Episode #124 A Guide to Infection Prevention for Anesthesia Professionals, Part 2

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. Last week, we were broadcasting from the Anesthesia work area to start talking about infection prevention focusing on patient decolonization and hand hygiene. We are continuing the conversation today.

Before we dive into the episode today, we’d like to recognize Medtronic, a major corporate supporter of APSF. Medtronic has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Medtronic – we wouldn’t be able to do all that we do without you!”

Our featured article today is once again “A Best Practice for Anesthesia Work Area Infection Control Measures: What Are You Waiting For?” by Jonathan Charnin and colleagues. To follow along with us, head over to APSF.org and click on the newsletter heading. First one down is the current issue. Then, scroll down until you get to our featured article today.

We are going to do a quick quiz before we return to our featured article. What is the 8^th APSF Patient Safety Priority? Go ahead and just say it out loud. If you said Infectious Diseases, then you would be right. This includes emerging infectious diseases including patient management, guidelines development, equipment modification, and determination of operative risk. There is an important role for anesthesia professionals to help keep patients safe during anesthesia care by preventing infection. For more information about the APSF Patient Safety Priorities, head over to APSF.org and click on the APSF Priorities heading.

Last week, we discussed implementation and consideration for two strategies.

First, Patient Decolonization which involves the following:

• Two doses of 5% nasal povidone iodine within one hour of the surgical incision and use of 2% chlorhexidine gluconate wipes on the morning of surgery.
• An alternative strategy includes at least 2 days of treatment (ideally the day before and the day of surgery) with 5% nasal mupirocin ointment with 2% chlorhexidine gluconate wipes or 4% shampoo.
• Prescribe post-discharge decolonization for your patients colonized with methicillin-resistant Staphylococcus aureus (MRSA) as a result of the health care exposure.

And second, Hand Hygiene which includes the following recommendations:

1. Increase hand hygiene frequency during anesthesia care. Perform hand hygiene at least 8 times per hour during anesthesia care and at least 4 times per hour while providing care in critical care
2. Improve the frequency and quality of environmental cleaning to aid hand hygiene improvement efforts.

Now, it’s time to move on to the next best practice measure, vascular care. Here are the recommendations:

1. Disinfect injection ports, using 70–90% isopropyl alcohol prior to access. We suggest hard scrubbing to create friction for 5–30 seconds followed by drying. If using caps designed to clean needleless connectors, use products proven to be effective and follow manufacturer recommendations. Some of these devices require at least 10 seconds of contact time to be effective.
2. Avoid use of open lumens, that is uncovered stopcocks, as they are at increased risk of contamination, cannot be disinfected well once contaminated, and contamination has been repeatedly associated with increased patient mortality.
3. Clean all medication vials with an alcohol wipe after the dust cover is removed from the vial and prior to access to prevent contamination and infection. Keep injection ports, syringe tips, and IV tubing off the floor.

Now, let’s get into the rationale for these recommendations. First, scrubbing injection ports and medication vials with 70-90% isopropyl alcohol swabs is important prior to each connection. The duration is a range from 5-30 seconds of scrubbing followed by 30 seconds of drying time which has been shown to prevent injection of bacteria from anesthesia professionals’ hands in a randomized ex vivo study by Loftus and colleagues, published in Anesthesia and Analgesia in 2012. In this study, use of a disinfectable, needless closed catheter device with surface disinfection before injection led to significantly reduced risk of inadvertent bacterial injection. I will include the citation in the show notes as well. When appropriate vascular access aseptic practice is not adhered to, there is a risk for injecting up to 50,000 colony forming units of live bacteria into the IV fluid pathway. This can lead to increased risk for the development of surgical site and bloodstream infections and increased patient morbidity and mortality. There is evidence that intraoperative stopcock contamination has been traced to postoperative infection with advanced molecular typing. In addition, randomized controlled clinical trials have revealed that improved vascular care with the use of injection port disinfecting caps mounted to the IV pole has led to decreased pathogen transmission and decreased infectious complications. There is recent evidence to support intraoperative contamination of a patient IV stopcock with SARS-CoV-2 virus, so these recommendations are important for bacterial and viral pathogens. The key features for implementation require making sure that alcohol pads and alcohol disinfection caps are available close to healthcare professionals in the different perioperative spaces as well as to provide education about the appropriate disinfection time for each method.

We made it to our final best practice strategy which is Environmental Cleaning. Here are the recommendations.

1. Implement postinduction/sedation cleaning using a 2-hit approach involving wipes containing at least one alcohol and a quaternary ammonium compound. Use a microfiber cloth to increase removal of the bioburden.
2. Organize the environment into separate clean and dirty spaces.
3. Augment surface disinfection cleaning with ultraviolet irradiation with proven efficacy, effectiveness, and implementation feasibility. Use monitoring for targeted implementation of more advanced cleaning procedures.

Let’s discuss the rationale for these recommendations. This is a big topic with a lot of physical space to cover in a multifaceted approach that includes routine between-case cleaning as well as terminal cleaning. Understanding environmental contamination is important. The peak times are during induction and emergence of anesthesia which are also the times with the lowest levels of hand hygiene compliance. The locations of interest for contamination include the anesthesia work area environment, specifically the adjustable pressure-limiting valve and the agent dial on the anesthesia machine which have been implicated in infection transmission and linked to the development of infection. At least 50% of Staph Aureus surgical site infections have been linked to 1 or more anesthesia work area bacterial reservoirs at the time of the surgery. The good news is that there is something that we can do about this to help prevent infection. At Dartmouth Hitchcock Medical Center, investigators evaluated postinduction cleaning, organization of clean and dirty spaces, use of microfiber cloths, and the use of multimodal surface disinfection wipes and discovered a significant reduction in the number of measured reservoirs measuring over 100 CFU per surface area sampled which is the threshold for contamination associated with high-risk transmission events linked to infection.

Let’s take a look at another study by Wilson and colleagues published in Critical Care Medicine in 2011. This is a prospective, randomized cross-over study over 1 year in two intensive care units comparing standard cleaning with enhanced cleaning that involved increased frequency of cleaning and the use of microfiber cloths and led to decreased bacterial contamination of surfaces and on doctors’ hands. Another enhanced cleaning modality involves the use of ultraviolet C or UV-C light and when this is combined with increased frequency and quality of surface disinfection environmental cleaning as well as patient decolonization, vascular care, and hand hygiene, there may be significantly decreased staph aureus transmission, SARS-CoV-2 transmission, and surgical site infections.

The authors provide several key implementation features. First, the use of post-induction/sedation cleaning is necessary to address the peak time of environmental contamination. Next, organize the anesthesia work area into clean and dirty spaces. Finally, the use of ultraviolet C light can be used to enhance the surface disinfection cleaning. Considerations for the UV-C devices includes the importance of operating room time, clear implementation strategies, and the use of devices that have been shown to prevent intraoperative transmission of bacterial and viral pathogens.

Check out the 2021 article by Birchansky and colleagues, “Statistical Design of Overnight Trials for the Evaluation of the Number of Operating Rooms That Can Be Disinfected by an Ultraviolet Light Disinfection Robotic System.” This paper addresses important questions related to how many ultraviolet light disinfection robot systems are needed for a given number of operating rooms taking into consideration how long the cleaning process takes and how many rooms needs to be cleaned each night. Maybe you have seen these robots being set up to clean an operating room overnight at your institution.

We made it to the end of the article and the authors leave us with a call to action that I will read now:

“Anesthesia teams are well positioned to work collaboratively with the perioperative surgical and nursing team to maximally attenuate perioperative bacterial transmission and subsequent infection. The basic infection control measures have been developed and rigorously tested with proven efficacy, effectiveness, and implementation feasibility and practicality. It is up to anesthesia professionals to act on this information to improve perioperative patient safety.”

What steps will you take to act on this information in your practice to help prevent infection and keep patients safe during anesthesia care?

Before we wrap up for today, we are going to hear from Charnin again. I asked him, what do you hope to see going forward. Let’s take a listen now.

[Charnin] “I hope to see the anesthesia community take as much pride in saving lives with infection prevention as we do in airway. Saving lives through prevention may have less glory than securing a difficult airway, but hey, it’s still saving lives.”

[Bechtel] Thank you so much to Charnin for contributing to the show today and reminding us that infection prevention is lifesaving. We hope that you will be able to use some of these considerations to help keep your patients safe from infection during anesthesia care going forward.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

If you have not done so already, we hope that you will rate us and leave a review on iTunes or wherever you get your podcasts and feel free to share this podcast with your friends and colleagues and anyone that you know who is interested in anesthesia patient safety and infection prevention. Plus, you can let us know that you are listening by tagging us @APSForg using the hashtag #APSFpodcast.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2022, The Anesthesia Patient Safety Foundation