed on admission in the sideward off the operating theatre until it is decided what opera-tive measures, if any, may be required. As long as activetreatment, such as douching, is required the nurse in chargeis not allowed to assist in the dressing of any case of

erysipelas or cellulitis. Coats are worn by the doctor andnurse when attending to the case, and rubber gloves if

douching or dressing is needed. When the operation hasbeen performed and another case has been admitted requiringoperative treatment, the first case is transferred to the mainward. Thus during the same week there were six cases ofpuerperal fever in the main ward and one case in the sideward.The cases of erysipelas and cellulitis are treated with

ordinary cleanliness only, no special isolation measures beingadopted. The same remark applies to patients having noinfectious disorder but some such condition as lobar pneu-monia or a non-infective skin disease.

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With cases of varicella, pertussis, and doubtful or genuinecases of scarlet fever or diphtheria, more rigid measures areadopted. Two long coats kept for each case are worn, oneby the doctor and the other by the nurse, whilst examiningor attending to the patient. Drinking-vessels, knife, fork,spoon, and spitting-mug are boiled after use, and separatesanitary utensils, bowl and brush for washing, and bathblankets are reserved for the use of each of these patients.No interchange of toys or books is permitted. After removingthe coat worn in attending to the case the doctor or nursewashes the hands before proceeding to another patient. Forthis purpose a table with three bowls is kept half-way downeach ward; additional bowls are placed on the lockerof the patient concerned if isolation measures are likelyto be prolonged or if the case is requiring frequentattention.Temperatures are taken in the axilla and the thermometers

washed in lysol after use. In the case of patients sufferingfrom varicella or enteric fever a separate thermometer is keptfor each patient.

If the case is one of the prime infections mentionedthis routine is adopted until the patient is considerednon-infectious, in cases of doubtful diagnosis until a nega-tive opinion is arrived at. The patient is allowed to getup when all signs of acute disease likely to prove infectioushave subsided. From now on he is allowed to mix freelywith the other convalescent patients until discharged, pro-vided that he is not a scarlet fever or diphtheria patient withrhinorrhcea or otorrhoea, in which cases a longer stay in bedis adopted, in the former case until the rhinorrhoea hasceased. Special precautions - are, of course, adopted indealing with nose or ear discharges. The convalescenttransfers from other wards are similarly allowed freely tomix with the convalescent patients of the ward.The total number of cases admitted to the ward during the

years 1910 and 1911 was 668. Of this number, as will beseen in the following table, 27 showed no actual disease ; alarge proportion of these 27 cases were babies admittedwith their mothers, the latter suffering from puerperalfever.

Table giving Varieties of Oases Admitted d2cring the Years1910 and 1911. ’

Infectious Diseases.

Disease. Total ConvalescentIsease.

cases. transfers.Scarlet fever ..................... 69 ............ 16

Diphtheria ..................... 40 ............ 15

Measles ........................ 37 ............ 29

ltubella ........................ 12 ............ 5Varicella ........................ 38 ............ 12Pertussis ........................ 9 ............

-

Scarlet fever and pertussis............ 2 ............ 1Measles and pertussis ............... 2 ............ 1Varicella and paratyphoid fever ...... 1 ............

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Diphtheria and scarlet fever ......... 1 ............ 1

Typhoid fever..................... 10 ............ -

Puerperal fever .................. 35 ............ -

Erysipelas........................ 215 ............ -

Vincent’s angina .................. 1 ............ 1

Anthrax ........................ 1 ............ -

Total............ 473 ............ 81 I

Other Diseases,

Disease. Total Disease. cases>Phthisis ............... 3 Conjunctivitis............ 1

Tuberculosis of other organs 4 Syphilis ............... 2

Lobar pneumonia ......... 4 Acute rheumatism......... 2

Empyema ............... 3 Anaemia ............... 2

Bronchitis, broncho-pneu- Carcinoma............... 2monia ............... 18 Chorea.................. 1

Laryngitis....., ......... 1 Rickets ............... 2Tonsillitis ............... 50 Icterus neonatorum ...... 1

Retro-pharyngeal abscess ... 1 Marasmus, malnutrition ... 8Ulcerative stomatitis ...... 1 Cellulitis, septic wounds ... 8Alveolar abscess ......... 1 Cutaneous abscesses, mas-

Gastro-enteritis, epidemic titis .................. 3diarrhcea............... 33 Skin diseases ............ 13

Dyspepsia, constipation ... 2 --

Nephritis ............... 1 Total............ 168

Myocarditis ............ 1jYo disease.-27.

During the two years under review the number of patientswho developed an infectious disease whilst under treatmentwas two. One instance occurred in a girl, aged 7 years, whohad been admitted suffering from rubella, but notified as acase of scarlet fever. After 14 days’ stay in bed she wasallowed up, but 13 days later was again confined to bed witha typical attack of scarlet fever. The other secondary casewas that of a girl, aged 10 years, admitted with a mildattack of faucial diphtheria. After 28 days in bed she wasallowed up, and in six days’ time developed scarlet fever.

In the list of cases given attention may be drawn to thelarge number of non-infectious patients, many of whom-as,e.g., those suffering from epidemic diarrhoea-were youngchildren. None of these contracted any infectious diseasewhile in the ward.The above figures represent the result of two years’

observation, and although not large they certainly justify acontinuation of this work and support the opinions arrived atby Martin, of the Institut Pasteur, Crookshank,l and others.

Caiger 2 is a recent paper defines three methods by whichinfection may be transmitted from one patient to anather,both occupying beds in a hospital ward : 1. By "direct

projection of infective particles from the patient’s mouth ornose, the recipient being in immediate proximity." 2. By11 meditate infection "-i.e., the indirect conveyance of recentinfective material from the patient to the recipient by meansof some article common to both. Under this heading may beincluded spread of infection I I by fomites.

" 3. By I I aerialinfection "-i.e., infection at a distance (such as that inter-vening between neighbouring beds) by means of minute

droplets of saliva, mucus, &c.A consideration of the results obtained by bed isolation

compared with those of cubicle isolation should be of definite.value in deciding upon the comparative importance of thesethree modes of infection. Facilities for the spread of infec-tion by method (3)-i.e., aerial infection-are obviouslygreater under the system of bed isolation than that of cubicleisolation ; in fact, a total breakdown of the system of bedisolation might be expected if "aerial infection were ofcommon occurrence. In the light, however, of the verysatisfactory results obtained by this latter system, as com-pared with those of cubicle isolation, it may be fairly arguedthat the danger of spread of infection in a hospital ward bymeans of "aerial infection " is to be disregarded for practicalpurposes. It would appear that the practice of rigorousasepsis on surgical lines has a value equal to, or greater than,that of any of the accepted methods of separation by arti-ficial barrier.

If the suggestion be accepted that " aerial infection " is afactor of limited importance, a suggestion receiving supportfrom the results of this investigation, it may be questionedwhether glass partitions do not involve a false security inregard to the nursing staff, rather than that protection to thepatient which is claimed for them. In short, it would appearthat in this matter of individual or 11 unit " isolation, thequality of nursing obtainable is the sole factor of success orfailure. In probably no other branch of her professionalwork is a nurse called upon to display so large a capacity fordetail and administrative control as in the bed isolation ofcases of infectious disease.

1 THE LANCET. Feb. 19th, 1910, p. 477.2 Public Health, June, 1911.

3 Ibid.