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current practices, practical considerations, writing group opinion, and consideration of potential harm where applicable. No EG can anticipate all clinical situations, and this guidance
document is not meant to be a substitute for individual clinical judgment by qualified professionals.
Methods Document development
This expert guidance document follows the process outlined in the “Handbook for SHEA-Sponsored Guidelines and Expert Guidance Documents.”1 The topic was among those proposed and selected by the SHEA Guidelines Committee (GLC). The subsequent manuscript proposal developed by the GLC was approved by the SHEA Publications Committee and the SHEA Board of Trustees. The writing panel developed PICO-style (population, inter-
vention, control, and outcomes) questions based on themes identified by the panel. These questions were used in the devel- opment of search terms (medical subject heading [MeSH] and text word), and both the questions and search terms were voted on by the panel until unanimous approval was achieved. The writing panel identified the period from which articles would be collected as January 1, 1990, to June 30, 2016. Only English language articles were included. The lists of articles generated from the searches were reviewed by a primary reviewer and secondary reviewer for inclusion. For this topic, the authors conducted 2 surveys of the SHEA Research Network (SRN) and subsets of the American Association of Nurse Anesthetists (AANA), the American Society of Anesthesiologists (ASA), and the American Academy of Anesthesiologist Assistants (AAAA) membership. SHEA EGs are developed with a formalized process for
reaching expert consensus. Recommendations are listed with rationale statements that consider relevant evidence as well as the consensus of the group. Consensus around recommendations and rationale was determined via an anonymous comment period. For this EG, full consensus was achieved.
Review and endorsement
The document was reviewed and approved by the SHEA Guidelines Committee and the SHEA Publications Committee and was endorsed by the SHEA Board of Trustees, the AAAA, the AANA, the Association for periOperative Registered Nurses (AORN), and the Anesthesia Patient Safety Foundation (APSF). The ASA provided a letter of support with qualifications (Appendix 1).
Surveys
SHEA Research Network (SRN) In December 2016, a survey was sent to SHEA Research Network (SRN) members to gather information on infection prevention and control policies and practices for anesthesia providers in the OR setting. In total, 59 individual healthcare epidemiologists at their healthcare institutions responded (43 United States mem- bers and 16 international members) from the 130 invited to participate, for a response rate of 45.8%. The minority of SRN respondents (35.6%) reported having infection prevention and control policies specific to anesthesia
L. Silvia Munoz-Price et al
practice in the OR, with international respondents (10 of 16) more likely thanUSrespondents (11 of 43) tohave suchpolicies (P=.008). For respondents answering that there were no (n=35) or unknown (n=7) policies specific to anesthesia, 97.5%reported the expectation that anesthesia provider practice in the OR would be in compliance with institutional policies (supplementary Table 1). Only 3 respondents reported that their facility has a policy
that allows anesthesia providers to perform HH on gloved hands as an alternative to changing gloves followed by HH, and in one instance this was a written policy. Also 7 respondents answered that anesthesia providers are allowed to wear 2 sets of gloves during airway management and to remove the outer glove without performing additional HH, although in no instance was this a written policy. Among respondents who were aware of their facility’s practices, 34.9% and 21.6% of institutions routinely used single-use laryngoscopes or video- laryngoscopes, respectively. Generally, facilities audited anes- thesia providers’ infection prevention and control practices in the OR when there was a concern about practices (52.5%), although 13 respondents (22%) reported a monthly audit. Only 4 facilities (6.8%) never conducted audits (supplementary Table 2).
Survey to members of ASA, AANA, and AAAA The panel sent a survey focused on practices that providers follow while giving care in the OR setting to 3 groups of anesthesia providers in March 2017; 5,000 members of ASA; 5,000 members of AANA, and 1,761 members of the AAAA. We received responses from 396 physicians (8%; 113 in academic practice, 277 in private practice, 6 in training), 246 nurse anesthetists (5%; 236 certified, 10 in training), and 70 anesthesiologist assistants (4%; 56 certified, 14 in training). The majority had >10 years in practice (0–10 years, 27.3%; 11–30 years, 49.4%; >30 years, 23.3%). Two-thirds of respondents reported having infection prevention and control guidelines specific for anesthesia services in their institution (supplementary Table 3). Alcohol-based hand rub (ABHR) was generally readily avail-
able within the anesthesia work area (always or usually: 93.8%) and was located at entry points to every OR (always or usually, 92.3%). Respondents identified the following barriers to HH: lack of time in emergency situations (58.3%), lack of time in general (44.2%), skin factors (35.8%), HH equipment not easily accessible (27%), and lack of support from OR personnel for HH-related workflow interruptions (15.5%) (supplementary Table 4). Anesthesia providers identified several barrier precautions
used for inserting central lines: mask (94.4%), sterile gloves (93.8%), gown (88%), cap (91.6%), and full drape (79.2%). The practice was different for placing arterial lines, with providers using all barrier elements less frequently: masks, 82%; sterile gloves, 74.2%; gown, 10.9%; cap, 76.8%; full drape, 3.7%). Almost half did not use a drape (48.1%). Institutions provided feedback variably on their departments’
adherence to HH (never, 40.9%; every 6–12 months, 34.9%; quarterly, 24.2%) and other infection prevention and control practices and procedures (never, 42.3%; every 6–12 months, 36.8%; quarterly, 20.9%).
Discussion
Given the low response rate from anesthesia providers, it is difficult to determine how generalizable findings are to all
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