Infection Control & Hospital Epidemiology


HH. Systematic reviews of studies conducted outside of the OR concluded that insufficient information exists to recommend the use of automated monitoring and feedback,89,90 although a study of personal, wearable ABHR dispensers that emitted an audible alarm 6 minutes after the previous activation of the dispensers reported a 27-fold increase in HH compared to standard fixed ABHR dispensers.6 An intermittent reminder to perform HH displayed on a video screen in the anesthesia work area increased the hourly frequency of HH by approximately 10-fold.91


What is the impact of providing measurement and feedback data on environmental disinfection?


Recommendation: Facilities should utilize measures to assess the appropriateness and adequacy of environmental disinfection, track the measures, and share the results with stakeholders to optimize adherence to recommended disinfection practices. Rationale: Measurement and feedback improve thoroughness of cleaning in inpatient settings54,92–100 via use of checklists of areas to clean,101 improvements to the cleaning methodology, including the cleanser used,97 and the use of visual indicators, such as ultraviolet visible markers93–97,99,100 and ATP biolumines- cence.54,97 A study that focused on cross contamination of the work area by anesthesia providers reported improvements in anesthesia providers’ adherence following engagement by coach- ing, as viewed through remote video observation.68 Multiple studies have demonstrated improved cleaning after sharing monitoring data with environmental service (EVS) staff, along with education, observation, and collaboration between infection prevention and EVS personnel.54,92–100 Some facilities improved adherence through capital investment in EVS, most often through the creation of a dedicated environmental disinfection team.94,97,100 The authors recognize that these short-term responses may


not be sustainable or generalizable to all contexts, and we did not identify studies that measured how feedback alone affects envir- onmental disinfection. Nonetheless, the literature suggests improvements to adherence derive from the belief among envir- onmental services personnel that adequate cleaning protects the health of patients and families, is expected, and is supported by the facility.102


Background Evidence for infectious sources in the anesthesia work area


A growing body of literature suggests that the anesthesia work area can become contaminated with pathogens.20,23–25,32,34,35,103 Hall32 confirmed the presence of blood contamination on 33% of surfaces that have direct contact with the patient (eg, blood pressure cuffs and pulse oximeter probes), and found that visual inspection of anesthesia work area surfaces was insensitive for detecting it. In 2001, Miller et al103 reported the presence of proteinaceous material, even after cleaning, on most laryngeal masks and laryngoscope blades. Maslyk et al20 identified a sig- nificant environmental bioburden with both commensal and pathogenic bacteria, including coagulase-negative Staphylococcus, Bacillus spp, Streptococcus, S. aureus, Acinetobacter and other gram-negative bacilli. With providers’ use of double gloves for airway management, contamination of the anesthesia work area decreased but was not eliminated.104 Fukada et al35 reported


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significant bacterial cross transmission. Loftus et al33 studied the impact of bacterial contamination of patients, providers’ hands, and the environment on stopcock contamination in the OR. Providers’ hands and, in particular, the surrounding environment, were important drivers of stopcock cross transmission, which was associated with increased patient 30-day mortality.105 In a subsequent study, Loftus et al34 demonstrated that bacterial transmission in the OR anesthesia work area was associated with 30-day postoperative infections, impacting as many as 16% of patients undergoing surgery. Loftus et al found anesthesia pro- vider hand contamination was a proximal source of both enter- ococcal and staphylococcal transmission in the anesthesia work area.23,25 Birnbach et al63 reported a high degree of fluorescent marker spread following simulated airway management, includ- ing fluorescence on the face of a mannequin, the IV hub, and the keyboard, highlighting the potential for bacterial cross- transmission during anesthesia care. A host of bacteria such as coagulase-negative staphylococci,


significant contamination of the computer keyboard in the OR with commensals and pathogens such as S. aureus and MRSA due to anesthesia provider HH practice. The intraoperative environment poses a threat for clinically


Bacillus spp, and MRSA inhabit the anesthesia work area, including computer touchscreens and keyboards.35 The anesthe- sia computer mouse is 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 key- boards, increase the risk of transmitting S. epidermidis from one surface to another.35 Additional areas of concern include semi- sealed parts of anesthesia equipment and areas not readily subject to cleaning procedures, where bacteria may chronically colonize surfaces and microbial growth may go undetected.61 Medications used in anesthesia practice can become con-


taminated during use and support the growth of microorganisms, including bacteria and fungi.106 Mahida et al107 assessed the fre- quency of bacterial contamination of intravenous fluids and medications used in a sample from 101 surgical procedures per- formed at a single center. Of 426 used medication syringes (median, 4 per case), 15% of syringe tips and 4% of syringe contents grew bacteria, predominantly low colony counts of skin organisms (coagulase-negative Staphylococcus spp, Micrococcus, and Kocuria). Contamination of syringe contents was sig- nificantly more common during emergency than elective surgical procedures (odds ratio, 4.50; P=.01), but the authors did not compare the frequency of medication administration or HH practices between emergency and elective procedures. As noted previously, Gargiulo et al29 found bacterial growth in 10 of 197 syringes (5%), 5 of 17 needles (35%), and 5 of 38 IV fluid bags (13%) into which medications were injected, and gram-positive bacteria were most commonly isolated. The investigators observed that HH was never performed before entry into the simulation center or before drawing up medications, and that the septa of medication vials and IV injection ports were never dis- infected with alcohol before they were used. They also observed nonsterile equipment, including stethoscopes and medical records, placed on top of uncapped, in-use medication syringes, but these researchers did not report the frequency with which it was observed. Although the literature search for this guidance did not identify a study that compares the impact of capping versus noncapping syringes used to administer multiple doses of medi- cation on the frequency of bacterial contamination in simulation


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