Progress on preventing surgical site infections (SSI’s) and other healthcare-associated infections (HAI’s) has been slow. But several new articles suggest maybe we’ve been looking in all the wrong places for solutions!
The January 2011 issue of Anesthesia & Analgesia has an article on the role of hand contamination of anesthesia providers as a risk factor for intraoperative bacterial transmission (Loftus 2011). Researchers at Dartmouth-Hitchcock did microbiological cultures of the IV stopcock set on the patient and of 2 sites on the anesthesia equipment from randomly selected OR cases (limited to first or second cases of the day) plus cultures from the hands of anesthesia providers. Overall, they identified bacterial transmission to the operative environment in 89% of cases and anesthesia providers were identified as the source in 12% of these cases. Transmission to the patient IV stopcock setup occurred in 11.5% of cases and anesthesia providers were identified as the origin in almost half (47%) those cases. Note that they were able to culture one or more pathogenic bacteria from 66% of provider hands before intraoperative patient care. Remarkably, this occurred despite 90% compliance with hand hygiene practices during the period of the study, suggesting that the effectiveness rather than the frequency of the hand hygiene techniques is of concern.
Other factors identified as independent predictors of environmental transmission included anesthesia provider supervising more than one room, first case of the day, patient age, and discharge to the ICU from the OR. The fact that anesthesia providers moving from one room to another may increase the rates of transmission certainly raises the likelihood that any healthcare worker moving from room to room may increase transmission rates. In some of our prior articles on the relationship between surgical duration and SSI rates (see our March 10, 2010 Patient Safety Tip of the Week “Prolonged Surgical Duration and Time Awareness” and our January 2010 What’s New in the Patient Safety World column “Operative Duration and Infection”), we have noted that OR traffic typically increases in longer duration cases. That likely increases the risk of bacterial transmission as well. As cases go on longer, foot traffic in and out of the OR increases, both as staff go on breaks or change shifts and as interruptions for questions, etc. begin to affect the surgeons and anesthesiologists. Long duration of surgery has long been known to be a factor associated with increased risk of surgical site infection and increased foot traffic may be one factor that increases the likelihood of surgical site infections (Lynch 2009).
The same group from Dartmouth-Hitchcock had previously demonstrated that such transmission was associated with increased patient mortality (Loftus 2008) and that use of a novel hand sanitation strategy dramatically reduced the intraoperative bacterial transmission and reduced healthcare-associated infections (Koff 2009). In the latter study, anesthesia providers were given a hand sanitation device to be worn and used in addition to the typical wall-mounted dispensers. Hourly hand decontamination events increased 27-fold. Contamination of the anesthesia work area and patient IV tubing dropped dramatically and HAI rate dropped to 3.8% compared to the 17.2% rate seen in controls.
An editorial accompanying the current article (Roy 2011) discusses the ubiquity of the bacterial “slime” we all carry and discusses documented cases of bacterial transmission from healthcare workers resulting in actual HAI’s for patients. It raises many interesting issues like “should all OR personnel routinely be cultured?” and “what would we do with the results?”. They also point out we should be developing better disinfecting protocols for not only our anesthesia equipment but for the host of other equipment and “toys” we bring into the OR (stethoscopes, computer keyboards, cell phones, iPads, iPods, pagers, personal bags, etc.).
A second editorial (Hollman 2011) notes that anesthesia providers currently participate in tasks designed to reduce SSI’s (eg. timely hanging of prophylactic antibiotics, maintenance of normothermia, etc.) but that SSI rates seem to have plateaued and we need better strategies to further reduce them. They call for improving the effectiveness of decontamination of the anesthesia work area and better hand hygiene practices. An editorial accompanying the Koff article (Hopf 2009) discusses the low rates for hand hygiene by anesthesiology providers in particular and some of the barriers that exist in the OR environment.
But surgical duration in the OR is not the only place to look when addressing SSI’s and HAI’s. A recent paper (Vogel 2010) showed that in-hospital delays in patients undergoing elective surgical procedures are associated with significant increases in infectious complications and mortality. Those delays also are associated with significant increases in hospital cost. The procedures looked at included elective colon resections, lung resections, and coronary artery bypasses. The association between preoperative delays and the infectious complications and mortality persisted even after adjustment for demographic factors and comorbidities. However, since the source of data was an administrative database, no information was available regarding the reason for delays, which obviously may have included other factors that predisposed to infections. Nevertheless, we know that the risk of complications of care and medical errors increases every day one is hospitalized. This study certainly suggests that hospitals should monitor and investigate cases where delays occur between admission and surgery for elective cases. It is certainly in their best interest from both a quality and patient safety perspective and a financial perspective. It should also serve as an alert to those surgeons who continue to say “I like to admit my patients a day before surgery”.
Lastly, a study (Alter 2011) found that patients treated with ALS (advanced life support) prior to hospitalization had higher rates of nosocomial infections than those who did not have ALS. Though this association may simply mean that patients who require ALS are sicker or otherwise more predisposed to nosocomial infections, it does highlight the need for further investigation of the prehospital environment as a potential contributory factor to nosocomial infections.
Collectively, these articles clearly show we must broaden our universe when we deal with nosocomial infections and thinking outside the box may provide us with some unexpected solutions to preventing them.
Loftus, RW, Muffly MK, Brown JR, et al. Hand Contamination of Anesthesia Providers Is an Important Risk Factor for Intraoperative Bacterial Transmission. Anesth Analg 2011; 112: 98-105
Lynch RJ, Englesbe MJ, Sturm L, et al. Measurement of Foot Traffic in the Operating Room: Implications for Infection Control. American Journal of Medical Quality 2009; 24: 45-52
Loftus RW, Koff, MD, Burchman CC, et al. Transmission of Pathogenic Bacterial Organisms in the Anesthesia Work Area. Anesthesiology 2008; 109(3): 399-407
Koff MD, Loftus RW, Burchman CC, et al. Reduction in Intraoperative Bacterial Contamination of Peripheral Intravenous Tubing Through the Use of a Novel Device. Anesthesiology 2009; 110(5): 978-985
Roy, RC, Brull SJ, Eichorn JH. Surgical Site Infections and the Anesthesia Professionals' Microbiome: We've All Been Slimed! Now What Are We Going to Do About It?
Anesth Analg January 2011 112:4-7
Hollmann MW, Roy RC. Antisepsis in the Time of Antibiotics: Following in the Footsteps of John Snow and Joseph Lister (editorial). Anesth Analg January 2011 112:1-3
Hopf HW, Rollins MD. Reducing Perioperative Infection Is as Simple as Washing Your Hands. Anesthesiology 2009; 110(5): 959-960
Vogel TR, Dombrovskiy VY, Lowry SF. In-Hospital Delay of Elective Surgery for High Volume Procedures: The Impact on Infectious Complications. Journal of the American College of Surgeons 2010; 211(6): 784-790
Alter SM, Merlin MA. Nosocomial and community-acquired infection rates of patients treated by prehospital advanced life support compared with other admitted patients. American Journal of Emergency Medicine 2011; 29: 57–64