Implementation of Single-Use Anesthesia Circuit Disinfection Guidelines in a Resource-Scarce Setting

Implementation of Single-use Anesthesia Circuit Disinfection Guidelines in a Resource-scarce Setting

Item Type text; Electronic Dissertation

Authors Johnston, Rachel

Citation Johnston, Rachel. (2021). Implementation of Single-use Anesthesia Circuit Disinfection Guidelines in a Resource-scarce Setting (Doctoral dissertation, University of Arizona, Tucson, USA).

Publisher The University of Arizona.

Rights Copyright © is held by the author. Digital access to this material is made possible by the University Libraries, University of Arizona. Further transmission, reproduction, presentation (such as public display or performance) of protected items is prohibited except with permission of the author.

Download date 30/09/2021 06:12:15

Link to Item http://hdl.handle.net/10150/658601 IMPLEMENTATION OF SINGLE-USE ANESTHESIA CIRCUIT DISINFECTION

GUIDELINES IN A RESOURCE-SCARCE SETTING

Rachel M. Johnston

A DNP Project Submitted to the Faculty of the

COLLEGE OF NURSING

In Partial Fulfillment of the Requirements

For the Degree of

DOCTOR OF NURSING PRACTICE

In the Graduate College

THE UNIVERSITY OF ARIZONA

2 0 2 1

ACKNOWLEDGMENTS

To my fiancé Andy, thank you. I wonder every day how I got so lucky to cross your path in a tiny town in Guatemala. I wonder how it is that you have so tirelessly supported me through every crazy idea and seemingly unobtainable goal I have put in front of us. I wonder what I would have done without you through these last three years that have felt like they would never end. Thank you for always making me laugh, for being a temporary single parent to our two fat cats, and to holding it together when all I wanted to do was fall apart. Your love, your patience, and your never-ending support is what has gotten me to the finish line. This is as much your success as it is mine. I love you, forever and always.

DEDICATION

This project is dedicated to every healthcare worker who has had to deliver care in a setting without adequate supplies or resources. Your dedication and flexibility in the face of extreme challenge does not go unnoticed.

TABLE OF CONTENTS

LIST OF FIGURES ...... 8 LIST OF TABLES ...... 9 ABSTRACT ...... 10 INTRODUCTION...... 11 Background Knowledge ...... 12 Local Problem ...... 14 Intended Improvement ...... 15 Project Purpose ...... 15 Project Question ...... 15 Project Objectives ...... 16 Project Stakeholders ...... 16 Theoretical Framework ...... 16 Literature Synthesis ...... 20 Identified Themes...... 21 ABC Reuse with Filter Use ...... 21 Surface Disinfection of the ABC and Work Environment ...... 22 Adherence to Protocol ...... 23 Strengths, Weaknesses and Gaps of Evidence ...... 23 METHODS ...... 24 Project Design...... 24 Model for Implementation ...... 25 Plan ...... 25 Do ...... 26 Study...... 26 Act...... 26 Setting and Stakeholders ...... 27 Planning the Intervention ...... 29 Guideline Creation ...... 29

TABLE OF CONTENTS - Continued

End of Each Case ...... 29 End of Day ...... 30 Weekly...... 31 Guideline Revision ...... 31 Education Session...... 31 Timeline ...... 32 Participants ...... 33 Methods of Evaluation ...... 33 Data Collection and Analysis ...... 33 Consent and Ethical Considerations ...... 34 RESULTS ...... 35 Survey Delivery ...... 35 Outcomes ...... 35 DISCUSSION ...... 38 Summary ...... 38 Interpretation ...... 38 Implications ...... 38 Limitations ...... 39 DNP Essentials Addressed ...... 39 DNP Essential I: Scientific Underpinnings for Practice ...... 40 DNP Essential II: Organizational and Systems Leadership for Quality Improvement and Systems Thinking...... 40 DNP Essential III: Clinical Scholarship and Analytical methods for Evidence-Based Practice...... 40 DNP Essential IV: Information Systems/Technology and Patient Care Technology for the Improvement and Transformation of Health Care ...... 41 DNP VI: Interprofessional Collaboration for Improving Patient and Population Health Outcomes ...... 41

TABLE OF CONTENTS - Continued

DNP Essential VIII: Advanced Nursing Practice ...... 41 Conclusions ...... 42 Plan for Sustainability ...... 42 Plan for Dissemination ...... 42 APPENDIX A: LAO FRIENDS HOSPITAL FOR CHILDREN SITE APPROVAL ...... 44 APPENDIX B: CONSENT DOCUMENT (DISCLOSURE FORM) ...... 46 APPENDIX C: EVALUATION INSTRUMENTS (GUIDELINE COMPLIANCE – ORIGINAL SURVEY / GUIDELINE COMPLIANCE - SURVEY RESULTS) ...... 48 APPENDIX D: PARTICIPANT MATERIAL (LAO FRIENDS HOSPITAL FOR CHILDREN [LFHC] – ANESTHESIA BREATHING CIRCUIT [ABC] DISINFECTION GUIDELINES [REVISED] / LAO FRIENDS HOSPITAL FOR CHILDREN [LFHC] – ANESTHESIA BREATHING CIRCUIT [ABC] DISINFECTION GUIDELINES [ORIGINAL] / SHORTENED VERSION OF ABC DISINFECTION GUIDELINES)...... 53 APPENDIX E: SPAULDING CLASSIFICATION OF EQUIPMENT DECONTAMINATION ...... 57 APPENDIX F: PROJECT TIMELINE ...... 59 APPENDIX G: LITERATURE REVIEW GRID...... 61 APPENDIX H: OTHER DOCUMENTS AS APPLICABLE TO THE PROJECT (EMAIL COMMUNICATIONS REGARDING APPROVAL AND REVISIONS REGARDING GUIDELINES / WEBSITE LINK FOR LIST OF PRODUCTS THAT KILL COVID-19 VIRUS) ...... 73 REFERENCES ...... 80

LIST OF FIGURES

Figure 1 Adapted Diffusion of Innovations Theory Illustration ...... 19 Figure 2 Model for Improvement Illustration...... 27

LIST OF TABLES

Table 1 Participant Responses to Survey Questions on Guideline Compliance...... 36 Table 2 Participant Responses to Survey Questions on Barriers to Guideline Use ...... 37

ABSTRACT

Purpose: The purpose of this quality improvement project was to create and implement

evidence-based guidelines on the reuse of single-use anesthesia breathing circuits at Lao Friends

Hospital for Children in Luang Prabang, Laos.

Background: Single-use medical devices are used in both developed and developing countries throughout the world. In developing countries, a gross lack of resources results in this practice occurring without a standardized way to reprocess and reuse the devices. This leads to an increased risk of infection and adverse patient outcomes. Anesthesia breathing circuits are among some of the most commonly reused single-use medical devices in developing countries.

Methods: A single-use anesthesia breathing circuit disinfection guideline was created based on available evidence, and tailored to fit within the funding and resource capacity of Lao Friends

Hospital for Children (LFHC). Education on guideline use was provided remotely, and

compliance to the guideline was assessed via verbal survey at a remote follow-up meeting

approximately three weeks following implementation. Barriers to compliance were also assessed

through survey delivery.

Results: Guideline compliance was achieved for nearly every component of the guideline from

all three participants. The exceptions were a result of lack of supplies and inapplicability of one

of the questions to current practice at LFHC. The only identified barrier to compliance was the

lack of necessary supplies. No changes to the guideline were suggested.

Conclusions: After incorporating evidence-based practice with appropriate changes tailored to

the unique setting of LFHC, guideline creation and implementation was successful. This

demonstrates that even in resource-scarce settings, improvements to practice can be made.

INTRODUCTION

The reuse of single-use medical devices (SUDs) is a common practice in many countries throughout the world (Popp et al., 2010). While the abundance of resources in developed countries allows for disposal of SUDs after each patient use, SUD reprocessing and reuse often occurs for economic or environmental reasons (Mansur, 2017). The SUDs that are reused tend to

be more expensive products, where their reuse is deemed safe after following strict reprocessing

protocols that ensure adequate disinfection and continued functionality (Eze et al., 2018). In

developing countries, the practice of reusing SUDs is borne out of necessity. The shortage of

medical equipment in these countries actively contributes to the higher mortality rate that is seen

for conditions that would otherwise, if the resources were available, be treated promptly (Eze et

al., 2018). Lack of funding and resources creates an environment where the reuse of SUDs is the

only available option for treatment delivery (Mansur, 2017).

Anesthesia breathing circuits (ABCs) are among some of the most commonly reused

SUDs (Popp et al., 2010). Surgery and subsequent anesthetic delivery is a universal need in the

healthcare industry. In developing countries, the need for surgery often surpasses its delivery due

to a lack of availability of vital equipment (Meara et al., 2015). The solution comes in the form

of reusing necessary items such as ABCs.

Developed countries have the advantage of being overseen by regulatory bodies who

ensure SUD reuse is carried out safely and effectively. In most developing countries, no such

regulation exists (Eze et al., 2018). The risk to patient safety when SUDs are reused without any

regulation or oversight can carry devastating consequences. In order to mitigate this risk,

guidelines that ensure adequate reprocessing and reuse must be developed that can fit within the

scope of the resource-scarce setting. Unfortunately, there is a gross lack of research available in the literature that lends to how developing countries can safely reuse SUDs. Furthermore, available literature on ABC reuse comes from developed countries where their methods of reuse are now well-established and designed with whatever resources are required (Association of

Anaesthetists of Great Britain and Ireland [AAGBI], 2008; Dubler et al., 2016; McGain et al.,

2014). Although the available literature is both limited and somewhat irrelevant to a resource- scarce setting, the need for change in these settings still exists. Guidelines for single-use ABC reuse can be developed from available literature and tailored appropriately for the implementation setting.

Background Knowledge

According to the United States Food and Drug Administration (USFDA), “reprocessing includes all the steps performed to make a contaminated reusable or single-use device patient ready” (USFDA, 2000, p. 38). This practice typically includes cleaning the device, ensuring its functionality, disinfecting or sterilizing it, repackaging it, and then relabeling it (USFDA, 2000).

Depending on the device, this process can be extremely costly and is often not feasible in a resource-scarce setting. This results in these settings having to use whatever is available to reprocess the device, which is often inadequate (Popp et al., 2010).

ABCs consist of long, corrugated tubing that can be challenging to clean properly

(Juwarkar, 2013). They are a vital component of day-to-day anesthesia care; without a clean, functioning circuit, the patient is at an increased risk of postoperative respiratory infection and adverse events related to intraoperative circuit failure (Lemos & Poveda, 2019; Schulz-Stubner et al., 2013). Schulz-Stubner et al. (2013) conducted an experimental study following a

vancomycin-resistant enterococci (VRE) outbreak among five patients in an 18-bed intensive

care unit (ICU). They found that inadequate surface decontamination of a transport breathing

circuit was the likely vector for infection (Schulz-Stubner et al., 2013). Additionally, a closed claims analysis by Caplan et al. (1999) noted that ABCs were the most frequently-cited source of anesthesia breathing equipment-related claims, with death and brain damage cited as the most common adverse outcomes.

Both reusable and single-use ABCs are available for use. Reusable ABCs are made with material meant to withstand disinfection and reuse. In contrast, single-use ABCs are made with cheaper, less durable material (Appendix H) (K. Fallon, personal communication, Oct. 29, 2019).

ABCs are designated as semi-critical items per the Spaulding classification scheme, meaning that their contact with mucous membranes and non-intact skin requires high-level disinfection for reuse (Appendix E) (Rutala & Weber, 2019; Spaulding, 1968). The most common practices for high-level disinfection of ABCs include thermal disinfection such as pasteurization, or chemical disinfection with glutaraldehyde (Rutala & Weber, 2019).

In developed countries, both single-use ABCs and reusable ABCs are used. However, significant variation exists in how long the ABCs are used for. The practice in the United States

(US) is to use single-use ABCs and dispose of them after each surgical case (Halbeis et al.,

2008). In the United Kingdom (UK), the AAGBI (2008) recommends that ABCs are disposed of daily provided a filter is used with each patient, although they acknowledge the safety of seven- day use. The typical practice in Germany calls for a seven-day use of ABCs if a filter is used with each patient; the ABC is then disposed of if single-use, or disinfected per hospital protocol if reusable (Dubler et al., 2016). Although no specific recommendations exist for Australia, a

prospective microbiological study by McGain et al. (2014) demonstrated no statistically significant difference in bacterial contamination with seven-day use of the ABC with filter use for each patient, prompting wide adoption of the seven-day use.

Depending on the disposal interval, pursuing a large inventory of single-use ABCs can be costly. A reusable ABC is considerably more expensive than a single-use ABC as they are designed to withstand high-level disinfection, although the overall savings can be significant considering the much smaller inventory required. However, both the funds and resources needed for high-level disinfection must be considered. Additionally, a hospital that chooses to use reusable ABCs must have a standardized protocol in place that details reprocessing (Mansur,

2017). Developing countries often cannot afford the high price of reusable ABCs, nor the equipment and materials necessary for reprocessing them. Their solution comes in the form of purchasing and reusing inexpensive single-use ABCs.

Local Problem

This project takes place at Lao Friends Hospital for Children (LFHC) in Luang Prabang,

Laos. The country of Laos, with a population of approximately seven million people, is one of the poorest countries in Southeast Asia (Central Intelligence Agency [CIA], 2020). Their current health expenditure, or the amount spent on health relative to economy size, is only 2.4% (CIA,

2020). Life expectancy at birth is approximately 66 years, ranking Laos 193rd among other countries in the world (CIA, 2020). Approximately 46 of every 1000 newborns die before their first birthday, emphasizing the desperate need for improved access to health care among infants and children (CIA, 2020).

LFHC was established in 2015 by the charitable organization Friends without a Border

(FWAB) as a way to increase health care access for families residing in northern Laos (FWAB,

2019a; FWAB, 2019b). While it has greatly improved health care access to children in the

community, a shortage of resources remains a persistent problem. In order to meet anesthetic demand, single-use ABCs are purchased from different manufacturers in China based on the lowest price available (R. Henker, personal communication, July 7, 2019). They are reused until they are no longer functional; loss of functionality is noted when leaks are detected intraoperatively, at which point small holes are usually found in the tubing (R. Henker, personal communication, July 7, 2019). The ABCs are surface-disinfected with chlorhexidine at inconsistent intervals, with no method identified for disinfecting the internal surfaces (R. Henker, personal communication, July 7, 2019). There are only one to two available ABCs in rotation at any given time (R. Henker, personal communication, July 7, 2019). This leaves very little room for error if a circuit becomes dysfunctional.

Intended Improvement

Project Purpose

The purpose of this doctor of nursing practice (DNP) project was to implement evidence-

based guidelines on the disinfection and reuse of single-use ABCs at LFHC. These guidelines

were tailored to fit within the scope of LFHC, keeping in mind the lack of available funding and

resources.

Project Question

Will implementation of evidence-based guidelines on the disinfection and reuse of single-

use ABCs at LFHC lead to overall compliance and sustainability of guideline use?

Project Objective

This project defined a single-use ABC disinfection guideline that was developed in collaboration with LFHC to ensure it did not exceed the local resource and funding limitations.

Guideline education was provided to LFHC staff prior to implementation. After education was complete and the staff felt confident in following the guideline, implementation occurred.

Implementation was assessed with LFHC staff via Zoom approximately three weeks following initial guideline education. Compliance with the guideline and barriers to guideline use were measured via verbal survey delivery. Data collected are not generalizable; the collected data was only used to measure guideline compliance and to assist in the identification and management of barriers to compliance at LFHC.

Project Stakeholders

The immediate stakeholders include the anesthesia staff, operating room (OR) staff, and organizational leaders at LFHC. In the long-term, the stakeholders also include the patients; although less measurable, the hope is that guideline implementation will lead to a decreased risk of postoperative respiratory infection and adverse intraoperative events in the future.

Theoretical Framework

The theoretical framework chosen for the purposes of this project is Everett Rogers’ diffusion of innovations (DOI) theory (Rogers, 2003). The DOI theory was developed by Rogers in 1962 as a way to describe the process by which an innovation diffuses through a social system

(Rogers, 2003). It includes four main components – the innovation itself, the channels through which the innovation is communicated, the time required for diffusion, and the social system

through which diffusion takes place (Rogers, 2003). Ultimately, all of these components play a

critical role in determining whether or not the innovation is adopted or rejected (Rogers, 2003).

Rogers believes that the innovation must prove advantageous to the stakeholders (i.e., an

improvement from the current practice), is compatible with existing workflow, is not overly

complex, can be trialed before full implementation, and has an observable benefit (Rogers,

2003). The channels through which the innovation diffuses can be as simple as informal word-

of-mouth communication, or through mass media channels that allow information dispersal to a larger audience at one time (Rogers, 2003). The element of time involves both the length of time it takes an individual to choose to adopt or reject the innovation, also known as the innovation- decision process, and how innovative each individual is as defined through adopter categories

(Rogers, 2003). The adopter categories include innovators, early adopters, early majority, late majority, and laggards; innovators and early adopters are quick to adopt the new innovation, while the late majority and laggards tend to be more skeptical and resistant to the change

(Rogers, 2003). The social system includes the interrelated members through which the innovation diffuses; the structure and behavior of each member within a social system can either accelerate or hinder the diffusion process (Rogers, 2003).

Diffusion theory has been used in the past to explain the successes or failures of innovation implementation in resource-scarce settings. For example, Belasco (1990) used diffusion research to investigate why Egyptian villagers preferred contaminated canal water to piped, chlorinated water that had been implemented as part of a project by the Egyptian government to provide clean water to the villagers. He found that that the villagers’ negative perceptions of the piped water and lack of cultural/behavioral consideration in innovation

development ultimately led to rejection of the innovation (Belasco, 1990). This highlights the

importance of first developing an innovation that carefully fits within the setting it will be

implemented in.

One of the limitations to utilizing Rogers’ theory in developing countries is the lack of

adaptability of certain technologies to the resource-scarce setting (Zanello et al., 2015).

However, Zanello et al. (2015) argue that this theory can be applicable to these settings when the innovation is developed using existing knowledge from developed countries, while keeping the available resources and limitations in mind. This was an extremely important component during the development of ABC disinfection guidelines for LFHC. While the literature from developed countries supports disinfection of ABCs with pasteurization or glutaraldehyde (Hartmann et al.,

2008; McGain et al., 2014; Rutala & Weber, 2019), the lack of funding, available equipment, and space for disinfection made this option impractical at LFHC. Therefore, the guideline was created according to what Rogers argues makes an innovation most successful – it proves advantageous to LFHC staff, is compatible with current practice, simple to use, can be tested before full implementation, and will have an observable benefit that further encourages adoption by staff (Figure 1) (Rogers, 2003).

The social system involved in guideline implementation is relatively small, consisting of anesthesia staff, the chief nursing officer, and the nurse educator (Figure 1). This intimate social system may prove advantageous in diffusion, as interpersonal channels can be more effective in persuading others to accept the new idea than more generic forms of information exchange

(Rogers, 2003). Diffusion may also be seen on a larger scale if initial implementation at LFHC proves successful, as LFHC is somewhat of a role model for other hospitals in Northern Laos (R.

Henker, personal communication, June 2, 2020). Additionally, ideas are more likely to be spread between individuals that share common beliefs, culture, and language (Rogers, 2003). An education session that targets those who are more apt to adopt the guideline, or as Rogers calls innovators and early adopters, will ideally encourage its spread throughout the social system

(Figure 1) (Rogers, 2003). The nurse educator at LFHC will provide valuable input for the creation and delivery of guideline education, as she has a thorough understanding of cultural and language factors that must be taken into consideration. Those who are more resistant to the guideline may require more time for adoption, but will ultimately be encouraged if those around them support its use (Rogers, 2003).

Figure 1

Adapted Diffusion of Innovations Theory Illustration

Literature Synthesis

A literature search was conducted using the PubMed, CINAHL, and Embase databases.

Each search included a combination of the following terms – “anesthesia circuit,” “circuit,”

“breathing circuit,” “single-use,” “disposable,” “equipment re-use,” “re-use,” “guidelines,” and

“disinfection.” Each search was narrowed to the last five years. However, given the gross lack of articles found that were published within the last five years on this topic, some older articles within the last 10 years were included. Most combinations resulted in zero results found, or a larger number of articles found that were not useful for this project topic. The most successful search combination was found using the terms “anesthesia circuit” and “disinfection” (Appendix

G).

In the advanced PubMed search builder, the terms “anesthesia circuit” and “disinfection” yielded 15 results. Narrowing to publication within five years yielded zero results. Expansion to

10 years yielded three results, two of which were accessible and relevant (Arai & Azevedo,

2011; McGain et al., 2014). Using the “similar articles” tool, four more articles were found

(Dubler et al., 2016; Hübner et al., 2011; Rutala & Weber, 2019; Spertini et al., 2011). In

CINAHL, using the terms “anesthesia circuit” and “disinfection” yielded four results, one of which was relevant but had already been found in the PubMed database (McGain et al., 2014).

In Embase, the following search terms were used – “anesthesia circuit,” “disposable” OR

“single use,” and “disinfection.” This yielded 230 results from 1964 to 2020. The search results were narrowed to the last five years, which yielded 65 results. Unfortunately, only one article was found to be relevant (Wilson & Nayak, 2019). Expansion to 10 years resulted in an additional article of relevance (Shuman & Chenowith, 2012). By searching the terms “circuit”

and “disinfection,” 121 articles were found. Narrowing to the last five years yielded 37 articles, only one of which was relevant but was in Mandarin and unfortunately was unable to be translated. By expanding the search to the last 10 years, 17 more articles were included of which four were considered relevant with some found to be duplicates from the other database searches

(Arai & Azevedo, 2011; McGain et al., 2014; Schulz-Stubner et al., 2013; Sui et al., 2012).

Articles were chosen based on their ability to contribute to the creation of single-use

ABC guidelines. The original hope of this project was to find literature that would support the continual reuse of single-use ABCs if a proper disinfection protocol was in place; however, as this literature does not exist and it was discovered that such a practice could actually contribute to circuit breakdown (Appendix H) (K. Fallon, personal communication, October 29, 2019), the focus shifted to what is both safe and feasible at LFHC. While it was difficult to find current literature specific to single-use ABC disinfection, several themes were identified as important aspects to guideline creation.

Identified Themes

ABC Reuse with Filter Use

Some of the most current literature included studies that attempted to discern if ABCs could be reused for up to seven days provided a new filter is used for each patient (Dubler et al.,

2016; Hubner et al., 2011; McGain et al., 2014). Dubler et al. (2016), Hubner et al. (2011), and

McGain et al. (2014) all tested pre- and post-use bacterial counts in the inner lumen of the ABC when used for up to seven days before disinfecting or disposing of them (depending on whether the ABC was reusable or single-use). All three studies concluded that ABCs can be safely reused

for up to seven days without a statistically significant increase in bacterial numbers on the inner

lumen of the ABC (Dubler et al., 2016; Hubner et al., 2011; McGain et al., 2014).

Surface Disinfection of the ABC and Work Environment

Further analysis of the literature shed light on the importance of outer surface disinfection

in addition to ensuring disinfection of the inner lumen of the ABC. The experimental study by

Schulz-Stubner et al. (2013) noted a 95% decrease in surface decontamination following a single-wipe disinfection of a transport ventilator circuit that was responsible for a VRE outbreak among ICU patients. While investigating both inner and outer surface ABC contamination,

Dubler et al. (2016) found a nearly 10% increase in the number of ABCs found to have bacterial contamination on their outer surface between samples taken at one day versus seven days of use.

Sui et al. (2012) noted a marked increase in bacterial contamination of ventilator circuits over an eight-hour time period following swab samples taken at 30 minutes, eight hours, and 24 hours after initial disinfection. This prompted recommendations for full surface disinfection at least every eight hours (Sui et al., 2012).

The experimental study by Sui et al. (2012) also included a discussion of bacterial contamination throughout the work area surrounding the breathing circuit and ventilator. While this project did not initially aim to include this as a focus, using the “similar article” function led to the discovery that this issue also strongly applies to the anesthesia work area (AWE) (Loftus et al., 2012). A randomized observational study by Loftus et al. (2012) found the AWE to be a vector for bacterial transmission to intravenous (IV) stopcock sets when disinfection is inadequate, placing the patient at risk for infection with each IV injection. Additionally, Hubner

et al. (2011) found high levels of bacterial contamination on the respiratory bags of the

anesthesia machine from samples that were taken at multiple time points throughout use.

Adherence to Protocol

The available literature also highlighted the importance of adhering to standardized

protocols to ensure thorough and consistent disinfection practice (Altinisik et al., 2016; Gray et

al., 1999; Spertini et al., 2011). Spertini et al. (2011) performed an observational study that

demonstrated bacterial growth in 43% of internal ABCs; interestingly, the bacterial

contamination appeared to be related to lack of adherence to the disinfection protocol as opposed

to deficiencies in the protocol itself. In exploring this topic further, a retrospective study by Gray

et al. (1999) discovered a breakdown in the standard disinfection process of ventilator circuits to

be responsible for a bacillus cereus outbreak among neonates in the neonatal ICU. Additionally, a survey conducted by Altinisik et al. (2016) on anesthesia providers’ knowledge of anesthesia machine disinfection practices discovered significant gaps in knowledge of how disinfection should be performed, despite this being a typical job responsibility.

Strengths, Weaknesses and Gaps of Evidence

It is worth noting the immense difficulty in finding current literature to improve practices in a resource-poor setting, when these practices have already been improved and perfected for many years in developed countries (Shuman & Chenoweth, 2012). However, any change to

current practice – even if based on older literature – may still result in improvement and is therefore worth investigating. The most significant strengths found in the available literature is that there are feasible, proven interventions that can be incorporated into guideline creation.

Outer surface ABC and AWE decontamination are both reasonable and cost-effective means of

decreasing infection risk, and are demonstrated as effective practices in the literature (Loftus et

al., 2012; Schulz-Stubner et al., 2013). The literature also shows the importance of adherence to

standardized disinfection practices (Spertini et al., 2011; Gray et al., 1999). This further

highlights both the importance and feasibility of developing a clear, standardized ABC

disinfection guideline that is designed within the setting’s resource boundaries.

Unfortunately, the weaknesses and gaps in the literature related to this project are vast.

As stated previously, literature on this topic that is specific to a resource-poor setting is virtually non-existent (Shuman & Chenoweth, 2012). To complicate matters, many of the issues faced in these resource-poor settings are not issues seen in many of the developed countries where literature of this kind is typically performed. This leads to a significant gap in what literature is available for guideline creation in this setting. Additionally, there is a gross lack of literature from within the last five years. This may be due to the fact that developed countries where studies of this kind are often performed have already established ABC disinfection and reuse guidelines (AAGBI, 2008). This results in guideline creation that must be based off older literature from settings where resource scarcity is not normally an issue.

METHODS

Project Design

The purpose of this project was to implement evidence-based guidelines on the disinfection and reuse of single-use ABCs in a resource-scarce setting. It involved the creation of an ABC disinfection guideline that was tailored to LFHC, with a remote education session conducted via Zoom to LFHC staff. Following remote implementation, the original plan was to test compliance and the need for guideline changes on-site in July of 2020 using surveys with

closed-ended questions, along with observance and in-person focus groups to supplement the quantitative methods (Appendix C). However, the 2019 coronavirus disease (COVID-19) pandemic has brought into question the ability to travel internationally. As of this writing,

COVID-19 has infected more than 99 million people worldwide, and has caused over two million deaths (World Health Organization [WHO], 2021). Given these circumstances, the safest and most feasible option for project implementation was planned for. Compliance was tested remotely via surveys delivered verbally online via Zoom. Results were recorded, analyzed, and followed up with any necessary guideline changes based on what was found.

Model for Implementation

This project used the model for improvement (MFI) developed by Langley et al. (2009) to accelerate the intended improvement at LFHC (Figure 2). The MFI begins with setting time-

specific and measurable aims, selecting the change that should occur, and identifying the

quantitative measures that will help determine if the change led to improvement (Institute for

Healthcare Improvement [IHI], 2019b). The plan-do-study-act (PDSA) tool is a component of the MFI and was used to test the implemented change (IHI, 2019b). It provides an effective way to first test change on a small scale (IHI, 2019a). Each PDSA cycle allows the change to be refined and perfected, ensuring successful long-term implementation (IHI, 2019a).

Plan

The ‘plan’ portion of the PDSA tool involves understanding the change one wants to make and developing the plan to make that change happen (IHI, 2019a). At LFHC, recent focus has fallen on improving infection control practices in the OR; it was specifically noted that the way ABCs were being reused was a particular infection control problem that needed

improvement (R. Henker, personal communication, July 7, 2019). The plan that was created to

make this change happen came in the form of ABC disinfection guidelines, in the hopes that a

standardized protocol that was easy to follow will improve infection control practice (Figure 2).

The ‘do’ portion of the PDSA tool involves a small-scale test of the change (IHI, 2019a).

This trial-and-error step allows problems with the change to be brought to attention, as well as unexpected observations to be made and documented (IHI, 2019a). During this step, the staff at

LFHC had the opportunity to test out the guidelines following a remote education session on guideline use. While the original guidelines were created to fit within the resource constraints of

LFHC, it is hardly reasonable to think that initial implementation will come without problems.

This step was critical in determining the adjustments that needed to be made. A survey was given following an approximate three-week implementation period on guideline compliance that shed light on possible barriers (Figure 2).

Study

Following small-scale implementation, the ‘study’ portion of the PDSA tool involves careful analysis of what went right and what went wrong with implementation (IHI, 2019a).

Results from the surveys on compliance were analyzed, and themes identified. Additionally, staff input via Zoom meetings were invaluable in further describing what problems were discovered and subsequent changes that could be made (Figure 2).

Act

During the ‘act’ portion of the PDSA tool, changes are made to the intervention based on

the problems that were identified in the first test of change (IHI, 2019a). This came in the form

of changes to the guideline formatting in order to increase ease of use among LFHC staff. Once

necessary changes were made, reimplementation occurred (Figure 2).

Figure 2

Model for Improvement Illustration

Concepts from the Model for Improvement and Plan-Do-Study-Act Method developed by Associates in Process Improvement as it relates to this DNP project. Adapted from “The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd ed.),” by G.L. Langley, R. Moen, K.M. Nolan, T.W. Nolan, C.L., Norman, & L.P. Provost. Copyright 2009 by Jossey-Bass Publishers.

Setting and Stakeholders

As discussed previously, the setting of this project takes place at LFHC, one of only two

pediatric hospitals in Laos. Located in the northern province of Luang Prabang, LFHC offers a

wide range of services for pediatric care, and is the only hospital in northern Laos to offer

neonatal services (FWAB, 2019a). In addition to the neonatal unit, the surgical theatre was

opened in 2016 (FWAB, 2019b). LFHC served over 20,000 pediatric patients within its first year

of opening, and now sees over 100 patients per day (FWAB, 2019b). They typically perform 4-5

surgical cases per day (R. Henker, personal communication, July 7, 2019). Approval for this

project was granted by the Director of Nursing of LFHC on January 7, 2020 (Appendix A).

Also discussed previously, the stakeholders include the anesthesia staff, the OR staff, and

the organizational leaders at LFHC. There are currently three nurse anesthetists and one OR

technician on staff at LFHC who will primarily be using the guidelines. The Director of Nursing

at LFHC directly supervises the nurse anesthetists. She has extensive knowledge on day-to-day practice in the OR and has provided valuable feedback on what may be necessary for guideline revision (Appendix I). The Director of Administration at LFHC is responsible for supply line purchasing and budget management. His input regarding what is feasible and available for resource use has ultimately shaped vital guideline components. Lastly, Dr. Richard Henker is the program coordinator for the nurse anesthesia program at LFHC through the non-profit organization Health Volunteers Overseas (HVO). He typically spends four to eight weeks per year on-site at LFHC practicing and working closely with the nurse anesthesia staff, with frequent remote video consultation throughout the year when he is not on-site. He is the point of contact for this project and has provided invaluable information regarding practice improvement at LFHC and guidance on guideline creation.

Planning the Intervention

In planning guideline creation, it became clear almost immediately that the intervention developed for implementation at LFHC would be vastly different from what would be developed and implemented in a setting with a greater abundance of resources. As stated previously, the original goal was to find a safe way to allow continuous disinfection and reuse of single-use

ABCs and thus develop a guideline centered around this practice. However, as the literature does not support this practice, guidelines were instead developed based on both safe-practice themes found in the literature and interventions known to be feasible at LFHC. The guideline is broken down by tasks to be completed at specific time intervals – at the end of each case, the end of each day, and weekly (Appendix D).

Guideline Creation

End of Each Case

At the conclusion of the surgical case, the responsible staff member must determine if the patient has a highly pathogenic bacterial or viral infection that would warrant immediate disposal. There is ample evidence in the literature that reuse should not be attempted on these

ABCs due to possible cross-contamination (Association of Anaesthetists of Great Britain and

Ireland [AAGBI], 2008; Hubner et al., 2011; McGain et al., 2014). If there is no such infection present, the next step is to disinfect the outer surface with appropriate disinfectant wipes. Rutala and Weber (2013) recommend products that are chlorine-based or contain at least 70-90% alcohol, with at least one-minute surface exposure. Surface contamination of ABCs happens easily due to their frequent handling, and can be a dangerous vector for bacterial transmission

(Dubler et al., 2016; Hubner et al., 2011; Schulz-Stubner et al., 2013). Following surface

disinfection, the condensate should be drained out of the ABC prior to the filter being changed.

McGain et al. (2014) found that an increase in ABC contamination counts that occurred

following extension to 48-hour circuit changes was due to inadequate emptying of circuit

condensate. The filter on the ABC is then changed; this step of the guideline is perhaps the most

well-documented in the literature (Dubler et al., 2016; Hartmann et al, 2008; Hubner et al., 2011;

McGain et al., 2014), and is already a part of regular practice at LFHC. The last step is to

disinfect the AWE and any additional equipment that was used with the appropriate disinfectant

wipes. This portion of the guideline was developed based on the general thought process that

bacteria spreads easily and often. Evidence in the literature has demonstrated significant bacterial

contamination in different areas of the AWE, emphasizing the need for frequent decontamination

(Hubner et al., 2011; Loftus et al., 2012).

End of Day

At the end of each day, the guideline calls for a more thorough disinfection of the AWE

and anesthesia equipment with the appropriate disinfectant wipes. The reasoning behind this

intervention is based on the idea that short turnover times between cases may result in inadequate

disinfection, requiring a deeper disinfection when time allows for it. This has been shown in the literature; Loftus et al. (2012) found bacterial contamination on the AWE shortly after

disinfection between cases. Interestingly, Goebel et al. (2016) argues that a perceived lack of

time on the part of anesthesia providers may actually contribute to less time spent and

subsequent inadequate disinfection of the AWE.

Weekly

Based on the literature, the guideline recommends weekly disposal of the single-use ABC

(Dubler et al., 2016; Hubner et al., 2011; McGain et al., 2014). As anticipated, this portion of the guideline depended greatly on the current budget status at LFHC, and has required adjusting.

While no current evidence exists that lends to longer ABC use, the previous practice at LFHC has been indefinite use until the ABC is no longer functional (R. Henker, personal communication, July 7, 2019). Therefore, a consistent change interval that is less frequent than what is currently in practice could be considered an improvement.

Guideline Revision

The original guidelines were sent to the Director of Nursing in May of 2020 to identify any changes that needed to occur prior to implementation and to ensure weekly ABC changes fit within the allotted budget (Appendix D). Based on her feedback, minor changes were made that included a list of specific highly infectious pathogens that would warrant immediate ABC disposal, and clarification within the guidelines of the type of disinfectant that should be used

(Appendix D). Considering the seriousness of the recent COVID-19 outbreak, the disinfectants listed in the guideline were confirmed as appropriate methods for killing the COVID-19 virus based on recommendations by the United States Environmental Protection Agency (2020)

(Appendix H). The revised guidelines were sent back to her via email for approval, and no other changes were recommended.

Education Session

The education session to LFHC staff took place via Zoom. A copy of the guideline was emailed to each staff member prior so they could refer to it throughout the session. The guideline

is self-explanatory, therefore no additional tangible teaching materials were provided. Each

component of the guideline was discussed with staff, and all questions regarding guideline

execution were answered. All staff members at LFHC speak English, and an interpreter was not

required (R. Henker, personal communication, July 7, 2019). A condensed version of the

guideline in a more “checklist”-like format was requested by staff, and was subsequently created

and emailed to them prior to implementation (Appendix D).

Timeline

The steps in this developed guideline are all easy to carry out, cause little disruption in

normal practice, and theoretically fit within the resource confines of LFHC. They are, however, a

starting point. Guideline creation has been a fluid process in order to create a sustainable

product. Therefore, the timeline for this project included email communication with the Director

of Nursing in May to discuss what changes needed to be made to the guideline prior to

implementation. Following those changes, proposal defense, and IRB approval, a Zoom meeting

took place on November 6, 2020 with the Director of Nursing and Dr. Henker to confirm the

necessary supplies needed for this project and an outlined plan for education and

implementation. On November 26, 2020, the education session was held with the three LFHC

nurse anesthetists via Zoom. All questions were answered and concerns addressed.

Approximately three weeks were given for implementation, and a follow-up meeting was held on

December 21, 2020 at which point the compliance survey was delivered verbally and answers

were recorded (Appendix C). Barriers to compliance were addressed. At the time of this writing,

a follow-up meeting will be held with the date yet to be determined to further assess the progress of guideline use. Additionally, Dr. Henker has agreed to ensure the sustainability of this project

by keeping the site informed of results and encouraging ongoing changes as necessary

(Appendix H).

Participants

The participants in this study included the three LFHC nurse anesthetists. Due to the significant time difference and subsequent difficulties in coordinating scheduled Zoom sessions that were convenient for all LFHC staff, the OR technician was unable to attend. However, he has a vital role in disinfection of the ABCs and surrounding work area and thus will provide valuable input in the future as guideline use continues to evolve.

Methods of Evaluation

Data Collection and Analysis

Data collection occurred through a verbal survey delivered via Zoom approximately three weeks following implementation. Since the survey was delivered verbally, the respondent’s role at LFHC was the only demographic information recorded prior to survey delivery. The survey consisted of 10 closed-ended questions with a mixture of dichotomous, multiple-choice, and rank-order answer options that target whether compliance to the guideline occurred, and what barriers to compliance were identified (Appendix C). Closed-ended questions offer the advantage of easy administration and analysis of descriptive information (Polit & Beck, 2017). All answers to the survey were kept confidential, and are stored on a password-protected computer only accessible to the principal investigator. To ensure reliability and validity of the survey tool, the survey was peer-reviewed and validated by the committee members of this project. Following survey delivery, the de-identified answers were recorded and inputted into Microsoft excel for analysis using descriptive statistics.

Consent and Ethical Considerations

Based on the definition of human research by the University of Arizona (2020), this QI

project does not meet criteria for human research. Instead, the nature of this project and lack of

patient involvement calls for completion of the Determination of Human Research form and subsequent exemption from full IRB review. However, this QI project still involves the participation of LFHC staff members and therefore requires a discussion of ethical considerations. The creation of the Belmont Report in 1979 identified three ethical principles that must be followed to ensure protection of human subjects – respect for persons, beneficence, and justice (U. S. Department of Health and Human Services [USDHHS], 2018).

Respect for persons requires that each individual is treated as autonomous and able to make their own informed decisions throughout the research process (HHS, 2018). The staff members at LFHC were read a disclosure form prior to the education session that informs them of the voluntary nature of both guideline use and survey participation (Appendix B). The concept of beneficence requires that no harm is done, and that benefit is maximized for each individual

(HHS, 2018). This project calls for a change to current practice at LFHC that is made within the current practice and resource capacity, with the hope that these small changes in the form of guideline implementation will lead to overall improved infection control. This both benefits the staff and, indirectly, the patients, without causing any harm. No demographic information will be recorded except the role of the participant (i.e., nurse anesthetist, OR tech), which is clearly stated in the disclosure form (Appendix B). Additionally, no Zoom meetings were recorded.

Lastly, justice calls for each individual to be treated equally in regard to the distribution of burden and benefit of the research being conducted (HHS, 2018). Final guideline creation and

implementation has involved input from all vested LFHC staff members to ensure that no single part creates an uneven workload or inconvenience to any one individual.

RESULTS

Survey Delivery

On December 21, 2020, a Zoom meeting was held with the three LFHC nurse anesthetists approximately three weeks following implementation for verbal survey delivery regarding guideline compliance and barriers to guideline use. As mentioned previously, the time difference between Luang Prabang and Arizona made it difficult to find a convenient time for meeting. In order to avoid LFHC staff having to use their personal time for meetings pertaining to this project, all meetings were held at the beginning of their work day prior to the start of operative cases. In order to ensure that all three nurse anesthetists had time to participate, the survey was delivered to the group, with each nurse anesthetist having the opportunity to answer each question.

Outcomes

The survey was broken up into two sections, with the first seven questions pertaining to guideline compliance and the last three questions pertaining to barriers to guideline use. While each participant was given the opportunity to answer, all three participants were in agreement on each question (Appendix C). Concerning guideline compliance, all participants agreed that there had been no known infectious cases to warrant immediate ABC disposal, that the outer surface of the ABC, the anesthesia machine, and any used equipment had been consistently disinfected following each operative case, and that a more thorough disinfection consistently occurred at the

end of each day. One participant also noted that, in addition to the end-of-day disinfection, they were also doing a morning disinfection of the anesthesia machine and equipment.

All three participants answered “No” to question #4 regarding whether or not the filter had been changed following each operative case. One participant elaborated on this by explaining that current budget and supply restrictions only allowed for daily filter changes. This also applies to question #7 regarding weekly ABC disposal. All of the respondents answered

“No” when asked if the ABCs had been disposed of weekly, as the shipment of new ABCs had not yet arrived at the time of survey delivery (Table 1). According to the Director of Nursing, medical supply shipments have taken significantly longer than normal due to the COVID-19 pandemic and subsequent holdups at the border (M. Evans, personal communication, December

21, 2020).

In regard to barriers to guideline use, all participants agreed that the guidelines were

“Very easy” to follow. Not surprisingly, the only barrier to guideline use they reported was

“Lack of materials needed for compliance” due to the delay in circuit shipment. They had no feedback for ways in which the guideline could be improved (Table 2).

Table 1 Participant Responses to Survey Questions on Guideline Compliance Participant Response % (n=3) 1. Since guideline implementation and/or last survey delivery, has the Yes 0% anesthesia breathing circuit (ABC) been discarded after every known No 0% infectious case? Not applicable 100% Yes 100% 2. Has the outer surface of the ABC been disinfected following each No 0% operative case? Unsure 0% Yes 0% 3. Is the ABC adequately drained of condensate following each operative No 0% case? Unsure 100% Yes 0% 4. Has the ABC filter been changed following each operative case? No 100% Unsure 0%

Table 1 – Continued Participant Response % (n=3) Yes 100% 5. Has the anesthesia machine and any used equipment been disinfected No 0% at the end of each case? Unsure 0% Yes 100% 6. Has the anesthesia machine and any used equipment been re- No 0% disinfected at the end of the day? Unsure 0% Yes 0% 7. Has the ABC been disposed of weekly? No 100% Unsure 0%

Table 2

Participant Responses to Survey Questions on Barriers to Guideline Use Participant Response % (n=3) Very easy 100% Somewhat easy 0% Neither easy nor 0% 8. Overall, how easy was it to follow the guideline? difficult Somewhat difficult 0% Very difficult 0% Lack of clarity in 0% the guideline Lack of materials 100% needed for compliance (i.e. disinfectant 9. What were the greatest barriers to complying with the guidelines? solution, new (select all that apply) ABCs) Lack of time to 0% complete the necessary tasks Other – please 0% describe It can be 0% clearer/easier to follow It can be 0% simplified/less steps 10. How can this guideline be improved? (select all that apply) It can require less 0% materials It can require less 0% time Other – please 0% describe

DISCUSSION

Summary

Overall survey results demonstrated compliance to nearly every component of the guideline from all three participants. The only exceptions were due to a lack of supplies (filters and new ABCs) and one of the questions not being applicable to every day practice. The latter is in regard to question #3 asking whether the condensate had been drained out of the ABC following each operative case – according to one participant, the cases are not long enough for any condensate to accumulate, and thus the participants answered “Unsure” to this question

(Appendix C). Additionally, no barriers to guideline use were identified except for the more obvious issue of lack of supplies.

Interpretation

Survey results demonstrate that, with careful tailoring and the incorporation of feedback from stakeholders, successful guideline creation and implementation is possible even in the most challenging of settings. Although, it is worth noting that true measurement of two important aspects of the guideline were not able to be accurately measured due to supply issues. This could also have the potential to change what barriers may be identified in the future. However, overall, the results of the survey lend cautious optimism to the ongoing sustainability of this project.

Implications

The successful creation and implementation of the LFHC single-use ABC disinfection guidelines brings hope to the idea that, even in the most unique and seemingly challenging of settings, practice improvement is possible. While it could be considered a failure that an essential part of this guideline has yet to be carried out, this should rather be considered a part of the

improvement process. As stated previously, these guidelines are a starting point, and this process remains fluid. In settings like LFHC more than anywhere, this is a critical consideration to remember.

Available research that pertains to resource-scarce settings is still sorely lacking (Shuman

& Chenoweth, 2012). However, as this project demonstrates, this does not mean that change is impossible. It is this author’s hope that research continues to evolve to include settings similar to

LFHC, and that this encourages ongoing projects in other resource-scarce settings throughout the world.

Limitations

The most obvious limitation faced in this project was the limited availability of supplies that is so often seen in these settings. This was also complicated by the current global COVID-19 pandemic that has made the shipment and delivery of supplies increasingly challenging.

However, it could also be argued that this limitation is what highlighted the true resourcefulness of this facility and its staff in their ability to successfully make practice changes with what is made available to them.

Another obvious limitation was the inability to implement this project on-site due to the global COVID-19 pandemic. This could have afforded the opportunity for in-person education, observance of guideline compliance, and more individualized survey delivery. As this project evolves, the hope is that on-site visits will be possible.

DNP Essentials Addressed

The DNP Essentials created by the American Association of Colleges of Nursing

(AACN) are considered the foundation of the DNP curriculum (American Association of

Colleges of Nursing [AACN], 2006). These competencies set forth by the AACN are what guide

the doctoral-prepared student throughout their educational journey, and what they build upon

over time as they prepare to enter their role as an advanced practice nurse (AACN, 2006). In

order to meet the standards set forth by the AACN, these essentials were addressed throughout

the creation and evolution of this project.

DNP Essential I: Scientific Underpinnings for Practice

DNP Essential I can be considered the foundation of nursing; it describes how the

complexity and multi-faceted nature of the nursing discipline must be integrated into practice

(AACN, 2006; Chism, 2010). The creation and execution of this project did exactly this by

drawing from the analytical, organizational, and psychosocial sciences in order to create and

successfully implement a tailored yet evidence-based guideline in an extremely unique setting.

DNP Essential II: Organizational and Systems Leadership for Quality Improvement and

Systems Thinking

DNP Essential II prepares the DNP graduate to effect change on both small and large scales in order to promote the health of populations (AACN, 2006). The creation and implementation of ABC disinfection guidelines at LFHC promotes change to infection control practices within the OR, with the hope that this small change can highlight the need for further improvement throughout the organization.

DNP Essential III: Clinical Scholarship and Analytical Methods for Evidence-Based

Practice

DNP Essential III involves the evaluation of emerging science and its translation into practice (AACN, 2006). The creation of ABC disinfection guidelines occurred only after a

rigorous and exhaustive appraisal of the literature, ensuring that what was created was not only

evidence-based, but appropriate for the practice setting.

DNP Essential IV: Information Systems/Technology and Patient Care Technology for the

Improvement and Transformation of Health Care

DNP Essential IV calls on the DNP graduate to utilize available technology for the

development of evidence-based interventions and improvement of patient care (AACN, 2006;

Chism, 2010). Technology was used throughout this project for literature searches, email

communication with University of Arizona faculty and LFHC staff, and Zoom meetings for

guideline education and implementation. Especially during the time of the COVID-19 pandemic,

this project would not have been possible without it.

DNP Essential VI: Interprofessional Collaboration for Improving Patient and Population

Health Outcomes

DNP Essential VI stresses the importance of collaboration among the health care team,

emphasizing the value that each profession can bring to the improvement of patient care (AACN,

2006). This project required input from University of Arizona faculty, the LFHC Director of

Nursing, the LFHC Director of Administration, and the LFHC nurse anesthesia staff. These

contributions are what led to the creation of an appropriately tailored and sustainable ABC

disinfection guideline.

DNP Essential VIII: Advanced Nursing Practice

DNP Essential VIII acknowledges that specialization within nursing is what ensures

competence and expertise (AACN, 2006). This expertise, however, is built upon the foundational

concepts of the DNP degree (AACN, 2006; Chism, 2010).

This project, while focused specifically on the anesthesia specialty, draws from these

foundational concepts to create and implement an evidence-based intervention related to infection control practices for the overall improvement of patient safety and care delivery.

Conclusions

ABC disinfection is but one small part of the improvements that are needed at LFHC. It

is, nevertheless, no less important. Change often begins on a small scale, and this must not be

forgotten. It is for this reason that healthcare improvement in resource-scarce settings is often

overlooked. Attempts at change are disregarded as too difficult due to lack of funding, supplies,

or overall support. Whatever the excuse, the narrative must be changed. The statement “it isn’t

possible” must be turned into the question, “how do we make it possible here?”

Plan for Sustainability

These guidelines were created with input from LFHC stakeholders in order to ensure both

a beneficial and sustainable intervention. Additionally, as discussed previously, Dr. Henker has

agreed to ensure the sustainability of this project through his ongoing work at LFHC. Future

Zoom meetings will also be held to assess the frequency of ABC changes once the supply issue

is resolved. Lastly, this author plans to do an on-site visit in the future to assess the progress of

guideline use and to address any new barriers to compliance.

Plan for Dissemination

The results of this project will be made available to all stakeholders at LFHC, including

the Director of Nursing, the Director of Administration, and the OR staff. Discussion of this

project and its implications will also take place in future Zoom meetings with LFHC staff. As

guideline use continues to evolve, it is the hope of this author and Dr. Henker that similar

guidelines can be created and implemented at another FWAB-affiliated hospital, Angkor hospital for children in Siem Reap, Cambodia.

APPENDIX A:

LAO FRIENDS HOSPITAL FOR CHILDREN SITE APPROVAL

APPENDIX B:

CONSENT DOCUMENT (DISCLOSURE FORM)

IMPLEMENTATION OF SINGLE-USE ANESTHESIA CIRCUIT DISINFECTION GUIDELINES IN A RESOURCE-SCARCE SETTING Rachel M. Johnston

The purpose of this Doctor of Nursing Practice project is to implement evidence-based guidelines on the disinfection and reuse of single-use anesthesia breathing circuits at Lao Friends Hospital for Children (LFHC). These guidelines will be tailored to fit within the scope of LFHC, keeping in mind the lack of available funding and resources. Following guideline implementation, compliance to the guideline and any barriers to guideline use will be tested via verbal survey.

If you choose to take part in this project, you will be asked to begin implementing the guideline as a part of normal work routine following a short education session on guideline use. One to two weeks following implementation, you will be asked to answer a short ten-question survey that will be delivered verbally via Zoom regarding guideline compliance and barriers to guideline use. It will take approximately 5-10 minutes to complete the survey. This survey will be delivered a second time at another Zoom meeting one to two weeks later. There are no foreseeable risks associated with participating in this project. You will receive no immediate benefit from your participation. Your role at LFHC will be recorded as a part of your answers to each question, but no other demographic information will be used or recorded.

If you choose to participate in the project, participation is voluntary, and refusal to participate will involve no penalty or loss of benefits to which you are otherwise entitled. You may withdraw at any time from the project. In addition, you may skip any question that you choose not to answer. By participating, you do not give up any personal legal rights you may have as a participant in this project.

For questions, concerns, or complaints about the project, you may call myself, Rachel Johnston, at (206) 459-0680, or contact me via email at [email protected].

You agree to have your responses used for this project.

APPENDIX C:

EVALUATION INSTRUMENTS (GUIDELINE COMPLIANCE – ORIGINAL SURVEY /

GUIDELINE COMPLIANCE - SURVEY RESULTS)

Guideline Compliance – Original Survey

1. Since guideline implementation and/or last survey delivery, has the anesthesia breathing circuit (ABC) been discarded after every known infectious case? a. Yes b. No c. Not applicable – there have been no known infectious cases since implementation and/or last survey delivery

2. Has the outer surface of the ABC been disinfected following each operative case? a. Yes b. No c. Unsure

3. Is the ABC adequately drained of condensate following each operative case? a. Yes b. No c. Unsure

4. Has the ABC filter been changed following each operative case? a. Yes b. No c. Unsure

5. Has the anesthesia machine and any used equipment been disinfected at the end of each case? a. Yes b. No c. Unsure

6. Has the anesthesia machine and any used equipment been re-disinfected at the end of the day? a. Yes b. No c. Unsure

7. Has the ABC been disposed of weekly? a. Yes b. No c. Unsure

Barriers to Guideline Use

8. Overall, how easy was it to follow the guideline?

a. Very easy b. Somewhat easy c. Neither easy nor difficult d. Somewhat difficult e. Very difficult

9. What were the greatest barriers to complying with the guidelines? (select all that apply) a. Lack of clarity in the guideline b. Lack of materials needed for compliance (i.e. disinfectant solution, new ABCs) c. Lack of time to complete the necessary tasks d. Other – please describe

10. How can this guideline be improved? (select all that apply) a. It can be clearer/easier to follow b. It can be simplified/less steps c. It can require less materials d. It can require less time e. Other – please describe

Guideline Compliance – Survey Results

2. Has the outer surface of the ABC been disinfected following each operative case? a. Yes (100% of respondents) b. No c. Unsure

3. Is the ABC adequately drained of condensate following each operative case? a. Yes b. No c. Unsure (100% of respondents) Notes – According to one participant, this is not applicable as no condensate forms in the ABC in the short amount of time each case takes

4. Has the ABC filter been changed following each operative case? a. Yes b. No (100% of respondents) c. Unsure Notes – Due to budget and supply restrictions, filters are currently being changed daily

5. Has the anesthesia machine and any used equipment been disinfected at the end of each case? a. Yes (100% of respondents) b. No c. Unsure

6. Has the anesthesia machine and any used equipment been re-disinfected at the end of the day? a. Yes (100% of respondents) b. No c. Unsure Notes – According to one participant, their team is also disinfecting the machine both at the end of the day and again in the morning

7. Has the ABC been disposed of weekly? a. Yes b. No (100% of respondents) c. Unsure

Notes – At the time of survey delivery, the new circuits had not yet been delivered

Barriers to Guideline Use

8. Overall, how easy was it to follow the guideline? a. Very easy (100% of respondents) b. Somewhat easy c. Neither easy nor difficult d. Somewhat difficult e. Very difficult

9. What were the greatest barriers to complying with the guidelines? (select all that apply) a. Lack of clarity in the guideline b. Lack of materials needed for compliance (i.e. disinfectant solution, new ABCs) (100% of respondents) c. Lack of time to complete the necessary tasks d. Other – please describe

APPENDIX D:

PARTICIPANT MATERIAL (LAO FRIENDS HOSPITAL FOR CHILDREN [LFHC] –

ANESTHESIA BREATHING CIRCUIT [ABC] DISINFECTION GUIDELINES [REVISED] /

LAO FRIENDS HOSPITAL FOR CHILDREN [LFHC] – ANESTHESIA BREATHING

CIRCUIT [ABC] DISINFECTION GUIDELINES [ORIGINAL] / SHORTENED VERSION OF

ABC DISINFECTION GUIDELINES)

Lao Friends Hospital for Children (LFHC) Anesthesia Breathing Circuit (ABC) Disinfection Guidelines

End of each case

Known infectious case (i.e. Tuberculosis, COVID-19) or visible contamination on outer surface? Dispose of ABC

Disinfect ABC outer surface with a single-wipe or spray surface disinfectant

Ensure any trapped water is drained out of each ABC prior to placing new filter

Change filter

Disinfect anesthesia machine and equipment with a single-wipe or spray surface disinfectant

End of day

Thoroughly decontaminate anesthesia machine and equipment using a single-wipe or spray surface disinfectant

Weekly

Dispose of single-use ABC

APPENDIX E:

SPAULDING CLASSIFICATION OF EQUIPMENT DECONTAMINATION

Adapted for “Global guidelines for the prevention of surgical site infection” by the World Health Organization, 2018, p. 50 (https://www.ncbi.nlm.nih.gov/books/NBK536404/pdf/Bookshelf_NBK536404.pdf) from Spaulding E.H. (1968). Chemical disinfection of medical and surgical materials. In C.A. Lawerence and S.S. Block (Eds.). Disinfection, sterilization and preservation (pp.517-31g). Lea & Febiger

APPENDIX F:

PROJECT TIMELINE

Pre- Completion Date Planning Implementation Evaluation Implementation Email communication with Director of May 2020 Nursing to discuss guideline/any possible changes Make guideline June 2020 changes; update proposal Proposal defense June/July 2020 with DNP project committee Submit IRB June/July 2020 application Meet with LFHC July 2020 staff to educate on guideline use Guideline July/August 2020 implementation Remote meeting via Zoom; survey August 2020 (first delivered verbally follow-up at 1-2 weeks on guideline

following compliance, implementation) barriers to guideline use; data analyzed Changes made to Changes guideline based on August 2020 implemented (if survey results (if needed) needed) Remote meeting via Zoom; survey August 2020 (second delivered verbally follow-up at 1-2 weeks on guideline

following re- compliance, implementation) barriers to guideline use; data analyzed Changes made to Changes guideline based on August 2020 implemented (if survey results (if needed) needed) August/September Final revisions 2020 January 2021 Final defense

APPENDIX G:

LITERATURE REVIEW GRID

Pub. Year Title of Author’s Type of Study Main Outcomes or Findings Support for and/or link to project Publication Last Name

2016 Evaluation of the Questionnaire - 21-question survey given to - Questionnaire demonstrated importance of Altınışık et al. approaches of the anaesthesiologists on anesthesia standardization of protocols/guideline for anaesthesiologists on machine maintenance. anesthesia machine and supply maintenance of - Topics covered included questions on maintenance. anaesthesia machines cleaning and sterilization issues, - Implications for LFHC: Educational among others; results showed lack of component is critical with guideline knowledge on purpose of filter and implementation. disinfection practices, including internal and external surface disinfection.

2008 Infection control in Consensus - Anesthesia circuits can be reused for - Recommendation given for length of time Association of anaesthesia document on up to seven days as long as circuit can be used, provided a new filter is Anaesthetists of anesthesia manufacturer recommendations on use placed for each case. Great Britain infection control – are followed. However, AAGBI - While circuits are changed out daily, the and Ireland updated guidelines recommends they should be changed life span of the circuit can be up to seven on a daily basis. days (although most common practice is - To ensure consistency, the circuit up to one day in the United Kingdom). should be disposed of each time the - Implications for LFHC: circuits can be anesthetic machine and monitors are used up to seven days; circuits are cleaned (i.e. daily). disposed of following that time period. - With highly infectious cases, circuits should NOT be reused but disposed of immediately after the case. - Filters should be used in-between each case if the circuit is being reused. - Circuit type recommended: Not stated, but states that whatever circuit used should follow manufacturer recommendations - Filter type recommended: Not specified

Pub. Year Title of Author’s Type of Study Main Outcomes or Findings Support for and/or link to project Publication Last Name

2011 Contamination of Prospective study - Samples taken from inspiratory and - Findings not relevant to LFHC specifically Arai & anesthesia circuits by expiratory limbs of 45 breathing due to lack of filter use. Azevedo pathogens circuits following hospital protocol on - Additionally, cleaning practices were not disinfection. always consistent and protocol was - Results showed contamination both changed part way through the study before use and after reprocessing. - Implications for LFHC: Details given on - Study suggests that sterilization is both cleaning and disinfection practices; required. may be able to use for structuring - Circuit type used: Drager, guidelines (i.e. what to do and what not to Intermedica, and Takaoka anesthesia do) circuits - Filter type used: No filter used

1997 Adverse anesthetic Closed claims - 2% of claims in database analyzed - While adverse events due to breathing Caplan et al. outcomes arising analysis were related to gas delivery equipment circuits/equipment malfunctions are low, from gas delivery - equipment failure accounted for 24% the consequences are devastating. equipment: A closed of these claims. - Implications for LFHC: Further claims analysis - Breathing circuit was identified as the emphasizes the need for properly most common source of injury. functioning circuits. - Almost all adverse outcomes related to gas delivery equipment resulted in death or permanent brain damage.

Pub. Year Title of Author’s Type of Study Main Outcomes or Findings Support for and/or link to project Publication Last Name

1999 High-quality Prospective study - 55 circuits sampled; bacterial samples - No bacterial contamination of circuit with Daggan et al. filtration allows taken at the beginning of the day at the reuse up to one day, provided a filter is reuse of anesthesia Y-piece proximal to the filter, used breathing circuits inspiratory port, and expiratory port, - Implications for LFHC: Further evidence resulting in cost and samples taken again at the end of that circuits can be safely reused. Cost savings and reduced day at the y-piece and from the saving not as relevant to LFHC. medical waste endotracheal tube (after all cases completed); results showed bacterial contamination at the endotracheal tube (expected), with negative growth at the y-piece. - Cost savings with reusing each breathing circuit at least twice would be approximately $50,778/year for this hospital. - Circuit type used: reusable Intersurgical’s Multipac anesthesia breathing circuit - Filter type used: Filta-Therm (type of Heat and Moisture Exchange (HME) filter)

2016 Bacterial and viral Prospective - Samples were taken from the inner - Circuits can be safely used for up to seven Dubler et al. contamination of observational and outer surfaces of 102 breathing days without an increase in endoluminal breathing circuits study circuits following one day of use, and bacterial contamination. after extended use – 101 breathing circuits following seven - Circuits were disposed of after seven-day an aspect of patient days of use; results demonstrated that period – not disinfected. safety? endoluminal bacterial contamination - Implications for LFHC: Circuits can be was unchanged between one-day and safely reused for up to 7 days. Proper seven-day use, although outer surface disinfection of outside surface important to bacterial contamination increased inhibit bacterial growth. (pathogens were of minimal clinical importance).

Pub. Year Title of Author’s Type of Study Main Outcomes or Findings Support for and/or link to project Publication Last Name

- The outer surface of the circuits were disinfected between each case with Incidin 0.5% tissues (Ecolab, Germany). - Filters were used between each case. - Circuit type used: disposable breathing circuits with water traps (VentStar", Draeger, Lubeck, Germany). - Filter type used: Ultipor 25" BSF, Pall, USA (HME filter)

2016 Bacterial Prospective cohort - 200 cleaning and disinfection - Implications for LFHC: Goebel et al. contamination of the study procedures monitored over two-month Training/checklists may be necessary to anesthesia workplace period ensure that adequate cleaning and and efficiency of - anesthesia nurse performed cleaning disinfection of anesthesia workplace routine cleaning and disinfection in 100 cases, trained occurs procedures: housekeeping in other 100 cases A prospective cohort - no checklist for cleaning/disinfection study duties of anesthesia nurses, although this is part of their responsibility - housekeeping staff given educational session on how to clean anesthesia machine - housekeeping staff performed both faster and better decontamination of anesthesia machine – bacterial load lower

Pub. Year Title of Author’s Type of Study Main Outcomes or Findings Support for and/or link to project Publication Last Name

1999 An outbreak of Retrospective - Microbiological studies of reusable - Actual contamination component not Gray et al. Bacillus cereus study ventilator circuits undertaken after six relevant, as no filters were used. respiratory tract ventilated neonates were found to be - Additionally, study over 20 years old – infections on a infected with Bacillus cereus. significant changes to disinfection neonatal unit due to - Contamination attributed to a processes since that time. contaminated breakdown of the disinfection process, - Implications for LFHC: study shows ventilator circuits including inadequate drying after that lack of adherence to disinfection reprocessing, and delayed transport of protocol resulted in increased infection the circuits back to the neonatal unit. risk to patients. - Circuit type used: Reusable, brand not listed - Filter type used: No filter used

2008 Microbiological risk Experimental - Inspiratory and expiratory samples - No statistically significant bacterial Hartmann et al. of anaesthetic observational were taken on 112 breathing circuits at contamination with reuse of circuits up to breathing circuits study 24 hrs, 48 hrs, and 72 hrs of reuse; 72 hours. after extended use results showed no statistically - Implications for LFHC: Further evidence significant difference in bacterial that circuits can be safely reused. contamination across three different changing intervals. - Circuits used were disinfected at the end of each interval using an automatic thermal disinfection program; included washing-drying cycles at 94 C. - Circuit type used: Draeger Medical reusable tubes - Filter type used: Humid-Vent filter (type of HME filter)

Pub. Year Title of Author’s Type of Study Main Outcomes or Findings Support for and/or link to project Publication Last Name

2011 Microbiological Prospective - Microbiological investigation of the - Cost savings portion not relevant to LFHC Hubner et al. safety and cost- longitudinal inner and outer surface of the circuits due to significant differences in materials effectiveness of clinical survey for 378 patients were examined purchased, staff utilized, and method in weekly breathing following 24-hour (n=110), 48-hour which disinfection and reuse occurs. circuit changes in (n=75), five-day (n=138), and seven- - Implications for LFHC: Circuits can be combination with day (n=55) continuous use; filters safely reused for seven days without heat moisture changed between each case. bacterial contamination; filters effective in exchange filters: a - No respiratory tract flora or other preventing contamination. prospective pathogens detected beyond filter use. longitudinal clinical - Cost savings of up to 50% survey demonstrated. - Circuit type used: Tyco 300/13324 (Mallinckrodt, Mirandoly, Italy) - Filter type used: Ultipor 25 (PALL AG, Dreieich, Germany) (type of HME filter)

2019 Adverse events in Integrative review - 21 studies used; main adverse events - May be difficult to link some of these Lemos & anesthesia: An included respiratory, drug error, issues specifically to project, especially Poveda integrative review cardiology, and neurology, and were considering that issues at LFHC are due related to human errors, slips, and more to resource issues rather than lack of lapses. provider vigilance. - Lapse in equipment check mentioned - Implications for LFHC: Biggest as cause of error. takeaway is importance of thorough equipment checks.

2012 Multiple reservoirs Prospective - Anesthesia work environment was a - Implications for LFHC: Proper Loftus et al. contribute to randomized primary contributor to bacterial disinfection of work area between cases is intraoperative observational contamination of IV stopcock sets. important to prevent cross-contamination. bacterial study - Contamination occurred both during transmission and between cases, despite between- case disinfection of environment.

Pub. Year Title of Author’s Type of Study Main Outcomes or Findings Support for and/or link to project Publication Last Name

2014 The microbiological Prospective - Samples taken from a total of 305 - No statistically significant difference in McGain et al. and sustainability microbiological breathing circuits at both the bacterial contamination with reuse of effects of washing study inspiratory and expiratory limbs circuits up to seven days. anaesthesia breathing following three circuit-changing - Implications for LFHC: Circuits safe to circuits less intervals – 24-hour (baseline), 48- reuse up to seven days. Education on frequently hour, and seven-day. Results showed a draining circuit condensate could also be larger amount of bacterial considered, although this may already be a contamination in the 24-hr group as part of practice. compared to the 48-hr and seven-day group, with no statistically significant difference seen between the 48-hr and seven-day group. - 48-hr and seven-day circuit changes occurred after personnel education on draining circuit condensate appropriately. - Circuits were disinfected using thermal disinfection in an industrial washing machine at 80 C for 10 minutes following appropriate time interval (24-hr, 48-hr, or seven-day) - Circuit type used: reusable anaesthetic circuits (Parker Healthcare, Melbourne, Vic., Australia) - Filter type used: DAR electrostatic filter-350 U5879; Covidien, Boulder, CO, USA

Pub. Year Title of Author’s Type of Study Main Outcomes or Findings Support for and/or link to project Publication Last Name

2019 Reprocessing Review - Anesthesia equipment is considered a - Implications for LFHC: If decision made Rutala & semicritical items: semi-critical item and therefore must to disinfect circuits rather than dispose of Weber Outbreaks and undergo high-level disinfection. them, multiple chemical disinfectant current issues - Semi-critical items can undergo options available. However, quality of disinfection with chemical circuit currently in use at LFHC would disinfectants (glutaraldehyde, have to be considered (i.e. whether circuit hydrogen peroxide, ortho- can withstand high-level disinfection). phthalaldehyde (OPA), peracetic acid, Also emphasizes need for proper training peracetic acid + hydrogen peroxide, or of staff on disinfection process. chlorine-based system are cleared by FDA). Many of these items are too sensitive to heat for steam sterilization. - Exposure time for most high-level disinfectants varies from 8-45 minutes at 20-25 C. - Manufacturer’s recommendations for reprocessing should be followed. - Staff should receive training on reprocessing. - Semi-critical items that come into contact with upper respiratory tract should be rinsed with sterile or tap water prior to disinfection. - Single-use devices should not be reused.

2013 Disinfection and Review - Unlike more recent article from Rutala - Implications for LFHC: Review gives Rutala & sterilization: An & Weber (2019), this review recommendations for effective surface Weber overview addresses approach to surface disinfectants and how they should be used. disinfection. - Items that are surface-disinfected do not need to be transported to a central

Pub. Year Title of Author’s Type of Study Main Outcomes or Findings Support for and/or link to project Publication Last Name

processing area but can be disinfected where they are used. - Chlorine-based products or products that contain 70-90% alcohol should be used for surface disinfection, with at least a one-minute exposure time.

2013 VRE transmission Experimental - Following VRE outbreak in an ICU - Implications for LFHC: Surface Schulz-Stubner via the reusable study after noting colonization on a reusable disinfection an important part of guidelines et al. breathing circuit of a transport ventilator breathing circuit, and should be incorporated. transport ventilator: experiment conducted on effectiveness Outbreak analysis of surface decontamination and experimental - Following single wipe disinfection study of surface process, more than 95% of surface disinfection area of the breathing circuit was decontaminated - Routine surface disinfection of breathing circuits recommended

2012 Reuse of Medical Review - Articles discusses issues surrounding - No clear reprocessing standards for single- Shuman & Devices: reuse of single-use devices in both use devices Chenoweth Implications for developed and developing countries - Increased infection risk with reuse of infection control single-use devices, but very little data available to support this - Limited data also makes attributing adverse events to single-use device reuse difficult

Pub. Year Title of Author’s Type of Study Main Outcomes or Findings Support for and/or link to project Publication Last Name

2011 Bacterial Observational - 40 anesthesia machines’ internal - lack of adherence to reprocessing protocol Spertini et al. contamination of study breathing circuit systems (BCSs) were emphasized. anesthesia machines’ investigated for bacterial growth. - Strong summary of different manufacturer internal breathing - Bacterial growth found in 43% of recommendations given. circuit systems internal BCSs; however, bacterial - Implications for LFHC: While specifics contamination appeared to be related regarding the IBC will not necessarily be to the way in which reprocessing was addressed in this project (focus is on handled rather than from patient external circuit), this study’s findings on contamination. the risk to the patients when adherence to protocol is not maintained will help emphasize importance of protocol.

2012 Effectiveness of Experimental - Surface swab taken from 17 in-use - Ventilator surfaces should be disinfected at Sui et al. bacterial study mechanical ventilators, 15 breathing least every eight hours to limit bacterial disinfectants on circuits, and four different kinds of growth and spread surfaces of bedside equipment in a respiratory - Implications for LFHC: Surface mechanical ventilator care center disinfection component should be added to systems - Swabs were taken at 30 minutes, eight guidelines – important for overall infection hours, and 24 hours after initial control. disinfection with 0.5% sodium hypochlorite and pasteurization. - Areas swabbed were then placed into control or experimental groups – experimental groups included 75% aerosol alcohol with air drying 24 hours after initial swab, and aerosol alcohol with tissue drying 24 hours after initial swab - Samples were re-swabbed at same time intervals (30 minutes, eight hours, 24 hours) following alcohol disinfection

Pub. Year Title of Author’s Type of Study Main Outcomes or Findings Support for and/or link to project Publication Last Name

- Bacterial contamination increased significantly at the 8-hr mark

2019 Disinfection, Review - Medical device reuse discussed, more - Discusses advantages versus disadvantages Wilson & sterilization and specific to anesthetic equipment. of single-use and reusable devices. Nayak disposables - Methods of disinfection discussed.

APPENDIX H:

OTHER DOCUMENTS AS APPLICABLE TO THE PROJECT (EMAIL

COMMUNICATIONS REGARDING APPROVAL AND REVISIONS REGARDING

GUIDELINES / WEBSITE LINK FOR LIST OF PRODUCTS THAT KILL COVID-19

VIRUS)

https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2-covid- 19

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