Infection Control Guidelines in the OR and Anesthesia Work Area

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Several unique elements of anesthesia practice were identified as problematic for infection prevention, including anesthesia machines, anesthesia carts and provider-prepared drugs and IV infusion bag.
Several unique elements of anesthesia practice were identified as problematic for infection prevention, including anesthesia machines, anesthesia carts and provider-prepared drugs and IV infusion bag.

A panel of current and past members of the Society for Healthcare Epidemiology of America (SHEA) Guidelines Committee has issued a guidance document to aid facilities in their review of anesthesia operating room policies. The guideline reflects the potential for clinically significant cross transmission in the intraoperative environment that poses a threat to patient safety and a growing body of literature that shows contamination in the anesthesia work area. The document was published in Infection Control & Hospital Epidemiology.

The guidance statement covered the areas of hand hygiene and environmental disinfection and implementation. It was based on survey results and included background evidence for each section.

Regarding hand hygiene, it was recommended that hand hygiene be performed according to the World Health Organization My 5 Moments for Hand Hygiene approach and that it be performed before all aseptic tasks, at the minimum. The statement also recommended that practitioners consider using double gloves during airway manipulations, with removal of the outer gloves immediately afterward. In addition, the placement of alcohol-based hand rub dispensers were recommended at the entrances to operating rooms and near anesthesia providers. These providers should also change gloves and perform hand hygiene between doffing and donning infection prevention equipment.

Recommendations for environmental disinfection included that standard direct laryngoscope or video-laryngoscope reusable handles and blades undergo high-level disinfection, at the minimum, or sterilization prior to use. Replacing reusable laryngoscopes with single-use standard direct laryngoscopes or video-laryngoscopes should be considered. In addition, clean blades and handles should be stored in packaging appropriate for semi-critical items designated for high-level disinfection. Between operating room use, the panel recommended that high-touch surfaces on anesthesia machines and anesthesia work areas be cleaned and disinfected with an Environmental Protection Agency-approved hospital disinfectant compatible with the equipment and surfaces; this recommendation extended to computer keyboards and touchscreen monitors.

Anesthesia providers are also advised to only use disinfected ports for intravenous access and to wipe medication vial rubber stoppers and the necks of ampules with 70% alcohol prior to vial access and medication withdrawal. Further, central venous catheters and axillary and femoral arterial lines should be placed with full maximal sterile barrier precautions. Syringes that are not actively being used should be capped with sterile caps between administrations, the accessible outer surfaces of the anesthesia supply cart should be wiped clean between cases, and provider-prepared sterile injectable drugs should be used as soon as practicable following preparation.

Finally, anesthesia providers should minimize time between spiking fluid bags and patient administration and single dose vials and flushes should be used whenever possible.

The panel recommended that implementation of their guidelines be aided by regular monitoring of infection control practices and that efforts be collaborative and include the input of frontline anesthesia personnel. They also suggested regular monitoring of hand hygiene performance, followed up with feedback.  Finally, the panel encouraged facilities to use measures that assess the appropriateness and adequacy of environmental disinfection and to track and share these measures and results with all stakeholders.

The panel acknowledged that survey responses were low, which limits the generalizability and may be an overestimation of adherence because respondents were more likely to be individuals interested in infection control practices.

Regardless of these limitations, and while acknowledging that the operating room is a uniquely challenging environment for implementing ideal infection control, the panel drew several conclusions: infection prevention and control policies specific to anesthesia care are not universal in healthcare facilities in the United States, audits are not routine, and not all anesthesia work areas are appropriately cleaned and disinfected between patients. Further, certain practices remain problematic; specifically, the use of multiple dose vials for more than one patient, less than 100% of medical providers using gloves for airway management, lack of hand hygiene after removing gloves, and entry into anesthesia cart drawers without hand hygiene.

Reference

Munoz-Price LS, Bowdle A, Johnston BL, et al. Infection prevention in the operating room anesthesia work area [published online December 11 2018]. Infect Control Hosp Epidemiol. doi:10.1017/ice.2018.303

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