An impressive body of research has emerged in recent years that suggests anesthesia providers play a significant role in incidents of healthcare-acquired infections simply through patient interactions from the head of the surgical table. Many providers are skeptical, asking "Are our practices in the OR really that bad?" While it's not likely we're the leading cause of surgical site infections, studies make it clear that we anesthesia providers contribute. Let's examine the risks that we pose and the practices that could divert them.

Reasons for risk
It's hard to know exactly how much responsibility anesthesia providers carry for surgical infections. Few, if any, symptoms of SSIs present until days after surgery. In hospitals, we don't follow patients that long after their recovery from anesthesia, and in the outpatient setting there's usually no contact at all after discharge. But considering some traditional practices among anesthetists, the ergonomics of their workplace and the requirements of anesthesia care, you can argue that they share the risk for inadvertently transferring infectious bacteria to patients, or passing it from one patient to another.

• A separation on sterility. There is a sharp divide between OR staff and anesthesia providers in accepted practices regarding instrument sterility. It would be unimaginable for surgical staffers to reuse devices in patient cases without cleaning, disinfecting, even sterilizing them between uses. There is a certainty that the instruments you unwrap or unpack for use at the surgical site are sterile. But you might be surprised to find that there's often less of an assurance that anesthesia's tools are. That laryngoscope the provider is using to place an endotracheal tube, for example, may have been sitting in a non-sterile cart drawer where it may have been contaminated by other items or the provider's hands. Another example: We frequently prepare for the next case — drawing up drugs, pulling airway equipment, setting up IVs — while participating in the current case, something that a circulator would never do. This step can potentially transfer bacteria from one case and patient to the next, but it's simply the way things have always been done.
• Contact and access. In addition to the variability of aseptic practices among providers, the equipment that we routinely work with doesn't always lend itself to quick and convenient disinfection between cases. The knobs, dials, valves and drawers on the anesthesia machine and cart, the keyboards for electronic charting, the blood pressure apparatus, EKG cables and pulse oximeter can be difficult to thoroughly wipe down. It's always possible that a provider's hands can contaminate one patient with remnants from the last case. Since we also work with IV lines and injection stopcocks, such contamination has a direct connection to the patient's bloodstream. Researchers from the Dartmouth-Hitchcock Medical Center in Lebanon, N.H., connected these dots in a study published in the January 2011 issue of the journal Anesthesia & Analgesia. "The contaminated hands of anesthesia providers serve as a significant source of patient environmental and stopcock set contamination in the operating room," the researchers said, especially by providers supervising more than one case at a time.
• Hand hygiene hurdles. Anesthesia providers may reply, perhaps angrily so, that these studies have unfairly assailed them, that they're being held to an unreasonably high standard. The job they do and the rapid-sequence tasks demanded of them — switching between the patient, the anesthesia machine, the cart and the IV line — make it difficult to maintain uncontaminated hand hygiene at every step. Even for the most conscientious of providers, it's impossible to wash or sanitize their hands that many times, and transferring bacteria from a patient's airway to their equipment is practically inevitable. Plus, stopcocks may be the best option we have available at present, but injection by any means always creates some manner of breach in aseptic technique.

Suggestions and solutions
Improved hand hygiene is the simplest, most effective weapon against SSIs. The construction of an anesthesia workstation and the pace and pressure of the ambulatory surgery workflow may make better between-case disinfection of equipment difficult, but you can also set up workstations to better enable hand hygiene as a routine. Making sure there's always a dispenser pump of hand sanitizer on the anesthesia cart, immediately available, means the provider won't have to turn his back on the patient or leave the table to reach a wall-mounted dispenser. I've even seen mini-bottles of hand rub, designed to beep every so often to remind users to cleanse their hands, clipped to scrubs or lab coats.

Double-gloving is a simple approach toward anti-bacterial, anti-viral efforts. The anesthesia provider who puts on 2 pairs of gloves can administer the mask and intubate the patient, then once the tube has been placed, remove the gloves that may have been contaminated by the mouth. The provider is then operating the equipment with cleaner hands. (This requires, of course, that the machine has been previously disinfected.)

A surgeon wouldn't think of operating without a sterile protective gown and mask. But for an anesthesia provider starting a peripheral nerve block or epidural injection, gloves are sometimes the extent of his personal protective equipment. There is nothing formally mandating the use of personal protective equipment for regional anesthesia, but wouldn't you want maximum precautions taken if someone was inserting a needle into your central nervous system?

There is clearly a chasm in terms of antiseptic practice between what surgical staff members and what anesthesia providers routinely do. Ultimately, bridging this gap rests with the providers educating themselves on the potential risks and owning up to the responsibility to change their ways.