Anesthesiologists numb to infection control

Cowboys’ may bring more than sleep

Anesthesiologists in hospitals with some of the best infection control programs in the country are reusing needles and contaminated multiple dose vials on multiple patients, according to survey results presented in Chicago at the annual meeting of the Society for Healthcare Epidemiology of America (SHEA).

"I think in many ways they are the cowboys of medicine," said Loreen Herwaldt, MD, hospital epidemiologist at the University of Iowa Hospitals and Clinics in Iowa City. "They practice behind a screen and they don’t get much feedback. They also don’t tend to follow patients over a period of time unless they are doing pain medicine."

Such practices have been long associated with outbreaks of bloodborne infections, including a report last year of transmission of hepatitis C virus to four patients undergoing general anesthesia.1 While the findings would have dismayed the SHEA audience in any case, they were particularly troubling because of the hospitals surveyed. The researchers surveyed anesthesiologists working at the seven national prevention "epicenter" hospitals that collaborate with the Centers for Disease Control and Prevention on infection control projects.1

"[We wanted] to determine whether reported practices at medical centers with very active infection control programs would be better than that described in the literature," Herwaldt explained.

It’s apparent enough that the presence of a top notch infection control program didn’t necessarily translate to infection control adherence by anesthesia providers (AP), but the web-based survey conducted by Herwaldt and colleagues still is being studied for its myriad implications. For example, it’s not clear whether the findings reflect an education gap, blatant disregard for established practices or some combination of the two.

"We really just skimmed the surface with this questionnaire," she said. "I think these findings are actually pretty consistent with what we found in the literature before, in terms of what anesthesia providers have reported. The thing that surprised me is that those were done in the ’80s and ’90s. We now have many more years of bloodborne pathogen training. We have had numerous outbreaks, and yet we still have pockets even in these big institutions where people haven’t gotten the message."

Indeed, it’s fair to say that APs historically have suffered under the perception that they could take — or mostly leave — the advice of ICPs. "Surveys from the 1980s and 1990s found that anesthesia providers often do not follow infection control measures," Herwaldt reported. "Anesthesia providers have reported reusing syringes, entering IV tubing and multidose vials without using aseptic techniques, using equipment from more than one patient without cleaning or disinfecting the items, recapping needles and not using protective barriers."

The scary part

The web-based survey netted 339 (32%) responses from 963 APs. "This is where it really starts to get scary," she said. "Thirty-one percent said they have used a used’ syringe or a needle in a multidose vial. If they used a used syringe or needle to enter a multidose vial, 84% said that they discarded the multidose vial after the case. But 9% — seven people — said they reused multidose vials that had been entered with a dirty syringe or a needle for another patient. Seven anesthesia providers admitted using one syringe to administer drugs to more than one patient, and 20 or 6% used three-way stopcocks and one-way valves when doing total IV anesthesia so that they could save the remaining drug for another patient."

There was disregard for personal as well as patient safety, as 69% of responding APs risk needlesticks by recapping needles. "Not surprisingly, 24% had a needlestick in the past year," she said. A little less than two-thirds of the APs injured reported the incidents, and of those, 26% received post-exposure prophylaxis to prevent HIV infection.

"There was no significant association between being a physician or a certified nurse anesthetist with respect to using multidose vials, using multidose vials for more than one patient, having had a needlestick, having reported a needlestick, [and] recapping needles," Herwaldt said. "However, [nurses] were two to 2½ times more likely than physicians to perform hand hygiene before patient contact in the operating room [and] before placing an IV in the operating room or another hospital setting. In contrast, physicians were more likely to enter a multidose vial with a used needle or syringe."

The self-reported hand hygiene practices were much better in contrast, with APs saying they always or frequently practiced hand hygiene before seeing patients (78%); after seeing patients (90%); when moving from a dirty to a clean site while caring for a patient (74%); after removing gloves (57%-60%); before placing an intravenous catheter (IVC; 61%); and before inserting an epidural or intrathecal catheter (72%). APs always or frequently changed gloves after every procedure (89%-92%) and when they were soiled (94%-98%), Herwaldt reported.

References

  1. Germain JM, Carbonne, A Thiers V et al. Patient-to-patient transmission of hepatitis C virus through the use of multidose vials during general anesthesia. Infect Control Hosp Epidemiol 2005; 26:789-792.
  2. Herwaldt LA, Schultz-Stubner S, Kuntz J, et al. Infection control practices among anesthesia providers (AP) in the 7 CDC prevention epicenter hospitals. Abstract 315. Society for Healthcare Epidemiology of America. Chicago; March 18-21, 2006.