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touchscreens and keyboards.35 Research has identified the anes- thesia computer mouse as one of the most contaminated surfaces in the OR, followed by the OR bed, nurse computer station mouse, the OR door, and the surfaces of the anesthesia medical work cart.36 Moist surfaces, such as damp gloves or computer keyboards, increase the risk of transmitting Staphylococcus epidermidis from one surface to another.61 Additional areas of concern include semi-sealed parts of anesthesia equipment, where bacteria may chronically colonize surfaces in areas not readily subject to cleaning procedures and where microbe growth may go undetected.61
What infection prevention and control modifications should be made, if any, for patients in contact isolation?
Recommendation: Anesthesia providers should follow all institution-specific guidelines when caring for patients on contact isolation in the OR, including performing HH and using appro- priate personal protective equipment (PPE). Environmental dis- infection should follow recommendations regarding cleaning between cases, irrespective of an individual patient’s multidrug- resistant organism status. Rationale: Data demonstrate that microorganisms, including multidrug-resistant organisms, can be spread via anesthesia providers in the OR. Research has shown contaminated hands of anesthesia providers contaminate the anesthesia work area, including the anesthesia machine, anesthesia cart, supplies on the cart, stopcocks and keyboards.23,34,62,63 In addition, up to 30% of organism transfer occurred between cases and was linked to an anesthesia work area that was not completely decontaminated with routine cleaning.34 The highest risk of contamination of the anesthesia work area occurs during induction and emergence of anesthesia.34,62 HH, contact precautions, and environmental dis- infection recommendations to decrease transmission of patho- genic organisms outside of the OR also apply to providers in the OR environment.
Implementation
Which techniques should be used to improve infection prevention practices by anesthesia providers?
Recommendation: Facilities should conduct regular monitoring and evaluation of infection prevention practices. To promote adherence, improvement efforts should be collaborative and should include input from frontline anesthesia personnel and local champions. Hospital and physician leadership should identify clear expectations and goals, should ensure data trans- parency, and should facilitate use of process measures to improve performance. Rationale: Although the authors did not identify studies that specifically addressed the efficacy of interventions to improve infection control among anesthesia providers, studies in anes- thesia and elsewhere can inform an approach to implementing and sustaining improvements. Improvement efforts should involve monitoring, evaluation,
and feedback. Timely collection, analysis, and provision of data to providers are important, but they can be cumbersome and time consuming because collecting adherence data most often involves human observers. Overt observation of behaviors can improve practice,64 but it may be subject to the Hawthorne effect, in which
L. Silvia Munoz-Price et al
the awareness of being observed changes one’s behavior.65,66 Covert observations have been successful using video observation of anesthesia practices67,68 and procedural technique.69 Video recordings allow evaluation during all shifts and in many areas without overextending observing staff.67 Healthcare worker volunteers52 and nonprovider volunteers70 have assessed HH practices on inpatient units. Facilities providing feedback should focus on ways to improve
can help focus educational activities.79 Interventions such as reminder cards or checklists have been utilized to improve adherence to transmission-based precautions,80,81 as has simula- tion for education and evaluation of different aspects of anes- thesia practice.29,82–84 A Children’s Hospital Association working group developed an evaluation tool for infection prevention in anesthesia practice. While not validated empirically, facilities may consider use of this tool to initiate discussions among anesthesia providers and infection preventionists to identify areas of importance and in need of improvement.77 Leadership support helps to define goals, remove barriers, and
hold practitioners accountable for their performance.85 One institution demonstrated sustained improvements in HH adher- ence following a ‘stand-down’ event following a HH summit attended by hospital leaders. This involved a hospital-wide 15- minute period when all nonessential activity was stopped, plans to improve HH were discussed, and written action plans were sub- mitted. Improvement efforts were supported by frequent covert observation and direct discussions of performance with institu- tional leaders.86 Although they are important to improving practices, institutions should be careful to not allow standards, monitoring, and incentives to have a negative effect on culture, learning, and interpersonal relationships.87
What is the impact of providing measurement and feedback data on HH?
Recommendation: Facilities should monitor providers’ HH per- formance and give them feedback as part of a comprehensive program to improve and maintain adherence. Insufficient data exist to recommend the routine use of automated, electronic, or video monitoring and feedback, although examples in the litera- ture demonstrate efficacy of such technology. Rationale: Facilities have used various types of monitoring and feedback to increase providers’ adherence to HH. Because of the expense and the likelihood that measuring HH adherence through direct observation only provides a small sample of pro- vider behavior, facilities’ interest in automated measurements has increased, including video surveillance88 and a variety of elec- tronic devices that detect and record providers’ use of ABHR, to include such features as delivering real time reminders to perform
adherence rather than place blame. Researchers have found that providers fail to adhere to infection prevention practices not out of malice or indifference but due to a complex combination of beliefs, work environment, technology, information load, and conditioning.71–75 Audit and feedback programs have been shown to be effective when designed using both theory and evidence.76 Institutions should be mindful that the hierarchical nature of team organization in the anesthesia work area could hinder honest communication and feedback.77 Fostering psychological safety and comfort in taking interpersonal risk may help work- place team learning and improvement.78 Clarity of expected behaviors in the context of a provider’s role
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