Infection prevention and control (IPC) are critical elements of perioperative quality and safety. Healthcare-associated infection is the leading cause of postoperative complications and hospital readmissions (asamonitor.pub/3tk4yG9). Perioperative teams and pre-anesthesia clinics are uniquely positioned to implement interventions that reduce postoperative infection (Anesthesiology June 2022).
However, anesthesiologists have not historically partnered with IPC (or “hospital epidemiology”) teams, and conflicting perspectives have occasionally produced discord between these groups (asamonitor.pub/3p3IgVo). Despite the role of anesthesiologists as perioperative physicians, representation from our specialty is lacking in national guidelines for surgical antimicrobial prophylaxis and the prevention of surgical site infection (Am J Health Syst Pharm 2013;70:195-283; JAMA Surg 2017;152:784-91).
This is now changing, as reflected in the work of Randy Loftus, David Birnbach, and Andrew Bowdle (AMA Netw Open 2020;3:e201934; Anesth Analg 2020;131:37-42; Br J Anaesth 2019;123:531-4; Anesth Analg 2015;120:853-60; Anesth Analg 2019;129:1557-60; Am J Infect Control 2020;48:246-8; Infect Control Hosp Epidemiol 2019;40:1-17; Anesthesiology 2020;132:1292-5; Anesth Analg 2020;131:1342-54). In this article, we discuss traditional challenges to partnership between anesthesiology and IPC teams, our experience at Harborview Medical Center, and practical suggestions for collaboration
Challenges for anesthesiologists
- Limited exposure to the field of infectious disease
Perioperative infection is not routinely addressed in anesthesiology residency training, standardized examinations, continuing education, or maintenance of certification.
- Understanding limitations of standardized surveillance
National standards require surgical site infection surveillance for only abdominal hysterectomy and colon surgery (asamonitor.pub/3GXbVbT). Surveillance data collected by hospitals are rarely presented in a way that informs how our practice influences perioperative infection.
- Counterintuitive IPC team structures
IPC team structures are often not aligned with perioperative health care delivery. Separate infection preventionists may focus on colorectal surgery, hysterectomy, catheter-associated urinary tract infection, and central-line associated bloodstream infection, providing no point person with which anesthesiologists can engage.
- Overcoming OR “exceptionalism”
The technical complexity, high stakes, and production pressures of the OR may cause anesthesiologists to resist infection prevention measures developed for other settings such as the ICU. It may also be challenging for anesthesiologists to participate in meetings scheduled during OR hours, promoting a notion that our specialty is less committed to infection prevention.
Challenges for IPC teams
- Grounding in public health and internal medicine
Medical directors of IPC programs are typically infectious disease physicians with limited front-line exposure to anesthesiology and surgery. “Infection preventionists” who perform the work of surveillance, reporting, and protocol implementation commonly have backgrounds in nursing or public health, but perioperative experience is uncommon.
- Unfamiliarity of the OR environment
The absence of training or clinical experience in procedural medicine creates physical and cultural barriers to integrating IPC teams into the perioperative setting.
- Centrality of surveillance and reporting activities
Standardized surveillance and reporting are central functions of IPC programs directly linked to hospital reimbursement. Hospital allocation of staff for activities beyond this scope is highly variable, and the focus of smaller programs can easily be skewed toward compliance rather than quality improvement.
- Overcoming perceptions of “policing” the OR
To ensure compliance with health codes and Joint Commission guidelines, IPC teams may be required to oversee policies perceived as outdated or arbitrary. If the implementation fails to promote partnership and practicality, anesthesiologists may view IPC teams as “enforcers” rather than collaborators in patient safety.
Experience at Harborview Medical Center
Harborview Medical Center is an academic safety net hospital affiliated with the University of Washington. It is the only level 1 trauma center for a five-state region of the U.S. Pacific Northwest. Providing emergency care for a diverse population at a county hospital during the pandemic has posed challenges to maintaining robust infection prevention practices.
Prior to the pandemic, we engaged in quality improvement initiatives on hand hygiene and academic collaboration on enhanced recovery and surgical site infection (Spine 2019;44:959-66; Spine 2021;46:143-51). Anesthesiology residents also initiated a multidisciplinary effort to improve the timing of prophylactic vancomycin administration. These successes were built on transparent data sharing and commitments from leadership to fostering mutual respect.
When the first U.S. case of COVID-19 was reported in the Seattle area, these relationships allowed us to adapt readily (Anesth Analg 2020;131:55-60). We published data on SARS-CoV-2 testing and nosocomial transmission that was used to guide our staffing and allocation of PPE (Clin Infect Dis 2021;72:323-6; Open Forum Infect Dis 2020;7:ofaa435). We developed “crash” protocols for quarantining physical materials from COVID-unknown cases until screening tests resulted. We established standing meetings between anesthesiology and IPC scheduled before/after OR hours. We jointly investigated perioperative outbreaks. We anticipated shortages of key ICU medications and instituted programs to conserve these. Even with this background, many aspects of communication and coordination were less than smooth but provided a basis to overcome and keep moving forward.
More recently, collaboration between anesthesiology and IPC teams has led to a redesign of our MRSA screening program to accommodate remote preoperative evaluation. We have also incorporated infection prevention into didactic programs for anesthesiology residents and critical care fellows.
- Identify a “point person”
Task an anesthesiologist and an infection preventionist as “point people” for their respective teams. These individuals can take responsibility for guiding communication on hand hygiene, surgical site infection, contact precautions, PPE, and screening.
- Maintain an ongoing project of mutual interest
Collaboration on quality improvement and research can help facilitate effective communication when challenges arise.
- Acknowledge the unknown
Acknowledge the inherent uncertainties between emerging science, practical experience, and official policy, and be willing to adapt as knowledge and circumstances change.
- Shift the conversation
Anesthesiology education in infection prevention often occurs in response to observations of poor hand hygiene, I.V. handling, or sterile procedure. Proactive education, woven into conferences and didactics, can improve the quality of this instruction.
- Share the responsibility
Shift some responsibility for perioperative infection prevention to surgery, anesthesiology, and nursing. Anesthesiologists can lend expertise in preoperative optimization, multidisciplinary partnerships, and defining meaningful process metrics. IPC can provide content expertise, administrative advocacy, and ensure regulatory compliance.
- Advancing professional partnerships
ASA should partner with the Society for Healthcare Epidemiology of America, the Infectious Disease Society of America, and the Surgical Infection Society to develop enduring relationships and programs that decrease infectious complications of surgery and improve patient outcomes