It is important for those in the anesthesiology community to work together to improve infection control practices and to prevent the occurrence of infections linked to the practice of anesthesiology.
That was the message from a session (“Infection Control Issues Impacting Anesthesia Practice: What’s the Evidence?”) held at the recent New York State Society of Anesthesiologists’ (NYSSA) 68th Annual PostGraduate Assembly (PGA) in Anesthesiology. The speakers cited an article (Anesth Analg 2014 Jun 16. that found a within- and between-case Enterococcus faecalis transmission rate of 11% to 23%. They also noted that some hepatitis B and C outbreaks in health care settings over the past 15 years have been attributed to mishandling of medications, fluids, syringes, needles and cannulae by anesthesia professionals. Meanwhile, however, some published infection control recommendations, such as a provision of the US Pharmacopeia (USP) Chapter <797>, present unique challenges to anesthesia professionals.
“Anesthesia professionals often react negatively to infection control policies, and many of these policies have been developed without input from anesthesia professionals,” Richard A. Beers, MD, professor of anesthesiology at State University of New York Upstate Medical University, in Syracuse, told the audience. As a result, he added, many of the policies include provisions that are “contradictory and paradoxical” to the safe and efficient delivery of anesthesia. For example, anesthesia professionals know the importance of hand hygiene; however, according to Dr. Beers, protocols that call for hand hygiene after every patient contact are impractical in the intraoperative setting because, during induction, anesthesia providers may contact the patient more than 150 times.
Elliott S. Greene, MD, professor of anesthesiology, Albany Medical College, in New York, noted that the state is mulling legislation that would require pharmacists who are compounding medications to comply with the provisions of USP <797>. Nevertheless, he said there is limited evidence supporting the “immediate-use” provision of USP <797>, which is applicable to clinicians and requires a “use time” (time between preparation and use of medications and fluids) of one hour, after which disposal is required. He also noted that USP <797>, originally published in 2004, does not include reference citations.
Anesthesiologists Can Do a Better Job
Most infection control guidelines are strongly supported by clinical data—and there is evidence that anesthesia professionals can do a better job of following them. According to Dr. Greene, the Centers for Disease Control and Prevention (CDC) issued recommendations in 2007 for the safe use of needles, cannulae, syringes, medications and fluids, and reported on the etiology of outbreaks of blood-borne infections in health care settings.
According to Dr. Greene, the CDC found that these outbreaks stemmed from:
- the reuse of a syringe, cannula or needle for more than one patient;
- the use of a contaminated syringe, cannula or needle to access a medication or fluid container;
- the use of single-use containers for multiple patients; and/or
- the preparation of medications in the same workplace where used needles, cannulae and syringes were dismantled.
Multiple studies, he said, have documented these outbreaks, identified the faulty practices and discussed recommendations to eliminate unsafe practices. However, since 2001, the CDC has identified at least 49 hepatitis B, hepatitis C or bacterial outbreaks attributed to the aforementioned causes, with 26 outbreaks occurring since 2007—after the publication of its guidelines.
Amanda Rhee, MD, assistant professor of anesthesiology, Icahn School of Medicine at Mount Sinai in New York City, acknowledged that “many health care professionals don’t like being asked to wash their hands.” She noted that there are creative solutions to the time constraints that potentially limit proper hand hygiene among anesthesia professionals, including the practice of “double-gloving” or the use of specially designed tools (she cited an example of a small portable device that dispenses hand sanitizer). As Dr. Rhee told the audience at PGA, “We are different, therefore we need to address this problem differently.”
Indeed, according to Dr. Rhee, hand hygiene has to be a fundamental component of any infection control program designed to reduce the incidence of surgical site infections (SSIs). At her institution, for example, researchers cultured the hands of anesthesia professionals to demonstrate the level of contaminants and “gain their buy-in” to the program. Her team has also posted signs throughout the surgical section touting the message “foam in, foam out,” which reminds providers to wash their hands every time they enter and leave the room. Hygiene dispensers are conveniently located inside and outside the doors to every room in the section.
Although he was not a speaker during the PGA lecture, Brian Currie, MD, MPH, assistant dean, clinical research, Montefiore Medical Center and professor of clinical epidemiology and population health, Albert Einstein College of Medicine, New York City, said in an interview that he was pleased that anesthesiologists are paying greater attention to the issue of infection control, as he believes the profession, like many who work in the hospital setting, can improve in this regard. He lauded the NYSSA for including the topic on the PGA agenda; in comparison, he said infection control was only included as part of two larger sessions at the annual meeting of the American Society of Anesthesiologists.
Dr. Currie acknowledged that some of the provisions of USP <797> “may be more onerous than necessary,” but given the limited locations and circumstances in which medications are prepped outside of the pharmacy, he added, it is clear that anesthesiologists as well as nurses working in these areas need additional education in proper medication preparation and safe-handling techniques. “There are a lot of infection control–related issues in anesthesiology—the most glaring one being the transmission of hepatitis B and C due to improper use of syringes,” Dr. Currie said. His own hospital has incorporated the CDC’s “One & Only Campaign” protocol emphasizing “one needle, one syringe, only one time,” and built a training module off that program.
Dr. Rhee explained that the SSI control program at Icahn School of Medicine includes restrictions on traffic in and out of the operating room (OR), and instills a communications protocol with OR technicians about frequently contaminated areas, which has led to better cleaning. Other program components have been developed to improve antibiotic compliance. Thanks to these and other initiatives, her unit has seen incidence of coronary artery bypass graft SSIs reduced from 6.6% in 2011 to 2.1% as of winter 2014.
“Compared with immediate physiologic changes associated with anesthesia, infection control issues are not quite so sexy,” Dr. Beers told the audience at PGA. “But the long-term consequences of infections for our patients can be devastating. Sound, practical procedures must be designed to reduce their incidence and developed with the unique needs of anesthesia professionals in mind.”