"No standard best practice exists specifically

for preventing cross-contamination in the anesthesia workspace." (p.551)

HH-142  Plemmons MM, Marcenaro J, Oermann MH, Thompson J, Vacchiano CA. Improving infection control practices of nurse anesthetists in the anesthesia workspace. Am J Infect Control. 2019;47(5):551-557. doi:10.1016/j.ajic.2018.12.009

A pragmatic approach

(Suggestions)

to reduce intra-operative contamination

of anesthetized patients may include:

Many of these interventions can be done by the individual anesthesia provider.

(Sanitizing intravenous caps requires institutional support.)

1. Minimize anesthesia work area contamination.

Keep anesthesia supply cart clean.

Divide work area into dirty and clean.

During critical task dense times like induction

Missed hand hygiene and contamination of anesthesia machine

may be unavoidable (designated dirty area).

Double glove for intubation

remove outer gloves after airway secured.

Breathing for patient and establishing airway is highest priority.

Control contamination from used laryngoscope equipment.

Have designated isolated dirty area.

"sheathing" dirty equipment in outer gloves may reduce contamination.

Sanitize (wipe down) dirty area after airway secured (patient is stable).

wipe down touched anesthesia parts (partial list):

adjustable pressure-relief value

anesthetic and medical gas control buttons

work surfaces

2. Perform traditional hand hygiene whenever time allows (especially)

alcohol-based hand rub (ABHR) after removing gloves.

Gel-in and Gel-out (ABHR).

Seeing patient in pre-op holding area.

Entering the operating room.

After Handoff in Recovery Room.

3. Protect the intravenous port.

Passive sanitizing caps.

Do not contaminate intravenous ports with unclean hands.

Double glove, for airway manipulation.

remove dirty outer layer prior to access intravenous port.

ABHR to gloved hands if not time for traditional hand hygiene.

(single patient use only)

This web page provides the reasoning and supporting evidence.

Epidemiological Triad of Infectious Disease

(ETID)

Infectious Agent

Susceptible Host

Environmental Source

When considering the ETID and the prevention of surgical site infections, it appears that the classic preventive measures within the anesthesia realm seem mostly targeted towards making the host less susceptible.  For example:

Pre-incision antibiotic prophylaxis

Normothermia

Glycemic control

But what happens when the infectious agent becomes highly transmissible and multi-drug resistant?  No longer will just making the host less susceptible be sufficient to protect patients from infections.  And this is the present and the future as bacteria develop resistance faster than new antibiotics can be developed. And these multi-drug resistance organisms develop and dwell in healthcare facilities.

Improved adherence to Surgical Care Improvement  Program (SCIP)

(including normothermia and timely administration of appropriate pre-incision antibiotics)

did not reduce surgical site infection rates (SSI).

HH-205 Hawn MT, Vick CC, Richman J, et al. Surgical site infection prevention: time to move beyond the surgical care improvement program. Ann Surg. 2011;254(3):494-501. doi:10.1097/SLA.0b013e31822c6929

This reference was cited in HH-113 Hopf HW. Bacterial reservoirs in the operating room. Anesth Analg. 2015;120(4):700-702. doi:10.1213/ANE.0000000000000247

Cross Contamination

Prevention

So far, we have considered host susceptibility and the infectious agent--specifically, making the host less susceptible.  But an increasingly dangerous infectious agent can overwhelm bolstered host defenses. This brings us to the third leg of the epidemiological triad of infectious disease:

Environment

How can we reduce the burden/load of pathogens in the environment?

How can we prevent the cross contamination in the operating room of the anesthetized patient?

Cross contamination can be from many potential sources including:

1. providers such as the anesthesia provider to the patient.
2. environment such as pathogen from prior patient that is still present in the environment.
3. even the patients own flora such as mouth pathogen contaminating patients intravenous port during an intubation followed by a medication sequence.

This interplay of host, pathogen, and environment is captured by

the chain of infection.

Loftus et al. 2023

"The impact of pathogen transfer and prophylactic antibiotic resistance on SSI development highlights the importance of preventing transmission in the first place to augment host optimization strategies such as antibiotic selection and timing of administration, temperature management, glucose control." (p.2)

HH-42 Loftus RW, Dexter F, Brown J. The importance of targeting intraoperative transmission of bacteria with antibiotic resistance and strain characteristics. Am J Infect Control. 2023;51(6):612-618. doi:10.1016/j.ajic.2022.07.024

Reducing intra-operative cross contamination:

A potential CMS QAPI project.

Quality Assessment and Performance Improvement (QAPI)

Code of Federal Regulations

Title 42

Chapter IV

Subchapter G

Section 482.21

Conditions of Participation (COP)

(Eligible for Medicare payment)

Hospital Quality Assessment and Performance Improvement

Brief Summary:

1. "Show measurable improvement in indicators for which there is evidence that it will improve health outcomes ..."

482.21(a)(1).

2. "Must use the data . . . to monitor effectiveness and . . . identify opportunity for improvement and changes. . . "

482.21(b)(2)

3. "Frequency and detail of data collection . . . specified by the hospital's governing body."

482.21(b)(3)

4. "Focus on high-risk, high-volume, or problem-prone areas"

482.21(c)(1)

5. "Must conduct performance improvement projects"

482.21(d)

6. "Must document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects."

482.21(d)(3)

Loftus et al. 2020

Bundle: (Not in priority order)

1. Vascular care with disinfecting 70% isopropyl alcohol caps.

2. Anesthesia machine disinfection after intubation and patient stabilized.

3. Improved hand hygiene.

4. Patient Decolonization.

Results:

236 patients: 106 intervention, 130 control

"Overall, 11 patients (4.7%) experienced surgical site infections, 10 (7.7%) in the control group and 1(0.9%) in the treatment group. Transmission was associated with an increased risk of surgical site infection (8 of 73 patients [11.0%] with transmission vs 3 of 163 [1.8%] without; risk ratio, 5.95; 95% CI, 1.62-21.86; P = .007). Treatment reduced the risk of surgical site infection (hazard ratio, 0.12; 95% CI, 0.02-0.92; P = .04)."

HH-44 Loftus RW, Dexter F, Goodheart MJ, et al. The Effect of Improving Basic Preventive Measures in the Perioperative Arena on Staphylococcus aureus Transmission and Surgical Site Infections: A Randomized Clinical Trial. JAMA Netw Open. 2020;3(3):e201934. Published 2020 Mar 2. doi:10.1001/jamanetworkopen.2020.1934

Dexter et al. 2023

Anesthesia Work Area Infection Control

Compared single interventions to bundle.

This is mostly another review of the data in HH-44 Loftus 2020 and lists risk factors for surgical site infection (SSI) for stratification and to consider monitoring for SSI for longer than 30 days post-operatively.

SSI risk factors included ASA status and duration of surgery.

HH-43 Dexter F, Brown JR, Wall RT, Loftus RW. The efficacy of multifaceted versus single anesthesia work area infection control measures and the importance of surgical site infection follow-up duration. J Clin Anesth. 2023;85:111043. doi:10.1016/j.jclinane.2022.111043

Wall et al. 2022

Bundle: (Not in priority order)

1. Vascular care with disinfecting 70% isopropyl alcohol caps.

2. Anesthesia machine disinfection after intubation and patient stabilized.

3. Improved hand hygiene.

801 surgical patients

Bundle decreased S. aureus transmission [24% before (85/357) to 9% after (42/444), IRR 0.39, 95% CI 0.28 to 0.56, P <.001].

Bundle decreased  90-day surgical site infections [8% before (29/360) and 3% after (15/444) (IRR 0.42, 95% CI 0.23 to 0.77, P =.005; adjusted for American Society of Anesthesiologists' physical status).

ASA physical status, sex, and surgical procedure were risk factors associated with SSI. (p.6)

Staphylococcus aureus transmission was used as a marker for cross-contamination. "Other pathogens besides S. aureus can cause SSIs. There was in fact a reduction in the overall bacterial inoculum. The reduction in S. aureus transmission was used as a marker for overall behavioral compliance with interventions." (p.8)

HH-36 Wall RT, Datta S, Dexter F, et al. Effectiveness and feasibility of an evidence-based intraoperative infection control program targeting improved basic measures: a post-implementation prospective case-cohort study. J Clin Anesth. 2022;77:110632. doi:10.1016/j.jclinane.2021.110632

Simmons et al. 2022

Proposed multi-modal peri-operative infection control bundle

HH-97 Simmons CG, Hennigan AW, Loyd JM, Loftus RW, Sharma A. Patient Safety in Anesthesia: Hand Hygiene and Perioperative Infection Control. Curr Anesthesiol Rep. 2022;12(4):493-500. doi:10.1007/s40140-022-00545-x 

Loftus 2016

Review article for bundle

Bundle: (Not in priority order)

1. Vascular care with disinfecting 70% isopropyl alcohol caps.

2. Anesthesia machine disinfection after intubation and patient stabilized.

3. Improved hand hygiene.

4. Patient Decolonization.

"Hyper transmissible, virulent, and antibiotic resistant bacterial strains have been identified in the operating room environment." (p.193)

"Transmitted bacterial pathogens isolated from intraoperative bacterial reservoirs were directly linked by pulsed-field gel-electrophoresis to 30% of 30-day postoperative infections, including bloodstream, respiratory, urinary tract and wound infection." (p.193)

HH-12 Loftus RW. Infection control in the operating room: is it more than a clean dish?. Curr Opin Anaesthesiol. 2016;29(2):192-197. doi:10.1097/ACO.0000000000000300

Loftus et al. 2015

HH-184 Loftus RW, Koff MD, Birnbach DJ. The dynamics and implications of bacterial transmission events arising from the anesthesia work area. Anesth Analg. 2015;120(4):853-860. doi:10.1213/ANE.0000000000000505

Sharma et al. 2020

HH-11 Sharma A, Fernandez PG, Rowlands JP, Koff MD, Loftus RW. Perioperative Infection Transmission: the Role of the Anesthesia Provider in Infection Control and Healthcare-Associated Infections. Curr Anesthesiol Rep. 2020;10(3):233-241. doi:10.1007/s40140-020-00403-8

Moureau and Flynn 2015 Literature Review

140 studies and 34 abstracts.

"Catheter associated infections are a significant safety issue, and contamination caused by lack of aseptic technique is preventable." (p.12)

"Colonization of catheter hubs and needleless connectors with subsequent bacterial ingress into the catheter lumen, is considered the cause of 50% of postinsertion catheter related infections." (p.2)

Review of Studies on p.11

"46 catheters received a 70% alcohol port protector with no detected CLABSI (central line associated bloodstream infection) over 707 catheter days."

"It was not until implementing the 70% alcohol disinfection cap that their rates of CLABSI fell to zero and remained from 2011 to the end of 2012.

Other reviewed study results:  after disinfection cap

CLABSI rates fell from 1.682/1000 catheter days (CD) to 0.6461 CD;

from 1.42 CD to 0.69 CD

from 2.3 CD to 0.3 CD

Moureau NL, Flynn J. Disinfection of Needleless Connector Hubs: Clinical Evidence Systematic Review. Nurs Res Pract. 2015;2015:796762. doi:10.1155/2015/796762. (HH-194)

SHEA Expert Guidance

Infection Prevention in the Operating Room

Anesthesia Work Area

Munoz-Price et al. 2019

 ". . . recommend that providers consider using isopropyl alcohol containing caps, which, when in place for the recommended period, make ports immediately available for use at all times." (p.5)

HH-140 Munoz-Price LS, Bowdle A, Johnston BL, et al. Infection prevention in the operating room anesthesia work area [published correction appears in Infect Control Hosp Epidemiol. 2019 Apr;40(4):500]. Infect Control Hosp Epidemiol. 2019;40(1):1-17. doi:10.1017/ice.2018.303



Duncan et al. 2018

Implementing disinfecting caps for all hospital patients was achieved nearly 90% compliance and  successfully decreased primary bloodstream infections due to peripheral intravenous lines (from 0.57 infections per 1000 patient-days preintervention to 0.11 infections per 1000 patient-days; p < 0.001). We confirmed that improving care for PIVs would decrease primary bloodstream infections associated with these devices." (p.15)

HH-207 Duncan M, Warden P, Bernatchez S, Morse D. A bundled approach to decrease the rate of primary bloodstream infections related to peripheral intravenous catheters. Journal of the Association for Vascular Access, 2018:23(1): 15-22. ISSN 1552-8855, https://doi.org/10.1016/j.java.2017.07.004. 

2. Anesthesia Work Area

Environmental Contamination Control

Clark et al. 2014

Intervention:  Educate to keep supply cart clean and anesthesia machine is designated dirty area. After contamination of anesthesia machine during task density such as induction and intubation, wipe down (disinfect) the anesthesia machine parts that were touched and contaminated.

Five sites on the anesthesia machine were cultured for contamination:

Adjustable pressure limiting valve

oxygen control knob

anesthetic agent control dial

Top two drawers on the anesthesia machine

Results: Intervention reduced the cases with colony counts per surface area (CPSS) > 100 from 46% to 12% (P = 0.001)

and reduced number of sites contaminated with > 100 CPSS from 15% to 3% ( P = 0.001)

HH-191 Clark C, Taenzer A, Charette K, Whitty M. Decreasing contamination of the anesthesia environment. Am J Infect Control. 2014;42(11):1223-1225. doi:10.1016/j.ajic.2014.07.016

Kampf and Lemmen 2017

"To date, three independent studies have shown that decontamination is at least as effective on gloved hands as on bare hands and that puncture rates are usually not higher after up to ten disinfections. . . . We conclude that disinfection of gloved hands by health care workers may substantially reduce the risk of transmission when gloves are indicated for the entire episode of patient care and when performed during multiple activities on the same patient." (p.3)

"Our review has found no evidence to indicate that disinfection of gloved hands is not safe, from the point of view of either efficacy of hand disinfection or the integrity of gloves being affected by decontamination procedures." (p.8)

HH-34 Kampf G, Lemmen S. Disinfection of gloved hands for multiple activities with indicated glove use on the same patient. J Hosp Infect. 2017;97(1):3-10. doi:10.1016/j.jhin.2017.06.021

Assadian et al. 2018

Researchers contaminated gloved hands with staphylococcus epidermis and then compared disinfected gloved hands to control and found that "non-disinfected, contaminated gloves transferred a mean of 5.18 log10 cfu S. epidermidis to the catheter valves. The disinfection of contaminated gloves reduced the number transferred by 4.4 log10 cfu to a mean of 0.78 log10 cfu; this reduction was statistically significant (P < 0.01)." (p.e58)

HH-64 Assadian O, Humphreys PN, Ousey KJ. Disinfection of artificially contaminated gloved hands reduces transmission of Staphylococcus epidermidis to catheter valves. J Hosp Infect. 2018;100(3):e57-e59. doi:10.1016/j.jhin.2018.03.010

Fehling et al. 2019

Studied the effect of allowing disinfection of gloved hands on the stem cell ward. "Hand hygiene compliance improved significantly from 50% to 76% (P < 0.001) when gloved hand disinfection was allowed. The biggest increase was for infection-prone procedures (WHO 2) from 31% to 65%;

P < 0.001. Severe infections decreased by trend (from 6.0 to 2.5 per 1000 patient-days) whereas transmission of multidrug-resistant organisms was not affected." (p.321)

HH-57 Fehling P, Hasenkamp J, Unkel S, et al. Effect of gloved hand disinfection on hand hygiene before infection-prone procedures on a stem cell ward. J Hosp Infect. 2019;103(3):321-327. doi:10.1016/j.jhin.2019.06.004

Birnbach et al. 2015

Wearing Double Gloves for Intubation

Remove outer gloves after intubation

In a six minute simulator exercise for intubation, wearing single gloves was compared to wearing double gloves for intubation. In the double glove group, the outer gloves were removed immediately after intubation. Anesthesia work area contamination with "single gloves versus those with double gloves was clinically and statistically significant. The number of sites that were contaminated in the operating room when the intubating resident wore single gloves was 20.3 ± 1.4 (mean ± SE); the number of contaminated sites when residents wore double gloves was 5.0 ± 0 .7 (P < 0.001)." (p.848)

"The average number of contaminated sites in the single-glove group was 4.1 times higher than the average in the double-glove group (99% confidence interval, 2.6–6.5). (p.849)

HH-98 Birnbach DJ, Rosen LF, Fitzpatrick M, Carling P, Arheart KL, Munoz-Price LS. Double gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the operating room. Anesth Analg. 2015;120(4):848-852. doi:10.1213/ANE.0000000000000230

" As half of postoperative S aureus surgical site infections have been linked by nucleotide variant analysis to S aureus isolates present in the OR at the time of the surgery, OR S aureus exposure is an important consideration. In this study, we found that nearly half off all observational units were exposed to S aureus despite the majority of cases involving orthopedic procedures with standardized decolonization practices. Therefore, infection control efforts extending beyond patient decolonization efforts are indicated." (p.1245)

HH-136 Robinson ADM, Dexter F, Renkor V, Reddy S, Loftus RW. Operating room PathTrac analysis of current intraoperative Staphylococcus aureus transmission dynamics. Am J Infect Control. 2019;47(10):1240-1247. doi:10.1016/j.ajic.2019.03.028

This study confirms "the importance of addressing the patient reservoir while at the same time highlighting the importance of hand hygiene and environmental decontamination for S aureus control." (p.813)

"Our data have led to the hypothesis that colonized patient skin surfaces serve as a major bacterial reservoir in the operative environment, one that often participates in vertical bacterial transmission leading to infection in the patient. Surprisingly, we have strong evidence suggesting that patient-derived strains were transmitted to subsequent patients who had procedures on the same day, again leading to HCAI development." (p.813)

"Future work should be directed toward improved screening and decolonization of patients entering the perioperative arena and improved intraoperative environmental cleaning to attenuate postoperative healthcare–associated infections." (p.870)

HH-39 Loftus RW, Koff MD, Brown JR, et al. The epidemiology of Staphylococcus aureus transmission in the anesthesia work area. Anesth Analg. 2015;120(4):807-818. doi:10.1213/ANE.0b013e3182a8c16a

1. Hand hygiene before preparing intravenous medications.

2. Decontaminate vial with alcohol wipe including vial access diaphragm before accessing medications.

Diaphragm is not always sterile under flip-top dust cover (HH-140)

Clean diaphragm after removing flip top

3. Hand hygiene before contact with patient or patient's IV ports.

4. Scrub the IV hub--e.g., 70% isopropyl alcohol for ten seconds followed by drying

or ideally, have port covered with passive sanitizing caps so always ready for immediate use.

(HH-140 p.5)

HH-140 Munoz-Price LS, Bowdle A, Johnston BL, et al. Infection prevention in the operating room anesthesia work area [published correction appears in Infect Control Hosp Epidemiol. 2019 Apr;40(4):500]. Infect Control Hosp Epidemiol. 2019;40(1):1-17. doi:10.1017/ice.2018.303