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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22 ICT April 2019 for terminal cleaning of the OR and all patient-care equipment, including anesthesia machines as well as anesthesia carts and equipment, including wheels and casters, as well as IV poles and IV pumps. • IV drug injection recommendations include using syringes and vials for only one patient; and that injection ports and vial stoppers should only be accessed after disinfection. As the guidance states, " To reduce the risk of bacterial contamination of the syringe and syringe contents, the authors recommend that anesthesia providers cap needleless syringes that will be used to administer multiple doses of a drug to the same patient after each administered dose. Needleless syringes should be capped with a sterile cap that completely covers the Luer connector on the syringe." The authors suggest that implementation of the recommendations requires multi-level collaboration within the hospital, regular monitoring, and evaluation of infection prevention practices with regular feedback for providers as well as clarity in expectations about behaviors. According to the guidance, leadership should defne goals, remove barriers to infection prevention, and empower practitioners to meet standards. The Role of IPs Infection preventionists may have a role in improvement processes in the OR relating to audit work. "When facilities implement measures for anesthesia infection prevention, it is important to attempt to measure the extent to which providers are actually able to carry out the desired behaviors and procedures," Bowdle says. "This requires data collection (audits). Data collection requires hospital resources. Certainly, infection preventionists can help to provide resources for collecting data concerning implementation of infection prevention measures." Infection preventionists also may become involved in quality improvement efforts. "The SHEA expert guidance is an excellent example of a cooperative effort between anesthesia providers, their professional societies, and infection preventionists," Bowdle adds. "This cooperative effort should be sought in individual facilities. Many infection preventionists have little or no experience with the anesthesia workplace, which is very different from most areas of the hospital. Most anesthesia providers have not thought deeply about the importance of infection prevention and how to achieve it. So, there is a lot of learning that needs to go on. Hopefully, the SHEA guidance will help to open minds to the need for a cooperative effort. As an anesthesia provider, I would recommend that infection preventionists who are not intimately familiar with the anesthesia workplace should start by reading the SHEA expert guidance, and then get into a scrub suit and spend some time simply watching what goes on." ASA president Linda Mason, MD, FASA, says the collaboration between anesthesiology and infection prevention is critical to patient safety: "These guidelines address the evidence base for infection prevention while taking into account the realities of the operating room and the complexities involved in providing anesthesia services." ASA says it supports local hospital-level discussions and decision-making regarding the use of laryngoscopes, including disinfection procedures per the manufacturer's recommendations or use of disposable tools, and emphasizes that practices and local administrators should follow any and all updates to the U.S. Pharmacopeia Chapter <797>, expected in the coming months. Unresolved Issues The SHEA guidance acknowledges several unique elements of anesthesia practice that pose unsolved problems for infection prevention, including the anesthesia machine, the anesthesia cart, and provider-prepared drugs and IV infusion bags. As the authors explain, "Numerous challenges exist for thorough cleaning of the anesthesia machine between cases. The anesthesia machine is a complicated apparatus with an irregular and complex external surface. Many anesthesia machines also have drawers to store supplies. Anesthesia machines were designed at a time when the importance of infection prevention in the anesthesia workplace was not well understood, and since then, the fundamental design has not changed greatly. The anesthesia machine may need to undergo fundamental redesign that allows for quick and effective cleaning of the external surfaces." The authors continue, "The anesthesia supply cart presents similar challenges and cleaning the anesthesia cart between cases can be extremely challenging depending upon the particular design of the cart. Anesthesia carts have many variations, which also can have a complex exterior surface due to attachment of electrical components such as a defbrillator or cardiac output monitor, sharps collection containers, waste bins, and discarded drug collection containers. Supplies and materials may be stored in cart drawers but also in bins on the top of the cart. Typical anesthesia carts contain supplies and materials intended to be used for numerous cases. Contamination of supplies can occur if providers do not remove soiled exam gloves and apply ABHR prior to obtaining supplies and materials from storage. Few examples exist of practices that have attempted to include the anesthesia cart in a clean zone, where only clean hands are allowed. Although some success has been documented with this approach, maintaining the desired provider behavior presents challenges." "As noted in the SHEA expert guidance, cleaning and disinfecting the anesthesia workplace is very challenging because of the physical complexity of the equipment and the minimal time available for cleaning between patients," Bowdle says. "The strategic use of single-use materials (example—single-use laryngoscopes, blood pressure cuffs, pulse oximeter sensors, ECG lead wires) and disposable plastic covers for reusable equipment (example—parts of the anesthesia machine, keyboards, touch screens) should be strongly considered. Cleaning of all uncovered surfaces of the anesthesia machine and anesthesia cart between cases may be impossible in the available time, and if so, cleaning should focus on high-touch areas." Reference: Munoz-Price S, Bowdle A, Johnston BL, Bearman GM, Camins BC, Dellinger EP, Geisz-Everson MA, Holzmann-Pazgal G, Murthy R, Pegues D, Prielipp RC, Rubin ZA, Schaffzin J, Yokoe D and Birnbach DJ. SHEA Expert Guidance: Infection Prevention in the Operating Room Anesthesia Work Area. Web (Dec. 11, 2018). Ò As noted in the SHEA expert guidance, cleaning and disinfecting the anesthesia workplace is very challenging because of the physical complexity of the equipment and the minimal time available for cleaning between patients.

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