IPAC in the OR for Anesthesia: Chris Wherrett, MD, FRCPC A review and a proposal Chris Wherrett, MD, FRCPC (Updated Nov 13, 2011) Marney Cooper RN, Nurse Educator

Objectives To review practical infection control issues related to routine practice in Anesthesia To present a proposal for: Routine best practice Contact precautions cases Syringe handling April 6, 2017

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More articles Infection control lapses at clinic ‘broadranging’, Levy says By Tom Spears and David Reevely, The Ottawa Citizen October 17, 201 Private endoscopy clinics not subject to provincial standards until 2010 By Pauline Tam October 17, 2011 April 6, 2017

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Current environment Hand Hygiene initiative Stepping stone to addressing other issues NSQIP results Contact precautions case numbers rising Informal changes to my own practice April 6, 2017

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Personal Observations Our workstations sometimes are sometimes: Messy and disorganized Used as stockpiles for sterile supplies and grossly contaminated instruments We don’t follow some guidelines We need more specific guidelines We have concerns April 6, 2017

Concerns raised by the Attendants: Don’t like to handle syringes at end of case. May not know which equipment and supplies are clean/dirty. Difficult to deal with varying practices of anesthetists. April 6, 2017

Concerns from Anesthesiologists and Nurses Cables sometimes have visible contamination from previous case. NIBP cuff is damp after Virox cleaning, gross contamination may be missed. Used airway equipment placed on the anesthesia machine can contaminate other equipment and the controls of the machine. Used suction tip is heavily contaminated and can easily come in contact with multiple pieces of equipment. The green towel on the machine is not changed between cases during the day, despite potential contamination. April 6, 2017

Concerns (2) Breathing circuit tubing only replaced at the end of the day. Blue circuit bag and ventilator controls may be touched by hands/gloves while managing airway and is not cleaned between cases. Temp probe is sometimes placed directly in the patient's airway. Determination of patient environment versus hospital environment is difficult and makes it challenging to set hand hygiene practices and audit them. April 6, 2017

Current cleaning between cases NIBP cuff and cables cleaned with Virox. NIBP cuff to be sent to LS if grossly contaminated. Filter and elbow on circuit replaced. Circuit: cleaned if soiled, replaced at end of day (cost issue). Mask and suction replaced. Pink K-basin emptied and removed. Note: plastic basins are not disposable. Green towel replaced if grossly soiled. Bed stripped to mattress; if there is no gross contamination only the top is cleaned; otherwise a more thorough cleaning is done. April 6, 2017

Areas not cleaned: Blue ventilation bag Controls and surface of machine, ventilator Monitors IV poles Pumps Surgical arm Computer keyboard, and mouse Anesthesia cart generally not touched April 6, 2017

Time for formal proposal Still open to feedback Aim to have full support at implementation Ongoing project Allow for individual preferences where reasonable April 6, 2017

Consultation to date Dept rounds x2 Dept working group Bonnie Dove Infection control Infectious Diseases Kent Woodhall Natalie Clavel Civic colleagues April 6, 2017

Proposals routine best practice Contact Precautions Safe injection practices April 6, 2017

The Airway Tray April 6, 2017

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The Airway Tray Use for all cases under GA. Mayo stand to be covered with green towel or plastic bag and placed near the patient for induction. Equipment that is anticipated to be used for induction is placed on tray. Additional supplies that have a lower likelihood of being used can be placed on the anesthesia machine. Avoid placing “extra” supplies in immediate patient vicinity. may become contaminated, and potentially used on multiple patients, or needlessly disposed of. Equipment that has contacted the patient is returned to the airway tray and is stored there until the end of the case or as requested to be sent to LS. It should not be placed on the patient’s chest or the pillow. April 6, 2017

After induction The tray is moved back away from the patient until the end of the case or any other time as needed. The used ETT or LMA when removed should be placed on the tray instead of the anesthesia machine. After the case the attendant will dispose of/process the supplies in the usual fashion and clean the tray. The use of a K-basin is optional. Syringes and other sterile supplies should not be stored on the airway tray. April 6, 2017

If used airway equipment is placed on anesthesia machine it will need additional cleaning at end of case Mention at debriefing April 6, 2017

Induction: What can I touch? OK: Blue bag APL Valve Ventilator toggle switch Avoid, until gloves removed and hand hygiene performed Gas flowmeters and vaporizer Ventilator controls Monitor controls April 6, 2017

If contamination occurs: Virox it yourself if possible Or, mention to circulating nurse Mention at debriefing April 6, 2017

Items not to re-use Tape, if it has come in contact with airway The syringe used to inflate cuffs The IV tourniquet if it has come in contact with blood. April 6, 2017

Temp Probe I prefer to place tip in glove first. On removal the glove is thrown out and temp probe place on hook This avoids having to coil a grossly contaminated probe and place it somewhere without contaminating other objects. Still gets sent to LS for cleaning April 6, 2017

Tan velcro arm straps Disposed of if visibly soiled or used on a patient with contact precautions. A green towel should be placed between the patient’s skin and the strap and the strap can be re-used if this procedure is followed. April 6, 2017

Suction Tip Avoid tucking an exposed tip under the mattress or draping it over ventilator/CO2 absorber module Can replace in its wrapper Or disconnect from tubing and place on the airway tray when no longer needed. April 6, 2017

Accessing IV injection ports Hands should be clean before doing so. IV ports should be cleaned with an alcohol swab before injecting. PICC lines and central lines have greater consequences when infected IVs started outside of the OR probably have greater likelihood of having contaminated ports April 6, 2017

End of case debriefing As per surgical safety checklist should also include: Any infection control issues? (e.g. contamination of “clean” equipment, antibiotic redosing) Clarify which equipment was used/not used, as applicable Example: if circuit used with RA. April 6, 2017

End of Case Cleaning Monitor cables that are draped over hook are wiped with Virox and then coiled and placed on retaining straps on machine. The hook and pole also need to be cleaned April 6, 2017

The green towel Green towel on anesthesia machine to be replaced with each case A clean, folded towel is placed on the machine along with a clean laryngoscope. The anesthesiologist will then unfold the towel and place it in its usual position. April 6, 2017

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Cleaning with Virox Surface of anesthesia machine, blue bag, green APL valve and toggle switch (to be reviewed), table control (Note this hasn’t yet been implemented) (Only make changes now that you can do independently) April 6, 2017

Classification of Instruments Critical items are those that will contact normally sterile tissues and must therefore be sterile at the time of use. Semi-critical devices contact mucous membranes or non-intact skin and require high-level disinfection. Non-critical devices will touch only intact skin and require intermediate or low-level disinfection April 6, 2017

Breathing circuit ASA Guidelines: Equipment requiring high-level disinfection includes: laryngoscopes, face masks, laryngeal airways, oral airways, bronchoscopes, TEE probes, temperature probes, and the anesthesia circuit We have requested Surgical Services review longstanding practice of re-use of circuits to ensure compliance with recommendations. April 6, 2017

Contact Precautions Perioperative policy last updated 2004 Presentation by Dr. McKenna two years ago April 6, 2017

Concerns Inconsistencies in practices exist between campuses and individuals. Island technique is commonly used but not described in policy. Temporary cart issues: Disposal of contents is wasteful. Only one cart is presently available Removal of regular cart increases traffic April 6, 2017

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Plastic sheet over machine ??? effective barrier; Difficult to apply properly Easily gets displaced, HCWs reach under plastic Impairs visualization of monitor April 6, 2017

Unnecessary equipment remains in room and may become contaminated Anesthesiologist wearing a contaminated yellow gown and gloves may contaminate numerous areas of hospital environment, e.g. chair, computer, machine, and surgical arm Unnecessary equipment remains in room and may become contaminated April 6, 2017

Yellow Gowns: Revised 2011 “HCWs need to assess the need to wear a gown. Gown must be worn if skin or clothing will come in contact with the patient or any furnishings, equipment, or other items in the patient’s environment.” April 6, 2017

Should I wear a gown? YES Physical examination component of preanesthetic assessment Transfer of patient to/from OR table Airway management (intubation/extubation) Other procedures with potential contact with body fluids, wounds NO IV lines table control contact with anesthesia machine BUT: gloves are needed. April 6, 2017

Island Technique: PATIENT ISLAND Patient and garments Table and control medical devices attached to patient IV poles, Infusion pumps on IV poles anesthesia monitor anesthesia circuit ventilator/absorber ventilator monitor and controls, toggle switch, APL valve and surrounding surface, blue ventilation bag, gas flow controls, vaporizers, anesthesia machine stainless steel surface (and towel), anesthesia mayo stands. April 6, 2017

PERIPHERY Everything else April 6, 2017

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Working in island Consider the need for a gown (and gloves of course) I.E. if you will be in contact with the patient or table/stretcher Gloves only: Injecting into IV Touching controls HH after removing gloves April 6, 2017

Room preparation April 6, 2017

Room preparation Remove all equipment that is not likely to be used from patient island. E.G. hot line, portable nerve stimulator, infusion pumps, supplies on top of anesthesia machine and surgical arm Anesthesia blue supply cart to be kept in room but moved from its usual position in periphery i.e. laterally along the wall. Ensure that adequate number of mayo stands are available April 6, 2017

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Preparation of anesthesia supplies One Mayo stand to be used as airway tray (same as for routine cases) All other sterile/clean supplies prepared for the patient (e.g. syringes, IV supplies, dressings): are to be placed either on a second mayo stand or the surface of the anesthesia machine. Plan ahead for what you need No more temporary cart. April 6, 2017

Maintenance phase of Anesthesia The Anesthesiologist will normally remove gown and gloves and perform HH. The SIMS computer is considered in the periphery. Additional supplies must be accessed by clean hands and dropped on the appropriate Mayo stands. Medical devices in the patient island may be contacted by donning gloves. Examples include injecting drugs into the IV, changing IV bags, adjusting infusion pump settings, using bed control. Gloves should be removed and HH performed afterwards. April 6, 2017

If a second person is present (e.g. RT, Resident) One person should work in the island zone and the other the periphery April 6, 2017

Emergency events Contamination of items outside the patient island sometimes happens Inform the circulating nurse that the usual precautions could not be followed and that additional decontamination procedures will be necessary April 6, 2017

End of case procedures SIMS: Complete as much of the record as possible before contact with the patient island. If you are gowned, ask the circulating nurse to assist with transferring the patient in SIMS. Debriefing: Review with the circulating nurse and the attendant: whether the contact precautions procedures have been followed; If any additional decontamination is required April 6, 2017

Pt transfer OR staff should remove shoe covers on leaving the OR. Surgeons need gloves (no gown) if only touching stretcher Anesthesiologists should wear gloves and gown since patient contact is still likely. April 6, 2017

Decontamination Cleaning in addition to the routine : The anesthesia monitor Ventilator monitor and control buttons Gas flow controls, vaporizers Infusion pumps on IV poles Arterial line pressure bags Dispose of blue ventilation bag, circuit (i.e. everything in the patient island). These are cleaned for all cases: mayo stands, table control, ventilator toggle switch, APL valve, and surrounding surface, machine stainless steel surface. April 6, 2017

Part 3: Safe Injection Practices Both campuses have had policies in place for over 15 years requiring that syringes shall not be used for more than one patient. Department does not have policy/guidelines to ensure adherence to existing policy. Current clinician practices may use several methods and rely on various cues but may not have strict enough guidelines. Some clinician's maintain a cluttered work station and this may increase the risk of error. Working with residents and students results in intermixing of methods and increased risk for confusion. Residents are aware of the policy but implementation guidelines have not been emphasized. April 6, 2017

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ASA and CDC safe injection practices: “Healthcare providers should never reuse a needle or syringe either from one patient to another or to withdraw medicine from a vial. Syringes, needles, and cannulae are sterile single-use items and must not be reused to access any medication or solution.” April 6, 2017

CDC Recommendations Do not enter any vial with a used syringe or needle. When any medication vial (or solution) is accessed, both the syringe AND the needle/cannula must be sterile Second layer of safety: do not use a medication or solution for multiple patients in the Immediate Patient Treatment Area. April 6, 2017

New Practice recommendations for Anesthesiologists All clean, unused syringes can be kept on the drug cart. Used syringes should never be placed on drug cart. Used syringes (and clean syringes intended for use) can be stored on the anesthesia machine or on a clean Mayo stand. Multi-dose vials should not be placed on the anesthesia machine. Encourage an uncluttered workspace. April 6, 2017

At the end of the case, discard all used syringes before leaving the room unless they are required during patient transport. (This is recommended by the ASA). In PACU dispose of all used syringes when leaving the patient. A good cue for this is when doing one's hand hygiene. Avoid placing syringes in pocket or other places where status of syringe could be uncertain. April 6, 2017

One and Only Campaign Since 1999, more than 125,000 patients in the United States have been notified of potential exposure to hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV due to lapses in basic infection control practices. April 6, 2017

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