Two patients come into a hospital for elective knee replacements. Their surgeries are uneventful, but both are found to have surgical site infections in follow-up visits. In the first patient, the anesthesia professional forgets to give antibiotics prior to the start of the procedure. The second patient gets pre-incision antibiotics, but the anesthesia professional uses an open stopcock for repeat medication injections during surgery. What role, if any, did the anesthesia professional play in the postoperative infection?
Fortunately, the first scenario is increasingly rare, due to heightened awareness and accountability stemming from national quality improvement projects, such as the Surgical Care Improvement Project that mandates administering indicated antibiotics within one hour of incision. The second scenario, however, is a common occurrence and highlights the challenges anesthesia professionals face as we seek to eliminate our role in health care-associated infections (HAIs). Although there have been significant decreases in HAIs over the past few years (46% decrease in central line-associated bloodstream infections and 19% decrease in surgical site infections1), an estimated 4% of inpatients are still affected by HAIs during their admission.2 HAIs are considered preventable and constitute serious safety and economic concerns, with an annual estimated cost between $28.4 and $33.8 billion.3 With recent changes in hospital reimbursement, treatment for many HAIs are no longer reimbursed and occurrences of HAIs may even invoke a financial penalty to the providers.4 This economic disincentive should stimulate clinicians and health care administrators to take an even more aggressive approach to preventing HAIs.
Anesthesia professionals can and should play an active role in the prevention of HAIs. While we have taken responsibility for timely administration of antibiotics and have reliably accomplished this goal, it is apparent that our role in preventing HAIs goes well beyond these measures. We are in frequent contact with the patient’s skin and mucosa and, more importantly, we repeatedly access the bloodstream while administering medications, fluids, and obtaining blood samples.5 Studies have found anesthesia professionals to have the lowest compliance with hand hygiene recommendations across all medical specialties,6 and that our hands are frequently contaminated with major bacterial pathogens even prior to patient contact.7 This contamination serves as a significant source of anesthesia work environment (AWE) and stopcock contamination.7,8 Recently, using bacterial phenotype and pulsed-field gel electrophoresis analysis, researchers from the Dartmouth group have shown that transmission of bacteria, including vancomycin-resistant enterococci, to IV stopcocks occurs frequently (32%) and early (< 5 minutes), and that higher levels of bacterial contamination are associated with higher rates of intravenous stopcock contamination, and possibly increased patient mortality (P=0.0395).8,9
Despite growing evidence that contaminated IV stopcocks can lead to HAIs, very few procedural changes have been implemented. There are several barriers towards reducing the contamination of the IV injection port that need to be overcome in order to reduce anesthesia-associated HAIs. First, the consequence of a contaminated injection port may not manifest itself until the patient develops a blood stream infection several days later, when they are no longer under our care. This delay, coupled with our inability to detect the culprit, makes it hard to obtain real-time feedback when the port has been contaminated. Thus, it is difficult for us to modify our behavior accordingly, whether at the time of contamination or generally in our protocols generating contamination. Second, in a typical general anesthesia procedure there are up to 60 opportunities for hand hygiene,10 even though the typical anesthesia provider performs hand hygiene less than once per hour during a procedure.11 During critical portions of anesthetic care, such as induction and emergence, the frequency of tasks performed makes it even harder to comply with hand hygiene recommendations. Not surprisingly, these 2 moments are associated with the highest rate of contamination of the AWE.12 Furthermore, unlike documenting antibiotic administration compliance, it would be nearly impossible to document every single opportunity for hand hygiene or scrubbing of the stopcock, making it hard to track and improve compliance of these decontamination efforts. We are therefore dependent on the habits of the individual provider, which leads to the last barrier—the culture of the practice. The collective habits of individuals working in the group shape the practice culture and these habits may be resistant to change. It typically requires more than one person to change a group’s practice, often coupled with efforts to enforce compliance with anesthesia infection reduction interventions.
Although the problem of addressing our potential role in HAIs is complex and challenging, it is possible to develop habits that can make a difference. One intervention to address hand hygiene involved placing hand-washing gels in easily accessible areas of the AWE, which in one study showed a 27-fold increase in hourly hand decontamination events leading to reduced bacterial transmission of stopcock sets, reduced AWE contamination, and ultimately reduced 30-day postoperative HAI.11 To decrease the contamination of IV injection ports, one hospital successfully implemented a medication manifold system that was kept away from the patient and only touched with clean hands after hand hygiene.13 This significantly reduced the incidence of blood stream infections in ICU patients who had traveled to the operating room for procedures from 14.1 per thousand trips to 0. Interventions intended to decrease contamination of the AWE include creating clearly demarcated areas for clean and contaminated items, defining work areas for “next case” preparation to minimize co-mingling current and future case supplies, defining policies on when unused items should be returned to storage, addressing the problem of keyboard/knob/drawer contamination, and working with anesthesia technicians to define best practices on cleaning the AWE between cases.14 Vendors can also play a role by designing equipment with contamination resistant materials and surfaces that are easy to clean. Still, more research is needed to address the “best” way to clean and prevent cross-contamination of the AWE. In order to sustain the practice changes associated with these interventions, leadership needs to be committed and provide resources, including frequent monitoring and feedback to the provider.
There is little doubt that the causes of surgical HAIs are numerous and involve many other health care professionals. Just because other professionals also contribute to HAIs does not mean that we should absolve ourselves of responsibility and resist additional rules and regulations governing anesthesia practice intended to reduce HAIs. The evidence suggests that anesthesia professionals contribute to the risk of HAIs in the perioperative setting and can play a role in reducing that risk. What is not clear are the best practices and technologies required to eliminate our role in HAIs. As the foremost organization on patient safety in the perioperative period, the Anesthesia Patient Safety Foundation should take the lead in tackling the barriers to eliminating the role of the anesthesia professional in HAIs through education, research, defining best practices, and aiding the appropriate organizations for implementation of policy.
Ian Yuan, MD Instructor of Anesthesiology and Critical Care Children’s Hospital of Philadelphia Perelman School of Medicine at the University of Pennsylvania Philadelphia, PA
Jeffrey M. Feldman, MD, MSE Professor of Clinical Anesthesiology and Critical Care Division Director, General Anesthesiology Children’s Hospital of Philadelphia Perelman School of Medicine at the University of Pennsylvania Philadelphia, PA
Disclosure of competing interest: The authors are not supported by, nor maintain any financial interest in, any commercial activity that may be associated with this article.
- National and State Healthcare Associated Infections Progress Report March 2015 CDC. HAIPR Executive Summary. 1–3 (2015). at <http://www.cdc.gov/hai/pdfs/progress-report/exec-summary-HAIPR.pdf> Last accessed: 12/30/15.
- Magill SS, Edwards JR, Bamberg W, et al. Multistate point-prevalence survey of health care–associated infections. N Engl J Med 2014;370:1198–208.
- Scott RD. The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention. Atlanta, GA: Centers for Disease Control and Prevention; 2009. http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf. Last accessed 12/30/15.
- Hospital-Acquired Conditions. https://www.cms.gov/medicare/medicare-fee-for-service-payment/hospitalacqcond/hospital-acquired_conditions.html. Last accessed 12/30/15.
- Shafer SL. Making a Difference in Perioperative Infection. Anesth Analg 2015;120:697–9.
- Pittet D, Simon A, Hugonnet S, Pessoa-Silva CL, Sauvan V, Perneger TV. Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med 2004;141:1–8.
- 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.
- Loftus RW, Koff MD, Birnbach DJ. The Dynamics and Implications of Bacterial Transmission Events Arising from the Anesthesia Work Area. Anesth Analg 2015;120:853–60.
- Loftus RW, Koff MD, Burchman CC, et al. Transmission of pathogenic bacterial organisms in the anesthesia work area. Anesthesiology 2008;109:399–407.
- Krediet AC, Kalkman CJ, Bonten MJ, Gigengack AC, Barach P. Hand-hygiene practices in the operating theatre: an observational study. Br J Anaesth 2011;107:553-558
- Koff M, Loftus R, Burchman C, et al. Reduction in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a novel device. Anesthesiology 2009;110:978.
- Rowlands J, Yeager MP, Beach M, Patel HM, Huysman BC, Loftus RW. Video observation to map hand contact and bacterial transmission in operating rooms. Am J Infect Control 2014;42:698–701.
- Martin LD, Rampersad SE, Geiduschek JM, Zerr DM, Weiss GK, Martin LD. Modification of anesthesia practice reduces catheter-associated bloodstream infections: a quality improvement initiative. Pediatric Anesthesia 2013;23:588–96.
- Prielipp RC, Brull SJ. If one is good, are two always better? Anesth Analg 2015;120:706–8