Anesthesia professionals have consistently been leaders in patient safety and have long recognized the importance of hand hygiene in the anesthesia workspace.1 Hand contamination is associated with pathogen transmission across multiple anesthesia workspace reservoirs, and genome analysis of bacteria cultured from provider hands and infection causing pathogens have confirmed that providers transmit pathogens that result in patient infections.2,3,4 Staphylococcus aureus (S. aureus) transmission among anesthesia workspace reservoirs is associated with an increased risk of surgical site infection (SSI).5 In fact, SSI risk increases over fivefold when the pathogens are sensitive to the prophylactic antibiotic employed and ninefold when the pathogens are resistant to the prophylactic antibiotic employed.6 In order to reduce this risk, a multifaceted approach is indicated to prevent SSIs.7 When improved hand hygiene is incorporated as part of a multifaceted program, substantial reductions in S. aureus transmission and SSIs can be achieved.8,9 These findings should provide the impetus for widespread improvements in hand hygiene compliance for all intraoperative personnel, with anesthesia professionals taking the lead.
The anesthesia workspace is a complex environment that includes the patient, the surgical bed/table, the anesthesia machine, the intravenous (IV) pole(s) with attached infusion devices, a cart with clean supplies, and medications stored within the cart or a separate medication station. Anesthesia professionals interact with the patient and multiple components of the anesthesia workspace during routine anesthesia practice.10,11 Given the complexity of this environment, hand decontamination is necessary to interrupt transmission events and reduce infection propagation. The World Health Organization (WHO) defines events, after which hand hygiene should be performed as the, “Five Moments of Hand Hygiene.”12 These moments that call for hand hygiene arethe following: before touching a patient, before a clean or sterile procedure, after touching a patient, after a task with a body-fluid exposure risk, and after touching the patient’s surroundings (Figure 1).12 Compliance with WHO and similar recommendations would require the anesthesia professional to perform hand hygiene as often as 54 times per hour13 up to 150 times per hour.11,13 However, studies reveal that anesthesia professionals perform hand hygiene less than once per hour.14 Clearly, there is substantial opportunity for some improvement. It might seem that fighting against the transmission of pathogens is impossible, given how ubiquitous bacteria are in our environment. However, research suggests that reducing the levels of S. aureus on provider hands to less than 100 colony-forming units (CFU) is an achievable goal that can help to protect our patients.9,15
The APSF Patient Safety Priorities Advocacy Group: Infectious Disease recommends that anesthesia professionals perform hand hygiene at least approximately eight times per hour during anesthesia care.16 Washing one’s hands or using hand sanitizer at a frequency of eight times per hour optimally reduced environmental and stopcock contamination and subsequent infection development.14 However, the proper methodology to prompt hand hygiene compliance at this frequency is not clear.16 Important future research include products (e.g., alcohol-based or soap and water), dispenser locations, cleansing technique, and potential risks.
While hands can be effectively decontaminated using alcohol-based solutions, visibly contaminated hands or potential contact with spore-forming organisms should be decontaminated with soap and water.14,17 Since scrub sinks must be outside the operating room, alcohol is the primary hand hygiene option for anesthesia professionals, and because it is associated with less skin irritation than soap and water, it may reduce the risk of irritated skin and higher bacterial counts on the irritated skin.18,19
Dispenser locations should be determined by task density, which is the number of tasks that need to be done in a period of time. Health care infection prevention organizations recommend dispenser placement in locations that are easily accessible within the patient care arena.20 Using dispensers placed outside the anesthesia work area (e.g., on the wall or near the entrance to the operating room) may disrupt patient care. The importance of task density is well-delineated. In one study, anesthesia professional use of a personalized, body-worn alcohol dispenser increased hand hygiene compliance 37-fold, and, in turn, reduced the incidence of environmental and stopcock contamination and health care associated infections.14 Other investigators evaluated dispenser placement on the intravenous pole to the left of the provider as part of a multifaceted program.8,9 Dispenser placement in this location reduced the incidence of bacterial transmission and subsequent SSI development.8,9
Because provider hand contamination is associated with environmental contamination, improving the frequency and quality of environmental cleaning may also help to augment hand hygiene improvement efforts. In one study, separating the anesthesia workspace into “clean” and “dirty” areas was associated with a reduction in the proportion of sites reaching ≥ 100 CFUs.14,21 It is intuitive that alcohol dispensers should be placed in areas designated as clean. For example, the dispenser may be secured to the anesthesia machine or supply cart with a mounting rack, or on the intravenous pole. If secured to the intravenous pole, then caution should be taken to protect the patient, surgical field, and underlying electrical plugs from splashes and drips (Table 1).
Table 1: Potential Considerations for Hand Sanitizer Locations in the Anesthesia Workspace.
While anesthesia professionals must have ready access to a hand sanitizer, there are potential hazards to consider. All alcohol-based sanitizers contain 60–80% ethyl or isopropyl alcohol and water. This is because a sufficient water component is necessary to hydrolyze microorganism membranes and slow evaporation of the product.22,23 Because alcohol products are flammable, fire codes regulate the total volume of sanitizers allowed within a procedure room and the minimum separation distance between alcohol dispensers. Dispensers must be separated by a minimum distance of four feet, and their combined volume in one room must not exceed 1.2 liters.24 The Centers for Disease Control and Prevention also espouses these fire safety recommendations.25 The volume for personalized, body-worn alcohol dispensers and one-handed alcohol pumps on an IV pole is less than 3 ounces.8,9,14 While there have not been reports of fires related to hand sanitizers, it is risk worth considering.
In summary, improved hand hygiene by anesthesia professionals is an essential element of a multifaceted approach to reducing bacterial transmission and infection development. Eight hand hygiene events per hour during routine anesthesia care should be encouraged. Alcohol-based sanitizers in the anesthesia workspace should be placed in clean and easily accessible locations that are clearly visualized by the clinician.
Jonathan E. Charnin, MD, FASA, Mayo Clinic, assistant professor of anesthesia, Department of Anesthesiology and Perioperative Medicine, Rochester, MN.
Brendan T. Wanta, MD, Mayo Clinic, assistant professor of anesthesia, Department of Anesthesiology and Perioperative Medicine, Rochester, MN.
Richard A. Beers, MD, professor emeritus at SUNY Upstate Medical University, Syracuse, NY.
Jonathan M. Tan, MD, MPH, MBI, FASA, assistant professor of clinical anesthesiology and spatial sciences, vice chair of analytics and clinical effectiveness, Department of Anesthesiology Critical Care Medicine, Children’s Hospital Los Angeles and University of Southern California, Los Angeles, CA.
Michelle Beam, DO, MBA, FASA, FACHE, anesthesiologist, Penn Medicine West Chester, West Chester, PA.
Sara McMannus, RN, BSN, MBA, Clinical Advisor at Sepsis Alliance
Desiree Chappell, MSNA, CRNA, VP Clinical Quality, NorthStar Anesthesia, Irving, TX.
Randy W. Loftus, MD, Mayo Clinic, associate professor of anesthesia, Department of Anesthesiology and Perioperative Medicine, Rochester, MN.
Jonathan Tan receives research grant funding from the Anesthesia Patient Safety Foundation, the Foundation for Anesthesia Education and Research (FAER), and the Southern California Environmental Health Sciences Center. He is a consultant for GE Healthcare and Edwards LifeSciences.
Desiree Chappell is on the Speakers Bureau for Medtronic and Edwards Life Sciences, Advisory Board for ProVation.
Randy Loftus reports current research funding by NIH R01 AI155752-01A1, “BASIC trial: Improving implementation of evidence-based approaches and surveillance to prevent bacterial transmission and infection” and has received funding from the Anesthesia Patient Safety Foundation, Sage Medical Inc., BBraun, Dräger, Surfacide, and Kenall, has one or more patents pending, and is a partner of RDB Bioinformatics, LLC, a company that owns OR PathTrac, and has spoken at educational meetings sponsored by Kenall and BBraun.
The other authors have no conflicts of interest.
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