Author: Thomas Rosenthal
The Society for Healthcare Epidemiology of America (SHEA) released new expert guidance to improve infection control practices specific to OR anesthesia care that aims to help protect patients from nosocomial infections (Infect Control Hosp Epidemiol 2019:1-17).
The new SHEA expert guidance is needed because “infection prevention and control policies specific to anesthesia care in the OR are not universal” in U.S. health care facilities, wrote L. Silvia Munoz-Price, MD, PhD, an enterprise epidemiologist for Froedtert Hospital and the Medical College of Wisconsin, in Milwaukee, and the lead author of the expert guidance.
“The potential for clinically significant microbial cross transmission in the intraoperative environment poses a threat to patient safety,” Dr. Munoz-Price wrote in the guidance.
The guidance addresses hand hygiene environmental disinfection, implementation and environmental cleaning, with recommendations; and their rationale is discussed in detail.
“This represents a timely document which should be reviewed by all infection prevention personnel and anesthesia providers,” Charles E. Edmiston Jr., PhD, CIC, FIDSA, FSHEA, FAPIC, an emeritus professor of surgery at the Medical College of Wisconsin, and a nationally recognized expert on OR infection control, wrote in an email to Anesthesiology News. He was not part of the SHEA guidance panel.
“Hand hygiene is not performed frequently enough” by anesthesia providers, Dr. Munoz-Price wrote in an email to Anesthesiology News. “We know that the OR and especially the anesthesia equipment are touched with contaminated hands, and the equipment is poorly disinfected and not removed between cases.”
SHEA’s new expert guidance recommends that hand hygiene be performed, at the minimum, before aseptic tasks, such as inserting central venous catheters and arterial catheters; when drawing medications and spiking IV bags; every time gloves are removed and before touching the anesthesia cart; when going in and out of the OR; and when hands are contaminated, for example, with oropharyngeal secretions.
The guidance also recommends that providers consider double-gloving during airway management to reduce the risk for contamination in the OR and to remove their outer gloves immediately after airway manipulation. They should then remove the inner gloves and wash their hands or use hand sanitizer “as soon as possible” after that management.
Peter Papadakos, MD, a professor of anesthesiology in the Department of Anesthesiology and Perioperative Medicine at the University of Rochester Medical Center, in New York, who was not part of the SHEA panel, said the guidance is a very important paper for anesthesiology providers. “It clearly reinforces the importance of hand hygiene for providers. Use of gloves during airway management should always be done, both to protect the provider and patient from infectious risks.”
Alcohol Rub and Hand Hygiene
The SHEA panel also recommends that facilities locate alcohol-based hand rub (ABHR) dispensers at OR entrances and near anesthesia providers inside the OR. “There is actually evidence that personal, wearable gel with a built-in reminder function is an effective intervention,” T. Andrew Bowdle, MD, PhD, FASE, a professor of anesthesiology and pharmaceutics at the University of Washington, in Seattle, and a co-author of the expert guidance, wrote in an email to Anesthesiology News.
Dr. Edmiston said the guidance, citing a multisite clinical study (Anesthesiology 2009;110:978-985), suggests that wearable ABHR dispensers resulted in an eightfold increase in hand hygiene compliance compared with wall-mounted dispensers. “This is an important observation and one which is poorly appreciated by clinical providers and operating room leadership,” he said.
Dr. Edmiston also concurred with the guidance’s view that there are no data to validate the controversial practice of applying ABHR to gloves, “but as the author correctly points out, the frequency of required hand hygiene, and albeit poor compliance among anesthesia practitioners within the perioperative environment, does merit further study.”
The recommendations go beyond hand hygiene to address anesthesiology equipment and carts. “The anesthesia work area is not conducive to be cleaned and disinfected between cases,” Dr. Munoz-Price said. As a result, the anesthesia cart is a risk for cross-contamination, the panel wrote. “This area needs to be reengineered,” she said.
The panel highlighted the contamination of “the anesthesia medical work cart, stopcocks, laryngeal masks and laryngoscope blades, touchscreens, and keyboards, as well as on providers’ hands, resulting in transmissions, healthcare-associated infections, and increased risk of patient mortality.” The guidance also noted certain anesthesia provider practices remain problematic, particularly the use of multiple-dose vials for more than one patient.
While Dr. Papadakos noted that the guidance was one of the first papers to address decontamination of keyboards and screens of electronic devices, “it does not, however, address personal electronic devices carried by staff that may also be a nidus in the spread of infections.”
Standard direct laryngoscope and video laryngoscope reusable blades and handles should undergo, at a minimum, high-level disinfection or sterilization before use, the SHEA guidance recommends. Additionally, handles and blades should be kept in the packaging used for semi-critical products slated for high-level disinfection. The recommendations also suggest that reusable laryngoscopes could be replaced with single-use standard direct laryngoscopes or video laryngoscopes.
“The anesthesia supplies in their unbroken containers are externally contaminated by providers between cases and never removed/disposed in between,” Dr. Munoz-Price said. “We need to come up with new ways to store anesthesia supplies in the anesthesia area so that the supplies left behind are not contaminated. There are studies that show transmission of organisms from the first surgical case to the second surgical case by contaminated anesthesia machines. The guidance aims to bring these basic infection control concepts into the anesthesia work area.”
Anesthesia machine surfaces can be disinfected between cases and a cover or mechanical barrier employed to reduce the possibility of pathogenic transmission.
Dr. Bowdle said the use of open stopcocks should cease because they can become rapidly contaminated and a source of infection. “Only closed stopcocks should be used, and the closed injection ports can be covered with isopropyl alcohol–containing caps, sterilizing them within minutes and keeping them sterile until needed, at which time they are instantly available for use,” he said.
Upsetting the Anesthesia Cart
Dr. Papadakos added that the guidance stresses many commonsense things, such as not using multidose vials for multiple patients and cleaning the work area and machines between patients. “I like the concept of high-touch areas being the focus of cleaning.”
The recommendations go into considerable detail regarding the cleaning and covering of anesthesia equipment and supplies, particularly the anesthesia cart.
“The traditional anesthesia cart is usually intended to serve multiple patients throughout a day or even over a number of days,” Dr. Bowdle said. “Although we can ask providers to take off their gloves and gel their hands before touching the contents of cart drawers and bins, this is really very difficult for providers to remember to do, especially during a very busy case.”
Dr. Bowdle said there was promise in anesthesiologists using case packs, similar to the single patient case packs for surgical supplies, although this was not described in the guidance. “Currently, the case pack approach to supplies is not typically used in anesthesia practice, but I think we need to consider it and try it,” he said.
A survey sent in December 2016 to 130 SHEA Research Network members to collect data on infection prevention and control policies and practices among anesthesia providers in the OR setting had a response rate of 45%, Dr. Munoz-Price wrote in the guidance. Of the 59 health care epidemiologists who responded, 35.6% reported infection prevention and control policies specific to anesthesia practice in the OR at their institutions, she wrote.
“The response rate of the survey was very low, especially among anesthesia providers,” Dr. Munoz-Price told Anesthesiology News. “This is telling us that infection control interventions are not a priority for anesthesia providers. The few providers that answered the survey mentioned that infection control practices are not standardized and are not monitored regularly in their institutions.”
Dr. Edmiston noted that the authors of the guidance are not shy in pointing out the difficulty in implementing many of the recommendations. He suggested that there needs to be an anesthesia champion within the anesthesia department, similar to existing surgical champions, “who, in a collegial fashion, works with the infection prevention personnel and can effectively communicate to his peers the pathway to process improvement.”