What’s New in the Patient Safety World

February 2019

Infection Prevention for Anesthesiologists



We’ve reminded our anesthesiology colleagues in a couple columns that they have a role in preventing surgical site infections (see our December 28, 2010 Patient Safety Tip of the Week “HAI’s: Looking In All The Wrong Places” and our August 2012 What's New in the Patient Safety World column “Anesthesiology and Surgical Infections”).


Now SHEA (Society for Healthcare Epidemiology of America) has just published an expert guidance on “Infection prevention in the operating room anesthesia work area” (Munoz-Price 2018)


The recommendations for hand hygiene are that it should be performed, at a minimum:

·       before aseptic tasks (eg, inserting central venous catheters, inserting arterial catheters, drawing medications, spiking IV bags)

·       after removing gloves

·       when hands are soiled or contaminated (eg, oropharyngeal secretions)

·       before touching the contents of the anesthesia cart

·       when entering and exiting the OR (even after removing gloves)


They also recommend anesthesia providers should consider wearing double gloves during airway management, remove the outer gloves immediately after airway manipulation, and remove the inner gloves and perform hand hygiene as soon as possible.


They recommend facilities locate alcohol-based hand rub (ABHR) dispensers at the entrances to ORs and near anesthesia providers inside the OR in order to promote frequent hand hygiene. Wearable ABHR dispensers with audible reminders increased the frequency of hand hygiene in several studies, as well as having the potential to decrease the incidence of HAI’s. They also stress the importance of delegating responsibility for filling of the ABHR dispensers to designated personnel and regularly ensure compliance with this practice.


They did not take a position on the question of whether applying ABHR’s over gloves that have been worn in a case is an acceptable alternative to removing the gloves, performing hand hygiene, and regloving with new sterile gloves (citing lack of evidence for or against).


They then had a series of recommendations regarding disinfection and/or sterilization of instruments and work areas:


Standard direct laryngoscope or video-laryngoscope reusable handles and blades should undergo high-level disinfection (at the minimum) or sterilization prior to use, or that reusable laryngoscopes are replaced with single-use standard direct laryngoscopes or video-laryngoscopes. Clean blades and handles should be stored in packaging appropriate for semicritical items designated for “high-level” disinfection.


High-touch surfaces on the anesthesia machine and anesthesia work area should

be cleaned and disinfected between OR uses with an EPA-approved hospital disinfectant that is compatible with the equipment and surfaces based on the manufacturers’ instruction for use. There should be prioritization of cleaning of the specific components

that are most likely to be contaminated. Monitoring equipment such as reusable blood pressure cuffs, pulse oximeter probes, electrocardiogram (ECG) leads, twitch monitor leads and sensors, and cables that are in physical contact with patients should receive high priority for thorough cleaning They note that single-use monitoring sensors may be useful for reducing the cleaning burden. The anesthesia machine work surface, gas flow controls, vaporizer dials, adjustable pressure limiting valve (APL), IV stands and fluid warmers, supply cart, and computer keyboard and mouse, are also examples of components that are particularly likely to be contaminated.


Then they make recommendation regarding IV’s, access ports, and other items related to vascular access and injection practices. Only disinfected ports should be used for intravenous access. Medication vials’ rubber stoppers and necks of ampules should be wiped with 70% alcohol prior to vial access and medication withdrawal. All central venous catheters (CVCs) and axillary and femoral arterial lines should be placed with full maximal sterile barrier precautions. Full maximal sterile barrier precautions include wearing mask, cap, sterile gown, and sterile gloves and using a large sterile drape during insertion. Peripheral arterial lines (eg, radial, brachial, or dorsalis pedis arterial lines) should be placed with a minimum of a cap, mask, sterile gloves, and a small sterile fenestrated drape.


IV drug injection recommendations include using syringes and vials for only one patient; and that injection ports and vial stoppers should only be accessed after disinfection. Any provider-prepared sterile injectable drugs should be used as soon as practicable following preparation. And the time between spiking IV bags and patient administration should be minimized.


After each case there should be cleaning and disinfection of computer keyboards and touchscreen computer monitors, using a hospital-approved disinfectant consistent with manufacturers’ recommendations. Cleaning and disinfection should also occur every

time there is obvious soiling or contamination of anesthesia work surfaces.


They also have recommendations for dealing with patients on contact isolation, including performing hand hygiene and using appropriate personal protective equipment (PPE), and performing environmental disinfection that follows recommendations regarding cleaning between cases, irrespective of an individual patient’s multidrugresistant organism status.


The recommendations also note the importance of leadership and champions and having goals to have an effective infection control program. They stress audit and feedback, particularly for hand hygiene practices.


The guidance was endorsed by the SHEA Board of Trustees, the American Academy of Anesthesiologist Assistants (AAAA), AANA, the Association for periOperative Registered Nurses (AORN), and APSF, with a letter of support from ASA.


There are a few things we would have liked to see in these guidelines as well. We still often see anesthesiologists (and other OR personnel) having lunch in the cafeteria wearing surgical “scrubs”. The guidance makes no mention about OR garb. Nor does it mention that OR garb should be laundered in the facility laundry, not taken home to be laundered. And it does not mention the role the anesthesia providers can play in limiting OR foot traffic and door opening, which are factors that can increase the risk of surgical infections. And perhaps some more comments about stethoscopes, given a recent article about widespread contamination of stethoscopes in ICU’s (Knecht 2018). And what about those everpresent cellphones?



Some of our other columns on handwashing and hand hygiene:



January 5, 2010           How’s Your Hand Hygiene?

December 28, 2010     HAI’s: Looking In All The Wrong Places

May 24, 2011              Hand Hygiene Resources

October 2011              Another Unintended Consequence of Hand Hygiene Device?

March 2012                 Smile…You’re on Candid Camera

August 2012               Anesthesiology and Surgical Infections

October 2013              HAI’s: Costs, WHO Hand Hygiene, etc.

November 18, 2014    Handwashing Fades at End of Shift, ?Smartwatch to the Rescue

January 20, 2015         He Didn’t Wash His Hands After What!

September 2015          APIC’s New Guide to Hand Hygiene Programs

November 2015          Hand Hygiene: Paradoxical Solution?

April 2016                   Nudge: An Example for Hand Hygiene

August 2016               Hand Hygiene: Who’s Watching? Does it Matter?

September 2016          More on Preventing HAI’s

July 18, 2017              Another Hazard from Alcohol-Based Hand Gels



Some of our prior columns on HAI’s (hospital-acquired infections):


December 28, 2010     HAI’s: Looking In All The Wrong Places

October 2013              HAI’s: Costs, WHO Hand Hygiene, etc.

February 2015             17% Fewer HAC’s: Progress or Propaganda?

April 2016                   HAI’s: Gaming the System?

September 2016          More on Preventing HAI’s

November 2018          Privacy Curtains Shared Rooms and HAI’s

December 2018           HAI Rates Drop

January 2019               Oral Decontamination Strategy Fails






Munoz-Price LS, Bowdle A, Johnston L, et al. Infection prevention in the operating room anesthesia work area. Infect Control Hosp Epidemiol 2018; Published online: 11 December 2018




Knecht VR, McGinniss JE, Shankar HM, et al. Molecular analysis of bacterial contamination on stethoscopes in an intensive care unit. Infect Control Hosp Epidemiol 2018; . published online December 12, 2018





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