By Gary Evans, Medical Writer
(Editor’s note: The Society for Healthcare Epidemiology of America [SHEA] recently issued infection control guidance on anesthesiology procedures in the operating room, an area where infection control has historically been difficult to implement. SHEA also held the first in a planned series of webinars on implementing the guidance. Coverage of this important initiative will continue in upcoming issues.)
The infection control challenges in anesthetizing patients in the operating room include longstanding problems with hand hygiene, frequent contamination of surfaces and equipment, and a work culture that drives rapid turnover of the OR after procedures, SHEA reports in recently issued guidance.1
“We need to reset the metrics that are measured by our hospitals. Turnover time is important, but it is equally important to ensure that an operating room that is going to care for the next patient is cleaned and disinfected,” said Silvia Munoz-Price, MD, PhD, lead author of the guidelines and an infectious disease professor at the Medical College of Wisconsin in Milwaukee. Munoz-Price and other anesthesiology experts spoke at a recent SHEA webinar on the guidelines.
“It is unfair to our patients to place them in dirty operating rooms. Most people assume that it is a sterile environment, but it is not.”
In addition to the environmental contamination and cross-transmission concerns, anesthesiologists routinely work with needles, syringes, and multidose vials. There are many well-documented, recurrent outbreaks involving contaminated needles, syringes, and solutions. A 1995 survey of anesthesiologists really put this issue on the map, finding that a staggering 20% of respondents “reported frequently or always reusing syringes for more than one patient.”2
Since then, of course, awareness of injection safety has been raised considerably through such efforts as the Centers for Disease Control and Prevention’s (CDC’s) “One & Only Campaign.”
Nevertheless, the SHEA guidelines reiterate the importance of this issue, stating: “Single-dose medication vials and flushes should be used whenever possible. If multiple-dose medication vials must be used, they should be used for only one patient and should only be accessed with a new sterile syringe and new sterile needle for each entry. Syringes and needles are single patient devices and syringes should never be reused for another patient, even if the needle is changed.”
SHEA recommends using provider-prepared sterile injectable drugs “as soon as practicable” after they are prepared.
“The maximum allowable time prior to administration of provider prepared sterile injectable drugs has been controversial. It is currently under continuing discussion at a national level,” said Andrew Bowdle, MD, a co-author of the guidelines and an anesthesiologist at the University of Washington in Seattle.
If available, commercial prefilled syringes or syringes prepared by hospital pharmacy may provide a better option. “These have a longer shelf life than provider-prepared drugs, and institutions should consider that option when possible,” he added.
The threats to patient safety in anesthesia are compounded by prevailing attitudes that favor entrenched practices and discount the risk of infections. Convincing anesthesiologists “to take this seriously” is an ongoing challenge, said co-author of the guidelines David J. Birnbach, MD, of the American Society of Anesthesiologists. The demographic shift that is impacting healthcare in general is true for anesthesiology, as more nurse and physician clinicians are nearing retirement, he notes.
“They have worked through many years in an environment where no one thought about OR-related infections,” Birnbach said.
Connecting the Dots
As with many healthcare-associated infections (HAIs), it is exceedingly difficult to link lapses in the delivery of anesthesia in the OR with a subsequent patient infection. However, anesthesia-related infections comprise some unknown portion of the tens of thousands of post-surgical infections that occur annually, many of which are thought to be preventable.
The CDC reported a total of 14.2 million operative procedures were performed in U.S. hospitals in 2014.3 Extrapolating surveillance data from the CDC’s National Healthcare Safety Network sentinel hospitals shows that some 1.9% of those procedures — more than 250,000 people — could have post-surgical infections.
“It’s very hard to connect the dots and imagine that an infection that occurs two or three days after surgery was somehow due to contamination in the operating room,” Birnbach said. “So, part of our efforts going forward are educational and motivational. At every level, we have got to convince everyone working in the OR to take this seriously.”
In a January 2019 update, the CDC warns that “while advances have been made in infection control practices … surgical site infections (SSIs) remain a substantial cause of morbidity, prolonged hospitalization, and death. SSI is associated with a mortality rate of 3%, and 75% of SSI-associated deaths are directly attributable to the [infection]. SSI is the most costly HAI type, with an estimated annual cost of $3.3 billion.”3
The new SHEA guidelines warn of “clinically significant microbial cross transmission” in the operating theater. “A growing body of literature has shown contamination in the anesthesia work area, including 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 states.
Sue Dolan, RN, an infection preventionist at Children’s Hospital Colorado in Aurora, was asked by SHEA to provide expert review of the guidelines from an IP perspective. “Anesthesia workflows can sometimes vary from usual practices IPs may be familiar with in other departments,” Dolan tells Hospital Infection Control & Prevention. “IPs have historically not focused concerted efforts in this department due to [this] unfamiliarity.”
There can be a mix of anesthesia providers, some of whom may not be employees of the facility, making it more difficult to develop consistent and sustainable practices, adds Dolan, a past president of the Association for Professionals in Infection Control and Epidemiology.
Some anesthesia staff may be reluctant to change their well-established workflows, especially when it involves critical sequences in their care delivery to the patient, she says.
“The concern is it could contribute to other risks and errors if they change what is innate in their practice,” Dolan says.
One reason SHEA consulted Dolan is that she is something of a pioneer in this area, serving as lead author of a previously published paper to raise IP awareness of the infection control challenges in anesthesia.
While she researched the anesthesia infection control literature for her paper, Dolan says the SHEA document can really move this issue forward because anesthesiologists were among the group that wrote the guidance.
“That provides credibility in the eyes of anesthesia providers,” she says. “Having their societies involved in the creation of the document can make the acceptance of the guidance easier.”
That could open new lines of communication and collaboration between IPs and anesthesiology staff, particularly as the SHEA initiative continues with subsequent training and implementation advice.
“We have a lot to learn from each other, which will only make patient care safer,” Dolan says.
The guidelines try to establish some continuity between infection control practices on the floor and measures taken in the OR. For example, SHEA recommends that patients on contact isolation be treated accordingly in the OR.
“Anesthesia providers should follow all institution-specific guidelines when caring for patients on contact isolation in the OR, including performing hand hygiene (HH) and using appropriate personal protective equipment,” the guidelines recommend.
“Data demonstrate that microorganisms, including multidrug-resistant organisms, can be spread via anesthesia providers in the OR. Research has shown contaminated hands of anesthesia providers contaminate the anesthesia work area.”
Thus, infection control measures — including environmental disinfection — “outside of the OR also apply to providers in the OR environment,” SHEA emphasizes.
Monitoring and Feedback
SHEA recommends conducting regular monitoring and evaluation of infection prevention practices in anesthesia. “Systems for monitoring, evaluation, and feedback may improve practices, but there was insufficient evidence for SHEA to recommend a specific approach of, for example, automated, electronic, or video monitoring in OR,” the guidance states.
“There was not specific evidence [in that respect], but there is quite a bit of literature that surrounds safety, inpatient care, and OR care in general,” said co-author Joshua Schaffzin, MD, PhD, director of infection control and prevention at Children’s Hospital in Cincinnati. “A major theme that came out of this was that there were collaborative efforts among frontline employees and leadership.”
These collaborations helped facilitate evaluations and feedback, so that would seem to be a key aspect of any strategy chosen.
“A collaboration between all of the employees who work in the perioperative area has been shown to be very effective in moving safety and other infection control efforts forward,” Schaffzin said.
Regardless of the method, facilities providing feedback should avoid assigning blame in favor of a focus on improving adherence.
“Researchers have found that providers fail to adhere to infection prevention practices not out of malice or indifference but due to a complex combination of beliefs, work environment, technology, information load, and conditioning,” the SHEA guidelines state.
In addition to expert consultations and panels, the SHEA guidance was informed by surveys of healthcare epidemiologists and anesthesia society members. One of the results was that more than one-third of respondents did not have infection control policies and procedures specifically for anesthesia.
In addition, 41% of institutions did not provide feedback on hand hygiene compliance. Among the major barriers to hand hygiene compliance during anesthesiology were emergency situations, lack of time in general, and skin factors. Alcohol hand rubs often were not easily accessible, and some said the work culture did not support interruptions for recurrent hand hygiene.
Washing Eight ‘Hands’
“This is a very difficult area because the anesthesiologist at certain times in a case — especially induction — appears to be an octopus doing eight things simultaneously,” Birnbach said. “Some of these things involve moments that would ideally require hand hygiene.”
SHEA recommends that, at a minimum, hand hygiene be performed before aseptic tasks such as “inserting central venous catheters, inserting arterial catheters, drawing medications, [and] spiking IV bags.” In addition, hands should be disinfected after removing gloves, “before touching the contents of the anesthesia cart,” and when entering or leaving the OR.
Accomplishing this in the real world is exceedingly difficult, Birnbach notes.
“Imagine that the anesthetic is induced intravenously, the anesthesiologist grabs a laryngoscope, puts it in the patient’s mouth, and takes an endotracheal tube — clearly at this point both hands and some of the environment are contaminated,” he said.
This process continues as various anesthesiology equipment is touched, handled, and removed, leaving the OR field increasingly contaminated, Birnbach said.
Indeed, if held to the gold standard of the “WHO 5 Moments for Hand Hygiene,” anesthesia providers would have to be disinfecting hands as much as 54 times per hour, SHEA noted in the guidelines.
To assess the level of contamination that can occur, Birnbach and colleagues conducted a clinical simulation study using a mannequin. Unbeknownst to the study participants, a luminescent solution was placed in the dummy’s mouth to simulate microbial contamination. After anesthesiologists went through six minutes of simulated procedures, a black light revealed widespread contamination in the OR.
“All of this florescent dye managed to find itself in the operating room,” Birnbach said, showing slides of the contamination in the webinar. “The laryngoscope contaminated the top of the anesthesia cart, there is a thumbprint on the anesthesia operating dial, and, perhaps more scary, we had the contamination of the IV hub. There was contamination of the computer keypad as well.”
Clearly, hand hygiene must be performed frequently, and the SHEA guidelines cite studies that show increasing access to alcohol dispensers boosts compliance. Other studies suggest that “wearable” hand rub dispensers — some with electronic reminders — can increase adherence. Wearable dispensers in one study led to an eightfold increase in hand hygiene over the rate with wall-mounted units, but not all of these devices are currently commercially available, SHEA added.
“There doesn’t seem to be any reason why an anesthesiologist cannot have a dispenser or carry a small hand rub in their pocket — or even better [secure it to] their waist to [disinfect] at frequent intervals,” Birnbach said.
Given the handwashing challenges, some anesthesiologists are exploring the option of double gloving, with the outer glove serving as a sheath that can be removed to minimize contamination at a key point in anesthesiology induction. There also is interest in periodically disinfecting gloved hands with alcohol solutions during OR procedures.
The SHEA guidelines recommend that alcohol rubs be placed at the entrances to the OR and at key stations inside the room.
“We note in several of our observations that anesthesiologists can often enter the OR without using alcohol-based hand rubs, even if they are covering two or three operating rooms and go back and forth between them,” Birnbach said. “If we want to promote frequent hand hygiene, we’ve got to make it easy and readily accessible.”
Cleaning and Disinfecting
In the aftermath of this contamination, cleaning and disinfecting equipment is problematic given the complex machine design and time constraints — as little as 10 to 15 minutes — to turn over the OR.
The SHEA guidelines underscore that the equipment can become contaminated with a variety of pathogens, but there has been little thorough review of cleaning processes and practices.
The cleaning and disinfecting challenges are best appreciated firsthand, said Bowdle.
“I strongly encourage people to actually get into scrubs and go in there,” he said. “Take a close look at the front and back of anesthesia machines and carts. Put yourself in the place of somebody trying to clean these things. I think you will quickly grasp that these are decades-old designs that evolved in an era when we didn’t have an appreciation of the risk of transmitting infectious diseases.”
While redesign of some of this equipment may be the long-term solution, in the interim SHEA recommends focusing on cleaning the areas most likely to be contaminated.
“Monitoring equipment such as reusable blood pressure cuffs, pulse oximeter probes, electrocardiogram leads, twitch monitor leads and sensors, and cables that are in physical contact with patients should receive high priority for thorough cleaning,” the SHEA guidelines note.
Likewise, “the anesthesia machine work surface, gas flow controls, vaporizer dials, IV stands, fluid warmers, supply cart, and computer keyboard and mouse are all at risk of becoming contaminated,” SHEA warns.
Laryngoscopes, common devices used by anesthesiologists, are semicritical devices, and as such both the blades and the handles should undergo high-level disinfection or sterilization between use, Bowdle notes.
Reusable laryngoscopes — which often are used during intubation — typically require disassembly before disinfection, and there is increasing interest in single-use scopes.
“There are now a number of these products available that are relatively inexpensive and function as well or in some cases even better than reusable laryngoscopes,” he said. “In some cases, they are recyclable. When the cost of cleaning a reusable laryngoscope is taken into account, it turns out single use may actually have a lower cost. I think this is something that institutions should seriously consider.”
With regard to infection control during line insertion, SHEA recommends full maximal sterile barrier precautions for placement of central venous catheters, and axillary and femoral arterial line insertion.
“Tracheal line insertion should be performed using aseptic technique and a small drape,” Bowdle said. “Kits containing the necessary supplies for these procedures greatly facilitate proper technique. Most institutions now use central line placement kits to facilitate the application of this central line bundle, but I think it is important to recognize that arterial line placement kits, which are less frequently used, are also available.”
- Munoz-Price LS, Bowdle A, Johnston BL, et al. Infection prevention in the operating room anesthesia work area. Infect Control Hosp Epidem 2019;40(1):1-17 doi:10.1017/ice.2018.303.
- Tait AR, Tuttle DB. Preventing perioperative transmission of infection: a survey of anesthesiology practice. Anesth Analg. 1995;80(4):764-769.
- CDC. Surgical Site Infection (SSI) Event: January 2019. Available at: https://bit.ly/2rA9IwQ.