Infection Control Today

APR 2019

ICT delivers to infection preventionists & their colleagues in the operating room, sterile processing/central sterile, environmental services & materials management, timely & relevant news, trends & information impacting the profession & the industry

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21 April 2019 ICT identifed several barrier precautions used for inserting central lines: mask (94.4%), sterile gloves (93.8%), gown (88%), cap (91.6%), and full drape (79.2%). The practice was different for placing arterial lines, with providers using all barrier elements less frequently: masks, 82%; sterile gloves, 74.2%; gown, 10.9%; cap, 76.8%; full drape, 3.7%). Almost half did not use a drape (48.1%). Institutions provided feedback variably on their departments' adherence to HH (never, 40.9%; every 6–12 months, 34.9%; quarterly, 24.2%) and other infection prevention and control practices and procedures (never, 42.3%; every 6–12 months, 36.8%; quarterly, 20.9%). The authors of the SHEA guidance emphasize that given the low response rate from anesthesia providers, it was diffcult to determine how generalizable their fndings are to all institutions and all anesthesia providers. "The survey confrms that we have problems to solve but we really don't have good data about what is happening in ORs nationwide," Bowdle says. "For example, in the frst SHEA webinar following the release of the expert guidance, many participants indicated that they did not have hand gel inside of their operating rooms. This was somewhat of a surprise, to say the least, to the SHEA webinar panelists. We really have no idea how many operating rooms have hand gel and how many do not. Obviously, hand hygiene is a very fundamental infection prevention measure. We need to understand why some ORs do not have hand gel that is accessible to the anesthesia providers and fgure out how to get hand gel into the anesthesia workplace. In all likelihood, there is wide variation between facilities, with some ORs having many good anesthesia infection prevention practices, and others not." The SHEA guidance authors drew four conclusions from the survey results: 1. Infection prevention and control policies specifc to anesthesia care in the OR are not universal in U.S. healthcare facilities. 2. Audits of infection prevention and control practices are not routine. 3. Not all anesthesia work areas are cleaned and disinfected between every patient, and the anesthesia cart is an item of risk for cross contamination. 4. Certain anesthesia-provider practices remain problematic, especially the use of multiple-dose vials for more than one patient, less than 100 percent use of gloves for airway management, lack of hand hygiene after removing gloves, and entry into anesthesia cart drawers without hand hygiene. "Standardizing infection control practices relating to anesthesia will require the combined efforts of professional societies such as SHEA, ASA, and A ANA," emphasizes Bowdle. "In addition, we need more much more scientifc data about what infection prevention measures are most effective in the anesthesia setting. Standardization ultimately requires good evidence upon which to base standards. Enforcement is the role of state and local health authorities, hospital governance, Joint Commission, CMS and others. Again, enforcement is not reasonable without evidence-based standards. T he key recommendations from the SH E A guidance include: • Hand hygiene should be performed, at a minimum, before aseptic tasks, after removing gloves, when hands are soiled, before touching the anesthesia cart, and upon room entry and exit. The authors also suggest strategic placement of alcohol-based hand sanitizer dispensers. As the guidance states, "Hand hygiene ideally should be performed according to the WHO 5 Moments for Hand Hygiene." The authors recommend that hand hygiene be performed at the minimum before aseptic tasks (e.g., inserting central venous catheters, inserting arterial catheters, drawing medications, spiking IV bags); after removing gloves; when hands are soiled or contaminated (e.g., oropharyngeal secretions); before touching the contents of the anesthesia cart; and when entering and exiting the OR (even after removing gloves). • During airway management, the authors suggest the use of double gloves so one layer can be removed when contamination is likely and the procedure moves too quickly to perform hand hygiene. The report also recommends high-level disinfection of reusable laryngoscope handles or adoption of single-use laryngoscopes. As the guidance states, "To reduce risk of contami- nation in the OR, providers should consider wearing double gloves during airway management and should remove the outer gloves immediately after airway manipulation. As soon as possible, providers should remove the inner gloves and perform HH." • For environmental disinfection, the guidance recommends disinfecting high-touch surfaces on the anesthesia machines, as well as keyboards, monitors and other items in work areas in between surgeries, while also exploring the use of disposable covers and re-engineering of the work surfaces to facilitate quick decontamination in what is often a short window of time. As the guidance states, "To reduce the bioburden of organisms and the risk of transmitting these organisms to patients, the facility should clean and disinfect high-touch surfaces on the anesthesia machine and anesthesia work area between OR uses with an EPA-approved hospital disinfectant that is compatible with the equipment and surfaces based on the manufacturer's instruction for use. Because of challenges in consistent cleaning and disinfection between cases of the anesthesia machine and anesthesia work area, the authors suggest prioritizing high-touch surfaces. In addition, the authors suggest evaluating strategies aimed at improving the ability to clean these surfaces (e.g., disposable covers, re-engineering of work surfaces)." Note: In its environmental cleaning guidance in the 2019 Guidelines for Perioperative Practice, AORN recommends that anesthesia machines be cleaned and disinfected after every patient use. It also calls Ò Standardizing infection control practices relating to anesthesia will require the combined ef forts of professional societies such as SHEA, ASA, and A ANA. — Andrew Bowdle MD, PhD, FASE

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