Infection Control During Emergencies: Protecting the Patient

Michael Anderson, DNP, CRNA; Leslie Jeter, DNP, CRNA; Lynn Reede, DNP, CRNA; Marjorie Everson, PhD, CRNA; Charles Griffis, PhD, CRNA

Introduction

Medical EmergencyThe medical literature recommends that infection control interventions be conducted for any contact with a patient, every time a clinical interaction of any kind occurs.1 Anesthesia practice involves many “patient contacts,” which can be divided into two categories depending upon the clinical circumstances: “elective,” where activities can be accomplished with a relative flexible time requirement given the lack of acute patient safety needs; and “urgent/emergent,” where activities must be accomplished in the shortest time possible to prevent patient injury. Recommended Infection control activities can take critical minutes during emergency care.

Anesthesia professionals must prepare “stat rooms” (trauma rooms; heart rooms; delivery rooms) for urgent/emergent patient care. There is a need for advance preparation of these rooms with equipment and drugs to prevent patient death or injury in accordance with principles of emergency and critical medical care.2 In contrast, the infection control literature recommends that the drugs and equipment used in these rooms be prepared only at time of use.1,3

This leads us to questions such as: What can a responsible anesthesia professional do to protect patients in an urgent/emergent situation from infection? How can infection control be applied to the essential advance preparation necessary to prevent undue safety risks in settings that provide complex emergency care? Answers to these questions are difficult to determine. Infection control guidance documents from both the American Society of Anesthesiologists4 and American Association of Nurse Anesthetists5 state that providers must use clinical judgment to determine appropriate infection control actions in life-threatening situations, but little specific guidance is provided. This gap in the literature presents the anesthesia professional with a conundrum: how should infection control measures be rationally and acceptably altered during urgent/emergent care—to accomplish rapid intervention, yet prevent or decrease infection risk to patient and provider? In order to address these concerns, selected literature offering guidance on prevention of infection during anesthesia and clinical care were consulted and basic principles are summarized in Table 1.1-7

Table 1: Strategies for Maintaining Infection Control During Urgent/Emergent Care1-7

1. Plan ahead, anticipating emergency situations that will or might arise in each clinical situation, using anesthesia and critical care training to appropriately prioritize and plan for associated infection control practices.
2. During emergency care, prioritize life-protecting and sustaining interventions, but include infection control activities as permitted without significant delay thereby increasing risk of patient injury.
3. Ensure immediate availability of all infection control supplies—PPE, alcohol-containing IV port caps, sterile needles and syringes and angiocatheters and IV infusion sets, and alcohol-based hand rubs.
4. Keep uncontaminated supplies clean, covered (e.g., in the anesthesia cart) and segregated from contaminated materials until needed.
5. Keep all IV and arterial line ports covered with alcohol-containing IV port caps.
6. Keep syringes covered with sterile tip caps when not in use.
7. Keep prepackaged sterile saline syringes immediately available for drug dilution and flushes.
8. In emergencies, consider double-gloving, removing outer gloves as these become contaminated, and removing inner gloves followed by HH as soon as possible.
9. Consider asking a colleague to monitor and debrief after patient stabilization regarding infection control activities such as equipment contamination and patient exposure during emergency care.
10. Clean and disinfect the patient and environment as soon as the patient is stabilized.
11. If contamination and exposure to infectious pathogens is likely to have occurred, consult with the patient’s primary care provider and/or an infectious disease specialist for monitoring and follow-up as indicated in the setting of care.
12. Prepare stat rooms (e.g., trauma rooms) as close to the time of use as possible, label all supplies with date and time of preparation, assure all supplies are kept clean and covered as allowed by the resuscitation requirements of the anticipated situation. Devise department policies governing the protection, care, and length of time such supplies may remain unused before being discarded.

PPE= Personal Protective Equipment

Review of Basic Infection Control Practices

“Universal Precautions” refer to the basic set of infection control activities (ICA) that all health care providers should engage in during each patient contact. They include hand hygiene (HH), wearing clean non-sterile gloves, donning personal protective equipment (PPE) depending on the situation, applying transmission-based precautions as indicated, performing clinical care by assuring appropriate single-patient use of clean or sterile equipment and preparation of intravascular entry points with alcohol cleansing, and then carefully doffing contaminated equipment and performing HH again.1,8

“Safe injection practices” are recommendations based on numerous sources in the infection control literature.1,3-7 These include HH prior to and following any injections. Glass ampule necks and rubber diaphragms should be cleansed with alcohol prior to entry. One sterile syringe and one sterile needle should be used to prepare and administer each medication and then discarded. Injection materials are to be used for one patient only and discarded at end of care. Syringes should be kept capped, and intravenous ports covered with single-use alcohol-containing luer lock caps. Intravenous administration sets and solution bags should be used for one patient and assembled only at time of use.

Recommendations for airway infection control include wearing two pairs of non-sterile gloves (double gloving) prior to instrumentation, removing the outer gloves immediately prior to necessary respiratory support activities, and then removing inner gloves and completing HH as soon as the airway is secured.4,5,6 It is advised that no airway equipment should be opened before use; single-use disposable equipment is suggested. Reusable equipment must be decontaminated and packaged appropriately until use.4,5,6

The challenge during urgent/emergent care is the time required to perform ICA such as repeatedly donning and doffing gloves, HH prior to and following every patient contact, cleansing ports for injection, and so forth. So many of these activities arise during regular anesthesia care, that the time to performing these ICAs may prevent more timely intervention, resulting in adverse outcomes. For example, sudden, unexpected coughing or movement during surgery must be rapidly treated to prevent patient injury. Airway loss or compromise bleeding and hypotension must be dealt with immediately to prevent hypoxic damage to the brain and vital organs.2 Anesthesia care involves all of these urgent care situations and more, which require immediate action. To address this challenge, a common-sense approach is proposed to combine the principles of acute care and emergency medicine with recommended infection control actions. It is important to note that many of these infection control practices, with the exception of HH—are based on relatively low quality evidence. It is hoped that the resulting list of strategies will be useful to anesthesia professionals in meeting patient safety goals, and that the research community will test the efficacy of these recommendations in future investigations.

Infection control during urgent/emergent care may not conform perfectly to proposed recommendations, but with careful planning, anesthesia professionals have the requisite background to appropriately prioritize life-saving actions, and infection control should and can be incorporated into this care as we work toward the goal of ensuring patient survival and eliminating complications including infection.

 

Dr. Anderson is a staff CRNA, clinical assistant professor, and clinical coordinator of the Anesthesia Nursing Program at the University of Iowa.

Dr. Jeter is an instructor at the Nell Hodgson Woodruff School of Nursing, Emory University Nurse Anesthesia Program.

Dr. Reede is associate clinical professor with Northeastern University Bouvé College of Health Sciences, School of Nurse Anesthesia.

Dr. Everson is an anesthesia education consultant and has been a practicing CRNA in the Ochsner Health System, New Orleans, LA.

Dr. Griffis is assistant clinical professor, UCLA School of Nursing, and Clinical Instructor at the University of Southern California Program of Nurse Anesthesia.

References

  1. Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee. 2007 guidelines for isolation precautions: preventing transmission of infectious agents in healthcare settings. http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf Accessed March 20, 2019.
  2. Gondek S, Schroeder ME, Sarani, B. Assessment and resuscitation in trauma management. Surg Clin N Am. 2017;97:985–998.
  3. US Pharmacopeial Convention, Inc. General Chapter <797>: pharmaceutical compounding—sterile preparations. In: United States Pharmacopeia 38—national formulary 33. Rockville (MD): United States Pharmacopeial Convention, Inc. 2015:567–611.
  4. Recommendations for infection control for the practice of anesthesiology (third edition). American Society of Anesthesiologists, 2011. https://www.asahq.org › asahq › files › public › resources › asa-committees Accessed June 13, 2019.
  5. Infection prevention and control guidelines for anesthesia care. American Association of Nurse Anesthetists. Park Ridge, IL: AANA, 2015.
  6. Munoz-Price LS, Bowdle A, Johnston BL, et al. Infection prevention in the operating room anesthesia work area. SHEA Expert Guidance. Infection Control & Hospital Epidemiology. 2019;40:1-17.
  7. Dolan SA, Felizardo G, Patrick, M. APIC position paper: safe injection, infusion, and medication vial practices in health care. Amer J Infec Control. 2016;44:750–757.
  8. Perspectives in disease prevention and health promotion update: universal precautions for prevention of transmission of human immunodeficiency virus, Hepatitis B Virus, and other bloodborne pathogens in health-care settings. MMWR. 1988;37:377–388. Centers for Disease Control. https://www.cdc.gov/mmwr/preview/mmwrhtml/00000039.htm Accessed June 13, 2019.