New Guidance Outlines Recommendations for Infection Control in Anesthesiology
Infection prevention policies in operating rooms are inconsistent, report shows
Arlington, Va. (December 11, 2018) — The Society for Healthcare Epidemiology of America has issued a new expert guidance on how hospitals and healthcare providers may reduce infections associated with anesthesiology procedures and equipment in the operating room. The Guidance, published in SHEA’s journal, Infection Control & Healthcare Epidemiology, recommends steps to improve infection prevention through increased hand hygiene, environmental disinfection, and continuous improvement plans.
“Even though the demands on anesthesia providers make infection prevention best practices more challenging, there are opportunities for improvement,” said Silvia Munoz-Price, MD, PhD, lead author of the guidance and Professor of Medicine at Froedtert & Medical College of Wisconsin. “We describe how the anesthesiology team and hospital leaders can optimize infection prevention in operating room anesthesia, and we give suggestions for the future, including the need for better equipment design.”
A growing body of research has shown that contamination in anesthesiology work areas is connected to healthcare-associated infections that put patients at risk. A survey of 49 U.S. and international facilities showed infection control policies and practices are inconsistent. A writing panel—consisting of representatives from SHEA, the American Society of Anesthesiologists (ASA), the Anesthesia Patient Safety Foundation (APSF), and the American Association of Nurse Anesthetists (AANA)—developed the guidance to establish procedures and best practices specific to anesthesia in the operating room.
The key recommendations 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.
- 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.
- 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.
- 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.
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 define goals, remove barriers to infection prevention, and empower practitioners to meet standards.
ASA President Linda Mason, MD, FASA, said 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 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.
The guidance was endorsed by the SHEA Board of Trustees, the American Academy of Anesthesiologist Assistants (AAAA), AANA, the Association for periOperative Registered Nurses (AORN), and APSF, with a letter of support from ASA.
An Opportunity for Anesthesia to Lead
The severe shortage of sodium chloride 0.9% IV bags and other saline bags due in large part to the devastation wrought by Hurricane Maria on pharmaceutical plants in Puerto Rico offers one of the more unsettling recent examples. (The commonwealth manufactures more pharmaceuticals for the United States than any of the 50 states or any foreign country.)
To help address the shortage, on January 24, the Food and Drug Administration (FDA) extended the shelf life of certain IV solutions made by Baxter Healthcare beyond the manufacturer’s labeled expiration date. In a statement, the FDA said it expects the shortage will improve in the coming weeks and months and is working with manufacturers to import product into the U.S. from their foreign facilities. (A comprehensive fact sheet on strategies for dealing with shortages of small-volume parenteral solutions is available from the ASHP.)
Drug shortages tend to hit anesthesia especially hard. In October 2017, the FDA announced a nationwide shortage of many injectable forms of fentanyl citrate, a shortage that persists. A 2014 GAO study found that central nervous system drugs accounted for 17 percent of all drug shortages and that the shortages of these drugs were routine. A 2012 survey by the American Society of Anesthesiologists (ASA) found that 97.6 percent of responding anesthesiologists were experiencing at least one anesthesia-related drug shortage.
Anesthesia providers have used some innovative approaches to help prevent or reduce the impact of drug shortages in the past at their institutions. Duke University Hospital (Durham, NC) formed a multidisciplinary perioperative drug shortage response team to address shortages of neuromuscular blocking agents such as succinylcholine in their operating rooms.
When a shortage is deemed critical, the coordinator of the Center for Medication Policy convenes a task force to discuss whether the shortage can be managed best by pharmacy alone or by a multidisciplinary group that includes anesthesiologists, nurse anesthetists, surgeons and OR nurses.
The team also uses data from its anesthesia information management system (AIMS) to identify trends and patterns in medication usage in the perioperative setting and develop strategies to repackage bulk medications into smaller unit doses whenever possible. The approach allows the hospital to conserve inventory, reduce waste and extend the availability of difficult to obtain medications.
Anesthesia providers might also take a cue from pharmacist Trac Pham, RPh, of Advocate Health Care, who outlined strategies that have worked at his health system:
- Use inventory control specialists whose responsibilities revolve around identifying red flags such as back orders and partial fulfillments. Empower frontline employees to identify these potential shortages.
- Assess current inventory when a potential shortage has been identified—a step many hospitals fail to take. How much is sitting on the shelf today? What is the hospital’s utilization rate? How long is the current supply going to last?
- Collaborate with supply chain and pharmacy to evaluate potential shortages, identify alternative therapies, prioritize patients who should receive the affected drug and modify clinical plans.
- Develop a process that allows executives, clinicians and employees to communicate in a timely manner with each other to navigate drug shortages.
- To ensure uninterrupted care, update the health information management system promptly to reflect alternative drugs when there is a shortage.
For more information, also see the ASHP Guidelines on Managing Drug Product Shortages in Hospitals and Health Systems, American Journal of Health-System Pharmacy, 2009; 66:1399-405.
