Infection Control & Hospital Epidemiology
fluorescent marker identified the hypothetical spread of material from the patient’s airway to the surrounding environment. Wearing double gloves and immediately discarding the outer gloves following airway management led to reduction in con- tamination of the environment. Contamination was further reduced when the laryngoscope was “sheathed” with an outer glove as it was removed.
Future Directions
The authors identified several unique elements of anesthesia practice that pose unsolved problems for infection prevention. These include the anesthesia machine, the anesthesia cart, and provider prepared drugs and IV infusion bags. Numerous challenges exist for thorough cleaning of the
anesthesia machine between cases. The anesthesia machine is a complicated apparatus with an irregular and complex external surface. Many anesthesia machines also have drawers to store supplies. Anesthesia machines were designed at a time when the importance of infection prevention in the anesthesia workplace was not well understood, and since then, the fundamental design has not changed greatly. The anesthesia machine may need to undergo fundamental redesign that allows for quick and effective cleaning of the external surfaces. The anesthesia supply cart presents similar challenges and
cleaning the anesthesia cart between cases can be extremely challenging depending upon the particular design of the cart. Anesthesia carts have many variations, which also can have a complex exterior surface due to attachment of electrical compo- nents such as a defibrillator or cardiac output monitor, sharps collection containers, waste bins, and discarded drug collection containers. Supplies and materials may be stored in cart drawers but also in bins on the top of the cart. Typical anesthesia carts contain supplies and materials intended to be used for numerous cases. Contamination of supplies can occur if providers do not remove soiled exam gloves and apply ABHR prior to obtaining supplies and materials from storage. Few examples exist of practices that have attempted to include the anesthesia cart in a “clean zone,” where only clean hands are allowed. Although some success has been documented with this approach, maintaining the desired provider behavior presents challenges. Anesthesia providers are frequently engaged in preparing
sterile drugs for injection by bolus and infusion. Provider pre- pared drugs are not prepared using the same stringent methods as pharmacies and commercial compounders, increasing the possi- bility for contamination. Because bacteria may multiply over time, common sense suggests that providers should commence administration of provider prepared drugs promptly; however, little evidence exists concerning the length of time that is safe. Minimizing the use of provider-prepared drugs by using drugs that are prepared in a pharmacy or by a commercial compounder is a possible or partial solution. Some of the recommendations provided in this guidance might need to be reinterpreted if a new version of USP 79728 is available (scheduled for release in late 2019). The authors encourage investment in research to better understand the infection prevention and control problems posed by the anesthesia work station and to develop design improve- ments that reduce the risk of infection.
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Acknowledgments. The authors thank Randall M. Clark, MD, Chair, American Society of Anesthesiologists (ASA) Section on Clinical Care, Den- ver, Colorado, for extensively reviewing and vetting the guidance, as well as review and feedback by ASA workgroup members: Lois A. Connolly, MD, Chair, ASA Committee on Quality Management and Departmental Admin- istration, Waukesha, Wisconsin; Elizabeth Rebello, MD, US Pharmacopeia Representative, ASA Committee on Quality Management and Departmental Administration, Houston, TX; Mary Ann Vann, MD, Chair, ASA Committee on Occupational Health, Medfield, MA; Richard A. Beers, MD, Advisory Group on Infectious Disease, ASA Committee on Occupational Health, Syr- acuse, NY; Matthew T. Popovich, PhD, Director of Quality and Regulatory Affairs, ASA, Washington, DC. The authors thank Charles Griffis, PhD, CRNA, Lynn Reede, DNP, MBA, CRNA, and Victoria Hledin, MPH, who reviewed the document on behalf of the American Association of Nurse Anesthetists (AANA). The authors thank Susan A. Dolan, RN, MS, CIC, Hospital Epidemiologist at the Children’s Hospital Colorado, Colorado Springs, Colorado, for serving as an expert reviewer of the guidance. The authors thank Valerie Deloney, MBA, for her organizational expertise and assistance in the development of this manuscript.
Financial support. This expert guidance was supported in part by the SHEA Research Network (SRN).
Conflicts of Interest. The following disclosures reflect what has been reported to SHEA. To provide thorough transparency, SHEA requires full disclosure of all relationships, regardless of relevancy to the guideline topic. Evaluation of such relationships as potential conflicts of interest is determined by a review process which includes assessment by the SHEA Guidelines Chair, the SHEA Conflict of Interest Committee, and may include the Board of Trustees and Editor of Infection Control and Hospital Epidemiology. The assessment of disclosed relationships for possible COI is based on the relative weight of the financial relationship (ie, monetary amount) and the relevance of the relationship (ie, the degree to which an association might reasonably be interpreted by an independent observer as related to the topic or recom- mendation of consideration). The reader of this guidance should be mindful of this when reviewing the list of disclosures. D.B. reports activity with APSF (Board of Directors) and Anesthesia and
Analgesia (A&A) Editorial Board. R.M. reports research grants/contracts with Medimmune, Johns Hopkins (lead in multicenter trial) HAI Among Surgical & ICU Patients. B.C. reports research grants/contracts with Pfizer, Merck, CDC, Preventing Hemodialysis Related BSI. E.P.D. reports research grants/ contracts with Tetraphase, A Phase 3 Randomized Double-Blind Double- Dummy Multicenter Prospective Study to Assess the Efficacy & Safety of Eravacycline vs Ertapenem in Intra-Abdominal Infections, advisory/ consultant roles with Merck, Baxter, Ortho-McNeil, Targanta, Schering- Plough, Astellas, CareFusion, Durata, Pfizer, Rib-X, institutional benefit with Exoxemis, UW letter to FDA supporting research proposal <$10,000, activities with SIS (Board Member), ICHE (Editorial Board), CDC/HICPAC (content expert for SSI guideline), SCIP. G.H.P. reports research grants/ contracts with UT, Decreasing Vancomycin Use in the NICU. B.L.J. reports research grants/contracts with Gilead Sciences Inc., A Multicenter Randomized Double-Blind Double-Dummy Phase 3 Study of the Safety & Efficacy of Ritonavir-Boosted Elvitegravir (EVG/r) vs. Raltegravir (RAL) Administered with a Background Regimen in HIV-1 Infected, Antiretroviral Treatment-expe, CHUM, The Canadian Cohort of Slow Progressors (HIV), Pfizer Canada, An International Multicenter Prospective Observational Study of the Safety of Maraviroc Used with Optimized Background Therapy in Treatment-experienced HIV-1 Infected Patients, Ottawa Hospital, A Randomized Control Clinical Trial of Micronutrient & Antioxidant Supplementation in Persons with Untreated HIV Infection, MAINTAIN Study CTN 238 & CTN 254: Inflammatory Markers Sub-Study, Canadian HIV Trials Network, VALIDATE, Capital Health Research FundFrailty in people living with HIV, PHAC CNISP: Surveillance for HA-CVC-BSI, CDI, PJI (hip & knee), VP shunt infection, MRSA, VRE, & CRE, and institutional benefit through Pfizer Canada, GSK, Sunovion Pharmaceuticals Canada (unrestricted
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