10


settings or clinical anesthesia practice, this same group of inves- tigators found similar results in a follow-up study of actual patients in ORs.29 A 1999 outbreak of Serratia marcescens among 7 postoperative


patients was linked to a single anesthesiologist who drew up multiple propofol syringes at a time and did not use gloves for drawing up the syringes or for intubations.108 Behaviors cited during observations of other anesthesia personnel in this center included preparing multiple syringes of propofol at one time, using a single syringe for drawing up doses for different patients, using a single vial of propofol during a period of >6 hours and for more than a single patient, lack of compliance with glove usage, and failing to disinfect the rubber stopper of the medication vial before use. Hilliard et al109 investigated flip-top drug vials and confirmed


that the surface of the stopper of flip-top vials is frequently not sterile. Although this was an expected finding because stoppers of flip-top vials are not designed to be sterile and should be scrubbed with alcohol prior to access, in a survey of 878 anesthesiologists, 52% of respondents believed that the vial stoppers were sterile under the flip-top caps.109 A survey performed among anesthesia providers in New Zealand found that almost 80% of respondents said they rarely or never wiped the intravenous line injection port with alcohol before injection. Furthermore, 54% of anesthesia providers failed to wipe the multi-dose vial septum with alcohol before use.110


Evidence for Infection Prevention Measures in the Anesthesia Work Area


Hand hygiene


Epidemiology studies suggest that improved intraoperative HH is an important component of intraoperative infection prevention in the OR.111 The indications for the WHO 5 Moments include before and after direct contact with patients, after contact with body fluids or mucous membranes (eg, during endotracheal intubation), and after removal of gloves.112 Several studies have assessed opportunities for and compliance with the WHO 5 Moments recommendations during the provision of anesthesia care.2,113,114 Biddle et al2 performed an observational study of the HH of anesthesia providers using trained observers impersonat- ing nurses to quantify HH practices during anesthesia delivery while minimizing the potential for observer influence. The overall failure to perform HH for all providers was 82%. They found that during certain cases (eg, extensive blood loss, patients with par- ticularly challenging airway issues, periods of high task density such as complicated emergence from anesthesia, and others) HH indications according to WHO reached 54 per hour. Muñoz-Price et al found that anesthesia providers performed


only 13 HH events in 8 hours of observation. A subsequent study by Muñoz-Price et al reported that placing an ABHR dispenser on the anesthesia machine, in addition to standard wall-mounted dispensers, increased the rate of HH events from 0.5 to 0.8 events per hour (p=01.01).4 ABHRs are able to achieve a ~4-log (99.99%) reduction in microorganisms on providers’ hands after a single application.115 Petty5 suggests routine use of wearable ABHR dispenser to improve HH compliance among anesthesia staff. Koff et al6 studied wearable ABHR dispensers. During the control period, providers performed HH using either a wall- mounted ABHR dispenser within 3 steps of the anesthesia work area or an ABHR dispenser on the anesthesia cart, and observers


L. Silvia Munoz-Price et al


recorded the frequency of HH events. The intervention consisted of the use of personal, wearable ABHR dispensers with an audible reminder that alerted the provider if ABHR use had not occurred for 6 minutes. The personal, wearable device increased the fre- quency of ABHR use from 0.15 to 7.1 events per hour for attending physicians (P=.008) and from 0.38 to 8.7 events per hour for other providers (P=.002). The increase in HH was associated with reduction in contamination of the anesthesia work area and peripheral intravenous tubing. HAI rates decreased from 17.2% to 3.8% (P=.02). Notably, when the same group of investigators attempted to replicate their own results in a larger, multicenter study, use of the wearable dispensers was associated with an increased frequency of HH but not with a reduction in HAIs.7 Wearable dispensers were also associated with a reduction in ventilator-associated pneumonia in the ICU.116 Anesthesia providers in the OR are vulnerable to acquiring


transient pathogenic microorganisms from hand contact with excretions, saliva, blood, or urine of hospitalized patients, and becoming vectors to transmit these organisms to others by direct touch.3,8,117 Gloves currently represent the most common barrier to prevent contamination and colonization of providers’ hands during patient contact, but they require frequent changes during the anesthesia workday and HH after each removal. The ASA Recommendations for Infection Control for the


Practice of Anesthesiology, 3rd edition, explicitly state that gloves should be worn whenever in contact with blood, body fluids, mucous membranes, or nonintact skin, and that gloves are not intended for reuse because removal of microorganisms and integrity cannot be ensured.47 Any time gloves are contaminated they should be removed and appropriate HH performed. In addition, the AANA Guidelines state that gloves should not be used with >1 patient.46


Injection of intravenous drugs


Peripheral intravenous tubing stopcocks and injection ports that are used for medication administration frequently become con- taminated with bacteria during intraoperative use. Bacterial contamination was detected in >30% of intraluminal surface samples of stopcocks cultured at the end of general anesthesia cases,22,23 and included common skin contaminants (eg, coagulase-negative staphylococci, Micrococcus) as well as multidrug-resistant organisms (eg, MRSA, vancomycin-resistant enterococcus, Acinetobacter). Several potential reservoirs within the OR have been associated with intravenous tubing stopcock contamination. Anesthesia providers report low overall rates of compliance


with national recommended practices for injection port disin- fection. Only 20.9% of New Zealand anesthetists reported “always” or “frequently” wiping the IV line with alcohol before injection in the OR although 31.6% responded “never” to this question.110 Similarly, 40% of anesthesia service managers in Australia reported “never disinfecting” arterial line access ports with 70% alcohol or povidone iodine before use.118 In a prospective observational study of 548 adult patients undergoing surgery requiring general anesthesia, Loftus et al33 found that 23% of stopcock samples became contaminated intraoperatively. Stopcock contamination was more often attrib- uted to bacterial strains contaminating the anesthesia machine’s adjustable pressure-limiting valve than to strains on anesthesia providers’ hands or colonizing the patient’s nasopharynx and axilla. Bacterial contamination rates of IV tubing stopcock


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