Reinforcing Infection Prevention in the Operating Room Anesthesia Work Area: New SHEA Guidelines

More than 16 million operative procedures were performed in acute care hospitals across the United States in 2010, according to estimates from the US Centers for Disease Control and Prevention (CDC). This high volume of procedures, coupled with the prevalence of infection prevention failures, brings with it an increased risk of surgical site infections.

Surgical site infections are a considerable threat to patients as they often lead to readmission, a long recovery road, and complications such as drug-resistant infections, and even death. Surgical-site infections were the second most common health care—associated infection in a survey of 183 acute care hospitals in the United States in 2011. Although surgical technique, the environment, operating room traffic, and more, tend to receive the most attention as potential culprits for these infections, infection control failures during anesthesia care are gathering increased attention. Because of the unique vulnerabilities and infection control challenges associated with anesthesia care, the Society for Healthcare Epidemiology of American (SHEA) recently released guidance on implementing infection prevention in the anesthesia area of the operating room.

Many studies have revealed substandard infection prevention practices in anesthesia care, such as the use of multiple-dose vials for more than one patient, low hand-hygiene compliance after removing gloves, failure to use gloves all the time for airway management, and accessing anesthesia cart drawers without hand hygiene.

The new guidelines from SHEA focus on policies and procedures for hand hygiene, safe preparation, and delivery of intravenous (IV) medication, environmental cleaning, and disinfection, etc. The guidance is considerable and focuses on providing answers to several key questions that commonly arise in this challenging environment.

Here are a handful of solutions that I felt were relevant, often disputed, and ultimately helpful, from the infection preventionist viewpoint:

Should clinicians wear double gloves during airway management and then discard the outer glove immediately after airway manipulation?

The SHEA guidelines indicate that “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 hand hygiene.”

The rationale for this decision is that during the process of airway management, hands are likely to become contaminated; however, clinicians may not be able to perform hand hygiene immediately, which creates a risk for cross-contamination.

The guidelines also include a recommendation to provide alcohol-based hand-sanitizer dispensers not only at the entrances to the operating room, but also near the anesthesia provider within the operating room, a recommendation that is much appreciated from my standpoint.

Should anesthesia machines be partially or completely covered with disposable covers to avoid contamination?

The guidelines state that there is inadequate data to recommend the use of disposable covers (hint: we need more studies!), but, ultimately, this is a good question that forces clinicians to think about anesthesia equipment and the possibility of contamination. I think this is an important component to highlight because environmental services staff may feel uncomfortable touching/cleaning certain equipment and these pieces can easily be forgotten.

The SHEA guideline authors recommend that the high-touch surfaces of these machines be cleaned and disinfected with an EPA-approved hospital disinfectant between cases in the operating room, in addition to the anesthesia work area. Furthermore, it is important not to forget to clean items within the work area as well—the computer keyboard, monitor and mouse, reusable patient monitoring equipment, etc. Bacterial contamination of clinical and operating room equipment has been well documented, and it is easy to forget screens (especially touch screens) and keyboards during the cleaning process.

How far in advance should IV bags be spiked prior to commencing use?

There were several points raised about medication management and delivery, in the guidelines, but I truly appreciated this one. Knowing when to spike IV bags is a frequent issue as cases are being prepped. SHEA recommends that anesthesia providers minimize the time an IV bag is spiked and administered to the patient. (Of course, emergent and urgent cases may require advanced set-up and providers should follow hospital policies.)

To date, there has been no designated and specified time published in the literature regarding spiking IV bags in advance, but the practice can pose a patient- and drug-safety risk, and so it should be done as close to the start of the surgical case as possible.

Throughout the recommendations, there are dozens of helpful and sadly, well-known issues that were raised, such as the challenges of the operating room culture and equipment and how guidance is yet to be established on cleaning the anesthesia cart, and so I strongly recommend that you read through the full document.

Ultimately, it is important that operating room staff and anesthesia providers are involved in infection prevention collaborative efforts at the individual hospital level to ensure not only representation, but also the institution’s guidelines and practices are relevant and effective.