Infections can be lethal in the hospital setting, of course, but awareness of anesthesiologists’ role in contamination is just starting to emerge.
According to data presented at the 2017 annual meeting of the Society for Technology in Anesthesia (abstract 29), anesthesia machines, which are notoriously difficult to clean, have been shown to be a potent reservoir for intraoperative exposure to pathogens (Anesthesiology 2008;109:399-407; Anesth Analg 2012;114:1236-1248; J Evol Med Dent Sci 2015;4:933-940; APSF[Anesthesia Patient Safety Foundation] Newsletter 2016;31:14-15). An innovation, the Anesthesia Hygiene Organizer, is a cover that provides barrier protection for the anesthesia machine and all other accessories and is designed to help prevent hospital-acquired infections.
“Infection control is every health care provider’s responsibility, but it remains a low priority among many anesthesiologists,” said Murlikrishna Kannan, MD, FRCA, in the Department of Anesthesiology, Mount Sinai Medical Center, in Miami Beach, Fla. “Structured organizational tools and protocols must be designed to empower anesthesia providers to maintain a clean and organized anesthesiology work environment.”
Contamination in the anesthesia work environment is difficult to control, given the large surface area and the hectic pace of the operating room. Used equipment is placed on anesthesia machines, and multiple tactile interactions with touch screens, monitors, keyboards and mice all increase possible affected areas.
“Anesthesiologists insert an IV, get blood on their hands and then touch the machine. They intubate their patient, come into contact with saliva and then touch the machine. They’re exposed to patients’ gastric secretions or sputum and then touch the machine,” Dr. Kannan pointed out. “It’s nonstop, back and forth.”
In addition, there is frequent intermingling of equipment supplies between surgical cases.
“Cleaning anesthesia machines in between cases is the only current strategy for infection control, but multiple studies have proven this to be ineffective,” Dr. Kannan said. “There’s no systematic approach in place to address the problem. All too frequently, we hear about a patient going in for an elective surgery like a total knee replacement, and dying from a hospital-acquired infection. Intraoperative pathogen exposure from the anesthesia work environment has been shown to be an important source for hospital-acquired infection.”
Organizing the Work Environment
To reduce contamination in the anesthesia work environment, Dr. Kannan and his colleagues designed the Anesthesia Hygiene Organizer (AHO) as barrier protection for the anesthesia machine and its accessories. Designed for single-patient use, the simple translucent barrier ensures that body fluids and biohazard materials remain on the AHO and are completely removed after patient care.
“It’s like putting a tablecloth on a table while you’re having dinner,” Dr. Kannan explained. “The AHO covers all the areas of the anesthesia work surface that are frequently touched through patient care; it provides a clean area to lay out equipment ready for use on a patient; and it includes a nonpermeable barrier to place contaminated equipment.”
This barrier, said Dr. Kannan, will help prevent transmission of bacterial organisms. A study by Loftus et al (Anesthesiology 2008;109:399-407)showed that bacterial contamination of the anesthesia work area increased significantly by case conclusion, with a mean difference of 115 colonies per surface area sampled (95% CI, 62-169; P<0.001). Moreover, these highly contaminated work areas increased the odds of stopcock contamination by 4.7 (95% CI, 1.42-15.42; P=0.011).
“The consequences can be deadly,” said Dr. Kannan, who cited another study by Loftus et al (Anesth Analg 2012;114:1236-1248), which found stopcock contamination was associated with increased mortality (Odds Ratio, 3.08; 95% CI, 0.56-17.5; P=0.11).
Intraoperative bacterial contamination of the hands of patients or providers was also linked to 30-day postoperative infections, Dr. Kannan reported.
“When we started this project, we made one prototype to show to people, but we’ve been developing variations for several institutions based on their feedback,” Dr. Kannan said. “It’s a slow process, but we’re making progress every single day.”
Dr. Kannan and his colleagues are partnering with academic universities to research the influence of the AHO on infection control without conflict of interest. “More studies are required to evaluate the effect of these devices in everyday anesthesia practices.”
Contamination at Multiple Sites
After using a fluorescent marker on the oropharynx of their mannequin during a simulation, Lori Rubin, MD, associate professor of clinical anesthesiology, and her colleagues at NewYork-Presbyterian/Weill Cornell Medicine, in New York City, found contamination on many sites of their institution’s anesthesia machine.
“It really demonstrated the need, in cases that require contact precautions, for a way to protect the anesthesia machine,” Dr. Rubin said.
- Andrew Bowdle, MD, PhD, FASE, professor of anesthesiology and pharmaceutics at the University of Washington, in Seattle, said, “In my institution, we have focused on implementing single-use laryngoscopes, single-use bronchoscopes, isopropyl alcohol caps on IV injection ports, and ‘full barrier precautions’ for central venous catheter and arterial catheter placements.
“Our next steps will be to try to clean up the anesthesia machine—which is a difficult problem—and to clean up the anesthesia supply cart by finding ways to keep providers from putting their contaminated gloved hands into the cart drawers.
“We have had a trial of the Anesthesia Hygiene Organizer, and it was very popular with our providers,” Dr. Bowdle added.
“It protects the work surface of the anesthesia machine from contamination by dirty airway equipment, and the Yankauer suction in particular. The Yankauer suction can be placed in one of the plastic pockets of the cover where it is ready to use and where it will not contaminate the surrounding area.”