Role of Anesthesia Providers in Infection Control
Myron Yaster MD, Lynn Martin MD, and Lynne G. Maxwell MD
“Health care-associated infections (HAIs) are a persistent problem associated with patient mortality and harm. HAIs have been shown to prolong hospital stay and to increase hospital readmission rates, patient mortality, the risk of intensive care unit (ICU) admission, and health care expenditure.”1 You all know the drill even if you fail to be completely compliant: wash your hands, wear gloves, aseptic technique when breaking the skin for IVs, arterial lines, peripheral and central nerve blocks, or when breaking into IV lines to administer drugs (especially stopcocks). And of course there is the cesspool of the anesthesia workstation, touch screen monitors, and the anesthesia circuit.
When I read today’s PAAD by Loftus et al.1 in the ASA Monitor, I thought a deeper dive into the senior author’s most recent publications would be perfect for the PAAD readership. I would urge all of you to read these articles and bring many of the issues raised in these articles up at your next staff meetings and journal clubs. Additionally, I recruited Dr. Lynn Martin to discuss why it is so hard to change human behavior and tips and tricks he has been using, particularly with Project Spruce to make change possible. I’d like to urge you all to “Be the agent of change in your professional life and practice!” Myron Yaster MD
Original articles
Randy W. Loftus, Franklin Dexter, Matthew D. Koff, Jonathan E. Charnin; Role of Anesthesia Providers in Infection Control. ASA Monitor 2024; 88:1–9 doi: https://doi.org/10.1097/01.ASM.0001004720.63302.ac
Gibbons S, Dexter F, Loftus RW, Brown JR, Wanta BT, Charnin JE. The relative efficacy of multiple syringe tip disinfection techniques against virulent staphylococcus contamination. J Hosp Infect. 2024 Mar;145:142-147. doi: 10.1016/j.jhin.2024.01.006. Epub 2024 Jan 24. PMID: 38272124.
Loftus RW, Brindeiro CT, Loftus CP, Brown JR, Charnin JE, Dexter F. Characterizing the molecular epidemiology of anaesthesia work area transmission of Staphylococcus aureus sequence type 5. J Hosp Infect. 2024 Jan;143:186-194. doi: 10.1016/j.jhin.2023.07.003. Epub 2023 Jul 13. PMID: 37451409.
Dexter F, Walker KM, Brindeiro CT, Loftus CP, Banguid CCL, Loftus RW. A threshold of 100 or more colony-forming units on the anesthesia machine predicts bacterial pathogen detection: a retrospective laboratory-based analysis. Can J Anaesth. 2024 Feb 27. English. doi: 10.1007/s12630-024-02707-3. Epub ahead of print. PMID: 38413516.
Dexter F, Loftus RW. Estimation of the contribution to intraoperative pathogen transmission from bacterial contamination of patient nose, patient groin and axilla, anesthesia practitioners' hands, anesthesia machine, and intravenous lumen. J Clin Anesth. 2024 Feb;92:111303. doi: 10.1016/j.jclinane.2023.111303. Epub 2023 Oct 22. PMID: 37875062.
Beyond the theory, anyone of us who has ever been a patient or has a family member who is or was a patient knows how catastrophic surgical site infections (SSI) can be. Our role in preventing SSIs by providing timely and appropriate antibiotic prophylaxis, primarily with cephalosporins, has been incorporated into our time outs and preoperative checklists and has over the past 2 decades transformed our practice.2,3 On the other hand, changing professional behavior like washing hands at regular intervals and keeping the anesthesia workstation clean may be the hardest part of getting anesthesiologists into the infection control fight.
There is a growing wealth of data showing the links between anesthesia workspace contamination and SSI and catheter-associated blood stream infection (CABSI). How do you change provider behaviors and practice? I (LDM) was confronted with this conundrum while Anesthesia Chief at Seattle Children’s in 2010 when my Chief Medical Officer showed me evidence that anesthesia care in the ORs, cardiac cath labs, and interventional radiology suites were associated with higher CABSI rates. My subsequent observations of my colleagues’ anesthesia practices viewed through an infection prevention lens were shocking and compelling. Using many widely used change management methods,4 we launched a volunteer improvement team that successfully changed provider behavior and anesthesia care practices, resulting in a 35% reduction in the hospital CABSI rate.5 Our approach created clean (anesthesia cart and medication administration) and dirty (anesthesia machine, computer, and patient) zones. Gloves are NOT used in the clean zone and hand-hygiene is done whenever gloves come off. Classic keys to behavior change as described by Kotter were used.6 These include (1) establishing a sense of urgency, (2) creating a guiding coalition, (3) developing a vision and strategy, (4) communicating the change vision, (5) empowering broad-based action, (6) generating short-term wins, (7) consolidating gains and producing additional change, and (8) anchoring new practices in the culture.
Quality Improvement efforts frequently struggle with limited and delayed access to necessary data for real-time feedback and iterative, continuous cycles of improvement. Frustratingly, many times this critical data lives in the theoretically accessible electronic medical record we work in daily. New software tools are increasingly removing this barrier, facilitating real-time data access, and thus leading to increasingly rapid improvements in clinical outcomes.7 My colleague, Dr. Liz Hansen, has been able to use this democratized data access to reduce greenhouse gas emissions at Seattle Children’s by 87%.8 Liz and Dr. Diane Gordon, using these same methods, are jointly leading a growing multicenter collaborative called SPRUCE Forest to spread these changes and reduce our specialty’s negative impact on our threatened climate. Every active center has seen significant reductions in greenhouse gas emissions in the first 3 months or less. Preliminary results will be presented at the upcoming SPA meeting in the moderated poster session on Saturday April 13 from 11:00-12:30. (SPA abstract). Please stop by to learn more.
Ok, what are some of the key pillars of infection control?1,9-15 Hand washing, environmental cleaning, vascular care, and patient decolonization. Let’s start with the anesthesia workspace and call it for what is: a cesspool. Just think of the anesthesia workstation, computer/EMR touch screens, tabletops, the adjustable pressure-limiting valve, infusion pumps, and vaporizers. Your hands touch all of these constantly throughout an anesthetic and bacterial organisms from your hands are constantly transferred to these surfaces.1,9,11,12
Vascular care, from how we prep and place IV catheters, how we dress the entrance site, and how we draw up and administer drugs can all affect HAIs. Your IVs and stopcocks are in direct continuity with the patient’s blood stream. Bacterial infection and transmission is well described and repeatedly linked to infection development.1,14 Thus, “prevention of such contamination is not only logical but clearly indicated.”1 Your hands which are the primary vector of transmission and the stopcocks are clearly the first targets of intervention to prevent bacterial transmission. Wash your hands frequently and alcohol swab the stopcocks before connecting your syringe!
Next, the anesthesia workspace and machines need to be frequently cleaned and decontaminated to less than 100 or more colony units.11 Doing it once, at the beginning of your work day and even between cases is insufficient. Finally, patient decolonization using chlorhexidine gluconate washcloths and intranasal antiseptic ointment is effective in eradicating MRSA in the nose and on the skin of patients and can dramatically reduce SSI and HAIs.1,16
Are you doing this in your practice? What roadblocks are preventing you from instituting these procedures? Send your thoughts and comments to Myron who will post in a Friday Reader response.
References
1. Loftus RW, Dexter F, Koff MD, Charnin JE. Role of Anesthesia Providers in Infection Control. ASA Monitor 2024;88(1):1-9. DOI: 10.1097/01.ASM.0001004720.63302.ac.
2. Berrios-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA surgery 2017 (In eng). DOI: 10.1001/jamasurg.2017.0904.
3. Gravenstein N, Fish JT, Klinker KP, Coursin DB. Prophylactic perioperative antibiotic administration: is it time to infuse our practices with new approaches? Anesthesia and analgesia 2015;120(4):709-11. (In eng). DOI: 10.1213/ane.0000000000000541.
4. Rampersad SE, Low DK, Martin LD. Change Management in Modern Anesthesia Practice. International anesthesiology clinics 2016;54(3):83-93. (In eng). DOI: 10.1097/aia.0000000000000101.
5. Martin LD, Rampersad SE, Geiduschek JM, Zerr DM, Weiss GK, Martin LD. Modification of anesthesia practice reduces catheter-associated bloodstream infections: a quality improvement initiative. Paediatric anaesthesia 2013;23(7):588-96. (In eng). DOI: 10.1111/pan.12165.
6. Kotter JP. Leading Change. Boston, MA: Harvard Business School Press, 1996.
7. Hansen EE, Chiem JL, Low DK, Rampersad SE, Martin LD. Enhancing Outcomes in Clinical Practice: Lessons Learned in the Quality Improvement Trenches. Anesthesia and analgesia 2024 (In eng). DOI: 10.1213/ane.0000000000006713.
8. Hansen EE, Chiem JL, Righter-Foss K, et al. Project SPRUCE: Saving Our Planet by Reducing Carbon Emissions, a Pediatric Anesthesia Sustainability Quality Improvement Initiative. Anesthesia and analgesia 2023;137(1):98-107. (In eng). DOI: 10.1213/ane.0000000000006421.
9. Loftus RW, Brindeiro CT, Loftus CP, Brown JR, Charnin JE, Dexter F. Characterizing the molecular epidemiology of anaesthesia work area transmission of Staphylococcus aureus sequence type 5. J Hosp Infect 2024;143:186-194. (In eng). DOI: 10.1016/j.jhin.2023.07.003.
10. Gibbons S, Dexter F, Loftus RW, Brown JR, Wanta BT, Charnin JE. The relative efficacy of multiple syringe tip disinfection techniques against virulent staphylococcus contamination. J Hosp Infect 2024;145:142-147. (In eng). DOI: 10.1016/j.jhin.2024.01.006.
11. Dexter F, Walker KM, Brindeiro CT, Loftus CP, Banguid CCL, Loftus RW. A threshold of 100 or more colony-forming units on the anesthesia machine predicts bacterial pathogen detection: a retrospective laboratory-based analysis. Canadian journal of anaesthesia = Journal canadien d'anesthesie 2024 (In eng). DOI: 10.1007/s12630-024-02707-3.
12. Dexter F, Loftus RW. Estimation of the contribution to intraoperative pathogen transmission from bacterial contamination of patient nose, patient groin and axilla, anesthesia practitioners' hands, anesthesia machine, and intravenous lumen. Journal of clinical anesthesia 2024;92:111303. (In eng). DOI: 10.1016/j.jclinane.2023.111303.
13. Fernandez PG, Loftus RW, Dodds TM, et al. Hand hygiene knowledge and perceptions among anesthesia providers. Anesthesia and analgesia 2015;120(4):837-43. (In eng). DOI: 10.1213/ane.0000000000000408.
14. Loftus RW, Brown JR, Koff MD, et al. Multiple reservoirs contribute to intraoperative bacterial transmission. Anesthesia and analgesia 2012;114(6):1236-48. (In eng). DOI: 10.1213/ANE.0b013e31824970a2.
15. Martin LD, Kallile M, Kanmanthreddy S, Zerr DM. Infection prevention in pediatric anesthesia practice. Paediatric anaesthesia 2017;27(11):1077-1083. (In eng). DOI: 10.1111/pan.13252.
16. Bebko SP, Green DM, Awad SS. Effect of a Preoperative Decontamination Protocol on Surgical Site Infections in Patients Undergoing Elective Orthopedic Surgery With Hardware Implantation. JAMA surgery 2015;150(5):390-395. DOI: 10.1001/jamasurg.2014.3480.