Episode #236 Revolutionizing Hand Hygiene in Anesthesia: A Path to Safer Surgeries

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. Happy New Year! We are about a week into the new year, and we hope that improved anesthesia patient safety is on your list of resolutions this year! Tuning into the podcast each week and checking out all of the great APSF articles is a sure way to be successful! Let’s start with a quiz. According to the APSF, how many hand hygiene events should an anesthesia professional perform during a routine anesthetic? Stay tuned for the answer.

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

The correct answer is 8 hand hygiene events per hour during routine anesthetic care. The complete answer is more complicated, which means that we have a lot to talk about on the show today.

Our featured article today is “Improving Hand Hygiene in the Anesthesia Workspace: The Importance, Opportunities, and Obstacles” by Jonathan Charnin and colleagues. To follow along with us, head over to APSF.org and click on the Newsletter heading. The first one down is the current issue. From here, scroll down until you get to our featured article today. I will include a link in the show notes as well.

We have one of the authors on the show today with some exclusive content. I asked Jonathan Charnin why he feels so passionate about this topic. Let’s take a listen now.

[Charnin] Anesthesia professionals have been leaders in patient safety for decades. I think that preventing the spread of pathogen in the anesthesia workspace is the next frontier in patient safety, and that small changes in our workflow can make differences in the rates of surgical side infections and save our patients from morbidity and mortality.

[Bechtel] Thank you so much to Charnin for helping to kick off the show today. Let’s just do a quick handwash and get into the article.

[Handwashing sound effect]

This is an important topic that is closely related to the 7^th APSF Patient Safety Priority, Infectious Diseases. This threat is related to hand contamination by pathogens that are transmitted across multiple anesthesia workspace reservoirs leading to patient infections. Genome analysis of bacteria cultured from the hands of anesthesia professionals and infection causing pathogens has confirmed the link. Staph aureus transmission between anesthesia workspace reservoirs has been shown to increase the risk for surgical site infection especially when pathogens are resistant to the prophylactic antibiotics that are administered. We are already working so hard to prevent these infections with sterile precautions and prophylactic antibiotics when applicable. A multifaceted approach must be used to prevent surgical site infections, and an essential consideration is hand hygiene by all members of the intraoperative team.

We are going to get into the details, but I just want to highlight Figure 1 in the article which describes the 5 moments for Hand Hygiene. We hope that these 5 moments are part of your regular routine and we are going to review them now.

1. Before touching a patient
2. Before clean or aseptic procedure
3. After body fluid exposure risk
4. After touching a patient
5. After touching patient surroundings.

Moments 1 and 2 are designed to help protect patients from harmful germs. Moments 3, 4, and 5 are designed to protect yourself and the healthcare environment from harmful germs from the patient. This is a great infographic and reference that you can use wherever you practice safe and clean anesthesia care.

Now, let’s head into the operating room and check out our anesthesia workspace. This area includes the patient, the surgical bed or table, the anesthesia machine, the IV pole or poles with attached infusion devices, a cart with clean supplies, and medications stored within the cart or on a separate medication station. During anesthesia care, there are many interactions between the anesthesia professional, the patient, and the other equipment in the anesthesia workspace. If anesthesia professionals are compliant with The World Health Organization’s 5 Moments of Hand Hygiene that we just reviewed, then hand hygiene would need to occur between 50 and 150 times every hour during anesthesia care. Studies evaluating hand hygiene in the operating room have found that anesthesia professionals perform hand hygiene less than once per hour. There is quite a large gap here. Perhaps, you may be overwhelmed by the challenge of preventing pathogen transmission, but it is possible to decrease the levels of staph aureus on our hands to less than 100 colony-forming units and this is an important step to providing safe and clean anesthesia care.

The good news is that the APSF is here to help with practical recommendations. The APSF Patient Safety Priorities Advocacy Group dedicated to infectious disease recommends hand hygiene for anesthesia professionals at least 8 times per hour during anesthesia care. This seems very manageable. Anesthesia professionals can help to keep their patients safe from environmental and stopcock contamination leading to infection with hand washing or using hand sanitizer 8 times every hour. The authors highlight considerations for future research in this area to evaluate products like alcohol based or soap and water, dispenser locations, cleansing technique, and potential risks. Keep in mind that if your hands are visibly contaminated or you have come into contact with spore-forming organisms, then you will need to step up to the sink and decontaminate with soap and water. Once you are in the operating room, the primary resource for hand hygiene is alcohol-based hand sanitizer which has the benefit of decreased skin irritation compared to soap and possibly reduced bacterial counts on irritated skin.

Where are the hand sanitizer dispensers located in your operating rooms? The answer to this should depend on task density or the number of tasks that need to be done in a period of time. The recommendations from health care infection prevention organizations are for dispensers to be easily accessible within the patient care arena. If the dispensers are placed too far away from the anesthesia workspace, like near the doors to the operating room, this may lead to decreased compliance with hand hygiene or interruptions in patient care.

Do you what time it is? It’s time for a literature review. First up, let’s discuss the 2009 Anesthesiology article by Koff and colleagues, “Reduction in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a novel device.” This is a controlled before and after study over a two-month time period with 114 operative cases. There were 2 sites on the anesthesia machine that were decontaminated and cultured before and then after the surgery (but before the regular room cleaning and disinfection.) The investigators evaluated the use of a novel personal hand decontamination device that also recorded the hand decontamination events. When the novel hand decontamination device was in use, hourly hand hygiene increased by 27-fold compared to the baseline rates. In addition, there was decreased contamination in the anesthesia work area and peripheral intravenous tubing. This extended to decreased rates of healthcare-associated infections from about 17% in the control group to 3.8% in the device group. The authors of the study concluded that improved hand hygiene compliance with the use of this novel device reduces that risk of intraoperative bacterial transmission, and this was associated with a reduction in healthcare associated infections.

Let’s continue our literature review with the article by Loftus and colleagues from 2020, “The Effect of Improving Basic Preventive Measures in the Perioperative Arena on Staphylococcus aureus Transmission and Surgical Site Infections: A Randomized Clinical Trial.” This study was a prospective randomized clinical trial that evaluated a bundle of interventions. Three of these included the addition of a dispenser on the IV pole in the OR and then to the bedrail during transport to the PACU, placement of a basket lined with a plastic bag on the IV pole to serve as a storage location for used or contaminated equipment, and disinfection caps for the IV lines. The investigators discovered that using these basic preventive measures were effective for decreasing the spread of staph aureus and surgical site infections.

For more information about these studies, check out the show notes for the citations. It makes sense that when the dispensers are close and easy to use, anesthesia professionals are more likely to use them, and this increased hand hygiene is a big step for improving patient safety.

Another important consideration is environmental contamination. This often occurs from hand contamination. Increased frequency and improved quality of environmental cleaning can help in conjunction with improved hand hygiene. Do you have designated clean and dirty areas in your anesthesia workspace? This can help to decrease contamination. And the VIP of the designated clean area should be the alcohol dispenser which may be secured to the anaesthesia machine, the supply cart or the IV pole taking care to protect the patient, surgical field, and any electrical plugs from splashes or drips.

Check out Table 1 in the article for some potential hand sanitizer locations in the anesthesia workspace. We are going to review it now.

• Attached to the IV pole. This has the advantages of a convenient location in a designated clean area that combats task density. This disadvantage is the potential for accidental spray into the surgical field or on the drapes and proximity to electrical outlets that may be secured to the IV pole as well. Studies support this location as part of a bundle.
• Body worn. This has the advantages of a convenient location that combats task density, but it is not in a clean area. Studies support this location.
• Attached to or on the anesthesia machine. It might be easy to attach the dispenser here, and it is always present, but this location has not been studied and may easily block other equipment.
• Attached to or on the anesthesia cart. This location is unlikely to cause interference, but it may be difficult to attach and has not been studied.
• Attached to wall near anesthesia area. Wall space may be available, but this location could be hard to reach and has not been studied.

Another important consideration is the potential hazards associated with hand sanitizer. All alcohol-based sanitizers contain 60-80% ethyl or isopropyl alcohol and water. The water component is necessary to hydrolyse microorganism membranes and slow evaporation of the product. Keep in mind that alcohol products are flammable, and fire codes regulate the total volume of sanitizers allowed within a procedure room which must be less than 1.2 Liters and the minimum separation distance between alcohol dispensers which is set at 4 feet. Another recommendation from the Centers for Disease Control and Prevention is for the volume of personalized body-worn alcohol dispensers and one-handed pumps on IV poles to be less than 3 ounces. There are not reports of fires related to hand sanitizers at this time.

The authors leave us with a call to action that is simple and easy to implement:

“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.”

We made it to the end of the article, but before we wrap up for today, I also asked Charnin what he hopes to see going forward. Let’s take a listen to what he had to say.

[Charnin] “I hope to see the entire anesthesia community start to embrace an attitude of cleaner is better in the anesthesia workspace.  Each of us can disinfect our vials and injection ports with alcohol.  We can increase by a huge margin our frequency of hand hygiene while providing anesthesia care. I hope that every anesthetizing location has hand sanitizer within arm’s reach, and it’s used often during anesthesia care.”

[Bechtel] Thank you so much to Charnin for contributing to the show today and sharing with us these quick, easy, and effective techniques for keeping the anesthesia workspace clean and keeping patients safe.

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.

We hope that your 2025 is off to a great start! Listening to the podcast is a great way to learn more about anesthesia patient safety. If you get a chance, we hope that you will share this podcast and all of the APSF resources with your colleagues, team members, and anyone you know who is interested in anesthesia patient safety.

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

© 2025, The Anesthesia Patient Safety Foundation