Infection Control & Hospital Epidemiology
institutions and all anesthesia providers. If respondents represent providers who are most interested in following infection pre- vention and control practices, these results likely overestimate adherence with infection prevention and control in the OR set- ting; nonetheless, some conclusions may be drawn:
1. Infection prevention and control policies specific to anesthesia care in the OR are not universal in US healthcare facilities.
2. Audits of infection prevention and control practices are not routine.
3. Not all anesthesia work areas are cleaned and disinfected between every patient, and the anesthesia cart is an item of risk for cross contamination.
4. Certain anesthesia provider practices remain problematic, especially the use of multiple-dose vials for >1 patient, <100% use of gloves for airway management, lack ofHHafter removing gloves, and entry into anesthesia cart drawers withoutHH.
The authors acknowledge that the OR is a challenging envir-
onment in which to affect ideal infection prevention and control practices, but we note the opportunity for improvement.
Guidance Statement Hand hygiene
Which activities in anesthesia care should always result in hand hygiene (HH)?
Recommendation:HHideally should be performed according to the WHO 5Moments for Hand Hygiene. The authors recommend that HHbe performed at theminimumbefore aseptic tasks (eg, inserting central venous catheters, inserting arterial catheters, drawing medi- cations, spiking IV bags); after removing gloves; when hands are soiled or contaminated (eg, oropharyngeal secretions); before touching the contents of the anesthesia cart; and when entering and exiting the OR (even after removing gloves). Rationale: Previous observational studies have reported that if the WHO 5 Moments for Hand Hygiene is used as the standard, the indications for HH among anesthesia providers in the OR can be as high as 54 per hour, leading to nonadherence rates of 83%.2 These findings have led some investigators to conclude that applying the WHO 5 Moments1 in the anesthesia work area, especially during induction, is logistically unfeasible.3 Muñoz- Price et al4 showed that increasing access to ABHR led to an increase in the number of times HH was performed by anesthe- siology staff during a surgical procedure.4 Another study suggests that wearable ABHR dispensers improve HH adherence among anesthesia providers.5 Koff et al6 showed that the use of a wear- able ABHR dispenser capable of recording HH events decreased the contamination rate of intravenous tubing in the operating room (OR). In a multisite randomized controlled trial, Koff et al7 also showed that providing wearable dispensers to anesthesia providers resulted in an 8-fold increase in the number of times HH was performed compared to rooms where only wall-mounted ABHR dispensers were available.
1WHO 5 Moments of Hand Hygiene: (1) before touching a patient; (2) before clean/
aseptic procedures; (3) after body fluid exposure/risk; (4) after touching a patient; and (5) after touching patient surroundings.
Should providers wear double gloves during airway management and discard the outer glove immediately after airway manipulation?
Recommendation: To reduce risk of contamination in the OR, providers should consider wearing double gloves during airway management and should remove the outer gloves immediately after airway manipulation. As soon as possible, providers should remove the inner gloves and perform HH. Rationale: Anesthesia providers’ hands may become con- taminated with upper-airway secretions while providing airway management and endotracheal intubation. Providers may not be able to perform HH during this time, and cross contamination of the anesthesia work area can occur. The literature search identi- fied 2 randomized trials and 1 anecdotal report related to the strategy of using double gloves to decrease contamination in the OR.8–10 The 2 trials found a significant decrease in OR con- tamination (P<.001) when double gloves were used during air- way manipulation and/or intubation and the outer layer was removed after intubation. Despite the significant decrease in contamination, it was not completely eliminated; therefore, anesthesia providers should remove the inner layer of gloves as soon as possible and perform HH. Although these investigations took place in a simulated OR with anesthesia residents, the authors believe that the results can be generalized to actual ORs in hospitals.
Where should facilities locate alcohol-based hand rub (ABHR) dispensers in the OR?
Recommendation: The authors recommend that facilities locate ABHR dispensers at the entrances to ORs and near anesthesia providers inside the OR in order to promote frequent HH. Several studies have demonstrated that wearable ABHR dispensers with audible reminders increase the frequency of HH as well as the potential to decrease the incidence of HAI. While the specific wearable devices used in these studies are not currently available, the authors recommend that facilities consider suitable wearable ABHR dispensers with automatic reminders when commercially available. ABHR dispensers should be located in accordance with applicable national and local fire safety standards and codes. Additionally, the authors recommend that the facility delegate the filling of the ABHR dispensers to designated personnel and reg- ularly ensure compliance with this practice. Rationale: Locating ABHR dispensers at entrances to ORs facil- itates the recommended practice of performing HH before entry and after exiting the room, and locating ABHR dispensers on the anesthesia machine has been associated with a modest increase in the frequency of HH.4 Researchers in one study found that the use of a wearable ABHR dispenser with an audible reminder resulted in a significant increase in HH and reduction in anes- thesia work area contamination, IV tubing contamination, and healthcare-associated infection6; however, a subsequent similar study found an increase in the rate of HH but no effect on the rate of healthcare-associated infection.7 A variety of local and national fire-prevention standards and
codes may restrict the placement of ABHR dispensers on top of the anesthesia machine. For example, the National Fire Protection Association (NFPA) 101: Life Safety Code11 stipulates the max- imum allowable volume of an individual ABHR dispenser to be 1.2 L and requires that dispensers be separated horizontally by at least 122cm (48 inches), and that dispensers be at least 2.5cm
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