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Anesthesia Alert: An Infection Risk at the Head of the Table?
There might be if your anesthetists practice poor hand hygiene.
Clarence Biddle
Publish Date: December 1, 2015   |  Tags:   Infection Prevention
breaches of aseptic technique DOUBLE STANDARD Shocking breaches of aseptic technique routinely occur on the anesthesia side of the surgical drape.

Yes, we anesthesia providers routinely do things that the folks on the surgery side of the table would consider abominable. For example, not disinfecting our hands after airway manipulation, not putting gloves on to start an IV and not cleaning the anesthesia workstation between cases.

Not that we're bad people, or less skilled, or less intelligent. The problem is that there's a cultural divide that's been perpetuated for many decades. The demarcation is the surgical drape between anesthesia and surgery, and the different standards are on display every day.

One reason is that it's nearly impossible to maintain aseptic technique when you're required to use both hands and then quickly move them to something else. While intubating, for example, you may have to quickly reach over and touch the reservoir bag to ventilate the patient. Or you may have to adjust the ventilator circuit, or inject drugs into stopcocks.

poor hand hygiene CAUGHT IN THE ACT Have you observed your anestheisa providers practicing poor hand hygiene?

Hands in motion
Anesthesia providers are involved in a continuous stream of activity. And a lot of tasks involving the patient, the equipment and drugs have to occur in rapid succession. If our only job were to draw up drugs and inject them aseptically, that in and of itself would be a task-dense, time-consuming activity. When you add the need to manage the airway and adjust the anesthesia machine, you have 3 different domains your hands are involved in, all at the same time. Even if you wear gloves, it's impossible not to transfer organisms from one domain to the others, as a wealth of literature (osmag.net/GVxT8d, for example) makes clear. And the notion that you might always be able to engage in some sort of hand hygiene between any 2 tasks is both impractical and far outside the culture.

There's a good chance providers are also dealing with 4th and 5th domains — the drug/equipment cart and the keyboard for the EHR. Take one break during a long case and touch that cart — maybe there's a need to start a new IV, or grab a bag of fluid — and the cart is going to be contaminated by biomaterial from those other domains.

6 Hand Hygiene Tips for Anesthetists

1 Make disinfection easier. To make it as easy as possible to thoroughly wipe down anesthesia machines between patients, mount disinfectant wipes on each machine so that your anesthesia providers can clean surface areas, knobs and dials.

2 Plan ahead. Try to have all supplies you might use out and on the anesthesia machine before the case starts, and treat the anesthesia machine as a contaminated area. If you have to go back to the cart during the case, make sure you remove your gloves and foam your hands.

3 Diligently wear gloves. A lot of breaches occur in this area. Providers are well aware that they need to wear them, but the gloves often come off for one reason or another. To the greatest extent possible — and it isn't always possible — switch to clean gloves every time you deal with a new domain.

4 Beware of the glove box. Most facilities have glove boxes with disposable gloves available to the anesthesia provider. But unless care is taken, every time you reach in to get a fresh pair, you may contaminate both the gloves you're about to put on and the other gloves in the box.

5 Double-glove during airway management. Once the airway is secure, take the outer pair off.

6 Educate. We regularly go through all kinds of educational modules to maintain privileges — modules having to do with harassment, fire safety, and trips and falls — but I've never seen one on the risks of diseases or transmission of pathogens in the workplace. It's been shown that a sophisticated campaign aimed at maintaining hand hygiene among anesthesia providers can lead to a reduction of surgical site infections, and maybe even a reduction in mortality.

— Clarence J. Biddle, CRNA, PhD

pie chart
OSM Logo\

Do your anesthesia providers practice poor hand hygiene?

  • Very often29%
  • Often22%
  • Sometimes32%
  • Rarely14%
  • Never3%

SOURCE: Outpatient Surgery Magazine, November 2015, n=232

Just the way it is?
Ultimately, what we're talking about is normalized deviance. If we were to objectively observe and judge what we do, we'd immediately recognize the inherent problems. But we've gotten away with it for so long that we've normalized our wrongful behavior.

And really, for a long time the idea that anesthesia providers might be contributing to SSIs or other complications was off our radar. After all, we typically lose touch with patients in the aftermath of our care, which is when complications usually manifest. Only in the last few years have a significant number of voices grown louder, trying to get this onto our radar screens as we've realized it's very likely that we're contributing to the problem.

Unfortunately, there's no Holy Grail in the quest for aseptic anesthetic technique. The ergonomics of the current anesthesia workstation make it impossible to engage in actions that those on the surgical side would consider acceptable. Some cross-contamination among the domains is inevitable. But that doesn't mean we can't do much better. We need to think creatively about improving designs, and there are steps we should be taking immediately.