Anesthesia & Analgesia

SHEA Expert Guidance: Infection Prevention in the Operating Room Anesthesia Work Area --Manuscript Draft--

Manuscript Number: AA-D-18-01467 Full Title: SHEA Expert Guidance: Infection Prevention in the Operating Room Anesthesia Work Area Short Title: Infection Prevention in the Anesthesia Work Area Article Type: Special Article Corresponding Author: Valerie M Deloney, MBA Society for Healthcare Epidemiology of America Arlington, VA UNITED STATES Corresponding Author Secondary Information: Corresponding Author's Institution: Society for Healthcare Epidemiology of America Corresponding Author's Secondary Institution: First Author: Valerie M Deloney, MBA First Author Secondary Information: Order of Authors: Valerie M Deloney, MBA L. Silvia Munoz-Price, MD, PhD Andrew Bowdle, MD, PhD B. Lynn Johnston, MD Gonzalo M. Bearman, MD, MPH Bernard C. Camins, MD, MSc E. Patchen Dellinger, MD Marjorie A. Geisz-Everson, PhD, CRNA Galit Holzmann-Pazgal, MD Rekha Murthy, MD David Pegues, MD Richard C. Prielipp, MD, MBA, FCCM Zachary A. Rubin, MD Joshua Schaffzin, MD, PhD Deborah Yokoe, MD, MPH David J. Birnbach, MD, MPH Order of Authors Secondary Information: Manuscript Region of Origin: UNITED STATES Abstract: This expert guidance document, written by a multidisciplinary panel of experts, provides recommendations specific to the anesthesia work area to improve infection prevention through hand hygiene (HH), environmental disinfection, and implementation of effective improvement efforts. The potential for clinically significant microbial cross- transmission in the intraoperative environment poses a threat to patient safety, and a growing body of literature has shown contamination in the anesthesia work area, including the anesthesia medical work cart, stopcocks, laryngeal masks and

Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation laryngoscope blades, touchscreens, keyboards, and providers’ hands, resulting in transmissions, healthcare-associated infections, and increased risk of patient mortality. The guidance’s recommendations are based on a systematic literature search, surveys of individuals working in infection prevention and anesthesia providers, expert panel consensus, and considerations of feasibility and harm. Requested Editor: Suggested Reviewers: Opposed Reviewers: Funding Information: Author Comments: Dear Dr. Pittet and Mr. Pointe, As you review the "SHEA Expert Guidance: Infection Prevention in the Anesthesia Work Area," please feel free to reach out to me with questions. Until publication, I will serve as the corresponding author, and will contact the author group with questions related to content. I should not be listed as an author, as I work as a member of SHEA staff. Per the agreement signed earlier this year, joint publication will occur with the SHEA journal, Infection Control and Hospital Epidemiology (ICHE). A&A will do the copy- editing and provide the file to ICHE. Dr. Suzanne Bradley serves as the Editor, and Brian Mazeski [email protected] as the Associate Production Manager. You may contact him and copy me and our Managing Editor, Lindsay MacMurray, [email protected], to coordinate the joint publication. The conflict of interest disclosures for the authors are listed both in the title page, as requested, and in the Acknowledgements, per SHEA format. Finally, 2 supplemental files will be posted to the SHEA website, as identified in the manuscript. One is a letter from ASA, and the other is a file with four tables. Please let me know when I should provide the URLs. Thank you very much for working with SHEA on this project. We are looking forward to publication, Valerie Deloney, MBA [email protected]

Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation Manuscript (All Manuscript Text Pages in MS Word format, including Title Page, References and Figure Legends)

1 2 3 4 SHEA Expert Guidance: Infection Prevention in the Operating Room Anesthesia Work 5 6 7 Area 8 9 L. Silvia Munoz-Price, MD, PhD, Froedtert & the Medical College of Wisconsin, 10 11 12 Milwaukee, WI 13 14 Andrew Bowdle, MD, PhD, University of Washington Medicine, Seattle, WA 15 16 B. Lynn Johnston, MD, Dalhousie University, Halifax, NS 17 18 19 Gonzalo M. Bearman, MD, MPH, Virginia Commonwealth University School of Medicine, 20 21 Richmond, VA 22 23 24 Bernard C. Camins, MD, MSc, University of Alabama at Birmingham, Birmingham, AL 25 26 E. Patchen Dellinger, MD, University of Washington Medicine, Seattle, WA 27 28 29 Marjorie A. Geisz-Everson, PhD, CRNA, University of Southern Mississippi, Hattiesburg, MS 30 31 Galit Holzmann-Pazgal, MD, Baylor College of Medicine, Houston, TX 32 33 34 Rekha Murthy, MD, Cedars-Sinai Medical Center, Los Angeles, CA 35 36 David Pegues, MD, University of Pennsylvania, Philadelphia, PA 37 38 Richard C. Prielipp, MD, MBA, FCCM, University of Minnesota, Minneapolis, MN 39 40 41 Zachary A. Rubin, MD, David Geffen School of Medicine at UCLA, Los Angeles, CA 42 43 Joshua Schaffzin, MD, PhD, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 44 45 46 Deborah Yokoe, MD, MPH, University of California San Francisco School of Medicine, San 47 48 Francisco, CA 49 50 51 David J. Birnbach, MD, MPH, University of Miami Miller School of Medicine, Miami, FL 52 53 Corresponding Author 54 55 L. Silvia Muñoz-Price, MD, PhD 56 57 58 Medical College of Wisconsin 59 60 61 62 1 63 64 65 1 2 3 4 8701 Watertown Plank Road 5 6 7 Milwaukee, WI 53226 8 9 (414) 955-0483 10 11 12 [email protected] 13 14 L. Silvia Munoz-Price: This author served as Chair of the writing panel that authored this 15 16 document, leading the processes for all discussions, deliberations, consensus-building, and 17 18 19 decision-making, and helped with the systematic literature search and writing of the document. 20 21 Andrew Bowdle: This author provided anesthesia expertise and helped lead discussions of all 22 23 24 aspects of the document and deliberations during the review phase, and helped with the 25 26 systematic literature search and writing of the document. 27 28 29 B. Lynn Johnston: This author provided infection prevention and healthcare epidemiology 30 31 expertise and led the development and analysis of the survey of the SHEA Research Network 32 33 34 and the survey of anesthesia providers. 35 36 Gonzalo M. Bearman: This author provided infection prevention and healthcare epidemiology 37 38 expertise and helped with the systematic literature search and writing of the document. 39 40 41 Bernard C. Camins: This author provided infection prevention and healthcare epidemiology 42 43 expertise, leading the literature search and writing process for the hand hygiene section of the 44 45 46 document. 47 48 E. Patchen Dellinger: This author provided expertise in infection prevention, healthcare 49 50 51 epidemiology, surgery, and insights into the operating room environment, and helped with the 52 53 systematic literature search and writing of the document. 54 55 56 57 58 59 60 61 62 2 63 64 65 1 2 3 4 Marjorie A. Geisz-Everson: This author provided anesthesia expertise, served as the liaison to 5 6 7 the American Association of Nurse Anesthetists (AANA), and helped with the systematic 8 9 literature search and writing of the document. 10 11 12 Galit Holzmann-Pazgal: This author provided infection prevention and healthcare 13 14 epidemiology expertise and helped with the systematic literature search and writing of the 15 16 document. 17 18 19 Rekha Murthy: This author provided infection prevention and healthcare epidemiology 20 21 expertise and helped with the systematic literature search and writing of the document, and 22 23 24 served as SHEA Guidelines Committee Chair and SHEA Guidelines Committee Past Chair 25 26 during the duration of its development. 27 28 29 David Pegues: This author provided infection prevention and healthcare epidemiology expertise 30 31 and helped with the systematic literature search and writing of the document. 32 33 34 Richard C. Prielipp, MD, MBA, FCCM, University of Minnesota, Minneapolis, MN 35 36 Zachary A. Rubin: This author provided infection prevention and healthcare epidemiology 37 38 expertise and helped with the systematic literature search and writing of the document 39 40 41 Joshua Schaffzin: This author provided infection prevention, healthcare epidemiology, and 42 43 implementation science expertise and helped with the systematic literature search and writing of 44 45 46 the document. 47 48 Deborah Yokoe: This author provided infection prevention and healthcare epidemiology 49 50 51 expertise and helped with the systematic literature search and writing of the document, and 52 53 served as SHEA Guidelines Committee Vice Chair and SHEA Guidelines Committee Chair 54 55 during the duration of its development. 56 57 58 59 60 61 62 3 63 64 65 1 2 3 4 David J. Birnbach: This author provided anesthesia expertise, served as liaison to the American 5 6 7 Society of Anesthesiologists (ASA), and helped with the systematic literature search and writing 8 9 of the document. 10 11 12 13 14 Financial Disclosure: The Society for Healthcare Epidemiology of America (SHEA) led and 15 16 funded the development of this manuscript. 17 18 19 Authors 20 21 The writing panel (the authors) consists of current and past members of the SHEA Guidelines 22 23 24 Committee and representatives of organizations that partnered with SHEA to write this 25 26 document: Dr. David J. Birnbach, American Society of Anesthesiologists (ASA); Dr. Richard C. 27 28 29 Prielipp, Anesthesia Patient Safety Foundation (APSF); and Dr. Marjorie Geisz-Everson, 30 31 American Association of Nurse Anesthetists (AANA). All panel members served as volunteers. 32 33 34 Author Disclosures (also in Acknowledgements): LSMP, GB, AB, DY reported nothing to 35 36 disclose. DB reported reported activity with APSF (Board of Directors) and Anesthesia and 37 38 Analgesia (A&A) Editorial Board. RM reported research grants/contracts with Medimmune, 39 40 41 Johns Hopkins (lead in multicenter trial) HAI Among Surgical & ICU Patients; BC reported 42 43 research grants/contracts with Pfizer, Merck, CDC, Preventing Hemodialysis Related BSI; EPD 44 45 46 reported research grants/contracts with Tetraphase, A Phase 3 Randomized Double-Blind 47 48 Double-Dummy Multicenter Prospective Study to Assess the Efficacy & Safety of Eravacycline 49 50 51 vs. Ertapenem in Intra-Abdominal Infections, advisory/consultant roles with Merck, Baxter, 52 53 Ortho-McNeil, Targanta, Schering-Plough, Astellas, CareFusion, Durata, Pfizer, Rib-X, 54 55 institutional benefit with Exoxemis, UW letter to FDA supporting research proposal <10,000, 56 57 58 activities with SIS (Board Member), ICHE (Editorial Board), CDC/HICPAC (content expert for 59 60 61 62 4 63 64 65 1 2 3 4 SSI guideline), SCIP; GHP reported research grants/contracts with UT, Decreasing Vancomycin 5 6 7 Use in the NICU; BLJ reported research grants/contracts with Gilead Sciences Inc., A 8 9 Multicenter Randomized Double-Blind Double-Dummy Phase 3 Study of the Safety & Efficacy 10 11 12 of Ritonavir-Boosted Elvitegravir (EVG/r) vs. Raltegravir (RAL) Administered with a 13 14 Background Regimen in HIV-1 Infected, Antiretroviral Treatment-expe, CHUM, The Canadian 15 16 Cohort of Slow Progressors (HIV), Pfizer Canada Inc., An International Multicenter Prospective 17 18 19 Observational Study of the Safety of Maraviroc Used with Optimized Background Therapy in 20 21 Treatment-experienced HIV-1 Infected Patients, Ottawa Hospital, A Randomized Control 22 23 24 Clinical Trial of Micronutrient & Antioxidant Supplementation in Persons with Untreated HIV 25 26 Infection, MAINTAIN Study CTN 238 & CTN 254: Inflammatory Markers Sub-Study, 27 28 29 Canadian HIV Trials Network, VALIDATE, Capital Health Research FundFrailty in people 30 31 living with HIV, PHAC CNISP: Surveillance for HA-CVC-BSI, CDI, PJI (hip & knee), VP 32 33 34 shunt infection, MRSA, VRE, & CRE, and institutional benefit through Pfizer Canada Inc., 35 36 GSK, Sunovion Pharmaceuticals Canada (unrestricted grant), Capital District Health Authority 37 38 Foundation, Infectious Diseases CME for Family Physicians (October 2013), <10,000, Optimer 39 40 41 Pharmaceuticals Canada, Merck Canada, ViiV Healthcare Canada, BMS Canada, Gilead 42 43 Sciences (unrestricted grant), Atlantic Canada HIV Education (September 2012), >$25,000, and 44 45 46 activity with PHAC Working Group for IC (Chair of Guidelines for HCW Infected with a 47 48 Bloodborne Pathogen), CJIDMM (Associate Editor), IDSA (influenza guideline panel, SHEA), 49 50 51 CPSNS (Chair), ad hoc Committee on BBP; DP reported activity with Extended National 52 53 Faculty (SHEA faculty stipend for HRET/AHA CUSP), RP reported activity with APSF (Board 54 55 of Directors) and Anesthesia and Analgesia (A&A) Editorial Board. 56 57 58 59 60 61 62 5 63 64 65 1 2 3 4 Abstract Word Count: 123 5 6 7 Introduction Word Count: 352 8 9 Discussion (Guidance) Word Count: 6,210 10 11 12 Overall Word Count (excluding abstract and references): 12,489 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 6 63 64 65 1 2 3 4 Abstract 5 6 7 This expert guidance document, written by a multidisciplinary panel of experts, provides 8 9 recommendations specific to the anesthesia work area to improve infection prevention through 10 11 12 hand hygiene (HH), environmental disinfection, and implementation of effective improvement 13 14 efforts. The potential for clinically significant microbial cross-transmission in the intraoperative 15 16 environment poses a threat to patient safety, and a growing body of literature has shown 17 18 19 contamination in the anesthesia work area, including the anesthesia medical work cart, 20 21 stopcocks, laryngeal masks and laryngoscope blades, touchscreens, keyboards, and providers’ 22 23 24 hands, resulting in transmissions, healthcare-associated infections, and increased risk of patient 25 26 mortality. The guidance’s recommendations are based on a systematic literature search, surveys 27 28 29 of individuals working in infection prevention and anesthesia providers, expert panel consensus, 30 31 and considerations of feasibility and harm. 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 7 63 64 65 1 2 3 4 Introduction 5 6 7 The potential for clinically significant microbial cross-transmission in the intraoperative 8 9 environment poses a threat to patient safety. A growing body of literature has shown 10 11 12 contamination in the anesthesia work area, including the anesthesia medical work cart, 13 14 stopcocks, laryngeal masks and laryngoscope blades, touchscreens, and keyboards, as well as on 15 16 providers’ hands, resulting in transmissions, healthcare-associated infections, and increased risk 17 18 19 of patient mortality. 20 21 The authors acknowledge that the operating room (OR) is a challenging environment in which to 22 23 24 affect ideal infection prevention and control practices. In addition, infection prevention and 25 26 control policies specific to anesthesia care in the OR are not universal, audits of infection 27 28 29 prevention practices are not routine, and consequently providers may not have clarity on 30 31 expected practices and behaviors. Studies have reported problematic practices by anesthesia 32 33 34 providers, including use of multi-dose vials for more than one patient, less than 100% use of 35 36 gloves for airway management, failure to perform hand hygiene (HH) after removing gloves, and 37 38 entry into anesthesia cart drawers without performance of HH. This guidance provides 39 40 41 recommendations specific to the anesthesia work area to improve infection prevention through 42 43 hand hygiene (HH), environmental disinfection, and implementation of effective improvement 44 45 46 efforts. 47 48 Furthermore, SHEA acknowledges significant challenges to implementing the array of infection 49 50 51 prevention and control recommendations in order to affect OR culture in general, and the work 52 53 flow of anesthesia providers in particular. Facility administrators will need to actively 54 55 collaborate with anesthesia department leaders to build an implementation plan that is timely, 56 57 58 comprehensive, and multi-disciplinary, and that will allocate hospital resources to educate 59 60 61 62 8 63 64 65 1 2 3 4 healthcare personnel and to acquire new infection prevention and control components (e.g., 5 6 7 single-use laryngoscopes). Facilities should consider this guidance document in revisions of their 8 9 anesthesia OR policies. 10 11 12 This guidance builds on the foundational premise that all facilities where anesthesia services are 13 14 delivered have formal infection prevention and control programs. Essential elements of these 15 16 programs include, but are not limited to, policies and procedures for HH, safe preparation and 17 18 19 delivery of intravenous medications, and environmental cleaning and disinfection. All 20 21 individuals who are involved in these procedures require training appropriate to their tasks, as 22 23 24 well as regular skills assessments. 25 26 Intended Use 27 28 29 SHEA develops expert guidance documents (EGs) for topics of relatively narrow scope that lack 30 31 the level of evidence required for a formal guideline developed using the GRADE or a similar 32 33 34 systematic methodology, but are important in provision of safe, effective healthcare. As such, 35 36 systematic grading of the evidence level is not provided for individual recommendations. Each 37 38 EG is based on a synthesis of limited evidence, theoretical rationale, current practices, practical 39 40 41 considerations, writing group opinion, and consideration of potential harm where applicable. 42 43 No EG can anticipate all clinical situations and this guidance document is not meant to be a 44 45 46 substitute for individual clinical judgment by qualified professionals. 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 9 63 64 65 1 2 3 4 Methods 5 6 7 EG Document Development 8 9 This paper follows the process outlined in the “Handbook for SHEA-Sponsored Guidelines and 10 11 1 12 Expert Guidance Documents” . 13 14 The topic was among those proposed and selected by the SHEA Guidelines Committee (GLC). 15 16 The subsequent manuscript proposal developed by the GLC was approved by the SHEA 17 18 19 Publications Committee and the SHEA Board of Trustees. 20 21 The writing panel developed PICO-style (population, intervention, control, and outcomes) 22 23 24 questions based on themes identified by the panel. These questions were used in the development 25 26 of search terms (medical subject heading (MeSH) and text word), and both the questions and 27 28 29 search terms were voted on by the panel until unanimous approval was achieved. The writing 30 31 panel identified the time period from which articles would be collected as January 1, 1990 to 32 33 34 June 30, 2016. Only English language articles were included. The lists of articles generated from 35 36 the searches were reviewed by a primary reviewer and secondary reviewer for inclusion. For this 37 38 topic, the authors conducted two surveys of the SHEA Research Network (SRN) and subsets of 39 40 41 the AANA, ASA, and the American Academy of Anesthesiologist Assistants (AAAA) 42 43 membership. 44 45 46 SHEA EGs are developed with a formalized process for reaching expert consensus. 47 48 Recommendations are listed with rationale statements that take into account relevant evidence as 49 50 51 well as the consensus of the group. Consensus around recommendations and rationale is 52 53 determined via an anonymous comment period. For this EG, full consensus was achieved. 54 55 56 57 58 59 60 61 62 10 63 64 65 1 2 3 4 Review and Endorsement 5 6 7 The document was reviewed and approved by the SHEA Guidelines Committee, the SHEA 8 9 Publications Committee, and endorsed by the SHEA Board of Trustees, the American Academy 10 11 12 of Anesthesiologist Assistants (AAAA), the American Association of Nurse Anesthetists 13 14 (AANA), and the Anesthesia Patient Safety Foundation (APSF). The American Society of 15 16 Anesthesiologists (ASA) provided a letter of support with qualifications (Supplemental File 1). 17 18 19 Surveys 20 21 SHEA Research Network (SRN) 22 23 24 In December 2016, a survey was sent to SHEA Research Network (SRN) members to gather 25 26 information on infection prevention and control policies and practices for anesthesia providers in 27 28 29 the OR setting. Fifty-nine individual healthcare epidemiologists at their healthcare institutions 30 31 responded (43 United States members and 16 international members) from the 130 invited to 32 33 34 participate, for a response rate of 45.8%. 35 36 The minority of SRN respondents (35.6%) reported having infection prevention and control 37 38 policies specific to anesthesia practice in the OR, with international respondents (10/16) more 39 40 41 likely than US respondents (11/43) to have such policies (p=0.008). For respondents answering 42 43 that there were no (n=35) or unknown (n=7) policies specific to anesthesia, 97.5% reported the 44 45 46 expectation that anesthesia provider practice in the OR would be in compliance with institutional 47 48 policies (Supplemental Table 1). 49 50 51 Three respondents reported that their facility has a policy that allows anesthesia providers to 52 53 perform 54 55 HH on gloved hands as an alternative to changing gloves followed by HH, and in one instance 56 57 58 this was a written policy. Seven answered that anesthesia providers are allowed to wear two sets 59 60 61 62 11 63 64 65 1 2 3 4 of gloves during airway management and remove the outer glove without performing additional 5 6 7 HH, although in no instance was this written policy. Among respondents who were aware of 8 9 their facility's practices, 34.9% and 21.6% institutions routinely used single-use laryngoscopes or 10 11 12 video-laryngoscopes respectively. Generally, facilities audited anesthesia providers’ infection 13 14 prevention and control practices in the OR when there was a concern about practices (52.5%), 15 16 although 13 respondents (22%) reported a monthly audit. Four facilities (6.8%) never conducted 17 18 19 audits (Supplemental Table 2). 20 21 Survey to Members of ASA, AANA, AAAA 22 23 24 The panel sent a survey focused on practices that providers followed while giving care in the OR 25 26 setting to three groups of anesthesia providers in March 2017; 5,000 members of ASA; 5,000 27 28 29 members of AANA, and 1,761 members of the American Academy of Anesthesiologist 30 31 Assistants (AAAA) and received responses from 396 (8%) physicians (113 in academic practice, 32 33 34 277 in private practice, 6 in training), 246 (5%) nurse anesthetists (236 certified, 10 in training), 35 36 and 70 (4%) anesthesiologist assistants (56 certified, 14 in training). The majority had >10 years 37 38 in practice (0-10 years: 27.3%; 11-30 years: 49.4%; >30 years: 23.3%). Two-thirds of 39 40 41 respondents reported having infection prevention and control guidelines specific for anesthesia 42 43 services in their institution (Supplemental Table 3). 44 45 46 ABHR was generally readily available within the anesthesia work area (always or usually: 47 48 93.8%) and placed at entry points to every OR (always or usually: 92.3%). Respondents 49 50 51 identified barriers to HH as: lack of time in emergency situations (58.3%), lack of time in general 52 53 (44.2%), skin factors (35.8%), HH equipment not easily accessible (27%), and lack of support 54 55 from OR personnel for HH-related workflow interruptions (15.5%) (Supplemental Table 4). 56 57 58 59 60 61 62 12 63 64 65 1 2 3 4 Anesthesia providers identified barrier precautions used for inserting central lines: mask 5 6 7 (94.4%), sterile gloves (93.8%), gown (88%), cap (91.6%), and full drape (79.2%). The practice 8 9 was different for placing arterial lines, with providers using all barrier elements less frequently 10 11 12 (masks: 82%; sterile gloves: 74.2%; gown: 10.9%; cap: 76.8%; full drape: 3.7%). Almost half 13 14 did not use a drape (48.1%). 15 16 Institutions provided feedback variably on departments’ adherence to HH (never: 40.9%; every 17 18 19 6-12 months: 34.9%; quarterly: 24.2%) and other infection prevention and control practices and 20 21 procedures (never: 42.3%; every 6-12 months: 36.8%; quarterly: 20.9%). 22 23 24 Discussion 25 26 Given the low response rate from anesthesia providers, it is difficult to know how generalizable 27 28 29 findings are to all institutions and all anesthesia providers. If respondents represent providers 30 31 who are most interested in following infection prevention and control practices, these results 32 33 34 likely overestimate adherence with infection prevention and control in the OR setting; 35 36 nonetheless, some conclusions may be drawn: 37 38 1. Infection prevention and control policies specific to anesthesia care in the OR are not 39 40 41 universal in US healthcare facilities. 42 43 2. Audits of infection prevention and control practices are not routine. 44 45 46 3. Not all anesthesia work areas are cleaned and disinfected between every patient, with the 47 48 anesthesia cart representing an item of risk for cross-contamination. 49 50 51 4. Certain anesthesia provider practices remain problematic, especially use of multi-dose vials 52 53 for >1 patient, less than 100% use of gloves for airway management, lack of HH after 54 55 removing gloves, and entry into anesthesia cart drawers without HH. 56 57 58 59 60 61 62 13 63 64 65 1 2 3 4 The authors acknowledge that the OR is a challenging environment in which to affect ideal 5 6 7 infection prevention and control practices, but note opportunity for improvement. 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 14 63 64 65 1 2 3 4 Guidance Statement 5 6 7 Hand Hygiene 8 9 Which activities in anesthesia care should always result in HH? 10 11 12 Recommendation: HH ideally should be performed following the WHO 5 Moments for Hand 13 14 Hygiene. The authors recommend that HH be performed at the minimum before aseptic tasks 15 16 (e.g., inserting central venous catheters, inserting arterial catheters, drawing medications, spiking 17 18 19 IV bags); after removing gloves; when hands are soiled or contaminated (e.g., oropharyngeal 20 21 secretions); before touching the contents of the anesthesia cart; and when entering and exiting the 22 23 24 OR (even after removing gloves). 25 26 Rationale: Previous observational studies have reported that if the WHO 5 Moments for Hand 27 28 29 Hygiene is used as the gold standard, the indications for HH among anesthesia providers in the 30 31 OR can be as high as 54 per hour, leading to non-adherence rates of 83% 2. These findings have 32 33 1 34 led some investigators to conclude that applying the WHO 5 Moments in the anesthesia work 35 36 area, especially during induction, is logistically not feasible 3. Muñoz-Price, et al showed that 37 38 increasing access to alcohol-based hand rub (ABHR) led to an increase in the number of times 39 40 4 41 HH was performed by anesthesiology staff during a surgical procedure . Research suggests 42 43 wearable ABHR dispensers improve HH adherence among anesthesia providers5. Koff, et al 44 45 46 showed that the use of a wearable ABHR dispenser capable of recording HH events decreased 47 48 the contamination rate of intravenous tubing in the OR6. In a multisite randomized controlled 49 50 51 trial, Koff, et al also showed that providing wearable dispensers to anesthesia providers resulted 52 53 in an eight-fold increase in the number of times HH was performed when compared to rooms 54 55 where only wall-mounted ABHR dispensers were available7. 56 57 58 59 1 WHO 5 Moments of Hand Hygiene: 1) before touching a patient; 2) before clean/aseptic procedures; 3) after 60 body fluid exposure/risk; 4) after touching a patient; 5) after touching patient surroundings 61 62 15 63 64 65 1 2 3 4 Should providers wear double gloves during airway management and discard the outer 5 6 7 glove immediately after airway manipulation? 8 9 Recommendation: To reduce risk of contamination in the OR, providers should consider 10 11 12 wearing double gloves during airway management and remove the outer gloves immediately 13 14 after airway manipulation. As soon as possible, providers should remove the inner gloves and 15 16 perform HH. 17 18 19 Rationale: Anesthesia providers’ hands may become contaminated with upper airway secretions 20 21 while providing airway management and endotracheal intubation. Providers may not be able to 22 23 24 perform HH during this time and cross contamination of the anesthesia work area can occur. 25 26 Two randomized trials and one anecdotal report exist related to the strategy of using double 27 28 8-10 29 gloves to decrease contamination in the OR . The two trials found a significant decrease in 30 31 OR contamination (P<0.001) when double gloves were used during airway 32 33 34 manipulation/intubation and the outer layer was removed after intubation. Despite the significant 35 36 decrease in contamination, this was not completely eliminated; therefore, anesthesia providers 37 38 should remove the inner layer of gloves as soon as possible and perform HH. Although these 39 40 41 investigations took place in a simulated OR with anesthesia residents, the authors believe the 42 43 results can be generalized to actual ORs in hospitals. 44 45 46 Where should facilities locate alcohol-based hand rub (ABHR) dispensers in the OR? 47 48 Recommendation: The authors recommend facilities locate ABHR dispensers at the entrances 49 50 51 to ORs and in close proximity to anesthesia providers inside the OR in order to promote frequent 52 53 HH. Several studies have demonstrated wearable ABHR dispensers with audible reminders 54 55 increase the frequency of HH as well as the potential to decrease the incidence of HAI. Several 56 57 58 studies have demonstrated wearable ABHR dispensers with audible reminders increase the 59 60 61 62 16 63 64 65 1 2 3 4 frequency of HH as well as the potential to decrease the incidence of HAI. While the specific 5 6 7 wearable devices used in these studies are not currently available, the authors recommend that 8 9 facilities consider suitable wearable ABHR dispensers with automatic reminders when 10 11 12 commercially available. ABHR dispensers should be located in accordance with applicable 13 14 national and local fire safety standards and codes. Additionally, the authors recommend the 15 16 facility to delegate the filling of the ABHR dispensers to designated personnel and regularly 17 18 19 ensure compliance with this practice. 20 21 Rationale: Locating ABHR dispensers at entrances to ORs facilitates the recommended practice 22 23 24 of performing HH before entry and after exiting the room, and locating ABHR dispensers on the 25 26 anesthesia machine was associated with a modest increase in the frequency of HH4. Researchers 27 28 29 found the use of a wearable ABHR dispenser with an audible reminder resulted in a significant 30 31 increase in HH and reduction in anesthesia work area contamination, IV tubing contamination, 32 33 6 34 and healthcare-associated infection ; however, a subsequent similar study found an increase in 35 36 the rate of HH but no effect on the rate of healthcare-associated infection 7. 37 38 A variety of local and national fire prevention standards and codes may restrict the placement of 39 40 41 ABHR dispensers on top of the anesthesia machine. For example, the National Fire Protection 42 43 Association (NFPA) 101: Life Safety Code 11, stipulates the maximum allowable volume of an 44 45 46 individual ABHR dispenser to be 1.2 L, requires that dispensers be separated horizontally by at 47 48 least 48 inches, and that dispensers be at least 1 inch away from an ignition source. However, the 49 50 12,13 51 incidence of fire from ABHR dispensers appears to be extremely small . 52 53 Can the anesthesia provider apply ABHR on gloves that are being worn during a case, 54 55 rather than removing the gloves, performing HH, and then replacing a new set of gloves if 56 57 58 contaminated? 59 60 61 62 17 63 64 65 1 2 3 4 Recommendation: Changing gloves with HH between doffing and donning is the preferred 5 6 7 method of disinfection. Current data are inadequate for the authors to either support or 8 9 discourage the procedure of using ABHR on gloved hands or to determine whether application of 10 11 12 foam or gel affects glove integrity. However, application of ABHR to gloved hands might be 13 14 better than to not perform any HH when doffing and donning is not feasible. 15 16 Rationale: The clinical practice of disinfecting latex or nitrile disposable gloves with ABHR is 17 18 19 an interesting but currently uncommon practice (Supplemental Table 4). Application of foam or 20 21 gel may have unknown or unintended consequences on glove integrity; however, during the 22 23 24 Ebola outbreak in 2014, CDC published a detailed guidance (revised in 2015) recommending 25 26 that ABHR be used for disinfecting the gloves at multiple times during doffing of the personal 27 28 14 29 protective equipment . A recent paper demonstrated that multiple ethanol-based hand rub 30 31 administrations did not show observable signs of material degradation with nitrile and latex 32 33 15 34 gloves ; however, the study did not test every available glove and was predominantly 35 36 evaluating tensile strength and/or permeability, which may serve as an indicator of glove 37 38 degradation. In addition, the authors reported that some types of glove material may become 39 40 41 sticky to touch after multiple administrations of ABHR, but this was not considered problematic 42 43 in clinical use. In the current, predominant approach to HH, gloved hands are usually assumed to 44 45 46 be contaminated, while bare hands are assumed to be clean (following appropriate washing or 47 48 ABHR application). The application of ABHR to gloves could produce the unintended 49 50 51 consequence of making the identification of clean hands more difficult (“are these gloves 52 53 contaminated or was ABHR applied?”). Nevertheless, the authors believe that application of 54 55 ABHR to gloves in the anesthesia workplace is worthy of consideration and further investigation. 56 57 58 CDC and WHO guidelines recommend removing gloves before performing hand hygiene (HH) 59 60 61 62 18 63 64 65 1 2 3 4 as standard practice; however, given the frequency of HH opportunities in the perioperative 5 6 7 setting, evaluation of the effectiveness and feasibility of application of ABHR to gloves in the 8 9 anesthesia workplace as an alternative practice merits further investigation. Additionally, the 10 11 12 authors encourage glove manufacturers to perform studies to indicate whether and how many 13 14 ABHR applications can occur while still maintaining the glove's integrity. 15 16 Environmental Disinfection 17 18 19 Should reusable laryngoscopes or video-laryngoscopes be replaced with single-use 20 21 laryngoscopes/video-laryngoscopes? 22 23 24 Recommendation: The authors recommend facilities ensure that standard direct laryngoscope or 25 26 video-laryngoscope reusable handles and blades undergo high-level disinfection (at the 27 28 29 minimum) or sterilization prior to use, or replace reusable laryngoscopes with single-use 30 31 standard direct laryngoscopes or video-laryngoscopes. Clean blades and handles should be stored 32 33 34 in packaging appropriate for semi-critical items designated for “high-level” disinfection. 35 36 Rationale: Researchers have found bacteria, blood, and lymphoid tissue contamination of 37 38 laryngoscope blades and handles following low-level decontamination 16. Infectious disease 39 40 17 41 outbreaks have been associated with contaminated laryngoscopes . Laryngoscopes are 42 43 considered to be “semi-critical” devices and therefore should be subjected to high-level 44 45 46 decontamination (at the minimum) or sterilization. The Joint Commission and other regulators 47 48 require that standard direct laryngoscope reusable blades be subject to high level 49 50 51 decontamination (at the minimum) or sterilization and that blades be packaged to maintain 52 53 decontamination until just prior to use. Optimal processing of laryngoscope handles has been 54 55 subject to some controversy. Many reusable laryngoscope handles require disassembly prior to 56 57 58 high-level decontamination or sterilization, making the cleaning process potentially costly. 59 60 61 62 19 63 64 65 1 2 3 4 The authors recommend that handles that are not able to undergo high-level disinfection as per 5 6 7 manufacturer's instructions should not be used. The State of California Health and Human 8 9 Services Agency Department of Health Services recommends high-level decontamination of 10 11 2 12 laryngoscope handles . A study of laryngoscope handles cleaned with bactericidal wipes 13 14 containing either 70% alcohol and 2% chlorhexidine or coco alkyl dimethyl benzyl ammonium 15 16 chloride found that common bacteria were effectively eliminated; however, the authors point out 17 18 19 that C. difficile and norovirus would not be expected to be eliminated by this treatment 19. They 20 21 recommend autoclaving laryngoscope handles at risk for the presence of C. difficile and also on a 22 23 24 routine, monthly basis. 25 26 Single-use laryngoscopes have evolved considerably in recent years. Their performance may be 27 28 29 comparable to reusable laryngoscopes and their cost per use may be less than reusable 30 31 laryngoscopes if the costs of high-level decontamination of reusable laryngoscopes are taken into 32 33 34 account. Environmental issues pertaining to single-use laryngoscopes are addressed by some 35 36 manufacturers with recycling programs for their products. 37 38 While the authors did not conduct a literature search specific to supraglottic airway masks, they 39 40 41 note the plausibility of residual contamination of these masks and suggest facilities consider 42 43 applying the same principles when deciding between reusable and single-use supraglottic airway 44 45 46 masks. 47 48 Should anesthesia machines be partially or completely covered with disposable covers to 49 50 51 prevent contamination? 52 53 54 55 56 57 58 2 “Items directly attached to instruments that contact mucous membranes, such as the handles of rigid 59 laryngoscopes, should be considered semicritical instruments”(18. Health SoCDo. Inadequate reprocessing of 60 semicritical instruments. In. Recommendations for reprocessing of rigid laryngoscopes. Vol AFL 07-092007. 61 62 20 63 64 65 1 2 3 4 Recommendation: Current data are inadequate for the authors to make recommendations 5 6 7 regarding the use of disposable covers to prevent contamination of anesthesia machines. 8 9 Rationale: While several studies demonstrate the potential for contamination of anesthesia 10 11 12 equipment and workspaces and possible transmission of a variety of microorganisms within the 13 14 anesthesia environment, the authors did not identify studies that evaluated the impact of 15 16 equipment covers on the level of environmental contamination or patient infection risk; however, 17 18 19 they suggest that facilities may consider use of disposable covers given plausible reduction in 20 21 contamination, and facilitation of cleaning and disinfection of anesthesia machines20-25. 22 23 24 When ORs are turned over between cases, what cleaning and disinfection of the anesthesia 25 26 machine and anesthesia work area should take place? 27 28 29 Recommendation: In order to reduce the bioburden of organisms and the risk of transmitting 30 31 these organisms to patients, the facility should clean and disinfect high-touch surfaces on the 32 33 34 anesthesia machine and anesthesia work area between OR cases using an EPA-approved hospital 35 36 disinfectant that is compatible with the equipment and surfaces based on manufacturers’ 37 38 instruction for use. Because of challenges in consistent cleaning and disinfection between cases 39 40 41 of the anesthesia machine and anesthesia work area, the authors suggest prioritizing high-touch 42 43 surfaces. In addition, the authors suggest evaluation of strategies aimed at improving the ability 44 45 46 to clean these surfaces (e.g., disposable covers, re-engineering of work surfaces). 47 48 Rationale: A number of studies have demonstrated that anesthesia machines and work areas can 49 50 51 become contaminated with a variety of potentially pathogenic microbes, and that these 52 53 organisms may be transmitted to patients through direct contact with contaminated equipment, 54 55 hands of anesthesia providers, or contaminated medications 20-25. However, few studies have 56 57 58 59 60 61 62 21 63 64 65 1 2 3 4 evaluated specific cleaning and disinfection products or practices specific to the anesthesia work 5 6 7 area. 8 9 The anesthesia work area, including the anesthesia machine, computer keyboard, monitor and 10 11 12 mouse, reusable patient monitoring equipment, anesthesia cart, and ancillary equipment (such as 13 14 ultrasound machines) are physically complex and are not primarily designed and engineered to 15 16 facilitate efficient and thorough cleaning. The focus of expedited OR turnover within 10-15 17 18 19 minutes adds to the challenge of adequate cleaning. In the future, the authors encourage engineers 20 21 and manufacturers to work with human factors experts to redesign the various components of the 22 23 24 anesthesia work area to solve this problem. The authors suggest that anesthesia machine covers 25 26 may be part of the solution, but note that evidence is lacking to endorse their use (see the 27 28 29 preceding recommendation). 30 31 While awaiting evidence-based guidance, the authors recommend the facility prioritize cleaning 32 33 34 of the specific components that are most likely to be contaminated. Monitoring equipment such as 35 36 reusable blood pressure cuffs, pulse oximeter probes, electrocardiogram (ECG) leads, twitch 37 38 monitor leads and sensors, and cables that are in physical contact with patients should receive 39 40 41 high priority for thorough cleaning (single-use monitoring sensors may be useful for reducing the 42 43 cleaning burden). The anesthesia machine work surface, gas flow controls, vaporizer dials, 44 45 46 adjustable pressure limiting valve (APL), IV stands and fluid warmers, supply cart, and computer 47 48 keyboard and mouse, are also examples of components that are particularly likely to be 49 50 51 contaminated. 52 53 Should injection ports used by anesthesia providers in the OR be covered with isopropyl 54 55 alcohol-containing caps? Should injection ports – without alcohol-containing caps – used 56 57 58 by anesthesia providers in the OR be scrubbed with alcohol before each use? 59 60 61 62 22 63 64 65 1 2 3 4 Recommendation: Anesthesia providers should only use disinfected ports for intravenous 5 6 7 access. Ports may be disinfected either by scrubbing the port with a sterile alcohol based 8 9 disinfectant before each use immediately prior to each use or by using sterile isopropyl alcohol 10 11 12 containing caps that cover ports continuously. Prior to use, isopropyl alcohol containing caps 13 14 should cover the port for the minimum time recommended by the manufacturer. Ports should be 15 16 properly disinfected prior to each individual drug injection or at the beginning of a rapid 17 18 19 succession of injections, such as during induction of anesthesia. The authors recommend that 20 21 providers consider using isopropyl alcohol containing caps, which, when in place for the 22 23 24 recommended period, make ports immediately available for use at all times. Stopcocks should 25 26 have closed injection ports installed to convert them into “closed ports”, or they should be 27 28 29 covered with sterile caps. 30 31 Rationale: Peripheral intravenous tubing stopcocks and injection ports that are used for 32 33 34 medication administration frequently become contaminated with potentially pathogenic bacteria 35 36 during intraoperative use. Lower rates of provider HH, higher numbers of intravenous 37 38 medications, and greater numbers of hub interactions increase the probability of injection port 39 40 41 contamination. Although the literature does not provide direct evidence of clinical benefit in 42 43 anesthesia practice, moderate to high quality evidence exists that disinfecting catheter hubs, 44 45 46 needleless connectors, and injection ports with a sterile alcohol-containing disinfectant reduces 47 48 the risk of central line-associated bloodstream infection (CLABSI) 26. Optimally, the authors 49 50 51 recommend disinfection of injection ports to be performed before each medication injection, 52 53 consistent with recommendations in other patient care settings; however, published studies do 54 55 not address the optimal frequency of injection port disinfection and the comparative 56 57 58 effectiveness of alcohol-containing caps and alcohol wipes in anesthesia practice, and the authors 59 60 61 62 23 63 64 65 1 2 3 4 acknowledge that the act of disinfecting injection ports for 10-15 seconds followed by a drying 5 6 7 time can be challenging in anesthesia practice, particularly during induction and emergence of 8 9 anesthesia 27. For this reason, compared to alcohol wipes, passive disinfection using sterile 10 11 12 alcohol-containing caps offers visual assurance of hub disinfection and may assist facilities in 13 14 improving and monitoring compliance with this best practice 27. 15 16 When anesthesia drugs are drawn at the point of care should vials be scrubbed with 17 18 19 alcohol prior to puncture? 20 21 Recommendation: Anesthesia providers should wipe medication vials’ rubber stoppers and 22 23 24 necks of ampules with 70% alcohol prior to vial access and medication withdrawal. 25 26 Rationale: The caps of anesthesia medications are not sterile; therefore, it should be standard 27 28 28 29 practice to disinfect the rubber stoppers and neck of ampules prior to each use . A study in New 30 31 Zealand observed 10 anesthesia teams during 20 simulated cases 29. None of the 32 33 34 anesthesiologists disinfected the vial septa prior to drawing intravascular solutions, and the 35 36 anesthesia teams said they believed this was in compliance with infection prevention and control 37 38 practices. These researchers isolated microorganisms from 5 of 38 collection bags (13%), 6 of 17 39 40 28-30 41 (35%) needles, and 10 of 197 syringes (5%) . 42 43 Which intravenous catheters should be placed with full barrier precautions? 44 45 46 Recommendation: All central venous catheters (CVCs) and axillary and femoral arterial lines 47 48 should be placed with full maximal sterile barrier precautions. Full maximal sterile barrier 49 50 51 precautions include wearing mask, cap, sterile gown, and sterile gloves and using a large sterile 52 53 drape during insertion. Peripheral arterial lines, e.g. radial, brachial, or dorsalis pedis arterial 54 55 lines, should be placed with a minimum of a cap, mask, sterile gloves, and a small sterile 56 57 58 fenestrated drape. 59 60 61 62 24 63 64 65 1 2 3 4 Rationale: The authors based this recommendation on the Compendium of Strategies to Prevent 5 6 26 7 Bloodstream Infections in Acute Care Hospitals and the 2011 Healthcare Infection Control 8 9 Practices Advisory Committee (HICPAC) guideline 31, which identify the following maximal 10 11 12 sterile barrier precautions for CVC and axillary and femoral arterial line insertion: 13 14 1. All healthcare personnel involved in the catheter insertion procedure should wear mask, cap, 15 16 sterile gown, and sterile gloves. 17 18 19 2. The provider should cover the patient with a large ("full body") sterile drape during catheter 20 21 insertion. 22 23 24 The provider should also follow these measures when exchanging a catheter over a guidewire. 25 26 Placement of other arterial lines should follow the HICPAC recommendations to use a minimum 27 28 31 29 of a cover, mask, sterile gloves, and a small sterile fenestrated drape . As with other standard of 30 31 care practices, in emergency situations providers should weigh other safety considerations. 32 33 34 Should providers always recap a medication syringe after giving a portion of the syringe 35 36 contents to the patient if the syringe and medication may be used again on that patient? 37 38 Recommendation: To reduce the risk of bacterial contamination of the syringe and syringe 39 40 41 contents, the authors recommend anesthesia providers cap needleless syringes that will be used 42 43 to administer multiple doses of a drug to the same patient after each administered dose. 44 45 46 Needleless syringes should be capped with a sterile cap that completely covers the Luer 47 48 connector on the syringe. 49 50 51 Rationale: Bacterial contamination of medication syringes can occur during anesthesia practice, 52 53 most commonly with skin microorganisms102. Higher rates of medication contamination have 54 55 been associated with emergency procedures, compared to elective surgical procedures. Low 56 57 58 provider HH, lack of injection port disinfection, and contact with non-sterile equipment may 59 60 61 62 25 63 64 65 1 2 3 4 increase the risk of intraoperative contamination of syringe contents when used to administer 5 6 7 multiple doses of medication to the same patient. Although research has not assessed the 8 9 effectiveness of capping medication syringes on reducing rates of medication contamination, it is 10 11 12 plausible that capping medication syringes will reduce the risk of inadvertent contamination of 13 14 the syringe and contents from the hands or work space of the anesthesia provider. The authors do 15 16 not recommend recapping needles, which is highly discouraged due to the associated 17 18 19 occupational hazards. 20 21 What measures should be taken to protect clean supplies in the anesthesia cart from 22 23 24 contamination? Should the anesthesia supply cart be cleaned between cases? 25 26 Recommendation: The anesthesia supply cart should have its accessible outer surfaces wiped 27 28 29 clean between cases. In order to prevent contamination of communal supplies, anesthesia 30 31 providers should always perform HH before opening the drawers or bins of the cart and handling 32 33 34 the contents of the drawers or bins. Storage of supplies on the top surface of the cart should be 35 36 avoided as much as possible and any supply items on the cart top surface should be removed 37 38 between cases to facilitate cleaning. The interior of the supply cart should be cleaned on a 39 40 41 periodic basis. Future innovation and re-engineering of the storage, dispensing, and re-stocking 42 43 of supplies in the anesthesia work area is needed in order to decrease the potential for bacterial 44 45 46 cross-contamination between cases. 47 48 Rationale: The anesthesia work area is contaminated with potential pathogens and poses a threat 49 50 51 for clinically significant bacterial cross transmission. Hall, et al confirmed the presence of blood 52 53 contamination on 33% of surfaces, including surfaces in direct contact with the patient, e.g. 54 55 blood pressure cuffs and pulse oximeter probes after visual inspection of anesthesia work area 56 57 58 surfaces 32. Research has found significant anesthesia work area bioburden with both commensal 59 60 61 62 26 63 64 65 1 2 3 4 and pathogenic bacteria, including coagulase-negative staphylococci, Bacillus spp., streptococci, 5 6 20 7 Staphylococcus aureus, Acinetobacter spp. and other Gram-negative rods . Loftus, et al studied 8 9 the impact of bacterial contamination of patients, providers’ hands, and stopcocks in the OR 33. 10 11 12 They found that providers’ hands and the surrounding environment were drivers of stopcock 13 14 cross transmission, which was associated with increased patient 30 day mortality 33. Bacterial 15 16 transmission in the anesthesia work area of the OR was associated with 30 day post-operative 17 18 19 infections, impacting as many as 16% of patients undergoing surgery 34. Studies have linked 20 21 anesthesia provider hand contamination as a proximal source of both enterococcal and 22 23 23,25 24 staphylococcal transmission in the anesthesia work area . 25 26 Although studies quantifying the impact of contamination of anesthesia supply carts and work 27 28 29 areas on surgical site infection (SSI) risks are lacking, a growing body of literature suggests 30 31 potential contamination 20,33,35,36. Given the threat of bacterial cross-transmission from the 32 33 34 anesthesia work area, including the anesthesia machine and supply cart, the facility should take 35 36 measures to minimize bioburden between all cases. 37 38 What is the expiration time for sterile injectable drugs and intravenous solutions prepared 39 40 41 by anesthesia providers? 42 43 Recommendation: Provider-prepared sterile injectable drugs (such as a drug drawn from a vial 44 45 46 into a syringe) are more likely to be subject to contamination than drugs prepared in an ISO 47 48 Class 5 setting, such as a pharmacy; therefore, provider-prepared sterile injectable drugs should 49 50 51 be used as soon as practicable following preparation. The package inserts for propofol that 52 53 contain a preservative typically specify that the use of propofol should commence within 12 54 55 hours of preparation. At the time this manuscript was written, United States Pharmacopeia (USP) 56 57 58 Chapter <797> recommends that the use of provider-prepared sterile injectable drugs commence 59 60 61 62 27 63 64 65 1 2 3 4 within 1 hour of preparation; however, a draft revision of USP General Chapter <797> suggests 5 6 7 that a drug from a single dose vial punctured or entered in environments with air less clean than 8 9 ISO Class 5 may be used until the end of a case 37. If available, commercially prefilled syringes 10 11 12 or syringes prepared by the hospital pharmacy in an ISO Class 5 setting have a relatively long 13 14 “beyond use date.” 15 16 Rationale: The USP<797> generally is considered to be the applicable authority for the 17 18 19 compounding of sterile injectable solutions and drugs. At the time this manuscript was written, 20 21 USP<797> states that the use of compounded sterile provider-prepared products outside of an 22 23 24 ISO Class 5 setting (such as a pharmacy IV room) be for “immediate use” only, commencing 25 26 within 1 hour of preparation and interprets “compounding” as including drawing medications 27 28 28 29 from vials into syringes . Scientific literature is sparse pertaining to a 1 hour limit on the 30 31 advance preparation of sterile drugs for injection in an “immediate use” setting. To the best of 32 33 34 the authors’ knowledge, the “1 hour limit” from USP<797> is based on the underlying principle 35 36 that drugs prepared outside of a properly regulated pharmacy IV “clean room” are more likely to 37 38 become contaminated, and bacterial counts may increase over time 38. Austin et al performed a 39 40 41 systematic review of the literature and found a significantly higher frequency of contamination 42 43 of doses prepared in clinical than in 10 pharmaceutical environments (3.7% vs. 0.5%, p=0.007) 44 45 39 46 . A draft of the revision of USP Chapter <797> released in July 2018 contains language 47 48 suggesting that provider prepared drugs could be used until “the end of a case” 37. This draft is 49 50 51 subject to change and will not be finalized until late in 2019. 52 53 Because no reliable method exists for knowing with certainty whether the drugs or solutions 54 55 have been used, the authors suggest designated healthcare personnel discard provider-prepared 56 57 58 sterile injectable drugs and intravenous solutions at the end of each case, whether used or not. If 59 60 61 62 28 63 64 65 1 2 3 4 the drugs or solutions have been used, they may be contaminated and subsequent use for another 5 6 7 patient may result in transmission of organisms to that patient. The facility may consider 8 9 returning to stock unused commercial prefilled syringes, which have not passed their “beyond 10 11 12 use” date, have intact security locking caps, and have been present in the anesthesia work area 13 14 during a case; however, consideration should be given to the possibility that the external surface 15 16 of such syringes may become contaminated during a case and pose an infection risk if reused for 17 18 19 another case. 20 21 In addition to USP<797>, the facility may consider the advice of other authorities, which may be 22 23 24 at variance with the 1 hour limit recommended by USP 797. For example, The Joint 25 26 Commission’s recommendations for syringe labeling do not require labeling provider-prepared 27 28 29 injectable drugs for “immediate use” with a date and time of expiration unless the expiration 30 31 occurs within 24 hours of preparation, suggesting that “immediate use” may extend beyond 1 32 33 34 hour. The Food and Drug Administration (FDA) “package insert” for propofol states that 35 36 propofol has a 12-hour expiration time after being drawn up into a syringe (formulations of 37 38 propofol without preservative may have a 6-hour expiration time after being drawn up into a 39 40 40 41 syringe) . 42 43 How long can IV bags be spiked in advance of commencing use? 44 45 46 Recommendation: Anesthesia practitioners should minimize the time between spiking IV bags 47 48 and patient administration; nevertheless, certain emergent or urgent circumstances may require 49 50 51 advanced set-up of IV fluids and anesthesia providers should comply with their hospital 52 53 protocols. 54 55 Following spiking of an IV bag, administration should commence as soon as possible. No 56 57 58 specific time limit has been identified in the literature for advance preparation of IV bags. 59 60 61 62 29 63 64 65 1 2 3 4 Rationale: Facilities should determine whether local regulatory authorities, e.g. state boards of 5 6 7 health or pharmacy, have rules regarding spiking of IV bags. Scientific literature pertaining to 8 9 spiking IV bags is sparse. A study by Haas et al found no bacterial growth up to 8 hours in 80 10 11 12 bags of lactated Ringer’s solution spiked by a single provider following proper HH, but did not 13 14 address whether these results are replicable across multiple providers, in other settings, and with 15 16 other types of IV solutions 41. 17 18 19 Anesthesia providers occasionally spike IV fluids in advance, especially in preoperative holding 20 21 areas and in ORs that are reserved for emergencies. Providers should weigh the risks vs. benefits 22 23 24 of spiking IV bags that are not intended for immediate use. The authors encourage facilities to 25 26 conduct a risk assessment in collaboration with their Infection Prevention and Control 27 28 29 Departments. 30 31 Should syringes and medication vials be reused? 32 33 34 Recommendation: Single-dose medication vials and flushes should be used whenever possible. 35 36 If multi-dose medication vials must be used, they should only be used for one patient and should 37 38 only be accessed with a new sterile syringe and new sterile needle for each entry. Syringes and 39 40 41 needles are single patient devices and syringes should never be reused for another patient, even if 42 43 the needle is changed. 44 45 46 Rationale: CDC established safe injection practices as part of its 2007 Guidelines for Isolation 47 48 Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 42,43. 49 50 51 Numerous authorities and organizations, including the Association for Professionals in Infection 52 53 Control and Epidemiology (APIC), AANA, ASA, and the Joint Commission have issued 54 55 guidelines and/or recommendations concerning injection safety and have referenced CDC safe 56 57 58 injection practices 44-47. The Association of Anaesthetists of Great Britain and Ireland has also 59 60 61 62 30 63 64 65 1 2 3 4 issued safe injection practices which mirror those of CDC 48. CDC recommendations are based 5 6 7 on reports of outbreaks of preventable healthcare-acquired viral and bacterial infections resulting 8 9 from improper injection safety practices 42. Improper injection safety practices include: use of 10 11 49-54 50,55,56 12 single-dose medication vials for multiple patients , improper use of multi-dose vials , 13 14 and use of a single syringe/needle to administer intravenous medication to multiple patients 15 16 42,44,53,57. Researchers have reported outbreaks of preventable healthcare-acquired viral and 17 18 19 bacterial infections in inpatient operating suites, adult and pediatric medical-surgical wards, and 20 21 outpatient endoscopy, surgery, infusion, myocardial perfusion testing, and pain centers 49-53,55-60. 22 23 24 How should keyboards and touch screens in the anesthesia work area be cleaned and 25 26 protected from contamination? 27 28 29 Recommendation: Facilities should require cleaning and disinfection of computer keyboards 30 31 and touchscreen computer monitors after each anesthesia case using a hospital-approved 32 33 34 disinfectant consistent with manufacturers’ recommendations. Additionally, cleaning and 35 36 disinfection should also occur every time there is obvious soiling or contamination of anesthesia 37 38 work surfaces. Facilities should consider use of commercial plastic keyboard shields, sealed 39 40 41 medical keyboards, or washable keyboards and touchscreens to facilitate thorough disinfection. 42 43 Rationale: The problem of bacterial contamination of clinical and OR equipment is well 44 45 46 documented as a host of bacteria such as coagulase-negative staphylococci, Bacillus spp., and 47 48 even MRSA inhabit anesthesia surfaces, such as workspace computer touchscreens and 49 50 35 51 keyboards . Research has identified the anesthesia computer mouse as one of the most 52 53 contaminated surfaces in the OR, followed by the OR bed, nurse computer station mouse, the OR 54 55 door, and the surfaces of the anesthesia medical work cart 36. Moist surfaces, such as damp 56 57 58 gloves or computer keyboards, increase the risk of transmitting Staphylococcus epidermidis from 59 60 61 62 31 63 64 65 1 2 3 4 one surface to another61. Additional areas of concern include semi-sealed parts of anesthesia 5 6 7 equipment, where bacteria may chronically colonize surfaces in areas not readily subject to 8 9 cleaning procedures and where microbe growth may go undetected 61. 10 11 12 What infection prevention and control modifications should be made, if any, for patients in 13 14 contact isolation? 15 16 Recommendation: Anesthesia providers should follow all institution-specific guidelines when 17 18 19 caring for patients on contact isolation in the OR, including performing HH and using 20 21 appropriate personal protective equipment (PPE). Environmental disinfection should follow the 22 23 24 recommendations included in B.3., irrespective of an individual patient’s multidrug-resistant 25 26 organism status. 27 28 29 Rationale: Data demonstrate that microorganisms, including multidrug-resistant organisms, can 30 31 be spread via anesthesia providers in the OR. Research has shown contaminated hands of 32 33 34 anesthesia providers contaminate the anesthesia work area, including the anesthesia machine, 35 36 anesthesia cart, supplies on the cart, stopcocks and keyboards23,34,62,63. In addition, up to 30% of 37 38 organism transfer occurred between cases and was linked to an anesthesia work area that was not 39 40 34 41 completely decontaminated with routine cleaning . The highest risk of contamination of the 42 43 anesthesia work area occurs during induction and emergence of anesthesia 34,62. HH, contact 44 45 46 precautions, and environmental disinfection recommendations to decrease transmission of 47 48 pathogenic organisms outside of the OR also apply to providers in the OR environment. 49 50 51 Implementation 52 53 Which techniques should be used to improve infection prevention practices by anesthesia 54 55 providers? 56 57 58 59 60 61 62 32 63 64 65 1 2 3 4 Recommendation: Facilities should conduct regular monitoring and evaluation of infection 5 6 7 prevention practices. In order to promote adherence, improvement efforts should be collaborative 8 9 and include input from frontline anesthesia personnel and local champions. Hospital and 10 11 12 physician leadership should identify clear expectations and goals, ensure data transparency, and 13 14 facilitate use of process measures to improve performance. 15 16 Rationale: While the authors did not identify studies that specifically addressed the efficacy of 17 18 19 interventions to improve infection control among anesthesia providers, studies in anesthesia and 20 21 elsewhere can inform an approach to implementing and sustaining improvements. 22 23 24 Improvement efforts should involve monitoring, evaluation, and feedback. Timely collection, 25 26 analysis, and provision of data to providers are important, but can be cumbersome and time 27 28 29 consuming because collecting adherence data most often involves human observers. Overt 30 31 observation of behaviors can improve practice 64 but may be subject to the Hawthorne effect, 32 33 65,66 34 where the awareness of being observed changes one’s behavior . Covert observations have 35 36 been successful using video observation of anesthesia practices 67,68 and procedural technique 69. 37 38 Video recordings allow evaluation during all shifts and in many areas without overextending 39 40 67 52 70 41 observing staff . Healthcare worker volunteers , and non-provider volunteers have assessed 42 43 HH practices on inpatient units. 44 45 46 Facilities providing feedback should focus on ways to improve adherence rather than place 47 48 blame. Researchers found providers fail to adhere to infection prevention practices not out of 49 50 51 malice or indifference, but due to a complex combination of beliefs, work environment, 52 53 technology, information load, and conditioning 71-75. Audit and feedback programs have been 54 55 shown to be effective when designed using both theory and evidence 76. Institutions should be 56 57 58 mindful that the hierarchical nature of team organization in the anesthesia work area could hinder 59 60 61 62 33 63 64 65 1 2 3 4 honest communication and feedback 77. Fostering psychological safety and comfort in taking 5 6 78 7 interpersonal risk may help workplace team learning and improvement . 8 9 Clarity of expected behaviors in the context of a provider’s role can help focus educational 10 11 79 12 activities . Interventions such as reminder cards or checklists have been utilized to improve 13 14 adherence to transmission-based precautions 80,81, as has simulation for education and evaluation 15 16 of different aspects of anesthesia practice 29,82-84. A Children’s Hospital Association working 17 18 19 group developed an evaluation tool for infection prevention in anesthesia practice. While not 20 21 validated empirically, facilities may consider use of this tool to initiate discussions among 22 23 24 anesthesia providers and infection preventionists to identify areas of importance and in need of 25 26 improvement 77. 27 28 29 Leadership support helps to define goals, remove barriers, and hold practitioners accountable for 30 31 their performance 85. One institution demonstrated sustained improvements in HH adherence 32 33 34 following a ‘stand-down’ event following a HH summit attended by hospital leaders. This 35 36 involved a hospital-wide 15-minute period when all nonessential activity was stopped, plans to 37 38 improve HH were discussed, and written action plans submitted. Improvement efforts were 39 40 41 supported by frequent covert observation and direct discussions of performance with institutional 42 43 leaders 86. While important to improving practices, institutions should be careful to not allow 44 45 46 standards, monitoring, and incentives to have a negative effect on culture, learning, and 47 48 interpersonal relationships 87. 49 50 51 What is the impact of providing measurement and feedback data on HH? 52 53 Recommendation: Facilities should monitor providers’ HH performance and give them 54 55 feedback as part of a comprehensive program to improve and maintain adherence. Insufficient 56 57 58 data exist for the authors to recommend the routine use of automated, electronic, or video 59 60 61 62 34 63 64 65 1 2 3 4 monitoring and feedback, although examples in the literature demonstrate efficacy of such 5 6 7 technology. 8 9 Rationale: Facilities have used various types of monitoring and feedback to increase providers’ 10 11 12 adherence to HH. Because of the expense and the likelihood that measuring HH adherence 13 14 through direct observation only provides a small sample of provider behavior, facilities’ interest 15 16 in automated measurements has increased, including video surveillance 88 and a variety of 17 18 19 electronic devices that detect and record providers’ use of ABHR, to include such features as 20 21 delivering real time reminders to perform HH. Systematic reviews of studies conducted outside 22 23 24 of the OR concluded that insufficient information exists to recommend the use of automated 25 26 monitoring and feedback 89,90, although a study of personal, wearable ABHR dispensers that 27 28 29 emitted an audible alarm 6 minutes after the previous activation of the dispensers found a 27-fold 30 31 increase in HH compared to standard fixed ABHR dispensers 6. An intermittent reminder to 32 33 34 perform HH displayed on a video screen in the anesthesia work area increased the hourly 35 36 frequency of HH by approximately 10-fold 91. 37 38 What is the impact of providing measurement and feedback data on environmental 39 40 41 disinfection? 42 43 Recommendation: Facilities should utilize measures to assess the appropriateness and adequacy 44 45 46 of environmental disinfection, track the measures, and share the results with stakeholders to 47 48 optimize adherence to recommended disinfection practices. 49 50 51 Rationale: Studies have shown measurement and feedback improved thoroughness of cleaning 52 53 in inpatient settings 54,92-100 via use of checklists of areas to clean 101, improvements to the 54 55 cleaning methodology, including the cleanser used 97, and the use of visual indicators, such as 56 57 58 ultraviolet visible markers 93-97,99,100 and ATP bioluminescence 54,97. A study that focused on 59 60 61 62 35 63 64 65 1 2 3 4 cross-contamination of the work area by anesthesia providers reported improvements in 5 6 7 anesthesia providers’ adherence following engagement by coaching, as viewed through remote 8 9 video observation 68. Multiple studies demonstrated improved cleaning after sharing monitoring 10 11 12 data with environmental service (EVS) staff, along with education, observation, and 13 14 collaboration between infection prevention and EVS personnel 54,92-100. Some facilities improved 15 16 adherence through capital investment in EVS, most often through the creation of a dedicated 17 18 19 environmental disinfection team 94,97,100. 20 21 The authors recognize that these short-term responses may not be sustainable or generalizable to 22 23 24 all contexts, and did not identify studies that measured how feedback alone affects environmental 25 26 disinfection. Nonetheless, the literature suggests improvements to adherence derive from the 27 28 29 belief among EVS personnel that adequate cleaning protects the health of patients and families, 30 31 is expected, and is supported by the facility 102. 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 36 63 64 65 1 2 3 4 Background 5 6 7 Evidence for Infectious Sources in the Anesthesia Work Area 8 9 A growing body of literature suggests that the anesthesia work area can become contaminated 10 11 20,23-25,32,34,35,103 12 with pathogens . Hall, et al confirmed the presence of blood contamination on 13 14 33% of surfaces that have direct contact with the patient, e.g. blood pressure cuffs and pulse 15 16 oximeter probes 32, and found that visual inspection of anesthesia work area surfaces was 17 18 19 insensitive for detecting it 32. In 2001, Miller, et al reported the presence of proteinaceous 20 21 material, even after cleaning, on the majority of laryngeal masks and laryngoscope blades103. 22 23 24 Maslyk, et al identified a significant environmental bioburden with both commensal and 25 26 pathogenic bacteria, including coagulase-negative Staphylococcus, Bacillus species, 27 28 20 29 Streptococcus, S. aureus, Acinetobacter and other Gram-negative bacilli . With providers’ use 30 31 of double gloves for airway management, contamination of the anesthesia work area was 32 33 104 34 decreased but not eliminated . Fukada, et al reported significant contamination of the computer 35 36 keyboard in the OR with commensals and pathogens such as S. aureus and MRSA due to 37 38 anesthesia provider HH practice35. 39 40 41 The intraoperative environment poses a threat for clinically significant bacterial cross- 42 43 transmission. Loftus et al studied the impact of bacterial contamination of patients, providers’ 44 45 33 46 hands, and the environment on stopcock contamination in the OR . Providers’ hands and, in 47 48 particular, the surrounding environment, were important drivers of stopcock cross-transmission, 49 50 105 51 which was associated with increased patient 30-day mortality . In subsequent studies, Loftus, 52 53 et al demonstrated that bacterial transmission in the OR anesthesia work area was associated with 54 55 30-day post-operative infections, impacting as many as 16% of patients undergoing surgery 34. 56 57 58 Loftus, et al found anesthesia provider hand contamination was a proximal source of both 59 60 61 62 37 63 64 65 1 2 3 4 enterococcal and staphylococcal transmission in the anesthesia work area 23,25. Birnbach, et al 5 6 7 reported a high degree of fluorescent marker spread following simulated airway management, 8 9 including fluorescence on the face of a mannequin, the IV hub, and the keyboard, highlighting 10 11 63 12 the potential for bacterial cross-transmission during anesthesia care . 13 14 A host of bacteria such as coagulase-negative staphylococci, Bacillus species, and MRSA inhabit 15 16 the anesthesia work area, including computer touchscreens and keyboards 35. The anesthesia 17 18 19 computer mouse is one of the most contaminated surfaces in the OR, followed by the OR bed, 20 21 nurse computer station mouse, the OR door, and the surfaces of the anesthesia medical work cart 22 23 36 24 . Moist surfaces, such as damp gloves or computer keyboards, increase the risk of transmitting 25 26 S. epidermidis from one surface to another 35. Additional areas of concern include semi-sealed 27 28 29 parts of anesthesia equipment and areas not readily subject to cleaning procedures, where 30 31 bacteria may chronically colonize surfaces and microbial growth may go undetected 61. 32 33 34 Medications used in anesthesia practice can become contaminated during use and support the 35 36 growth of microorganisms, including bacteria and fungi106. Mahida, et al assessed the frequency 37 38 of bacterial contamination of intravenous fluids and medications used in a sample from 101 39 40 107 41 surgical procedures performed at a single center . Of 426 used medication syringes (median, 4 42 43 per case), 15% of syringe tips and 4% of syringe contents grew bacteria, predominantly low 44 45 46 colony counts of skin organisms (coagulase-negative Staphylococcus spp., Micrococcus, and 47 48 Kocuria). Contamination of syringe contents was significantly more common during emergency 49 50 51 than elective surgical procedures (OR 4.50; P = 0.01), but the authors did not compare the 52 53 frequency of medication administration or HH practices between emergency and elective 54 55 procedures. As noted previously, Gargiulo, et al found bacterial growth in 5% of syringes 56 57 58 (10/197), 35% (5/17) of needles, and 13% (5/38) IV fluid bags into which medications were 59 60 61 62 38 63 64 65 1 2 3 4 injected 29, with Gram-positive bacteria most commonly isolated. The investigators observed that 5 6 7 HH was never performed before entry into the simulation center or before drawing up 8 9 medications, and that the septa of medication vials and IV injection ports were never disinfected 10 11 12 with alcohol before they were used. They also observed non-sterile equipment, including 13 14 stethoscopes and medical records, placed on top of uncapped, in-use medication syringes, but did 15 16 not report the frequency with which it was observed. While the literature search for this guidance 17 18 19 did not identify a study that compares the impact of capping versus non-capping syringes used to 20 21 administer multiple doses of medication on the frequency of bacterial contamination in 22 23 24 simulation settings or clinical anesthesia practice, this same group of investigators found similar 25 26 results in a follow-up study of actual patients in ORs 29. 27 28 29 A 1999 outbreak of Serratia marcescens among seven post-operative patients was linked to a 30 31 single anesthesiologist who drew up multiple propofol syringes at a time and did not use gloves 32 33 108 34 for drawing up the syringes or for intubations . Behaviors cited during observations of other 35 36 anesthesia personnel in this center included preparing multiple syringes of propofol at one time, 37 38 using a single syringe for drawing up doses for different patients, using a single vial of propofol 39 40 41 during a period of >6 hours and for more than a single patient, lack of compliance with glove 42 43 usage, and failing to disinfect the rubber stopper of the medication vial before use. 44 45 46 Hilliard, et al investigated flip-top drug vials and confirmed that the surface of the stopper of 47 48 flip-top vials is frequently not sterile 109. While this was an expected finding, as stoppers of flip- 49 50 51 top vials are not designed to be sterile and should be scrubbed with alcohol prior to access, in a 52 53 survey of 878 anesthesiologists, 52% of respondents believed that the vial stoppers are sterile 54 55 under the flip-top caps 109. A survey performed among anesthesia providers in New Zealand 56 57 58 found that almost 80% of respondents said they rarely or never wiped the intravenous line 59 60 61 62 39 63 64 65 1 2 3 4 injection port with alcohol before injection. Fifty-four percent of anesthesia providers failed to 5 6 110 7 wipe the multi-dose vial septum with alcohol before use . 8 9 Evidence for Infection Prevention Measures in the Anesthesia Work Area 10 11 12 Hand Hygiene 13 14 Epidemiology suggests that improved intraoperative HH is an important component of 15 16 intraoperative infection prevention in the OR 111. The indications for the WHO 5 Moments3 17 18 19 include before and after direct contact with patients, after contact with body fluids or mucous 20 21 membranes (such as during endotracheal intubation), and after removal of gloves 112. Several 22 23 24 studies have assessed opportunities for and compliance with the WHO 5 Moments 25 26 recommendations during the provision of anesthesia care 2,113,114. Biddle, et al performed an 27 28 29 observational study of the HH of anesthesia providers using trained observers impersonating 30 31 nurses to quantify HH practices during anesthesia delivery while minimizing the potential for 32 33 2 34 observer influence . The overall failure to perform HH for all providers was 82%. They found 35 36 that during certain cases (e.g., extensive blood loss, patients with particularly challenging airway 37 38 issues, periods of high task density such as complicated emergence from anesthesia, and others) 39 40 41 HH indications according to WHO reached 54 per hour. 42 43 Muñoz-Price, et al found that anesthesia providers performed only 13 HH events in 8 hours of 44 45 46 observation. A subsequent study by Muñoz-Price, et al reported that placing an ABHR dispenser 47 48 on the anesthesia machine, in addition to standard wall-mounted dispensers, increased the rate of 49 50 4 51 HH events from 0.5 to 0.8 events per hour (p=01.01) . ABHRs are able to achieve approximately 52 53 a 4-log (99.99%) reduction in microorganisms on providers’ hands after one application115. Petty 54 55 56 57 58 3 WHO 5 Moments of Hand Hygiene 59 1) before touching a patient; 2) before clean/aseptic procedures; 3) after body fluid exposure/risk; 4) after 60 touching a patient; 5) after touching patient surroundings. 61 62 40 63 64 65 1 2 3 4 suggests routine use of wearable ABHR dispenser to improve HH compliance among anesthesia 5 6 5 6 7 staff . Koff, et al studied wearable ABHR dispensers . During the control period, providers 8 9 performed HH using either a wall-mounted ABHR dispenser within three steps of the anesthesia 10 11 12 work area or an ABHR dispenser on the anesthesia cart, and observers recorded the frequency of 13 14 HH events. The intervention consisted of the use of personal, wearable ABHR dispensers with an 15 16 audible reminder that alerted the provider if ABHR use had not occurred for six minutes. The 17 18 19 personal, wearable device increased the frequency of ABHR use from 0.15 to 7.1 events per hour 20 21 for attending physicians (p=0.008) and from 0.38 to 8.7 events per hour for other providers 22 23 24 (p=0.002). The increase in HH was associated with reduction in contamination of the anesthesia 25 26 work area and peripheral intravenous tubing. HAI rates decreased from 17.2% to 3.8% (p=0.02). 27 28 29 Notably, when the same group of investigators attempted to replicate their own results in a 30 31 larger, multi-center study, use of the wearable dispensers was associated with an increased 32 33 7 34 frequency of HH but not with a reduction in HAIs . Wearable dispensers were also associated 35 36 with a reduction in ventilator- associated pneumonia in the ICU 116. 37 38 Anesthesia providers in the OR are vulnerable to acquiring transient pathogenic microorganisms 39 40 41 from hand contact with excretions, saliva, blood, or urine of hospitalized patients, and becoming 42 43 vectors to transmit these organisms to others by direct touch 3,8,117. Gloves currently represent the 44 45 46 most common barrier to prevent contamination and colonization of providers’ hands during 47 48 patient contact, but require frequent changes during the anesthesia workday and HH after each 49 50 51 removal. 52 53 The ASA Recommendations for Infection Control for the Practice of Anesthesiology (Third 54 55 Edition) explicitly state that gloves should be worn whenever in contact with blood, body fluids, 56 57 58 mucous membranes, or non-intact skin, and that gloves are not intended for reuse because 59 60 61 62 41 63 64 65 1 2 3 4 removal of microorganisms and integrity cannot be ensured 47. Any time gloves are contaminated 5 6 7 they should be removed and appropriate HH performed. In addition, the AANA Guidelines state 8 9 that gloves should not be used with more than one patient 46. 10 11 12 Injection of Intravenous Drugs 13 14 Peripheral intravenous tubing stopcocks and injection ports that are used for medication 15 16 administration frequently become contaminated with bacteria during intraoperative use. Bacterial 17 18 19 contamination was detected in more than 30% of intraluminal surface samples of stopcocks 20 21 cultured at the end of general anesthesia cases 22,33, and included common skin contaminants 22 23 24 (e.g., coagulase-negative staphylococci, Micrococcus) as well as multidrug-resistant organisms s 25 26 (e.g., MRSA, vancomycin-resistant enterococcus, Acinetobacter). Several potential reservoirs 27 28 29 within the OR have been associated with intravenous tubing stopcock contamination. 30 31 Anesthesia providers report low overall rates of compliance with national recommended 32 33 34 practices for injection port disinfection. Only 20.9% of New Zealand anesthetists reported 35 36 “always” or “frequently” wiping the IV line with alcohol before injection in the OR while 31.6% 37 38 responded “never” to this question110. Similarly, 40% of anesthesia service managers in Australia 39 40 41 reported “never disinfecting” arterial line access ports with 70% alcohol or povidone iodine 42 43 before use 118. 44 45 46 In a prospective observational study of 548 adult patients undergoing surgery requiring general 47 48 anesthesia, Loftus, et al found that 23% of stopcock samples became contaminated 49 50 33 51 intraoperatively . Stopcock contamination was more often attributed to bacterial strains 52 53 contaminating the anesthesia machine’s adjustable pressure-limiting valve than to strains on 54 55 anesthesia providers’ hands or colonizing the patient’s nasopharynx and axilla. Bacterial 56 57 58 contamination rates of IV tubing stopcock extensions were similar after six hours of incubation 59 60 61 62 42 63 64 65 1 2 3 4 following removal at the end of procedures. Intraoperative stopcock contamination was 5 6 7 associated with a lower hourly rate of HH compliance by anesthesia providers resulting in 8 9 increased risk of 30-day mortality for patients, but not increased risk of post-operative HAIs. The 10 11 12 article did not report the method and frequency of stopcock hub disinfection or medication 13 14 injection practices. 15 16 In a prospective study of same-day ambulatory surgery procedures, bacterial contamination rates 17 18 19 of IV tubing stopcock extension sets were similar after six hours of incubation following removal 20 21 at the end of procedures performed with (17.3%) and without (18.6%) administration of 22 23 106 24 ethylenediaminetetraacetic acid (EDTA)-containing propofol anesthetic . Procedures with 25 26 propofol anesthesia were longer (1 to 2 hours versus <1 hour) and associated with a greater 27 28 29 number of administered medications and hub interactions than non-propofol procedures. When 30 31 IV extension set sampling was repeated after 24 hours and 48 hours hold time, presence of 32 33 34 visible propofol in the dead spaces of stopcocks was associated with a significant increase in 35 36 bacterial colony counts compared with the extension set with no visible propofol or sets with no 37 38 use of propofol, suggesting that even preservative-containing propofol may promote bacterial 39 40 41 growth in IV stopcock and tubing associated with prolonged durations of administration. The 42 43 authors did not report compliance with stopcock injection port disinfection or provider 44 45 46 intraoperative HH. 47 48 In a prospective, single-blinded controlled trial at a single center, Loftus, et al randomized 592 49 50 51 ORs to use either conventional open stopcocks or conventional open stopcocks that were 52 53 disinfected with an alcohol containing scrub device 119. Disinfection of the open stopcocks 54 55 significantly reduced bacterial contamination of the stopcock lumen (32% vs. 41%; adjusted OR 56 57 58 0.703, P=0.047); however, the rate of contamination was high in both groups. Over half the 59 60 61 62 43 63 64 65 1 2 3 4 bacterial isolates identified in stopcock lumens or aspirated lumen effluent were coagulase- 5 6 7 negative staphylococci (52%), S. aureus (1%), Pseudomonas aeruginosa (1%), and other Gram- 8 9 negative bacilli (1%). 10 11 12 In another prospective, single-blinded controlled trial at the same center, Loftus, et al 13 14 randomized 468 ORs and anesthesia providers to one of three medication injection schemes: 1) a 15 16 closed stopcock device that was disinfected with 70% isopropyl alcohol before injection, 2) the 17 18 19 same closed stopcock device not disinfected before injection, and 3) usual practice with 20 21 conventional open-lumen stopcocks 105. The port disinfection arm required the use of 70% 22 23 24 alcohol for disinfection and 30 seconds drying between each injection, but the study did not 25 26 control for the technique (scrubbing vs. wiping) or alcohol source (pump dispenser vs. pad). 27 28 29 Following induction of anesthesia, the rate of bacterial contamination of the closed stopcock with 30 31 alcohol disinfection was 0%, while the closed stopcock device with no disinfection before 32 33 34 injection was 4%, and the open stopcock system was 3.2%, suggesting that the benefit of a 35 36 closed stopcock device derives primarily from the ability to disinfect the injection port prior to 37 38 drug injection. 39 40 41 In a quasi-experimental quality improvement project at a pediatric teaching hospital, Martin, et al 42 43 assessed the impact of a bundle of interventions on reducing rates of CLABSI among patients 44 45 68 46 that travelled out of the ICU for anesthesiology care in ORs or procedure areas . The 47 48 intervention included recommendations and anesthesia provider education to limit touch 49 50 51 contamination during airway management, peripheral IV insertion, and anesthesia cart contact. 52 53 In addition, providers were instructed to perform a single 15-second scrub with alcohol and 15- 54 55 second drying time of the IV injection ports at the start of each case before attaching medication 56 57 58 syringes to the series of three-way stopcocks. All medications administered via this stopcock set 59 60 61 62 44 63 64 65 1 2 3 4 were considered clean, although the study does not report provider HH before medication 5 6 7 administration. CLABSI rates decreased from a baseline of 14.1 per 100 trips from the ICU to 8 9 9.7 in year 1 and to zero in year 2. During this same period, hospital-wide CLABSI rates 10 11 12 decreased from 3.5 to 2.2 per 1,000 device days, suggesting that other interventions outside of 13 14 modifications in anesthesia practice likely contributed to the observed reduction in CLABSI rates 15 16 among ICU patients who received anesthesia care. 17 18 19 Cole, et al cultured stopcocks used for propofol and non-propofol anesthesia. Bacteria were 20 21 recovered from 17.3% of propofol anesthesia stopcocks (26/150) and 18.6% of non-propofol 22 23 106 24 stopcocks (28/150) . As expected, mean bacterial colony counts were much higher at 24 hours 25 26 for propofol stopcocks, whether or not propofol was visible (non-propofol 95 CFU/ml, non- 27 28 29 visible propofol 418 CFU/ml, visible propofol 2,361 CFU/ml), suggesting safe injection 30 31 practices may not consistently occur 106. 32 33 34 Environmental Cleaning 35 36 The bioburden of the anesthesia work area and potential cross-transmission dynamics pose a 37 38 threat to patient safety. Practices for the cleaning, handling, and processing of anesthesia 39 40 41 equipment have been published by the Association of periOperative Registered Nurses (AORN) 42 43 120. Martin, et al reported a significant reduction of CLABSIs by improving practices in the OR 44 45 46 including HH, strategic gloving, and standardized cleaning of the anesthesia cart, IV pole, 47 48 stopcock clamp, anesthesia machine, computer, monitor, knobs, surfaces, and laryngoscope 49 50 68 51 handle . Clark, et al trained a group of anesthesia providers to keep the anesthesia equipment 52 53 cart clean, placed a placard on the cart top stating “clean hands only,” designated the surface of 54 55 the anesthesia machine for materials used during the case, and placed a separate container on the 56 57 58 anesthesia machine for contaminated items. Known contaminated sites were wiped with an 59 60 61 62 45 63 64 65 1 2 3 4 ammonium chloride-based wipe. After enacting these interventions, colony counts substantially 5 6 7 declined (adjustable pressure limiting valve, oxygen control knob, anesthetic agent control dial, 8 9 drawer pulls to the first and second drawers in the anesthesia equipment cart) 121. 10 11 12 While several studies found by the literature search demonstrated contamination of anesthesia 13 14 equipment and workspaces, as well as possible transmission of a variety of microorganisms 15 16 within the anesthesia environment, the search did not identify studies that evaluated the impact 17 18 19 of equipment covers on the level of environmental contamination or on risk of patient infection. 20 21 Maslyk, et al swabbed anesthesia machine tabletops located in randomly selected ORs and 22 23 24 detected Acinetobacter and other Gram-negative bacilli, S. aureus, and coagulase-negative 25 26 staphylococci, both before and after devices were used, despite routine cleaning 20. Baillie, et al 27 28 29 obtained swabs from surfaces of anesthetic and monitoring equipment that were not in contact 30 31 with patients, but were routinely touched by anesthesia providers during surgical procedures, 32 33 34 including oxygen, nitrous oxide and air flow control knobs, vaporizer dials, breathing system 35 36 bags, adjustable pressure-limiting valves, and monitoring control buttons 21 and detected the 37 38 same types of bacteria as Maslyk, et al 20. 39 40 41 Loftus, et al assessed transmission of potentially pathogenic bacteria in the anesthesia work area 42 43 by culturing intravenous stopcock sets and adjustable pressure-limiting valve complex and agent 44 45 22 46 dials prior to the start of surgical procedures and after completion of the case . They noted a 47 48 significant increase in the number of bacterial colonies per surface area sampled at case 49 50 51 conclusion and found bacterial contamination of intravenous stopcock sets in 32% of cases, as 52 53 well as an association between the risk of stopcock contamination and degree of anesthesia work 54 55 space contamination. In a series of follow-up studies, they evaluated the dynamics of 56 57 58 transmission of enterococci, S. aureus, and Gram-negative organisms by comparing isolates 59 60 61 62 46 63 64 65 1 2 3 4 found on patient screening cultures, anesthesia providers’ hands, and the adjustable pressure- 5 6 7 limiting valves and agent dials of the anesthesia machines during the first and second operative 8 9 cases (case pairs) performed on a given day at three academic medical centers. Isolate 10 11 12 relatedness was based on species, antimicrobial susceptibility results, and temporal association 13 14 23-25,34. For all three organism types, possible transmission events were common and appeared to 15 16 involve both environmental and anesthesia provider hand contamination reservoirs. Mahida, et al 17 18 19 performed swab cultures of the external surface of syringe tips and syringe contents in addition 20 21 to surface swabs of ventilator machines and found that the same bacterial species was cultured 22 23 24 from both the ventilator and the syringe tip in 13% of cases, as well as in the intravenous fluid 25 26 administration set in 4% of cases, suggesting the potential for environmental contamination 27 28 107 29 leading to contamination of intravenously administered medications . 30 31 Gonzalez, et al compared different disinfectant wipes, finding S. aureus, Bacillus atrophaeus 32 33 34 spores, and Clostridium sporogenes spores on the surface of an anesthesia machine, sterile flat 35 36 caps, and ridged caps (used to simulate the actual knobs on anesthesia machines) and cleaned 37 38 with five commercially available disinfectant wipes containing: 1) diisobutylphenoxyethoxyethyl 39 40 41 dimethyl benzyl ammonium chloride, 2) citric acid, 3) sodium hypochlorite, 4) hydrogen 42 43 peroxide, and 5) o-phenylphenol/o-benzyl-p-chlorophenol as well as sterile gauze soaked in water 44 45 122 46 or 5% bleach diluted 1:10 in water . All wipes cleaned the surfaces significantly better than the 47 48 no-wipe control. Removal of S. aureus from the machine surface by the commercial wipes was 49 50 51 not better than gauze with bleach and water but outperformed gauze and water when cleaning the 52 53 flat and ridged caps. B. atrophaeus and C. sporogenes spores were more difficult to clean from 54 55 the machine surface and caps compared to S. aureus. Gauze with bleach and water removed 99% 56 57 58 of spores from the machine’s surface and only the sodium hypochlorite wipe significantly 59 60 61 62 47 63 64 65 1 2 3 4 outperformed gauze and bleach and water. None of the commercial disinfectant wipes performed 5 6 7 significantly better than gauze and bleach water when cleaning spores from the caps. Gonzalez, et 8 9 al found all three organism types maintained viability after being dried on these surfaces after a 10 11 12 month. The investigators concluded that these results emphasized the importance of physical 13 14 removal of bacteria from anesthesia device surfaces between uses. 15 16 Rutala, et al found novel touchless disinfection technologies such as ultraviolet-C light and 17 18 19 hydrogen peroxide cleaning systems are effective in further reducing bioburden after a standard 20 21 clean, and may be considered by facilities for terminal cleaning of ORs; however, the clinical 22 23 24 efficacy on reduction of device-associated infections and SSIs has not been studied and the 25 26 intervention has not been subjected to a cost-benefit analysis 123. 27 28 29 Airway Management 30 31 Though few articles have been published reporting outbreaks directly linked to contaminated 32 33 124,125 34 laryngoscopes , multiple studies have demonstrated the high frequency with which blood 35 36 and bacteria can be found on both laryngoscope blades and handles, even after reprocessing 37 38 16,126-129. One study found viable bacterial contamination in up to 57% of blades and 86% of 39 40 41 handles from laryngoscopes that were disinfected and ready for use on the next patient (16). 42 43 Bhatt, et al also found bacterial contamination of flexible fiber-optic laryngoscopes 130. Studies 44 45 46 have noted the theoretical risk of transmitting Creutzfeldt-Jakob Disease (CJD) from 47 48 contaminated reusable laryngoscopes. CJD proteins have been identified in lymphoid tissue from 49 50 131 51 patients with variant CJD (vCJD), but not other prion diseases and Hirsch, et al. found that 52 53 30% of laryngoscope blades contained lymphocytes after a single-use 132. While there are no 54 55 published reports of prion transmission via laryngoscopy, the long latency period between 56 57 58 exposure and onset of disease makes identification of transmissions difficult. Based on the 59 60 61 62 48 63 64 65 1 2 3 4 potential, though unproven, risk of vCJD transmission and the extreme difficulty of eradicating 5 6 7 prion proteins from equipment, the authors suggest facilities consider single-use laryngoscope 8 9 blades 131,132. 10 11 12 The literature search identified a number of studies that compare the cost and function of single- 13 14 use laryngoscopes or video-laryngoscopes, but did not find studies that used clinical infection 15 16 outcomes. Using direct patient care and simulated patient studies, the search identified more than 17 18 19 30 articles that compared devices based largely on indirect patient related outcomes, such as user 20 21 experience, ease of visualization of larynx during intubation, efficiency of use during rapid 22 23 24 sequence intubation, duration of laryngoscopy, peak force applied to tissues, and quality of light. 25 26 The various studies compared different products and used different outcomes. Overall providers 27 28 29 showed a preference toward reusable direct laryngoscopes/video-laryngoscopes over the single- 30 31 use devices; however, older studies do not reflect the current state of single-use laryngoscope 32 33 34 technology. 35 36 The authors identified unpublished, anecdotal reports from a number of hospitals that switched 37 38 from reusable to single-use laryngoscopes. These facilities cited lower cost of new generation 39 40 41 single-use laryngoscopes compared to previously tested models, especially when the cost of 42 43 high-level disinfection or sterilization of reusable laryngoscope handles was included. 44 45 46 Additionally, the function of single-use laryngoscopes was reportedly improved compared to 47 48 earlier models and compared favorably with reusable equipment, especially considering that 49 50 51 reusable laryngoscope function may degrade over time due to wear and tear. In addition, single- 52 53 use laryngoscope batteries hypothetically are fresh, while reusable laryngoscope batteries 54 55 discharge variably with repeated use. 56 57 58 59 60 61 62 49 63 64 65 1 2 3 4 Anesthesia providers’ hands may become contaminated with upper airway secretions while 5 6 7 providing airway management and endotracheal intubation resulting in cross-contamination of 8 9 the anesthetizing area 3,8,9,117. Two studies were identified in the literature search related to 10 11 8,9 12 “double gloving” during airway management . In these studies, conducted in a simulation 13 14 setting, a fluorescent marker identified the hypothetical spread of material from the patient’s 15 16 airway to the surrounding environment. Wearing of double gloves and immediately discarding 17 18 19 the outer gloves following airway management led to reduction in contamination of the 20 21 environment. Contamination was further reduced when the laryngoscope was “sheathed” with an 22 23 24 outer glove as it was removed. 25 26 Future Directions 27 28 29 The authors identified several unique elements of anesthesia practice that pose unsolved 30 31 problems for infection prevention. These include the anesthesia machine, the anesthesia cart, and 32 33 34 provider prepared drugs and IV infusion bags. 35 36 Numerous challenges exist for thorough cleaning of the anesthesia machine between cases. The 37 38 anesthesia machine is a complicated apparatus with an irregular and complex external surface. 39 40 41 Many anesthesia machines also have drawers to store supplies. Anesthesia machines were 42 43 designed at a time when the importance of infection prevention in the anesthesia workplace was 44 45 46 not well understood, and since then the fundamental design has not changed greatly. The 47 48 anesthesia machine may need to undergo fundamental redesign that allows for quick and 49 50 51 effective cleaning of the external surfaces. 52 53 The anesthesia supply cart presents similar challenges and cleaning the anesthesia cart between 54 55 cases can be extremely challenging depending upon the particular design of the cart. Anesthesia 56 57 58 carts have many variations, which also can have a complex exterior surface due to attachment of 59 60 61 62 50 63 64 65 1 2 3 4 electrical components such as a defibrillator or cardiac output monitor, sharps collection 5 6 7 containers, waste bins, and discarded drug collection containers. Supplies and materials may be 8 9 stored in cart drawers but also in bins on the top of the cart. Typical anesthesia carts contain 10 11 12 supplies and materials intended to be used for numerous cases. Contamination of supplies can 13 14 occur if providers do not remove soiled exam gloves and apply ABHR prior to obtaining 15 16 supplies and materials from storage. Few examples exist of practices that have attempted to 17 18 19 include the anesthesia cart in a “clean zone,” where only clean hands are allowed. While some 20 21 success has been documented with this approach, maintaining the desired provider behavior 22 23 24 presents challenges. 25 26 Anesthesia providers are frequently engaged in preparing sterile drugs for injection by bolus and 27 28 29 infusion. Provider prepared drugs are not prepared using the same stringent methods as 30 31 pharmacies and commercial compounders, increasing the possibility for contamination. Since 32 33 34 bacteria may multiply over time, common sense suggests that providers should commence 35 36 administration of provider prepared drugs promptly; however, little evidence exists concerning 37 38 the length of time that is safe. Minimizing the use of provider prepared drugs by the use of drugs 39 40 41 that are prepared in a pharmacy or by a commercial compounder is a possible or partial solution. 42 43 Some of the recommendations provided in this guidance might need to be re-interpreted if a new 44 45 28 46 version of USP <797> is available (scheduled for release in late 2019). 47 48 The authors encourage investment in research to better understand the infection prevention and 49 50 51 control problems posed by the anesthesia work station, and to develop design improvements that 52 53 reduce the risk of infection. 54 55 56 57 58 59 60 61 62 51 63 64 65 1 2 3 4 Acknowledgements and Conflict of Interest Disclosure 5 6 7 This expert guidance was supported in part by the SHEA Research Network (SRN). 8 9 The authors thank Randall M. Clark, MD, Chair, American Society of Anesthesiologists (ASA) 10 11 12 Section on Clinical Care, Denver, CO, for extensively reviewing and vetting the guidance, as 13 14 well as review and feedback by ASA workgroup members: Lois A. Connolly, MD, Chair, ASA 15 16 Committee on Quality Management and Departmental Administration, Waukesha, WI; Elizabeth 17 18 19 Rebello, MD, US Pharmacopeia Representative, ASA Committee on Quality Management and 20 21 Departmental Administration, Houston, TX; Mary Ann Vann, MD, Chair, ASA Committee on 22 23 24 Occupational Health, Medfield, MA; Richard A. Beers, MD, Chair, Infection Prevention 25 26 Subcommittee, ASA Committee on Occupational Health, Fayetteville, NY; Mathew T. 27 28 29 Popovich, PhD, Director of Quality and Regulatory Affairs, ASA, Schaumburg, IL. 30 31 The authors thank Susan A. Dolan, RN, MS, CIC, Hospital Epidemiologist at the Children’s 32 33 34 Hospital Colorado, Colorado Springs, CO for serving as an expert reviewer of the guidance. 35 36 The authors would like to thank Valerie Deloney, MBA for her organizational expertise and 37 38 assistance in the development of this manuscript. 39 40 41 The following disclosures are a reflection of what has been reported to SHEA. In order to 42 43 provide thorough transparency, SHEA requires full disclosure of all relationships, regardless of 44 45 46 relevancy to the guideline topic. Evaluation of such relationships as potential conflicts of interest 47 48 is determined by a review process which includes assessment by the SHEA Guidelines Chair, the 49 50 51 SHEA Conflict of Interest Committee, and may include the Board of Trustees and Editor of 52 53 Infection Control and Hospital Epidemiology. The assessment of disclosed relationships for 54 55 possible COI will be based on the relative weight of the financial relationship (i.e., monetary 56 57 58 amount) and the relevance of the relationship (i.e., the degree to which an association might 59 60 61 62 52 63 64 65 1 2 3 4 reasonably be interpreted by an independent observer as related to the topic or recommendation 5 6 7 of consideration). The reader of this guidance should be mindful of this when the list of 8 9 disclosures is reviewed. 10 11 12 LSMP, GB, AB, DY reported nothing to disclose. DB reported reported activity with APSF 13 14 (Board of Directors) and Anesthesia and Analgesia (A&A) Editorial Board. RM reported 15 16 research grants/contracts with Medimmune, Johns Hopkins (lead in multicenter trial) HAI 17 18 19 Among Surgical & ICU Patients; BC reported research grants/contracts with Pfizer, Merck, 20 21 CDC, Preventing Hemodialysis Related BSI; EPD reported research grants/contracts with 22 23 24 Tetraphase, A Phase 3 Randomized Double-Blind Double-Dummy Multicenter Prospective 25 26 Study to Assess the Efficacy & Safety of Eravacycline vs. Ertapenem in Intra-Abdominal 27 28 29 Infections, advisory/consultant roles with Merck, Baxter, Ortho-McNeil, Targanta, Schering- 30 31 Plough, Astellas, CareFusion, Durata, Pfizer, Rib-X, institutional benefit with Exoxemis, UW 32 33 34 letter to FDA supporting research proposal <10,000, activities with SIS (Board Member), ICHE 35 36 (Editorial Board), CDC/HICPAC (content expert for SSI guideline), SCIP; GHP reported 37 38 research grants/contracts with UT, Decreasing Vancomycin Use in the NICU; BLJ reported 39 40 41 research grants/contracts with Gilead Sciences Inc., A Multicenter Randomized Double-Blind 42 43 Double-Dummy Phase 3 Study of the Safety & Efficacy of Ritonavir-Boosted Elvitegravir 44 45 46 (EVG/r) vs. Raltegravir (RAL) Administered with a Background Regimen in HIV-1 Infected, 47 48 Antiretroviral Treatment-expe, CHUM, The Canadian Cohort of Slow Progressors (HIV), Pfizer 49 50 51 Canada Inc., An International Multicenter Prospective Observational Study of the Safety of 52 53 Maraviroc Used with Optimized Background Therapy in Treatment-experienced HIV-1 Infected 54 55 Patients, Ottawa Hospital, A Randomized Control Clinical Trial of Micronutrient & Antioxidant 56 57 58 Supplementation in Persons with Untreated HIV Infection, MAINTAIN Study CTN 238 & CTN 59 60 61 62 53 63 64 65 1 2 3 4 254: Inflammatory Markers Sub-Study, Canadian HIV Trials Network, VALIDATE, Capital 5 6 7 Health Research FundFrailty in people living with HIV, PHAC CNISP: Surveillance for HA- 8 9 CVC-BSI, CDI, PJI (hip & knee), VP shunt infection, MRSA, VRE, & CRE, and institutional 10 11 12 benefit through Pfizer Canada Inc., GSK, Sunovion Pharmaceuticals Canada (unrestricted grant), 13 14 Capital District Health Authority Foundation, Infectious Diseases CME for Family Physicians 15 16 (October 2013), <10,000, Optimer Pharmaceuticals Canada, Merck Canada, ViiV Healthcare 17 18 19 Canada, BMS Canada, Gilead Sciences (unrestricted grant), Atlantic Canada HIV Education 20 21 (September 2012), >$25,000, and activity with PHAC Working Group for IC (Chair of 22 23 24 Guidelines for HCW Infected with a Bloodborne Pathogen), CJIDMM (Associate Editor), IDSA 25 26 (influenza guideline panel, SHEA), CPSNS (Chair), ad hoc Committee on BBP; DP reported 27 28 29 activity with Extended National Faculty (SHEA faculty stipend for HRET/AHA CUSP), RP 30 31 reported activity with APSF (Board of Directors) and Anesthesia and Analgesia (A&A) Editorial 32 33 34 Board. 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 54 63 64 65 1 2 3 4 References 5 6 7 1. SHEA. The Society for Healthcare Epidemiology of America (SHEA) Handbook for 8 9 SHEA-Sponsored Guidelines and Expert Guidance Documents. http://www.shea- 10 11 12 online.org/images/docs/2017_Handbook.pdf. Published 2017. Accessed January, 2017. 13 14 2. Biddle C, Shah J. Quantification of anesthesia providers' hand hygiene in a busy 15 16 metropolitan operating room: what would Semmelweis think? Am J Infect Control. 17 18 19 2012;40(8):756-759. 20 21 3. Munoz-Price LS, Riley B, Banks S, et al. Frequency of interactions and hand 22 23 24 disinfections among anesthesiologists while providing anesthesia care in the operating 25 26 room: induction versus maintenance. Infect Control Hosp Epidemiol. 2014;35(8):1056- 27 28 29 1059. 30 31 4. Munoz-Price LS, Patel Z, Banks S, et al. Randomized crossover study evaluating the 32 33 34 effect of a hand sanitizer dispenser on the frequency of hand hygiene among 35 36 anesthesiology staff in the operating room. Infect Control Hosp Epidemiol. 37 38 2014;35(6):717-720. 39 40 41 5. Petty WC. Closing the hand hygiene gap in the postanesthesia care unit: a body-worn 42 43 alcohol-based dispenser. J Perianesth Nurs. 2013;28(2):87-93; quiz 94-87. 44 45 46 6. Koff MD, Loftus RW, Burchman CC, et al. Reduction in intraoperative bacterial 47 48 contamination of peripheral intravenous tubing through the use of a novel device. 49 50 51 Anesthesiology. 2009;110(5):978-985. 52 53 7. Koff MD, Brown JR, Marshall EJ, et al. Frequency of Hand Decontamination of 54 55 Intraoperative Providers and Reduction of Postoperative Healthcare-Associated 56 57 58 59 60 61 62 55 63 64 65 1 2 3 4 Infections: A Randomized Clinical Trial of a Novel Hand Hygiene System. Infect 5 6 7 Control Hosp Epidemiol. 2016;37(8):888-895. 8 9 8. Birnbach DJ, Rosen LF, Fitzpatrick M, Carling P, Arheart KL, Munoz-Price LS. Double 10 11 12 gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the 13 14 operating room. Anesth Analg. 2015;120(4):848-852. 15 16 9. Birnbach DJ, Rosen LF, Fitzpatrick M, Carling P, Arheart KL, Munoz-Price LS. A New 17 18 19 Approach to Pathogen Containment in the Operating Room: Sheathing the Laryngoscope 20 21 After Intubation. Anesth Analg. 2015;121(5):1209-1214. 22 23 24 10. Gadalla F, Fong J. Improved infection control in the operating room. Anesthesiology. 25 26 1990;73(6):1295. 27 28 29 11. Association NFP. NFPA 101: Life Safety Code. In. Vol 19.4.3. Avon, MA2015. 30 31 12. Boyce JM, Pearson ML. Low frequency of fires from alcohol-based hand rub dispensers 32 33 34 in healthcare facilities. Infect Control Hosp Epidemiol. 2003;24(8):618-619. 35 36 13. Kramer A, Kampf G. Hand rub-associated fire incidents during 25,038 hospital-years in 37 38 Germany. Infect Control Hosp Epidemiol. 2007;28(6):745-746. 39 40 41 14. CDC. Guidance on personal protective equipment (PPE) to be used by healthcare 42 43 workers during management of patients with confirmed ebola or persons under 44 45 46 investigation (PUIs) for Ebola who are clinically unstable or have bleeding, vomiting, or 47 48 diarrhea in US hospitals, including procedures for donning and doffing PPE. 49 50 51 https://www.cdc.gov/vhf/ebola/healthcare-us/ppe/guidance.html. Published 2015. 52 53 Accessed, January 2017. 54 55 56 57 58 59 60 61 62 56 63 64 65 1 2 3 4 15. Gao P, Horvatin M, Niezgoda G, Weible R, Shaffer R. Effect of multiple alcohol-based 5 6 7 hand rub applications on the tensile properties of thirteen brands of medical exam nitrile 8 9 and latex gloves. J Occup Environ Hyg. 2016;13(12):905-914. 10 11 12 16. Lowman W, Venter L, Scribante J. Bacterial contamination of re-usable laryngoscope 13 14 blades during the course of daily anaesthetic practice. S Afr Med J. 2013;103(6):386-389. 15 16 17. Muscarella LF. Reassessment of the risk of healthcare-acquired infection during rigid 17 18 19 laryngoscopy. J Hosp Infect. 2008;68(2):101-107. 20 21 18. Health SoCDo. Inadequate reprocessing of semicritical instruments. In. 22 23 24 Recommendations for reprocessing of rigid laryngoscopes. Vol AFL 07-092007. 25 26 19. Howell V, Thoppil A, Young H, Sharma S, Blunt M, Young P. Chlorhexidine to maintain 27 28 29 cleanliness of laryngoscope handles: an audit and laboratory study. Eur J Anaesthesiol. 30 31 2013;30(5):216-221. 32 33 34 20. Maslyk PA, Nafziger DA, Burns SM, Bowers PR. Microbial growth on the anesthesia 35 36 machine. AANA J. 2002;70(1):53-56. 37 38 21. Baillie JK, Sultan P, Graveling E, Forrest C, Lafong C. Contamination of anaesthetic 39 40 41 machines with pathogenic organisms. Anaesthesia. 2007;62(12):1257-1261. 42 43 22. Loftus RW, Koff MD, Burchman CC, et al. Transmission of pathogenic bacterial 44 45 46 organisms in the anesthesia work area. Anesthesiology. 2008;109(3):399-407. 47 48 23. Loftus RW, Koff MD, Brown JR, et al. The epidemiology of Staphylococcus aureus 49 50 51 transmission in the anesthesia work area. Anesth Analg. 2015;120(4):807-818. 52 53 24. Loftus RW, Brown JR, Patel HM, et al. Transmission dynamics of gram-negative 54 55 bacterial pathogens in the anesthesia work area. Anesth Analg. 2015;120(4):819-826. 56 57 58 59 60 61 62 57 63 64 65 1 2 3 4 25. Loftus RW, Koff MD, Brown JR, et al. The dynamics of Enterococcus transmission from 5 6 7 bacterial reservoirs commonly encountered by anesthesia providers. Anesth Analg. 8 9 2015;120(4):827-836. 10 11 12 26. Yokoe DS, Anderson DJ, Berenholtz SM, et al. A compendium of strategies to prevent 13 14 healthcare-associated infections in acute care hospitals: 2014 updates. Infect Control 15 16 Hosp Epidemiol. 2014;35(8):967-977. 17 18 19 27. Moureau NL, Flynn J. Disinfection of Needleless Connector Hubs: Clinical Evidence 20 21 Systematic Review. Nurs Res Pract. 2015;2015:796762. 22 23 24 28. USP-NF. General Chapter <797> Pharmaceutical Compounding. In. Sterile 25 26 Preparations: United States Pharmacopeia (USP) and the National Formulary (NF); 27 28 29 2008. 30 31 29. Gargiulo DA, Sheridan J, Webster CS, et al. Anaesthetic drug administration as a 32 33 34 potential contributor to healthcare-associated infections: a prospective simulation-based 35 36 evaluation of aseptic techniques in the administration of anaesthetic drugs. BMJ Qual Saf. 37 38 2012;21(10):826-834. 39 40 41 30. Hemingway CJ, Malhotra S, Almeida M, Azadian B, Yentis SM. The effect of alcohol 42 43 swabs and filter straws on reducing contamination of glass ampoules used for neuroaxial 44 45 46 injections. Anaesthesia. 2007;62(3):286-288. 47 48 31. O'Grady NP, Alexander M, Burns LA, et al. Summary of recommendations: Guidelines 49 50 51 for the Prevention of Intravascular Catheter-related Infections. Clin Infect Dis. 52 53 2011;52(9):1087-1099. 54 55 32. Hall JR. Blood contamination of anesthesia equipment and monitoring equipment. Anesth 56 57 58 Analg. 1994;78(6):1136-1139. 59 60 61 62 58 63 64 65 1 2 3 4 33. Loftus RW, Brown JR, Koff MD, et al. Multiple reservoirs contribute to intraoperative 5 6 7 bacterial transmission. Anesth Analg. 2012;114(6):1236-1248. 8 9 34. Loftus RW, Koff MD, Birnbach DJ. The dynamics and implications of bacterial 10 11 12 transmission events arising from the anesthesia work area. Anesth Analg. 13 14 2015;120(4):853-860. 15 16 35. Fukada T, Iwakiri H, Ozaki M. Anaesthetists' role in computer keyboard contamination 17 18 19 in an operating room. J Hosp Infect. 2008;70(2):148-153. 20 21 36. Link T, Kleiner C, Mancuso MP, Dziadkowiec O, Halverson-Carpenter K. Determining 22 23 24 high touch areas in the operating room with levels of contamination. Am J Infect Control. 25 26 2016;44(11):1350-1355. 27 28 29 37. USP. Proposed Revision to General Chapter <797> Pharmaceutical Compounding - 30 31 Sterile Preparations. http://www.usp.org/compounding/general-chapter- 32 33 34 797.http://www.usp.org/compounding/797-download. Published 2018. Updated July 27, 35 36 2018. Accessed August 16, 2018. 37 38 38. Fukada T, Ozaki M. Microbial growth in propofol formulations with disodium edetate 39 40 41 and the influence of venous access system dead space. Anaesthesia. 2007;62(6):575-580. 42 43 39. Austin PD, Hand KS, Elia M. Systematic review and meta-analysis of the risk of 44 45 46 microbial contamination of parenteral doses prepared under aseptic techniques in clinical 47 48 and pharmaceutical environments: an update. J Hosp Infect. 2015;91(4):306-318. 49 50 51 40. Jelacic S, Bowdle A, Nair BG, Kusulos D, Bower L, Togashi K. A System for Anesthesia 52 53 Drug Administration Using Barcode Technology: The Codonics Safe Label System and 54 55 Smart Anesthesia Manager. Anesth Analg. 2015;121(2):410-421. 56 57 58 59 60 61 62 59 63 64 65 1 2 3 4 41. Haas RE, Beitz E, Reed A, et al. No bacterial growth found in spiked intravenous fluids 5 6 7 over an 8-hour period. Am J Infect Control. 2017;45(4):448-450. 8 9 42. Siegel JD, Rhinehart E, Jackson M, Chiarello L, Committee HCICPA. 2007 Guideline 10 11 12 for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care 13 14 Settings. Am J Infect Control. 2007;35(10 Suppl 2):S65-164. 15 16 43. CDC. Safe Injection Practices to Prevent Transmission to Patients. In:2011. 17 18 19 44. Dolan SA, Felizardo G, Barnes S, et al. APIC position paper: safe injection, infusion, and 20 21 medication vial practices in health care. Am J Infect Control. 2010;38(3):167-172. 22 23 24 45. Commission J. Preventing infection from the misuse of vials. Sentinel Event Alert. 25 26 2014(52):1-6. 27 28 29 46. AANA. Safe Injection Guidelines for Needle and Syringe Use. In. Vol Position 30 31 Statement2014. 32 33 34 47. Stackhouse R, Beers R, Brown D, et al. Recommendations for Infection Control for the 35 36 Practice of Anesthesiology (Third Edition), ASA Website. 37 38 48. Ireland AoAoGBa. Infection control in anaesthesia. Anaesthesia. 2008;63(9):1027-1036. 39 40 41 49. Greeley RD, Semple S, Thompson ND, et al. Hepatitis B outbreak associated with a 42 43 hematology-oncology office practice in New Jersey, 2009. Am J Infect Control. 44 45 46 2011;39(8):663-670. 47 48 50. (CDC) CfDCaP. Acute hepatitis C virus infections attributed to unsafe injection practices 49 50 51 at an endoscopy clinic--Nevada, 2007. MMWR Morb Mortal Wkly Rep. 2008;57(19):513- 52 53 517. 54 55 56 57 58 59 60 61 62 60 63 64 65 1 2 3 4 51. Wong MR, Del Rosso P, Heine L, et al. An outbreak of Klebsiella pneumoniae and 5 6 7 Enterobacter aerogenes bacteremia after interventional pain management procedures, 8 9 New York City, 2008. Reg Anesth Pain Med. 2010;35(6):496-499. 10 11 12 52. Pan A, Dolcetti L, Barosi C, et al. An outbreak of Serratia marcescens bloodstream 13 14 infections associated with misuse of drug vials in a surgical ward. Infect Control Hosp 15 16 Epidemiol. 2006;27(1):79-82. 17 18 19 53. Gutelius B, Perz JF, Parker MM, et al. Multiple clusters of hepatitis virus infections 20 21 associated with anesthesia for outpatient endoscopy procedures. Gastroenterology. 22 23 24 2010;139(1):163-170. 25 26 54. Branch-Elliman W, Robillard E, McCarthy G, Gupta K. Direct feedback with the ATP 27 28 29 luminometer as a process improvement tool for terminal cleaning of patient rooms. Am J 30 31 Infect Control. 2014;42(2):195-197. 32 33 34 55. Germain JM, Carbonne A, Thiers V, et al. Patient-to-patient transmission of hepatitis C 35 36 virus through the use of multidose vials during general anesthesia. Infect Control Hosp 37 38 Epidemiol. 2005;26(9):789-792. 39 40 41 56. Katzenstein TL, Jørgensen LB, Permin H, et al. Nosocomial HIV-transmission in an 42 43 outpatient clinic detected by epidemiological and phylogenetic analyses. AIDS. 44 45 46 1999;13(13):1737-1744. 47 48 57. Samandari T, Malakmadze N, Balter S, et al. A large outbreak of hepatitis B virus 49 50 51 infections associated with frequent injections at a physician's office. Infect Control Hosp 52 53 Epidemiol. 2005;26(9):745-750. 54 55 56 57 58 59 60 61 62 61 63 64 65 1 2 3 4 58. Lagging LM, Aneman C, Nenonen N, et al. Nosocomial transmission of HCV in a 5 6 7 cardiology ward during the window phase of infection: an epidemiological and molecular 8 9 investigation. Scand J Infect Dis. 2002;34(8):580-582. 10 11 12 59. Moore ZS, Schaefer MK, Hoffmann KK, et al. Transmission of hepatitis C virus during 13 14 myocardial perfusion imaging in an outpatient clinic. Am J Cardiol. 2011;108(1):126- 15 16 132. 17 18 19 60. Krause G, Trepka MJ, Whisenhunt RS, et al. Nosocomial transmission of hepatitis C 20 21 virus associated with the use of multidose saline vials. Infect Control Hosp Epidemiol. 22 23 24 2003;24(2):122-127. 25 26 61. Hodgson ES, Ruis-Frutos C. A case report of contaminated operating theatre 27 28 29 multipurpose equipment: a potential hazard for health care workers. Ann Occup Hyg. 30 31 1991;35(3):341-346. 32 33 34 62. Rowlands J, Yeager MP, Beach M, Patel HM, Huysman BC, Loftus RW. Video 35 36 observation to map hand contact and bacterial transmission in operating rooms. Am J 37 38 Infect Control. 2014;42(7):698-701. 39 40 41 63. Birnbach DJ, Rosen LF, Fitzpatrick M, Carling P, Munoz-Price LS. The use of a novel 42 43 technology to study dynamics of pathogen transmission in the operating room. Anesth 44 45 46 Analg. 2015;120(4):844-847. 47 48 64. Borer A, Gilad J, Meydan N, et al. Impact of active monitoring of infection control 49 50 51 practices on deep sternal infection after open-heart surgery. Ann Thorac Surg. 52 53 2001;72(2):515-520. 54 55 56 57 58 59 60 61 62 62 63 64 65 1 2 3 4 65. Chen LF, Vander Weg MW, Hofmann DA, Reisinger HS. The Hawthorne Effect in 5 6 7 Infection Prevention and Epidemiology. Infect Control Hosp Epidemiol. 8 9 2015;36(12):1444-1450. 10 11 12 66. Srigley JA, Furness CD, Baker GR, Gardam M. Quantification of the Hawthorne effect in 13 14 hand hygiene compliance monitoring using an electronic monitoring system: a 15 16 retrospective cohort study. BMJ Qual Saf. 2014;23(12):974-980. 17 18 19 67. Rampersad SE, Martin LD, Geiduschek JM, Weiss GK, Bates SW. Video observation of 20 21 anesthesia practice: a useful and reliable tool for quality improvement initiatives. 22 23 24 Paediatr Anaesth. 2013;23(7):627-633. 25 26 68. Martin LD, Rampersad SE, Geiduschek JM, Zerr DM, Weiss GK. Modification of 27 28 29 anesthesia practice reduces catheter-associated bloodstream infections: a quality 30 31 improvement initiative. Paediatr Anaesth. 2013;23(7):588-596. 32 33 34 69. Friedman Z, Katznelson R, Devito I, Siddiqui M, Chan V. Objective assessment of 35 36 manual skills and proficiency in performing epidural anesthesia--video-assisted 37 38 validation. Reg Anesth Pain Med. 2006;31(4):304-310. 39 40 41 70. Linam WM, Margolis PA, Atherton H, Connelly BL. Quality-improvement initiative 42 43 sustains improvement in pediatric health care worker hand hygiene. Pediatrics. 44 45 46 2011;128(3):e689-698. 47 48 71. Weinger MB, Englund CE. Ergonomic and human factors affecting anesthetic vigilance 49 50 51 and monitoring performance in the operating room environment. Anesthesiology. 52 53 1990;73(5):995-1021. 54 55 72. Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice 56 57 58 guidelines? A framework for improvement. JAMA. 1999;282(15):1458-1465. 59 60 61 62 63 63 64 65 1 2 3 4 73. Beatty PC, Beatty SF. Anaesthetists' intentions to violate safety guidelines. Anaesthesia. 5 6 7 2004;59(6):528-540. 8 9 74. Pennathur PR, Thompson D, Abernathy JH, et al. Technologies in the wild (TiW): human 10 11 12 factors implications for patient safety in the cardiovascular operating room. Ergonomics. 13 14 2013;56(2):205-219. 15 16 75. Carthey J, Walker S, Deelchand V, Vincent C, Griffiths WH. Breaking the rules: 17 18 19 understanding non-compliance with policies and guidelines. BMJ. 2011;343:d5283. 20 21 76. Hysong SJ, Kell HJ, Petersen LA, Campbell BA, Trautner BW. Theory-based and 22 23 24 evidence-based design of audit and feedback programmes: examples from two clinical 25 26 intervention studies. BMJ Qual Saf. 2017;26(4):323-334. 27 28 29 77. Dolan SA, Heath J, Potter-Bynoe G, Stackhouse RA. Infection prevention in anesthesia 30 31 practice: a tool to assess risk and compliance. Am J Infect Control. 2013;41(11):1077- 32 33 34 1082. 35 36 78. Derickson R, Fishman J, Osatuke K, Teclaw R, Ramsel D. Psychological safety and error 37 38 reporting within Veterans Health Administration hospitals. J Patient Saf. 2015;11(1):60- 39 40 41 66. 42 43 79. Gurses AP, Seidl KL, Vaidya V, et al. Systems ambiguity and guideline compliance: a 44 45 46 qualitative study of how intensive care units follow evidence-based guidelines to reduce 47 48 healthcare-associated infections. Qual Saf Health Care. 2008;17(5):351-359. 49 50 51 80. Russell CD, Young I, Leung V, Morris K. Healthcare workers' decision-making about 52 53 transmission-based infection control precautions is improved by a guidance summary 54 55 card. J Hosp Infect. 2015;90(3):235-239. 56 57 58 59 60 61 62 64 63 64 65 1 2 3 4 81. Denton A, Topping A, Humphreys P. Evolution of an audit and monitoring tool into an 5 6 7 infection prevention and control process. J Hosp Infect. 2016;94(1):32-40. 8 9 82. Lim G, Krohner RG, Metro DG, Rosario BL, Jeong JH, Sakai T. Low-Fidelity Haptic 10 11 12 Simulation Versus Mental Imagery Training for Epidural Anesthesia Technical 13 14 Achievement in Novice Anesthesiology Residents: A Randomized Comparative Study. 15 16 Anesth Analg. 2016;122(5):1516-1523. 17 18 19 83. Forrest FC, Taylor MA, Postlethwaite K, Aspinall R. Use of a high-fidelity simulator to 20 21 develop testing of the technical performance of novice anaesthetists. Br J Anaesth. 22 23 24 2002;88(3):338-344. 25 26 84. Burtscher MJ, Manser T, Kolbe M, et al. Adaptation in anaesthesia team coordination in 27 28 29 response to a simulated critical event and its relationship to clinical performance. Br J 30 31 Anaesth. 2011;106(6):801-806. 32 33 34 85. Edwards VR. Preventing and managing healthcare-associated infections: linking 35 36 collective leadership, good management, good data, expertise, and culture change. J Hosp 37 38 Infect. 2016;94(1):30-31. 39 40 41 86. Cunningham D, Brilli RJ, McClead RE, Davis JT. The Safety Stand-down: A Technique 42 43 for Improving and Sustaining Hand Hygiene Compliance Among Health Care Personnel. 44 45 46 J Patient Saf. 2015. 47 48 87. Brewster L, Tarrant C, Dixon-Woods M. Qualitative study of views and experiences of 49 50 51 performance management for healthcare-associated infections. J Hosp Infect. 52 53 2016;94(1):41-47. 54 55 56 57 58 59 60 61 62 65 63 64 65 1 2 3 4 88. Armellino D, Hussain E, Schilling ME, et al. Using high-technology to enforce low- 5 6 7 technology safety measures: the use of third-party remote video auditing and real-time 8 9 feedback in healthcare. Clin Infect Dis. 2012;54(1):1-7. 10 11 12 89. Ford S, Birmingham E, King A, Lim J, Ansermino JM. At-a-glance monitoring: covert 13 14 observations of anesthesiologists in the operating room. Anesth Analg. 2010;111(3):653- 15 16 658. 17 18 19 90. Srigley JA, Gardam M, Fernie G, Lightfoot D, Lebovic G, Muller MP. Hand hygiene 20 21 monitoring technology: a systematic review of efficacy. J Hosp Infect. 2015;89(1):51-60. 22 23 24 91. Rodriguez-Aldrete D, Sivanesan E, Banks S, et al. Recurrent Visual Electronic Hand 25 26 Hygiene Reminders in the Anesthesia Work Area. Infect Control Hosp Epidemiol. 27 28 29 2016;37(7):872-874. 30 31 92. Eckstein BC, Adams DA, Eckstein EC, et al. Reduction of Clostridium Difficile and 32 33 34 vancomycin-resistant Enterococcus contamination of environmental surfaces after an 35 36 intervention to improve cleaning methods. BMC Infect Dis. 2007;7:61. 37 38 93. Goodman ER, Platt R, Bass R, Onderdonk AB, Yokoe DS, Huang SS. Impact of an 39 40 41 environmental cleaning intervention on the presence of methicillin-resistant 42 43 Staphylococcus aureus and vancomycin-resistant enterococci on surfaces in intensive 44 45 46 care unit rooms. Infect Control Hosp Epidemiol. 2008;29(7):593-599. 47 48 94. Carling PC, Parry MM, Rupp ME, et al. Improving cleaning of the environment 49 50 51 surrounding patients in 36 acute care hospitals. Infect Control Hosp Epidemiol. 52 53 2008;29(11):1035-1041. 54 55 56 57 58 59 60 61 62 66 63 64 65 1 2 3 4 95. Carling PC, Parry MF, Bruno-Murtha LA, Dick B. Improving environmental hygiene in 5 6 7 27 intensive care units to decrease multidrug-resistant bacterial transmission. Crit Care 8 9 Med. 2010;38(4):1054-1059. 10 11 12 96. Munoz-Price LS, Birnbach DJ, Lubarsky DA, et al. Decreasing operating room 13 14 environmental pathogen contamination through improved cleaning practice. Infect 15 16 Control Hosp Epidemiol. 2012;33(9):897-904. 17 18 19 97. Sitzlar B, Deshpande A, Fertelli D, Kundrapu S, Sethi AK, Donskey CJ. An 20 21 environmental disinfection odyssey: evaluation of sequential interventions to improve 22 23 24 disinfection of Clostridium difficile isolation rooms. Infect Control Hosp Epidemiol. 25 26 2013;34(5):459-465. 27 28 29 98. Guerrero DM, Carling PC, Jury LA, Ponnada S, Nerandzic MM, Donskey CJ. Beyond 30 31 the Hawthorne effect: reduction of Clostridium difficile environmental contamination 32 33 34 through active intervention to improve cleaning practices. Infect Control Hosp Epidemiol. 35 36 2013;34(5):524-526. 37 38 99. Trajtman AN, Manickam K, Macrae M, Bruning NS, Alfa MJ. Continuing performance 39 40 41 feedback and use of the ultraviolet visible marker to assess cleaning compliance in the 42 43 healthcare environment. J Hosp Infect. 2013;84(2):166-172. 44 45 46 100. Kundrapu S, Sunkesula V, Sitzlar BM, Fertelli D, Deshpande A, Donskey CJ. More 47 48 cleaning, less screening: evaluation of the time required for monitoring versus performing 49 50 51 environmental cleaning. Infect Control Hosp Epidemiol. 2014;35(2):202-204. 52 53 101. Carling PC, Huang SS. Improving healthcare environmental cleaning and disinfection: 54 55 current and evolving issues. Infect Control Hosp Epidemiol. 2013;34(5):507-513. 56 57 58 59 60 61 62 67 63 64 65 1 2 3 4 102. Matlow AG, Wray R, Richardson SE. Attitudes and beliefs, not just knowledge, 5 6 7 influence the effectiveness of environmental cleaning by environmental service workers. 8 9 Am J Infect Control. 2012;40(3):260-262. 10 11 12 103. Miller DM, Youkhana I, Karunaratne WU, Pearce A. Presence of protein deposits on 13 14 'cleaned' re-usable anaesthetic equipment. Anaesthesia. 2001;56(11):1069-1072. 15 16 104. Biddle C, Robinson K, Pike B, Kammerman M, Gay B, Verhulst B. Quantifying the 17 18 19 rambunctious journey of the anesthesia provider's hands during simulated, routine care. 20 21 Am J Infect Control. 2016;44(8):873-878. 22 23 24 105. Loftus RW, Patel HM, Huysman BC, et al. Prevention of intravenous bacterial injection 25 26 from health care provider hands: the importance of catheter design and handling. Anesth 27 28 29 Analg. 2012;115(5):1109-1119. 30 31 106. Cole DC, Baslanti TO, Gravenstein NL, Gravenstein N. Leaving more than your 32 33 34 fingerprint on the intravenous line: a prospective study on propofol anesthesia and 35 36 implications of stopcock contamination. Anesth Analg. 2015;120(4):861-867. 37 38 107. Mahida N, Levi K, Kearns A, Snape S, Moppett I. Investigating the impact of clinical 39 40 41 anaesthetic practice on bacterial contamination of intravenous fluids and drugs. J Hosp 42 43 Infect. 2015;90(1):70-74. 44 45 46 108. Henry B, Plante-Jenkins C, Ostrowska K. An outbreak of Serratia marcescens associated 47 48 with the anesthetic agent propofol. Am J Infect Control. 2001;29(5):312-315. 49 50 51 109. Hilliard JG, Cambronne ED, Kirsch JR, Aziz MF. Barrier protection capacity of flip-top 52 53 pharmaceutical vials. J Clin Anesth. 2013;25(3):177-180. 54 55 110. Ryan AJ, Webster CS, Merry AF, Grieve DJ. A national survey of infection control 56 57 58 practice by New Zealand anaesthetists. Anaesth Intensive Care. 2006;34(1):68-74. 59 60 61 62 68 63 64 65 1 2 3 4 111. Munoz-Price LS, Birnbach DJ. Hand hygiene and anesthesiology. Int Anesthesiol Clin. 5 6 7 2013;51(1):79-92. 8 9 112. WHO. World Health Organization Guidelines on Hand Hygiene in Healthcare. Geneva, 10 11 12 Switzerland: WHO Press; 2009. 13 14 113. Scheithauer S, Rosarius A, Rex S, et al. Improving hand hygiene compliance in the 15 16 anesthesia working room work area: More than just more hand rubs. Am J Infect Control. 17 18 19 2013;41(11):1001-1006. 20 21 114. Sahni N, Biswal M, Gandhi K, Yaddanapudi S. Quantification of hand hygiene 22 23 24 compliance in anesthesia providers at a tertiary care center in northern India. Am J Infect 25 26 Control. 2015;43(10):1134-1136. 27 28 29 115. Paulson DS, Fendler EJ, Dolan MJ, Williams RA. A close look at alcohol gel as an 30 31 antimicrobial sanitizing agent. Am J Infect Control. 1999;27(4):332-338. 32 33 34 116. Koff MD, Corwin HL, Beach ML, Surgenor SD, Loftus RW. Reduction in ventilator 35 36 associated pneumonia in a mixed intensive care unit after initiation of a novel hand 37 38 hygiene program. J Crit Care. 2011;26(5):489-495. 39 40 41 117. Munoz-Price LS, Lubarsky DA, Arheart KL, et al. Interactions between anesthesiologists 42 43 and the environment while providing anesthesia care in the operating room. Am J Infect 44 45 46 Control. 2013;41(10):922-924. 47 48 118. Reynolds H, Dulhunty J, Tower M, Taraporewalla K, Rickard C. A snapshot of guideline 49 50 51 compliance reveals room for improvement: a survey of peripheral arterial catheter 52 53 practices in Australian operating theatres. J Adv Nurs. 2013;69(7):1584-1594. 54 55 56 57 58 59 60 61 62 69 63 64 65 1 2 3 4 119. Loftus RW, Brindeiro BS, Kispert DP, et al. Reduction in intraoperative bacterial 5 6 7 contamination of peripheral intravenous tubing through the use of a passive catheter care 8 9 system. Anesth Analg. 2012;115(6):1315-1323. 10 11 12 120. Association of periOperative Registered Nurses. Guideline for Environmental Cleaning. 13 14 AORN Guidelines for Perioperative Practice. 2018; 7-28. 15 16 121. Clark C, Taenzer A, Charette K, Whitty M. Decreasing contamination of the anesthesia 17 18 19 environment. Am J Infect Control. 2014;42(11):1223-1225. 20 21 122. Gonzalez EA, Nandy P, Lucas AD, Hitchins VM. Ability of cleaning-disinfecting wipes 22 23 24 to remove bacteria from medical device surfaces. Am J Infect Control. 2015;43(12):1331- 25 26 1335. 27 28 29 123. Rutala WA, Weber DJ. Disinfectants used for environmental disinfection and new room 30 31 decontamination technology. Am J Infect Control. 2013;41(5 Suppl):S36-41. 32 33 34 124. Jones BL, Gorman LJ, Simpson J, et al. An outbreak of Serratia marcescens in two 35 36 neonatal intensive care units. J Hosp Infect. 2000;46(4):314-319. 37 38 125. Cullen MM, Trail A, Robinson M, Keaney M, Chadwick PR. Serratia marcescens 39 40 41 outbreak in a neonatal intensive care unit prompting review of decontamination of 42 43 laryngoscopes. J Hosp Infect. 2005;59(1):68-70. 44 45 46 126. Phillips RA, Monaghan WP. Incidence of visible and occult blood on laryngoscope 47 48 blades and handles. AANA J. 1997;65(3):241-246. 49 50 51 127. Negri de Sousa AC, Vilas Boas VA, Levy CE, Pedreira de Freitas MI. Laryngoscopes: 52 53 Evaluation of microbial load of blades. Am J Infect Control. 2016;44(3):294-298. 54 55 128. Call TR, Auerbach FJ, Riddell SW, et al. Nosocomial contamination of laryngoscope 56 57 58 handles: challenging current guidelines. Anesth Analg. 2009;109(2):479-483. 59 60 61 62 70 63 64 65 1 2 3 4 129. Williams D, Dingley J, Jones C, Berry N. Contamination of laryngoscope handles. J 5 6 7 Hosp Infect. 2010;74(2):123-128. 8 9 130. Bhatt JM, Peterson EM, Verma SP. Microbiological sampling of the forgotten 10 11 12 components of a flexible fiberoptic laryngoscope: what lessons can we learn? 13 14 Otolaryngol Head Neck Surg. 2014;150(2):235-236. 15 16 131. Hill AF, Butterworth RJ, Joiner S, et al. Investigation of variant Creutzfeldt-Jakob 17 18 19 disease and other human prion diseases with tonsil biopsy samples. Lancet. 20 21 1999;353(9148):183-189. 22 23 24 132. Hirsch N, Beckett A, Collinge J, Scaravilli F, Tabrizi S, Berry S. Lymphocyte 25 26 contamination of laryngoscope blades--a possible vector for transmission of variant 27 28 29 Creutzfeldt-Jakob disease. Anaesthesia. 2005;60(7):664-667. 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 71 63 64 65