Frequency of interactions and hand disinfections among anesthesiologists while providing anesthesia care in the operating room: induction versus maintenance

[Sepsis outbreak associated with use of contaminated propofol: A new case series and literature review]

INTRODUCTION

Propofol is the most commonly used hypnotic agent for the induction and maintenance of general anesthesia. Due to its lipid-based composition, propofol requires a strict handling protocol to avoid an increased risk of extrinsic contamination.

METHODS

On September 09, 2021, 05 patients with post-anaesthetic Enterobacter cloacae infections were identified in the pediatric exploration department of the Hassan II University Hospital of Fez in Morocco. We describe the investigation into this outbreak. All patient medical records were reviewed to determine patient characteristics and potential risk factors. For the literature review, we identified relevant articles by searching PubMed, Medline, Embase and Science Direct.

RESULTS

Our study included five patients, 80% were boys. The average age was 4.6 years (1-7 years), with no medical history. All five patients underwent exploratory procedures. Immediately after the procedures, all 5 patients presented with chills, tachycardia and fever in the same order of admission. They were all admitted to hospital and blood samples were taken. Blood cultures were positive for E. cloacae. All patients had elevated levels of C-reactive protein (CRP) and an elevated white blood cell count. Bacteriological investigation revealed that the infection was caused by extrinsic contamination of the intravenous anesthetic propofol by E. cloacae.

CONCLUSION

Fatal infections due to contaminated drugs, including propofol, have been reported worldwide. Propofol is a potential source of infections due to its lipophilic nature which promotes microbial growth. This probably remains an underestimated problem that deserves awareness for early recognition.

Interactive Interventions Can Improve Hand Hygiene and Aseptic Techniques During Perioperative Care-Experience From the "Safe Hands" Project

PURPOSE

This paper evaluates a theory-driven, interactive hand hygiene (HH) intervention, the Safe Hands project, based on theories of organizational learning and culture including leadership support, dialogue and co-creation.

DESIGN

This prospective quasi-experimental study used unobtrusive overt observations to evaluate adherence to HH recommendations after implementing an infection-prevention intervention.

METHODS

The primary outcome was differences in HH practices "Before aseptic/clean procedure" (WHO moment 2), "After body fluid exposure risk" (WHO moment 3) and performance of aseptic techniques. One operating room (OR) department served as the study hospital and the other as the control hospital, both at Swedish university hospitals. Adherence to HH guidelines was measured 4 times during 2015 to 2017.

FINDINGS

The intervention site displayed a significant improvement in adherence to HH guidelines and aseptic techniques. WHO 2; from 23.8% to 36.2%, (P = .014), WHO 3; from 22.2% to 42.3%, (P = .002), and aseptic techniques; from 17.5% to 31.6%, (P = .003). No changes in adherence were identified at the control site. The use of contaminated gloves decreased post intervention at the study operating department.

CONCLUSIONS

This study shows that implementing tailored interventions that are underpinned by theories from organizational learning and culture can improve adherence to hand hygiene in a complex setting as the OR up to 6 months post-intervention. The interprofessional co-creation of standards operating procedures addressing specific care procedures and emphasizing the importance of aseptic techniques can be an acceptable and feasible way to reduce the risks of contaminating medical devices and patients during perioperative care.

Identifying the World Health Organization's fifth moment for hand hygiene: Infection prevention in the operating room

Background

The World Health Organization have designed the fifth of their '5 moments' for hand hygiene to account for microbial transfer from patients to equipment in a narrow area around that patient, known as the patient zone. The study was prompted by emerging local confusion about application of the patient zone in the operating room (OR).

Aim/Objectives

In two phases, we aimed to create a '5 moments' style poster displaying an OR patient zone: phase 1, quantify equipment, in direct contact with the patient and, touched by non-scrubbed staff immediately after touching the patient; and phase 2, categorise equipment identified in phase 1 into patient zone and healthcare zone. An objective is to produce a '5 moments' poster for the OR.

Methods

The first phase used non-participant direct overt observation. In phase 2, phase 1 data were collaboratively assigned to patient zone or healthcare zone. Photography and graphic design were used to produce the OR '5 moments' poster.

Results

In 11 full-length surgeries, 20 pieces of equipment were in direct contact with the patient and 57 pieces of equipment were touched. In phase 2, a '5 moments' poster showing an OR patient zone was designed.

Discussion

Content of the patient zone was identified and displayed in a novel resource. Having shared understanding of the patient zone has potential to sustain hand hygiene compliance and equipment cleaning in the OR.

Conclusion

Limitations in methods were balanced by collaboration with frontline staff. The study has been used as a teaching tool in the OR and similar settings.

[Hygiene aspects of multidrug-resistant pathogens in the operating room and intensive care unit]

The major multidrug-resistant pathogens (MRE) in human medicine are methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and multidrug-resistant Gram-negative rod bacteria (MRGN). MRE are a very heterogeneous group with respect to epidemiology and therapeutic or hospital hygiene consequences. After MRSA played an important role among MREs at the beginning of the twenty-first century, VRE and MRGN have come to the fore in recent years. During work in the operating room and on the intensive care unit, there are many possibilities for transmission of MRE between the patient environment and the patient, especially via the hands, e. g. during intubation or catheterization in vessels, tissues or the urinary tract. For this reason, hand and surface hygiene is of particular relevance in the prevention of nosocomial colonization or infection, in particular with MRE.

Infectious Disease Risk Associated with Contaminated Propofol Anesthesia, 1989-2014(1)

Transmission of illness to 144 patients, resulting in 10 deaths, has been linked to extrinsic contamination.

Administration of propofol, the most frequently used intravenous anesthetic worldwide, has been associated with several iatrogenic infections despite its relative safety. Little is known regarding the global epidemiology of propofol-related outbreaks and the effectiveness of existing preventive strategies. In this overview of the evidence of propofol as a source of infection and appraisal of preventive strategies, we identified 58 studies through a literature search in PubMed, Embase, and Lilacs for propofol-related infections during 1989–2014. Twenty propofol-related outbreaks have been reported, affecting 144 patients and resulting in 10 deaths. Related factors included reuse of syringes for multiple patients and prolonged exposure to the environment when vials were left open. The addition of antimicrobial drugs to the emulsion has been instituted in some countries, but outbreaks have still occurred. There remains a lack of comprehensive information on the effectiveness of measures to prevent future outbreaks.

Quantifying the rambunctious journey of the anesthesia provider's hands during simulated, routine care

BACKGROUND

The role of anesthesia providers in dispersing potentially pathogenic material from one patient to another during intraoperative care needs further study. In this study we aimed (1) to quantify the dispersion of a surrogate pathogen from a simulated patient's mouth to the anesthesia workstation during routine anesthetic induction, (2) to test the hypothesis that there would be fewer contamination sites by providers who used a double-gloving technique, and (3) to examine the effectiveness of between-case anesthesia apparatus disinfection.

METHODS

Twenty subjects were randomized to a single pair of gloves group (group 1) or a double-gloved group (group 2) and completed a simulated general anesthesia induction, completing a standardized set of interventions. Dispersion of a surrogate pathogen dye placed in the oral cavity of the simulated patient was tracked by a blinded observer and photography. Standard cleaning of the workstation was performed, and residual dye was quantified. Group performance was plotted using regression analysis and rate of contamination compared using parametric statistics.

RESULTS

Group 1 contaminated an average of 16.0 (SEM = 0.89) sites compared with group 2, who contaminated an average of 7.6 (SEM = 0.85). The cart drawers, gas flow dials, medication vials, and ventilator controls were significantly contaminated by group 1, but not by group 2 (P < .05 in all cases). There were similar rates of contamination in both groups for the airway equipment, breathing system, intravenous access ports, and the roll of tape used to secure the endotracheal tube. Once the airway management phase of the induction ended, new site contamination continued at a high rate in group 1 but not group 2.

CONCLUSIONS

A double-gloving technique was associated with less spread of an oral inoculum to the workstation but was not uniformly protective. Between-case cleaning was ineffective in removing the contaminant, indicating that biologic material from one patient may be present when subsequent patients are cared for. This suggests risks for the current patient (eg, skin or oral site transfer to an intravenous site) and also may place future patients at risk. Importantly, using models that simulate actual clinical events can inform clinical practice and decipher challenging areas of ergonomics.

A New Approach to Pathogen Containment in the Operating Room: Sheathing the Laryngoscope After Intubation

BACKGROUND

Anesthesiologists may contribute to postoperative infections by means of the transmission of blood and pathogens to the patient and the environment in the operating room (OR). Our primary aims were to determine whether contamination of the IV hub, the anesthesia work area, and the patient could be reduced after induction of anesthesia by removing the risk associated with contaminants on the laryngoscope handle and blade. Therefore, we conducted a study in a simulated OR where some of the participants sheathed the laryngoscope handle and blade in a glove immediately after it was used to perform an endotracheal intubation.

METHODS

Forty-five anesthesiology residents (postgraduate year 2-4) were enrolled in a study consisting of identical simulation sessions. On entry to the simulated OR, the residents were asked to perform an anesthetic, including induction and endotracheal intubation timed to approximately 6 minutes. Of the 45 simulation sessions, 15 were with a control group conducted with the intubating resident wearing single gloves, 15 with the intubating resident using double gloves with the outer pair removed and discarded after verified intubation, and 15 wearing double gloves and sheathing the laryngoscope in one of the outer gloves after intubation. Before the start of the scenario, the lips and inside of the mouth of the mannequin were coated with a fluorescent marking gel. After each of the 45 simulations, an observer examined the OR using an ultraviolet light to determine the presence of fluorescence on 25 sites: 7 on the patient and 18 in the anesthesia environment.

RESULTS

Of the 7 sites on the patient, ultraviolet light detected contamination on an average of 5.7 (95% confidence interval, 4.4-7.2) sites under the single-glove condition, 2.1 (1.5-3.1) sites with double gloves, and 0.4 (0.2-1.0) sites with double gloves with sheathing. All 3 conditions were significantly different from one another at P < 0.001. Of the 18 environmental sites, ultraviolet light detected fluorescence on an average of 13.2 (95% confidence interval, 11.3-15.6) sites under the single-glove condition, 3.5 (2.6-4.7) with double gloves, and 0.5 (0.2-1.0) with double gloves with sheathing. Again, all 3 conditions were significantly different from one another at P < 0.001.

CONCLUSIONS

The results of this study suggest that when an anesthesiologist in a simulated OR sheaths the laryngoscope immediately after endotracheal intubation, contamination of the IV hub, patient, and intraoperative environment is significantly reduced.

Quantification of hand hygiene compliance in anesthesia providers at a tertiary care center in northern India

Hand hygiene (HH) compliance continues to remain poor amongst anesthetists mainly because of multitasking and the need for repeated HH. We aimed to quantify HH compliance amongst anesthesia providers while performing anesthesia-related procedures inside operating rooms. The observations for HH before and after procedures, including placement of intravenous cannula, intubation, central line placement, arterial line placement, and neuraxial and peripheral nerve block, were made by a single observer in operating rooms where elective surgeries are carried out. The overall compliance of all health care workers was 39.6%. Resident physicians were less likely to be compliant than consultant physicians and there was significant variation in procedure-related HH with maximum compliance before neuraxial block (100%) followed by arterial line placement (93.7%), central line insertion (86.7%), and peripheral nerve block (80%) (P < .001). The compliance after performing the above procedures was <50% for all procedures.

Hand hygiene and aseptic techniques during routine anesthetic care - observations in the operating room

BACKGROUND

More knowledge is needed about task intensity in relation to hand hygiene in the operating room during anesthetic care in order to choose effective improvement strategies. The aim of this study was to explore the indications and occurrence of hand hygiene opportunities and the adherence to hand hygiene guidelines during routine anesthetic care in the operating room.

METHODS

Structured observational data on hand hygiene during anesthetic care during 94 surgical procedures was collected using the World Health Organization's observational tool in a surgical department consisting of 16 operating rooms serving different surgical specialties such as orthopedic, gynecological, urological and general surgery.

RESULTS

A total of 2,393 opportunities for hand hygiene was recorded. The number of hand hygiene opportunities when measured during full-length surgeries was mean = 10.9/hour, SD 6.1 with an overall adherence of 8.1%. The corresponding numbers for the induction phase were, mean =77.5/h, SD 27.4 with an associated 3.1% adherence to hand hygiene guidelines. Lowest adherence was observed during the induction phase before an aseptic task (2.2%) and highest during full-length surgeries after body fluid exposure (15.9%).

CONCLUSIONS

There is compelling evidence for low adherence to hand hygiene guidelines in the operating room and thus an urgent need for effective improvement strategies. The conclusion of this study is that any such strategy should include education and practical training in terms of how to carry out hand hygiene and aseptic techniques and how to use gloves correctly. Moreover it appears to be essential to optimize the work processes in order to reduce the number of avoidable hand hygiene opportunities thereby enhancing the possibilities for adequate use of HH during anesthetic care.