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.

New Years Predictions for Healthcare (Fortune Magazine)


The year ahead will see more strategic affiliations among healthcare organizations although perhaps fewer mega-mergers of health systems; developments in the use of telemedicine, and the launch and expansion of more perioperative surgical homes.  There will be continued efforts to repeal or weaken the Affordable Care Act.  There will be more opportunity than ever for sound leadership.

Let’s briefly consider some predictions for the year ahead in healthcare.  Below is a set of ten predictions that appeared in Fortune magazine earlier this month, along with several comments.

  1. The Federal Trade Commission (FTC) will block a major hospital merger based upon data showing clearly that consolidation leads to price increases more than quality gains. 

    On the other hand, as Philip Betbeze argues in Healthcare Delivery in 2016: A Lot of ‘Little Somethings’ Are Going to Happen (HealthLeaders Media, December 18, 2015),  There could be many arrangements between health systems to work together on specific strategic initiatives such as “ACO creation, building a continuum of care in the region, incorporating new value-based plans directly with employers, sharing of other resources, leveraging different sites of care to equalize patient volumes among facilities, and, of course, starting a health insurance plan, just to name a few.”  Anesthesiologists should hope and expect to play important roles in the launch of such initiatives.

  2. A new type of wearables will include substitutes for more expensive medical therapies, i.e., “’Wearables’ become ‘Ther-ables.’”  They will offer less invasive but highly effective treatments for diseases.  They will also reflect a business model based upon the creation of medical value, as opposed to wellness, entertainment and education.
  3. End-of-life care will be in the news and hospice use will double among accountable care organizations (ACOs) and capitated physicians.  High deductible health plans and new payment models—not to mention increasingly expensive treatments—will make it necessary for physicians to engage in more end-of-life discussions with patients.  One consequence, according to Fortune, will be increased pressure on drug pricing.  Another will be higher incomes for physicians.

    Anesthesiologists may undertake more responsibilities in the related areas of hospice and palliative care particularly as the Perioperative Surgical Home (PSH) model takes root.  In her article Palliative Care and the Perioperative Surgical Home (ASA Monitor 11 2015, Vol.79, 28-30) , Kristin Fortner, MD notes that “In 2006, the American Board of Anesthesiology acknowledged certification in Hospice and Palliative Medicine, formally designating it a medical specialty open to anesthesiologists. 

  4. A major hospital system will divest itself of its employed doctors, having avoided the move into risk-based reimbursement and losing too much of its investment.  In the wake of such a divestiture, hospitals will begin unwinding the money-losing practices they have been acquiring over the last five years, much like the 1990s when physician practice management roll-ups failed.
  5. The insurance innovation mania of 2015 will die down in 2016.  Several provider-sponsored health plans and startups will find it hard to offer competitive premiums and, as a result, will attract few members and will hemorrhage cash.  The “laws of physics” of health insurance favor large health plans that can use their market power to exact greater provider discounts and can use case managers to control their high-cost patients.
  6. The excitement over “precision medicine” will abate because “biology is too complex, and care is simply not reliable enough to benefit from the fine-tuning imagined by precision medicine.” 
  7. Hospitals will cut back on their use of population health analytics and some analytics companies will disappear because their current customers cannot obtain enough value from their analytics tools.  “In fact, most of the current value from these tools comes from upcoding and gaming the risk—adjustment system for higher payment as opposed to complication avoidance.  In addition, most providers already know which of their patients are high risk, making these tools dispensable.”
  8. The high cost of on-demand healthcare will reduce the attractiveness of this option.  High customer acquisition cost combined with the limited ability of most people to pay high prices will shrink the market for on-demand doctors and prescription drug delivery.  The high retail prices of traditional and on-demand care will help telemedicine to gain popularity, however, as patients actively seek increased access to care at lower cost.

    ACOs are expected to increase the use of telemedicine as a way to achieve greater cost savings while improving patient care quality.  (Lacktman N. 2016 Will be the Year of Telemedicine and ACOs.  Health Data Management, December 21, 2015.)  Telemedicine will also offer more and more applications for the preoperative and postoperative phases of the PSH model.

  9. PCSK9 cholesterol drugs will make Sovaldi look cheap.  PCSK9s are uniquely able to lower cholesterol to minuscule levels.  The success of weekly injections will improve patient compliance, leading to more innovation in drug delivery strategies that limit the risk of patients forgetting to swallow pills.
  10. Employers will start imposing rules to hold down spending on employee health.  Fortune foresees that “Large employers may choose which doctors and hospitals employees visit, require second opinions before high cost procedures or treatments, recommend telemedicine before going to an emergency room, or require online tools for managing their conditions and out-of-pocket expenses.”