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For decades, the field of hospital epidemiology has studied the transmission of infections within the health care setting. We know that the spread of organisms in hospitals occurs through the interactions of patients, health care providers, and their environments. Patients are colonized with organisms (both pathogenic and non-pathogenic) in their airways, gastrointestinal tracts, and on their skin. These organisms contaminate the hospital environment and patient equipment.1
Environmental contamination has two direct consequences: contaminating health care provider hands, and exposing the next patient admitted to the same area. Providers’ hands become contaminated not only after touching a patient, but also after touching contaminated surfaces in the patient’s environment (i.e., “patient zone”).2 Gloves do not reliably prevent hand contamination, as 13–29% of provider hands have been found to be contaminated after glove removal.3,4 Patients admitted to rooms previously occupied by patients colonized or infected with vancomycin-resistant Enterococci (VRE), methicillin-resistant Staphylococcus aureus (MRSA), or Clostridium difficile are at higher risk of acquiring these bacteria than other patients throughout the hospital.5 This evidence supports the premise that patient-to-patient transmission of organisms takes place through a contaminated environment. Further supporting this point is the finding that proper disinfection of the hospital environment is associated with decreased transmission of multidrug-resistant bacteria.6 Most of our knowledge of organism-based cross-transmission in the hospital environment comes from studies involving inpatient units, with operating rooms not as extensively studied. However, hand and environmental contamination has been shown to transmit S. aureus, Enterococcus spp., and Gram-negative bacilli in the operating room environment.7-9 Additionally, contamination of stopcocks by organisms present on patients, equipment, and provider hands has been linked to transmission during and between cases.10-12
From the hospital epidemiologist’s perspective, perioperative areas and specifically operating rooms, where the three necessary components for transmission (patients, environment, and health care providers), are in close proximity (Figure 1), create the ideal situation for cross-transmission of organisms. Operating rooms accommodate multiple patients each day, with numerous opportunities for environmental transmission. In the confined space of operating rooms, health care professionals touch patients, devices (e.g., intravenous hubs), environmental surfaces, and equipment at a high rate, and perform limited hand hygiene.13 Additionally, equipment and environmental disinfection in the operating room may not be sufficient.14
Contamination of operating room surfaces has been demonstrated both through environmental culturing15 and the use of fluorescent markers.14,16,17 These markers are transparent gels visible with ultraviolet light that can be wiped off with a moist cloth; their presence 24–48 hours following their application signify the absence of cleaning (at least once).14,17 Observational studies suggest that room cleaning across the country, both terminal and between cases, is suboptimal.14,17 In two separate studies, fluorescent markers were used to evaluate cleaning over a 24-hour period. More than half of marked surfaces had the markers still present, indicating inadequate cleaning.14, 17
The potential role of health care providers’ hands in contaminating the operating room environment was examined using a simulated operating room environment.16 Fluorescent gel was applied to the mouth of a human patient simulator before intubation and the simulator and operating room were evaluated after the encounter (Figure 2). More than half of forty areas evaluated were positive for the fluorescent marker in at least nine of ten simulations, thirteen of which were contaminated during all ten simulations.16
Equipment and environmental contamination may, in part, be due to facility design and operational factors that are not conducive to cleaning and disinfection between cases. Additionally, while hospitals closely monitor and track the turnaround time of operating rooms, they are less likely to measure the effectiveness of cleaning and disinfection.18,19 A possible association between shorter turnaround times to cleaning effectiveness and disease transmission deserves further study. From our perspective, turnaround times of less than 30 minutes20 (and even 60 minutes) are likely to make effective cleaning and disinfection extremely challenging, considering all the cluttered horizontal surfaces inside and on top of anesthesia carts and the convoluted surfaces of the anesthesia machine.
Disinfecting hands frequently enough to prevent transmission of organisms in the anesthesia work area can be challenging as well. Hand contamination opportunities are very frequent—averaging about 150 surface contacts per hour during induction, and 60 per hour during maintenance.13 Due to the nature of the work, performing hand hygiene according to World Health Organization (WHO) guidelines21 may be impractical, leading to infrequent hand hygiene performance despite numerous WHO-recommended opportunities for hand hygiene (before touching the patient, after touching the patient, after touching patient’s surroundings, after contact with bodily fluids, and before aseptic techniques).22 Making alcohol-based hand sanitizers more accessible has had mixed results. Placing dispensers on the anesthesia machine showed minimal improvement, while electronic reminders increased the rate of hand hygiene ten-fold.23,24 The use of portable alcohol-based hand sanitizers may significantly increase the frequency of hand disinfection and reduce contamination of stopcocks.25 While gloves might protect anesthesia professionals from contact with contaminated surfaces, they will not eliminate the contamination of patients or equipment.
Birnbach et al. noted that contamination was found 60% of the time on the operating room door handle, even though none of the health care providers had gloves on at the time of exit during a simulation exercise.16 This suggests the importance of not only glove replacement, but also of hand hygiene even when gloves are worn.
To address these challenges, the Society for Healthcare Epidemiology of America (SHEA) collaborated with the American Society of Anesthesiology (ASA), the Anesthesia Patient Safety Foundation (APSF), the Association of periOperative Registered Nurses (AORN), and the American Association of Nurse Anesthetists (AANA) to publish infection control guidance for the anesthesia work area.26 This guidance was designed to provide practical and evidence-based practices, with advice on how to implement them (Table 1). However, for these recommendations to be effective, anesthesia professionals need to change their behavior accordingly.
Table 1: Summary of Recommendations, SHEA Expert Guidance: Infection Prevention in the Anesthesia Work Area26
|Performed at the minimum:|
|• Before aseptic tasks|
|• After removing gloves|
|• When hands are soiled or contaminated|
|• Before touching anesthesia cart contents|
|• When entering and exiting the OR|
|Consider double gloves during airway management|
|• Remove outer gloves immediately after airway manipulation|
|• Remove inner gloves and perform hand hygiene as soon as possible|
|Locate alcohol-based hand rub dispensers at OR entrance and near anesthesia providers in the OR|
|Insufficient evidence for use of alcohol-based hand rub on gloves|
|• Changing gloves with hand hygiene between donning and doffing is preferred|
|• Standard direct laryngoscope and video-laryngoscope reusable handles and blades-complete high-level disinfection|
|• Consider replacement with single-use devices|
|Anesthesia machine and cart|
|• Insufficient evidence for disposable cover use|
|• Wipe accessible outer surfaces between cases|
|• Perform hand hygiene before opening and handling drawer contents|
|• Avoid storing supplies on top of cart|
|OR preparation between uses|
|• Clean and disinfect high-touch surfaces on the anesthesia machine and anesthesia work area between OR uses|
|• Only use disinfected ports for intravenous access|
|• Port disinfection|
|• Scrubbing with a sterile alcohol-based disinfectant immediately prior to each use|
|• Cover ports continuously with sterile isopropyl alcohol containing caps|
|• Disinfect before individual drug injection or at the beginning of a rapid succession of injections (e.g., anesthesia induction)|
|• Wipe rubber stopper and ampule neck with 70% alcohol prior to each access|
|• Use single-dose vials and flushes whenever possible|
|• Multi-dose vials should be used for 1 patient, use sterile needle and syringe for each entry|
|• Never reuse syringes or needles for another patient|
|Full barrier precautions|
|• Use of cap, sterile gown, mask, sterile gloves, and large sterile drape|
|• Use for insertion of all CVCs and femoral and axillary arterial catheters|
|• Recap if administering multiple doses to same patient from same syringe|
|Provider prepared sterile injectables|
|• Use as soon as practicable following preparation|
|Spiked IV bags|
|• Minimize the time between spiking and administration|
|Keyboards and touchscreens|
|• Clean and disinfect after each case|
|• Follow all institution-specific policies for hand hygiene, personal protective equipment, and environmental cleaning|
|• Conduct regular evaluation and monitoring of practice, hand hygiene, and environmental cleaning and disinfection|
|• Encourage collaboration of frontline providers and leadership|
|• Insufficient evidence to recommend technology-based monitoring|
As hospital epidemiologists, we call upon anesthesia professionals to acknowledge that transmission of organisms exists within hospitals, including operating rooms, and that change is needed in the anesthesia work area. We challenge you to help prevent organism transmission within operating rooms by improving your hand hygiene adherence, advocating better environmental and equipment disinfection, and identifying opportunities for anesthesia work area re-engineering that will facilitate disinfection and prevent cross-transmission. For example, hand hygiene is hindered by workflow and lack of easy availability of products.26 Engaging perioperative teams and human factors engineers to redesign workflows could better support proper hand hygiene. Similarly, engaging biomedical engineers to redesign equipment could both support hand hygiene and disinfection. We realize that some of the guidance recommendations26 may be dismissed as unrealistic, unreasonable, or unsubstantiated; however, patient-to-patient transmission of pathogens is an undeniable occurrence and needs to be addressed.
We and our infection prevention colleagues are often asked: so what? So what if patients are exposed to the organisms from previous patients? So what if hand hygiene is not performed? The answer is that the evidence shows these practices pose risks for bacterial transmission. The path to addressing these challenges has been established, and we in health care epidemiology stand ready to assist you. We look for leadership from within the operating room to seize the opportunity to prevent patient harm.
Joshua Schaffzin, MD, PhD, assistant professor of Clinical Pediatrics, Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
Lynn Johnston, MD, MSc, FRCPC, professor of Medicine, Division of Infectious Diseases, Department of Medicine, Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, NS.
Silvia Munoz-Price, MD, PhD, professor of Medicine, Division of Infectious Diseases, Department of Medicine, Froedtert and the Medical College of Wisconsin, Milwaukee, WI.
Drs. Schaffzin, Johnston, and Munoz-Price all served on the task force for the development of the SHEA Guidelines.
- Boyce JM, Havill NL, Otter JA, et al. Widespread environmental contamination associated with patients with diarrhea and methicillin-resistant Staphylococcus aureus colonization of the gastrointestinal tract. Infect Control Hosp Epidemiol. 2007;28:1142–1147.
- Bhalla A, Pultz NJ, Gries DM, et al. Acquisition of nosocomial pathogens on hands after contact with environmental surfaces near hospitalized patients. Infect Control Hosp Epidemiol. 2004;25:164–167.
- Olsen RJ, Lynch P, Coyle MB, et al. Examination gloves as barriers to hand contamination in clinical practice. JAMA. 1993;270:350–353.
- Tenorio AR, Badri SM, Sahgal NB, et al. Effectiveness of gloves in the prevention of hand carriage of vancomycin-resistant enterococcus species by health care workers after patient care. Clin Infect Dis. 2001;32:826–829.
- Huang SS, Datta R, Platt R. Risk of acquiring antibiotic-resistant bacteria from prior room occupants. Arch Intern Med. 2006;166:1945–1951.
- Donskey CJ. Does improving surface cleaning and disinfection reduce health care-associated infections? Am J Infect Control. 2013;41:S12–S19.
- Loftus RW, Brown JR, Patel HM, et al. Transmission dynamics of gram-negative bacterial pathogens in the anesthesia work area. Anesth Analg. 2015;120:819–826.
- Loftus RW, Koff MD, Brown JR, et al. The epidemiology of Staphylococcus aureus transmission in the anesthesia work area. Anesth Analg. 2015;120:807–818.
- Loftus RW, Koff MD, Brown JR, et al. The dynamics of Enterococcus transmission from bacterial reservoirs commonly encountered by anesthesia providers. Anesth Analg. 2015;120:827–836.
- Gargiulo DA, Mitchell SJ, Sheridan J, et al. Microbiological contamination of drugs during their administration for anesthesia in the operating Room. Anesthesiology. 2016;124:785–794.
- Loftus RW, Brown JR, Koff MD, et al. Multiple reservoirs contribute to intraoperative bacterial transmission. Anesth Analg. 2012;114:1236–1248.
- Mermel LA, Bert A, Chapin KC, et al. Intraoperative stopcock and manifold colonization of newly inserted peripheral intravenous catheters. Infect Control Hosp Epidemiol. 2014;35:1187–1189.
- Munoz-Price LS, Riley B, Banks S, et al. Frequency of interactions and hand disinfections among anesthesiologists while providing anesthesia care in the operating room: induction versus maintenance. Infect Control Hosp Epidemiol. 2014;35:1056–1059.
- Jefferson J, Whelan R, Dick B, et al. A novel technique for identifying opportunities to improve environmental hygiene in the operating room. AORN J. 2011;93:358–364.
- Loftus RW, Koff MD, Burchman CC, et al. Transmission of pathogenic bacterial organisms in the anesthesia work area. Anesthesiology. 2008;109:399–407.
- Birnbach DJ, Rosen LF, Fitzpatrick M, et al. The use of a novel technology to study dynamics of pathogen transmission in the operating room. Anesth Analg. 2015;120:844–847.
- Munoz-Price LS, Birnbach DJ, Lubarsky DA, et al. Decreasing operating room environmental pathogen contamination through improved cleaning practice. Infect Control Hosp Epidemiol. 2012;33:897–904.
- Rothstein DH, Raval MV. Operating room efficiency. Semi Pediatr Surg. 2018;27:79–85.
- Russ S, Arora S, Wharton R, et al. Measuring safety and efficiency in the operating room: development and validation of a metric for evaluating task execution in the operating room. J Am Coll Surg. 2013;216:472–481.
- Bhatt AS, Carlson GW, Deckers PJ. Improving operating room turnover time: a systems based approach. J Med Syst. 2014;38:148.
- World Health Organization. “WHO Guidelines on Hand Hygiene in Health Care.” World Health Organization 2009.
- Munoz-Price LS, Lubarsky DA, Arheart KL, et al. Interactions between anesthesiologists and the environment while providing anesthesia care in the operating room. Am J Infect Control. 2013;41:922–924.
- Munoz-Price LS, Patel Z, Banks S, et al. Randomized crossover study evaluating the effect of a hand sanitizer dispenser on the frequency of hand hygiene among anesthesiology staff in the operating room. Infect Control Hosp Epidemiol. 2014;35:717–720.
- Rodriguez-Aldrete D, Sivanesan E, Banks S, et al. Recurrent visual electronic hand hygiene reminders in the anesthesia work area. Infect Control Hosp Epidemiol. 2016;37:872–874.
- 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;110:978–985.
- Munoz-Price LS, Bowdle A, Johnston BL, et al. Infection prevention in the operating room anesthesia work area. Infect Control Hosp Epidemiol. 2019;40:1–17.