Healthcare-Associated Infections in Anesthesia



Healthcare-Associated Infections in Anesthesia


Joshua K. Schaffzin

L. Silvia Munoz-Price



INTRODUCTION

Dr. John Snow (1813-1858) is best known for his groundbreaking investigation to identify and mitigate the source of cholera outbreaks, the public Broad Street water pump, in London in 1853. Less known is that Snow’s primary specialty was anesthesia. His studies of the safe use of volatile agents helped the practice gain acceptance, and he administered chloroform analgesia to Queen Victoria for the birth of her eighth and ninth children.1

Infection prevention is often difficult to practice in the modern anesthesia work area. Both fields have evolved over time and produced innovations and advances to prevent patient harm. However, not all developments in anesthesia have addressed infection prevention, and similarly, many infection prevention processes do not take anesthesia into account. Significant advances in infection prevention, such as in prevention bundles, are meant to be implemented in a clinic or inpatient room setting. The World Health Organization’s (WHO) 5 moments of hand hygiene2 are difficult if not impossible to follow during anesthesia induction. As Dr. Snow did not combine his two areas of interest, so too have the respective fields not aligned practices effectively.

While numerous guidelines have been published on infection prevention in anesthesia practice,3,4,5,6,7 a lack of uniform knowledge and implementation of recommendations persists. In a recent survey of members of the American Academy of Anesthesiologist Assistants (AAAA), subsets of the American Association of Nurse Anesthetists (AANA), and the American Society of Anesthesiologists (ASA), only 87% of respondents reported always wearing gloves for airway management.8 In 2014, safe use of medication vials was the subject of a Joint Commission (TJC) Sentinel Event Alert9 after a Centers for Disease Control and Prevention (CDC) assessment of ambulatory surgery centers showed widespread deficiencies, including routine use of single-dose medication vials for multiple patients in 28% of facilities surveyed. Additionally, surveys of U.S. healthcare providers,10,11 New York State anesthesiologists,12 New Zealand anesthesiologists,13 and certified nurse anesthetist students14 reported improper practices despite knowledge of associated risks and existence of guidance. Despite widespread publicity, practice gaps likely persist. In the more recent survey referenced above, 92% reported always disposing of a needle or syringe between every patient, but only 43% reported never using multidose vials for more than 1 patient.8

This apparent disconnect has led some authors to conclude that attention to and redesign of the anesthesia work area, through collaboration between anesthesia and prevention professionals, is necessary to align the two practices. Notably, anesthesia professionals play a crucial role in surgical site infection (SSI) prevention, such as ensuring proper dosing and timing of antimicrobial prophylaxis and maintaining normoglycemia and normothermia,15 many of which carry a risk of disease transmission. This chapter reviews the evidence for pathogen transmission in the
operating room (OR) and anesthesia work area that can occur during delivery of preventive and other cares. The available evidence and current recommendations for preventing transmission are summarized.






FIGURE 34-1 Typical anesthesia process.


DISEASE TRANSMISSION IN THE ANESTHESIA WORK AREA


The Anesthesia Process

Infection prevention professionals may not be familiar with the routine processes their anesthesia colleagues follow. Prior to discussing modes of disease transmission, it may be helpful to review some of the terms and routines in a typical procedure involving general anesthesia. This description is not meant to be comprehensive, and much variation likely exists among contexts and providers.

The anesthesia work area is defined as the space occupied by the anesthesia machines and equipment and the portion of the patient where anesthesia is managed. In a typical OR, the anesthesia work area will be located along a wall to easily connect to electrical, data, and gas sources. There will be an anesthesia machine, which includes functions such as anesthetic delivery, oxygen delivery, and vitals monitoring. Close by will be the anesthesia cart, which will have drawers filled with equipment for airway management, intravenous (IV) catheter insertion and management, anesthetic gas delivery, and medications.16 The cart has a flat working space where equipment can be staged and medication prepared. There is often more space for equipment storage above the counter space. In order to provide airway management and intravenous medication delivery, the patient’s head and at least one upper extremity will be often used for anesthesia management. Depending on the procedure and patient, the location and setup of the anesthesia work area may vary.

Preparation of equipment and medications for a specific patient will often begin just prior to the patient’s arrival to the OR (a time point often denoted as “wheels in”). Once the patient arrives, preparation proceeds with positioning of the patient for the procedure and establishment of vascular access and monitoring. At this point, the patient is typically ready for anesthesia “induction,” which may involve any or all of preoxygenation, sedation, anesthetic delivery, muscle paralysis, and airway establishment (often through intubation). Once the patient is anesthetized and the airway is secure, they are termed “anesthesia ready,” and the surgical team can begin to prepare the site and commence with the operation. As the case progresses, the patient will require monitoring and pain and fluid management, known as anesthesia “maintenance.” As the operation nears completion, “emersion” can begin where the patient’s sedation is reversed and they are extubated. The patient then leaves the OR (“wheels out”), and room turnover (cleaning and disinfection) can begin. Once turnover is complete, setup for the next patient can commence, and the cycle restarts (Fig. 34-1).


Potential Sources of Disease Transmission

Portions of the typical anesthesia process pose substantial challenges to prevent disease transmission. During induction and emersion, the patient’s airway must often be secured while medications are given and other interventions performed. According to WHO guidelines, the exposure to patient secretions and the administration of medications should result in removal of gloves and performance of hand hygiene.2 However, the anesthesia professional cannot stop the process or release the patient in order to do so. Room turnover performed by environmental services staff typically involves cleaning of the surgical bed, floors, and walls, and waste removal, but not the anesthesia machine or cart. The responsibility therefore falls to anesthesia staff, who are pressured to be ready for the next patient and may not clean the machine adequately for fear of damaging the sensitive circuitry.

Not surprisingly, the potential for, as well as proven bacterial transmission have been demonstrated due to contamination of provider hands, the anesthesia machine, and the IV apparatus and stopcock.17,18,19,20,21,22,23,24,25,26 Finally, a lack of proper reprocessing of equipment needing high level disinfection or sterilization could potentially expose patients to pathogens.27 A sample of evidence supporting disease transmission in anesthesia practice is provided in Table 34-1.









TABLE 34-1 Evidence for Disease Transmission in the Anesthesia Work Area



















































































































Study


Year published


Setting/findings


Indirect Evidence


Environmental Contamination/Disinfection


Munoz-Price28


2012


Gram-negative bacillus recovery from OR surfaces


Biddle29


2016


Simulation tracking fluorescent dye placed in mannequin mouth


Birnbach22


2015


Simulation tracking fluorescent dye placed in mannequin mouth


Murrell30


2019


Reduction of SSI rate following installation of visible-light continuous disinfection system


Stopcock/Infusion System Contamination


Fukada31


2007


In vitro bacterial growth in intravenous medication and intravenous systems


Mermel26


2014


Bacterial contamination of catheter manifolds used during anesthesia


Koff25


2009


Bacterial contamination of intravenous tubing used during anesthesia


Gargiulo24


2016


Bacterial grown from syringes with remnant drug and filters used when injecting drug


Loftus23


2008


Bacterial contamination of stopcocks and catheter manifolds used during anesthesia


Loftus17


2012


Bacterial stopcock contamination, correlated with patient mortality


Direct Evidence


Transmission Demonstrated


Loftus20


2015


Bacterial transmission demonstrated comparing isolates from patient, provider hands, and anesthesia work environment


Loftus19


2015


Bacterial transmission demonstrated comparing isolates from patient, provider hands, and anesthesia work environment


Loftus18


2015


Bacterial transmission within and between cases demonstrated comparing isolates from patient, provider hands, and anesthesia work environment


Outbreaks


Rudnick32


1996


Bacteremia following open-heart surgery; bacterial contamination of pressure-monitoring equipment by use of disinfectant spray during end-of-day cleaning; ended when equipment was assembled immediately prior to use


Sack33


1970


Bacterial transmission during anesthesia; vial of medication used for multiple patients


CDC34


1990


Candida transmission in 4 states from intravenous infusion; use of same pump syringe for multiple patients


Veber35


1994


Bacteremia from contaminated medication vial used on multiple patients


Massari36


2001


Hepatitis C virus transmission during anesthesia for gynecologic surgery; vial reentry and use on multiple patients


CDC37


2008


Hepatitis C virus transmission during anesthesia for endoscopy; vial reentry and use on multiple patients


Samandari38


2005


Hepatitis B virus transmission in private physician office; poor separation of clean and dirty, multidose vial use


Germain39


2005


Hepatitis C virus transmission during general anesthesia; vial reentry and use on multiple patients


Lagging40


2002


Cardiac catheterization procedure; vial reentry, multidose vial saline used for flush on multiple patients


Wong41


2010


Bacterial infection following joint injection; vial reentry and use on multiple patients


Gutelius42


2010


Hepatitis B virus and hepatitis C virus transmission during anesthesia for endoscopy; vial reentry and use on multiple patients



INFECTION PREVENTION IN THE ANESTHESIA WORK AREA

Infection prevention in the anesthesia work area should focus on the sources of disease transmission (hand hygiene, environmental disinfection, and medication safety) and incorporate healthcare-associated infection (HAI) prevention efforts from outside the OR (such as prevention of SSIs, catheter-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and ventilator-associated respiratory infection (VARI) into routine practice) (Table 34-2).


Hand Hygiene

As described above, anesthesia professionals are challenged to follow the 5 moments of hand hygiene as defined in WHO guidelines.2 Unfortunately, this may have inadvertently made anesthesia professionals less likely to perform hand hygiene. Fewer than half of professionals surveyed reported always performing hand hygiene upon entry

to or upon exit from the OR. Only 58% and 61% reported always performing hand hygiene before and after patient contact, respectively.8 When using the WHO 5 moments to evaluate adherence, anesthesia professionals performed poorly, with ˜1% of opportunities during induction and 2% during maintenance, resulting in poor hand hygiene performance.43








TABLE 34-2 Summary of Recommendations, Society of Healthcare Epidemiology of America Expert Guidance: Infection Prevention in the Anesthesia Work Area8











Hand Hygiene


Performed at the minimum:




  • Before aseptic tasks



  • After removing gloves



  • When hands are soiled or contaminated



  • Before touching anesthesia cart contents



  • When entering and exiting the OR


Consider double gloves during airway management




  • Remove outer gloves immediately after airway manipulation



  • Remove inner gloves and perform hand hygiene as soon as possible


Locate alcohol-based hand rub dispensers at OR entrance and near anesthesia providers in the OR


Insufficient evidence for use of alcohol-based hand rub on gloves




  • Changing gloves with hand hygiene between donning and doffing is preferred


Environmental Disinfection


Laryngoscopes/video-laryngoscopes




  • Standard direct laryngoscope and video-laryngoscope reusable handles and blades—complete high-level disinfection



  • Consider replacement with single-use devices


Anesthesia machine and cart




  • Insufficient evidence for disposable cover use



  • Wipe accessible outer surfaces between cases



  • Perform hand hygiene before opening and handling drawer contents



  • Avoid storing supplies on top of cart


OR preparation between uses




  • Clean and disinfect high-touch surfaces on the anesthesia machine and anesthesia work area between OR uses


Injection ports




  • Only use disinfected ports for intravenous access



  • Port disinfection


    ○ Scrubbing with a sterile alcohol-based disinfectant immediately prior to each use


    ○ Cover ports continuously with sterile isopropyl alcohol containing caps


    ○ Disinfect before individual drug injection or at the beginning of a rapid succession of injections (eg, anesthesia induction)


Medication vials




  • Wipe rubber stopper and ampule neck with 70% alcohol prior to each access



  • Use single-dose vials and flushes whenever possible



  • Multidose vials should be used for 1 patient, use sterile needle and syringe for each entry



  • Never reuse syringes or needles for another patient


Full barrier precautions




  • Use of cap, sterile gown, mask, sterile gloves, and large sterile drape



  • Use for insertion of all CVCs and femoral and axillary arterial catheters


Needleless syringes




  • Recap if administering multiple doses to same patient from same syringe


Provider prepared sterile injectables




  • Use as soon as practicable following preparation


Spiked intravenous fluid bags




  • Minimize the time between spiking and administration


Keyboards and touchscreens




  • Clean and disinfect after each case


Contact isolation




  • Follow all institution-specific policies for hand hygiene, personal protective equipment, and environmental cleaning


Implementation




  • Conduct regular evaluation and monitoring of practice, hand hygiene, and environmental cleaning and disinfection



  • Encourage collaboration of frontline providers and leadership



  • Insufficient evidence to recommend technology-based monitoring


OR, operating room; CVC, central venous catheter.

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Jun 8, 2021 | Posted by in INFECTIOUS DISEASE | Comments Off on Healthcare-Associated Infections in Anesthesia

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