Infection Control & Hospital Epidemiology


extensions were similar after 6 hours of incubation following removal at the end of procedures. Intraoperative stopcock contamination was associated with a lower hourly rate of HH compliance by anesthesia providers resulting in increased risk of 30-day mortality for patients but not with increased risk of postoperative HAIs. The article did not report the method and frequency of stopcock hub disinfection or medication injection practices. In a prospective study of same-day ambulatory surgery pro-


cedures, bacterial contamination rates of IV tubing stopcock extension sets were similar after 6 hours of incubation following removal at the end of procedures performed with (17.3%) and without (18.6%) administration of ethylenediaminetetraacetic acid (EDTA)–containing propofol anesthetic.106 Procedures with propofol anesthesia were longer (1–2 hours versus <1 hour) and associated with a greater number of administered medications and hub interactions than nonpropofol procedures. When IV extension set sampling was repeated after 24 hours and 48 hours hold time, presence of visible propofol in the dead spaces of stopcocks was associated with a significant increase in bacterial colony counts compared with the extension set with no visible propofol or sets with no use of propofol, suggesting that even preservative-containing propofol may promote bacterial growth in IV stopcock and tubing associated with prolonged durations of administration. The authors did not report compliance with stopcock injection port disinfection or provider intraopera- tive HH. In a prospective, single-blinded controlled trial at a single


center, Loftus et al119 randomized 592 ORs to use either con- ventional open stopcocks or conventional open stopcocks that were disinfected with an alcohol containing scrub device. Disin- fection of the open stopcocks significantly reduced bacterial contamination of the stopcock lumen (32% vs 41%; adjusted odds ratio, 0.703; P=.047); however, the rate of contamination was high in both groups. More than half the bacterial isolates iden- tified in stopcock lumens or aspirated lumen effluent were coagulase-negative staphylococci (52%), S. aureus (1%), Pseudo- monas aeruginosa (1%), and other gram-negative bacilli (1%). In another prospective, single-blinded controlled trial at the


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and anesthesia cart contact. In addition, providers were instructed to perform a single 15-second scrub with alcohol and 15-second drying time of the IV injection ports at the start of each case before attaching medication syringes to the series of 3-way stopcocks. All medications administered via this stopcock set were considered clean, although the study does not report pro- vider HH before medication administration. CLABSI rates decreased from a baseline of 14.1 per 100 trips from the ICU to 9.7 in year 1 and to zero in year 2. During this same period, hospital-wide CLABSI rates decreased from 3.5 to 2.2 per 1,000 device days, suggesting that other interventions outside of mod- ifications in anesthesia practice likely contributed to the observed reduction in CLABSI rates among ICU patients who received anesthesia care. Cole et al106 cultured stopcocks used for propofol and nonpropofol anesthesia. Bacteria were recovered from 26 of 150 propofol anesthesia stopcocks (17.3% ) and 28 of 150 non- propofol stopcocks (18.6%). As expected, mean bacterial colony counts were much higher at 24 hours for propofol stopcocks, whether or not propofol was visible (nonpropofol 95 colony- forming units [CFU]/mL, nonvisible propofol 418 CFU/mL, visible propofol 2,361 CFU/mL), suggesting that safe injection practices may not consistently occur.106


Environmental cleaning


same center, Loftus et al105 randomized 468 ORs and anesthesia providers to 1 of 3 medication injection schemes: (1) a closed stopcock device that was disinfected with 70% isopropyl alcohol before injection, (2) the same closed stopcock device not disin- fected before injection, and (3) usual practice with conventional open-lumen stopcocks. The port disinfection arm required the use of 70% alcohol for disinfection and 30 seconds drying between each injection, but the study did not control for the technique (scrubbing vs wiping) or alcohol source (pump dispenser vs pad). Following induction of anesthesia, the rate of bacterial contamination of the closed stopcock with alcohol disinfection was 0%, while the closed stopcock device with no disinfection before injection was 4%, and the open stopcock system was 3.2%, suggesting that the benefit of a closed stopcock device derives primarily from the ability to disin- fect the injection port prior to drug injection. In a quasi-experimental quality improvement project at a


pediatric teaching hospital, Martin et al68 assessed the impact of a bundle of interventions on reducing rates of CLABSI among patients that travelled out of the ICU for anesthesiology care in ORs or procedure areas. The intervention included recommen- dations and anesthesia provider education to limit touch con- tamination during airway management, peripheral IV insertion,


The bioburden of the anesthesia work area and potential cross- transmission dynamics pose a threat to patient safety. Practices for the cleaning, handling, and processing of anesthesia equip- ment have been published by the Association of erioperative Registered Nurses (AORN).120 Martin et al68 reported a sig- nificant reduction of CLABSIs by improving practices in the OR including HH, strategic gloving, and standardized cleaning of the anesthesia cart, IV pole, stopcock clamp, anesthesia machine, computer, monitor, knobs, surfaces, and laryngoscope handle). Clark et al121 trained a group of anesthesia providers to keep the anesthesia equipment cart clean, placed a placard on the cart top stating “clean hands only,” designated the surface of the anes- thesia machine for materials used during the case, and placed a separate container on the anesthesia machine for contaminated items. Known contaminated sites were wiped with an ammonium chloride-based wipe. After enacting these interventions, colony counts substantially declined on the adjustable pressure limiting valve, the oxygen control knob, the anesthetic agent control dial, and drawer pulls to the first and second drawers in the anesthesia equipment cart.121 Although several studies identified by the literature search demonstrated contamination of anesthesia equipment and workspaces, as well as possible transmission of a variety of microorganisms within the anesthesia environment, the search did not identify studies that evaluated the impact of equipment covers on the level of environmental contamination or on risk of patient infection. Maslyk et al20 swabbed anesthesia machine tabletops located in randomly selected ORs and detected Acinetobacter and other gram-negative bacilli, S. aureus, and coagulase-negative staphylococci, both before and after devices were used, despite routine cleaning. Baillie et al21 obtained swabs from surfaces of anesthetic and monitoring equipment that were not in contact with patients but were routinely touched by anesthesia providers during surgical procedures, including oxygen, nitrous oxide and air flow control knobs, vaporizer dials,


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