Infection Control Practices in Anesthesia

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Infection Control Practices in Anesthesia

• Brian D. Thorson, CRNA,MA
• September 28, 2009

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1. Leave you with more questions than answers2.
Prevent one patient or another provider from
needlessly being exposed to something that could
adversely effect their life

• Goals of the presentation

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Fairy God Mother of Anesthesia
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I am now Anesthesia

• I do not wipe of injection ports
• I do not wipe of tops of vials of medication
  prior to inserting a needle
• I do not wear sterile gloves while suctioning a
  patients endotracheal tube
• I can drop suction catheters on the floor and not
  change them before re-inserting them in the
  patients mouth
• If unable to find a place for the yankauer
  suction catheter, just simply slip it between the
  mattress and the bedframe
• I can insert IV catheters/arterial lines without
  wearing gloves

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Will you do my sons anesthetic, 1994?

• How could you even question me?
• I am anesthesia, I could not have possibly caused
  a problem!

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Could I have possibly done something that may
have lead to the elevation in his temperature?
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Absence of evidence is not evidence of absence

• Because we do not see it and are temporally
  remote from the complications clinical
  manifestations, we may not recognize our role in
  causing it.
• Dr. Chuck Biddle AANA Journal June 2009

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Norman Oklahoma- James Hill, CRNAMore than 50
people at an Oklahoma hospital have potentially
been infected with Hepatitis C after a CRNA
repeatedly used the same needle and syringe when
administering anesthesia to his patients- 6 end
up with Hepatitis C (September 2002)
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AANAs Response

• Notify all 35,000 members, in an all member
  mailing that reuse of syringes was an
  unacceptable practice.
• Instructed CRNAs to discontinue this practice
• Reuse of needles between different patients as
  well as on the same patient is an unacceptable
  practice.
• Start of a national campaign to ensure that
  members were not engaging in this practice

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2002-2006

• Hope that alerts of unsafe practices to members
  will result in change of practice
• Examples of unsafe practices continue to surface
  within the anesthesia community
• First-hand and the Media
• Classroom
• Travel - laryngoscope blades/ETT
• Evidence continued to exist in my own clinical
  practice

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Nurse Accused of Spreading Hepatitis C at
Military Hospital

• August 6- October 12 2004
• Jon Dale Jones, CRNA may have potentially
  infected up to 15 patients with a potentially
  fatal strain of hepatitis C by stealing drugs
  meant for his patients and knowingly passing
  on his own infection to his patients.
• LA Times March 2008 nine count indictment of
  assault and obtaining a controlled substance by
  fraud
• Indictment comes after a more than 2 year
  investigation by the FBI

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Thousands May Be Infected With Hepatitis C from
Las Vegas Clinic

• February 28, 2008
• Problems occurred between March of 2004 and
  January 2008
• A Clark county investigation found that the
  clinic was not using clean syringes for each
  patient anesthetized there.
• Multi dose vials/syringe reuse
• As many as 40,000 patients may have been exposed

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Dr. Harvey Finkelstein

• 2007 -An anesthesiologist in Nassau County New
  York, told health officials that he would reuse a
  syringe to draw medications for patients from
  more than on vial. More than 600 patients
  exposed to hepatitis C

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Cleaning Equipment Improperly

• VA story about Veterans exposed to HIV secondary
  to scopes being improperly cleaned.
• TEE scope locally being soaked in Cidex and not
  rinsed prior to be inserted into a patients
  esophagus and left for a many hour procedure
  leading to tissue damage to the esophagus

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Safe Injection Practices Campaign 2009

• 9 organizations including Accreditation
  Association of Ambulatory Healthcare (AAAHC),
  American Association of Nurse Anesthetists
  (AANA), Ambulatory Surgery Foundation,
  Association for Professionals in Infection
  Control and Epidemiology(APIC) Becton, Dinkinson
  and Company, CDC, CDC Foundation, HONOR Reform
  Foundation, Nebraska Medical Association and
  Nevada State Medical Association.

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Safe Injection Practices Campaign

• Press conference held in Washington DC Feb 11th
  2009
• Majority Leader Harry Reid, D (NV)
• Shelley Berkley D (NV)
• One and Only One Campaign
• CDC

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With all of this going on, why do we still have
the problem?

• Awareness
• Not me, someone else
• Laziness
• Production Pressure
• Resources/supportive measures in hospitals

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Awareness

• Despite all of the publicity about unsafe
  practices in anesthesia, providers lack the
  awareness that their practices maybe unsafe.
• Anesthesia providers may hold the belief that
  because there is a lack of evidence that our
  routine practices have direct, negative,
  iatrogenic implications for patients, we are not
  participatory in the genesis of infective risk
  and complications ( AANA Journal, June 2009
  Biddle)

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Dr. Chuck Biddle, Absence of Evidence Is Not
Evidence of Absence

• The nature of anesthesias exposure to a given
  patient is defined by
• Relatively brief period of intense and invasive
  procedures
• Little meaningful follow-up once the patient
  leaves the OR
• Post-operative visits within 24hours

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Awareness

• In the United States, Hepatitis B, (HBV) and
  Hepatitis C (HCV) from health care exposures has
  been considered to be uncommon.
• However, recent outbreaks of HBV and HCV
  infections, primarily in settings outside of
  acute care hospitals, indicate a growing problem.
• Annuals of Internal Medicine 2009 review of
  records at the CDC revealed 33 outbreaks of HBV
  and HCV in nonhospital settings in the US from
  1998-2008. In hospital outbreaks numbered 7

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Awareness

• In the non hospital settings, infection control
  resources and oversight have traditionally been
  lacking
• Breaches of fundamental principles of infection
  control by health care personal were responsible
  for patient to patient transmission in all of the
  outbreaks
• CDC records indicate that more than 400 persons
  were infected
• All of these transmissions events could have been
  prevented through adherence to basic infection
  control practices

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Awareness

• Within the hospital setting- On a daily basis,
  the OR Schedule includes many patients coming
  directly to surgery from the ICUs
• The ICU is considered the epicenter of bacterial,
  viral and fungal organisms for many reasons
• Populations of patients with complex conditions
  with a wide range of pathophysiology
• Proximity to other patients
• High density of hands-on interventions by staff
• Widespread use of mechanical ventilation and
  antimicrobial resistance

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Awareness

• In 2006, national viral hepatitis surveillance
  data revealed that 50 of patients with acute HBV
  and HCV infection were reported without
  accompanying risk factor data
• Among those whom a risk factor data were
  reported, 56 with acute HBV and 32 with HCV
  when asked could not specify a known risk factor
  for their infection
• Take home message- Just because you review a
  patients risk factors, you can not assume they do
  not have HBV or HCV!

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Awareness

• Many of the outbreaks of HBV and HCV are directly
  attributable to unsafe injections, caused by
  failure to practice aseptic techniques when
  preparing and administering parenteral
  medications
• These outbreaks suggest a greater emphasis on
  aseptic technique in injection safety is needed

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Awareness

• Providers must become aware that the long term
  solutions to our infection control problems do
  not come from the pharmaceutical industry, but
  rather low cost interventions (Biddle)
• Efforts designed to enhance our knowledge of the
  process and mechanisms of nosocomial infection
  must be aggressively pursued so that effective
  interventions can be recommended, implement and
  complied with.

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Awareness of the Dangers

• Anesthesia workstation
• Maslyk et al,(AANA J. 2002) assessed the density
  and diversity of microbial organisms on a variety
  of randomly selected anesthesia machines
  following routine use
• Wide variety of pathogenic organisms were
  cultured including (Streptococcus, acinetobacter,
  staphylococcus aureus and gram-negative rods)
• Anesthesia providers daily perform a large number
  of interventions in which there is routine,
  direct contact with patients, often with their
  blood and bodily fluids

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Awareness of the Dangers

• A study performed more than 10 years ago that
  sampled laryngoscopes, found that 20 of the
  blades and 40 of the handles tested positive for
  occult blood.
• What are the implications of aerosolized
  particles from the surgical fields?

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Not Me, Someone Else/Laziness

• We are not as clean as we think
• The anesthesia work area is a fertile environment
  for all kinds of pathogens
• In one recent study, researchers noted that the
  anesthesia work area became contaminated within 4
  minutes from the start of the intraoperative
  care of the patient
• Suction catheters, vaporizer dials, blood
  pressure cuffs, your ink pen, computer keyboards,
  reservoir bag, monitor cables, pressure control
  valves
• Routine care versus Emergencies( code boxes,
  difficult airway carts)

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Laziness, Not Me, Someone Else

• Cost saving short cuts-
• EKG leads, close proximity to blood and arm pits
• Blood pressure cuffs- close proximity to arm
  pits, known to be a reservoirs for MRSA
• Wiping ports- One study found that the lumens of
  stopcock became contaminated with pathogenic
  bacteria in 32 of the cases

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Not me!

• In anesthesia Analgesia 1995 80(4) 764-769
• Providers who were providing care to patients
  believed to be harboring HIV and HBV washed their
  hands 95
• of the time versus about 58 when caring for the
  same patients when their HIV and HBV status was
  unknown.
• Another study J Hospital Infection 200870(2)
  researchers found a disturbingly high rate of
  computer keyboard use with contaminated hands
• Furthermore- 17 of anesthesia providers
  performed any sort or hand hygiene before caring
  for a patient although hand hygiene rose to 69
  before eating

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Not Me!We are not as clean as we think

• Anesthetic care requires performing interventions
  that involve close patient contact, under
  performance pressure, requiring skillful
  techniques with very little margin of error
• The potential for contamination of the anesthesia
  work area is great.
• Difficult airway carts and code boxes

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Production Pressure

• Operating rooms are a huge source of revenue for
  the hospital
• Intense pressure on providers of care to make
  sure rooms are turned over quickly between
  patients
• 10 minute turnovers-good for the bottom line, but
  are they good for the patient?
• Intense production pressure on those who may not
  understand the importance of a proper cleaning
  for the anesthesia workspace and the OR-
  anesthesia aides

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Production Pressure

• Patients with bacterial infections such as MRSA
  or VRE carry the organisms all over their bodies,
  clothing, lines and any inanimate object they may
  come into contact with such as IV pumps, door
  handles, bed side rails, BP cuffs, stethoscopes
• Transfer of the microorganisms readily occurs by
  many different vectors, with the hands being the
  most prominent

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Resources/Supportive Measures in the
Hospitals/ASCs/Office

• Visit the anesthesia department
• Inspections, do they work?
• Will another method of involvement by the
  Infection control department have better results
• Internal IC taskforce, IC zar
• In-services
• Include anesthesia in IC decisions that involve
  anesthesia

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Supportive Help/Resources

• Multi-dose vials- AANA working with CDC to
  eliminate
• Disposable leads?
• Infusion pumps/re use of syringes
• MRSA and entering the drawers of the work station
• Reward practitioners who display an interest in
  IC principles
• IC friendly workstations
• Educate staff/all staff
• Additional time for turnover of rooms following
  an ICU or MRSA/VRE case?

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Surveillance

• Common bag for neosynephrine ?
• Prepping the tops of vials before entering
• Where do you put the dirty laryngoscope blades?
  How often is that spaced cleaned?
• How about the laryngoscope handles?
• Culturing the code boxes/ difficult airway
  carts/terminal cleaning
• Using a new catheter every time you suction a
  patient
• What do you do with the dirty one?

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Surveillance

• IC practitioners considered a threat versus
  friendly
• Gowns, gloves and masks before CVL/arterial line
  insertion?
• Gowns gloves and masks before regional
  anesthesia?
• What to do with medications drawn up for one
  patient and not used? Safety versus cost
  containment
• Video taping induction and emergence for learning
  purposes

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USP 797

• USP 797 is a far-reaching regulation that governs
  a wide range of pharmacy policies and procedures.
  It is designed both to cut down on infections
  transmitted to patients through pharmaceutical
  products and to better protect staff working in
  pharmacies in the course of their exposure to
  pharmaceuticals.
• Issued by U.S. Pharmacopoeia (USP), the
  regulation governs any pharmacy that prepares
  "compounded sterile preparations" (CSPs).

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USP 797

• Persons who perform sterile compounding include-
  pharmacists, pharmacy technicians, anesthesia
  professionals, nurses and other physicians.
• The U.S. Pharmacopeia is the independent
  organization chartered by Congress in 1863 to act
  as the official standards setting authority for
  all prescriptions, OTC, dietary supplements and
  healthcare products manufactured and sold in the
  United States.

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USP 797

• CSPs are defined as low, medium and high risk
  depending on their probability of microbial
  contamination.
• With one exception and that being the immediate
  use provision, all CSPs must be compounded in a
  class 5 or better air quality environment.
  Operating rooms rarely, if ever meet this
  standard!
• Low risk CSP include any single drug drawn into a
  syringe for direct injection. Examples,
  ephedrine, fentanyl, vecuronium.

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USP 797

• Immediate use provisions-detailed criteria
• If administration is not begun within 1 hour
  following the start of the preparation of the
  CSP, the CSP shall be promptly, properly and
  safely discarded.
• OH BOY! What does this mean for anesthesia?

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Oh Boy, What does this mean for anesthesia?

• Guidelines, not law
• Joint Commission does not directly mandate

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APIC Urges Injection, Infusion Safety

• The Association for Professionals in Infection
  Control and Epidemiology has published
  recommendations emphasizing the safe use of
  syringes, IV infusions and medication
  vials.Besides strongly discouraging the use of
  syringes, IV supplies and medication vials for
  more than a single patient, the 48-point
  position paper urges healthcare workers to
  Wash or sanitize their hands before touching
  medication vials, IV supplies and injection
  supplies Disinfect IV ports using the friction
  method and 70 alcohol, an iodophor or another
  antiseptic agentRefrain from transferring
  medication from 1 syringe to another, even if
  it's for the same patient Refrain from
  carrying vials in the pockets of clothing and
  Refrain from leaving needles, cannulas or spikes
  in the rubber stoppers of medication vials.

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CMS Infection Control Guidelines ASC

• The Guidelines - "Infection Control Surveyor
  Worksheet"II. Injection Practices (injectable
  medications, saline, other infusates) Additional
  Instructions Observations are to be made of
  staff who prepare and administer medications and
  perform injections (e.g., anesthesiologists,
  certified registered nurse anesthetists,
  nurses). Practices to be Assessedgt A. Needles
  are used for only one patientgt B. Syringes are
  used for only one patientgt C. Medication vials
  are always entered with a new needlegt D.
  Medication vials are always entered with a new
  syringegt E.. Medications that are pre-drawn
  labeled with the time of draw, initials of the
  person drawing, medication name, strength, and
  expiration date or timegt

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CMS Guidelines Continued

• F. a. Single dose (single-use) medication vials
  are used for only one patient (A "No" response
  must be cited in relation to 42 CFR 416.48(a).)
  b. Manufactured prefilled syringes are used for
  only one patientc. Bags of IV solution are used
  for only one patientd. Medication administration
  tubing and connectors are used for only one
  patientG. List all injectable medications/
  infusates that are in a vial/ container used for
  more than one patient Name of Medication
  Average number of patients per vial/containe I.
  The rubber septum on a multi- dose vial used for
  more than one patient is disinfected with
  alcohol prior to each entry

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CMS Guidelines Continued

• J. Multi-dose medications used for more than
  one patient are dated when they are first
  opened and discarded within 28 days of opening or
  according to manufacturer' s recommendations,
  whichever comes firstK. Multi-dose medications,
  used for more than one patient, are not stored
  or accessed in the immediate areas where direct
  patient contact occursL. All sharps are
  disposed of in a puncture-resistant sharps
  container M. Sharps containers are replaced
  when the fill line is reached N. Additional
  breaches in injection practices, not captured by
  the questions above were identified (If YES,
  please specify further in comments)

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One Syringe, One Needle, One UseOnly One Patient

• A NATIONAL CAMPAIGN

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