1. Anesthesia’s Role in Infection Control
Stanford R. Plavin MD President Atlanta, Georgia

2. Learning Objectives
Define the term infection control and healthcare associated infection as it relates to the perioperative setting while focusing on the anesthesiologist’s role and impact.
Discuss various techniques and creative tools (checklist) to enhance workplace compliance in reducing or eliminating undesirable anesthesia practices that contribute to common HCAIs.
Review and present clinical case scenarios to illustrate and show differences before and after implementing an action plan for infection control.

3. Define the Problem and the Parameters
Infection Control is a discipline concerned with preventing nosocomial or healthcare-associated infection, a sub discipline of epidemiology
Until most recently often under-recognized and under-supported part of the infrastructure of health care.
Infection control: Essentially akin to public health practice and are practiced with the confines of a particular health-care delivery system rather than directed to society as a whole..
Society is the variable and how we manage the variable can impact what we can and cannot “control”.

4. Brief Overview of Infection Control
Factors related to the spread of Infections within healthcare setting
Prevention: Hand hygiene and washing, cleaning and disinfecting, sterilization; vaccination, surveillance
Monitoring and Investigation of demonstrated or suspected spread of infection within a setting (outbreak)/ Isolation
Management (interruption of outbreaks)
Total overview is “Infection Prevention and Control”
Will focus on a number of areas which Anesthesia can lead/assist

5. Surgeons- Infectious in many ways Anesthesiologists- Not so much
Who are the players?
Patient-Patient
Patient-Staff
Staff-Patients
Staff-Staff
Surgeons- Infectious in many ways
Anesthesiologists- Not so much
Physicians-staff-patients
“Prevention and Control”
Infection Control:
Addresses factors related to the spread of infections within a healthcare setting

6. 2009 Article frequently quoted- authored by Stone an economist $28-45 Billion annually in direct cost
Acknowledge we have a major healthcare issue
Reference point of total government spending on ASCs in was…….
Ambulatory surgical centers (ASCs) provide outpatient procedures to patients who do not require an overnight stay after the procedure. In 2015, nearly 5,500 ASCs treated 3.4 million fee-for-service (FFS) Medicare beneficiaries. Medicare program and beneficiary spending on ASC services was about $4.1 billion.( Mar 10, 2017)
Ambulatory surgical center services - Medicare Payment Advisory ...
Total ASC spending by Medicare was less than 10% of direct medical costs of HAIs as referenced in 2009 article..

7. Overview. HAIs are infections that patients get while receiving treatment for medical or surgical conditions, and many HAIs are preventable. ... At any one time in the United States, 1 out of every 25 hospitalized patients are affected by an HAI.

8. Healthcare associated Infections (HCAIs)
HCAIs affect ~ 10% of patients admitted to acute care facilities (772,00 pts/year per CDC 2014)
~ 500,000 infections/year
Despite new technologies, HCAIs are on the rise due to the evolving problem of multi-drug- resistant bacteria and the increasing complexity of the health care environment1
Thought to spread primarily through Cross- Contamination
First, lets have some historical persepctive on HCAIs. As of 2014 CDC estimated approximately 10% of patient . This translates to about 1 in 25 in patients Depending on quote: K; Also, it is clear the source of HCAIs is multifactorial, they are primarly thought to spread through cross contamination
1 Hayden MK. Insights into the epidemiology and control of infection with vancomycin-
resistant enterococci. Clin Infect Dis 2000;31:1058–65

9. Number of current cases Costs prevented Number of cases prevented
Notes: “Number of cases prevented” and “Costs prevented” refer to the cases and associated costs that are estimated to be currently prevented by the use of antiseptics, respectively. Totals may differ from the expected value due to rounding. As the number of cases in the low and high scenarios differs for each condition, the relationships between low and high estimates are influenced by factors other than the portion attributable and proportion associated with antiseptics and results are not linear.
Abbreviations: CAUTI, catheter-associated urinary tract infection; CLABSI, central line-associated bloodstream infection; GI, gastrointestinal infection; K, thousand; M, million; SSI, surgical site infection; VAP, ventilator-associated pneumonia; HAP, hospital-acquired pneumonia.
Condition
Low estimates
High estimates
Current costs
Number of current cases
Costs prevented
Number of cases prevented
CAUTI
$19M
93.3K
$2M
1.9K
$367M
449.3K
$110M
94.4K
CLABSI
$120M
71.9K
$12M
1.4K
$2,435M
92.0K
$730M
19.3K GI
$210M
123.1K
$21M
2.5K
$1,464M
178.0K
$439M
37.4K
SSI
$459M
157.5K
$46M
3.2K
$8,273M
290.5K
$2,482M
61.0K
VAP/HAP
$613M
$61M
$1,626M
52.5K
$488M
11.0K
Total
$1,422M
603.3K
$142M
12.1K
$14,165M
1,062.4K
$4,250M
223.1K

10. CDC National Progress Report 2016
50% decrease in central line associated bloodstream infections (CLABSI) between
No change in overall catheter-associated urinary tract infections (CAUTI) between
However, there was progress in non-ICU settings between 2009 and 2014, progress in all settings between and even more progress in all settings towards the end of 2014
17 Percent decrease in surgical site infections (SSI) related to the 10 select procedures tracked in previous reports
17 percent decrease in abdominal hysterectomy SSI between
2 percent decrease in colon surgery SSI between 2008 and 2014
8 percent decrease in hospital onset Clostridium difficile ( C.Diff) infections between 2011 and 2014
13 percent decrease in hospital onset methicillin-resistant Staphylococcus aureus (MRSA) bacteremia (bloodstream infections) between 2011 and 2014

11. Infection Control Assessment of Ambulatory Surgical Centers JAMA 2010: 303 (22); ; Schaeffer, MK et al
Assessment from surveyors from CMS; evaluating compliance with specific infection control practices
Hand hygiene
Safe injection and medication management practices
Equipment reprocessing
Environmental cleaning
Handling of blood glucose monitoring equipment
46 of 68 ASCs (67%) had at least one “lapse” in infection control
12 of 68 ASCs (15.5%0 had at least three lapses in infection control

12. Surgical Site Infections following Ambulatory Surgery Procedures JAMA 2014 Feb 19: 311(7) Owens, PL;Barrett, ML; Raetzman, S; Maggard-Gibbons, M; Steiner CA
RESULTS: Postsurgical acute care visits for CS-SSIs occurred in 3.09 ( 95% CI, ) per 1000 ambulatory surgical procedures at 14 days and 4.84 (95% CI ) per 1000 at 30 days. Two-thirds (63.7%) of all visits for CS-SSI occurred within 14 days of the surgery; of those visits; 3.2% (95% CI, %) involved treatment in the inpatient setting. All-cause inpatient or outpatient postsurgical visits, including those for CS-SSIs, following ambulatory surgery occurred in (95% CI ) per 1000 ambulatory surgical procedures at 14 days and (95%CI, ) per 1000 at 30 days.
CONCLUSION and RELEVANCE; Among patients in 8 states undergoing ambulatory surgery, rates of postsurgical visits for CS-SSIs were low relative to all causes; however, they may represent a substantial number of adverse outcomes in aggregate. Thus, these serious infections merit quality improvement efforts to minimize their occurrence.
Note: CS-SSI defined as clinically significant surgical site infection; 284,098 procedures (general surgery, neurosurgery, gynecologic and urologic)

13. Insurance Companies Pay the Price for HAIs
Hospitals publicize quality and safety
Still steady increase in occurrences and fatalities due to infections
True burden besides those being physically affected lies with those paying- US/Insurers
Hospitals historically coded to increase the severity weight of cases with HAIs to cover expenses
Insurers are now being more proactive in changing their payment models with an emphasis on HAI prevention
JAMA Internal Medicine 9/2/2013

14. Who is really behind the Mask?
Identify various risk factors
Where and who are the culprits
Revisit the basics.

15. Reduction and Elimination: Process
Setting the goals- Evidence based decisions?
Education and understanding of infection transmission
Realization of poor practice habits- Simulators
Willingness to change and adapt to culture of the facility
Accountability- all parties- consider punitive options for failure to adopt best practices
Fines, Privileges, peer pressure

16. Preoperative Selection Process: an Opportunity
Risk factors associated with higher predisposition
Age
Trauma
Obesity
Diabetes
Poor nutritional status/ immunocompromised
Nosocomial pneumonias, percutaneous intravascular infections, and postoperative wound infections
Infected patient: occupational exposures
HIV, Hep B,C, airborne agents: TB, HSV, VZV, CMV
Needlesticks are most common exposures
ASA Monitor, May 2015, Volume 79, Number 5
Preoperative Selection Process: an Opportunity
Anesthesia team can assist in identifying high risk patients that present for Procedures/Surgery
Avoid Nosocomial infections

17. Antibiotic prophylaxis when indicated by guidelines and in a timely
fashion to achieve serum and tissue levels at incision time. Redose
when indicated.
Perioperative glycemic control to achieve levels less than 200
mg/dL in patients with and without diabetes.
Maintain normothermia.
Oxygenation optimized.
Prosthetic total joints.
Total joints: projected to increase to 3.8 million procedures per
year. Infections projected to increase from 2.18% to 6.5% per year

18. Surgical focus and Anesthesia focus aligned
Antibiotic prophylaxis
Perioperative glycemic control
Normothermia
Oxygenation
Sterility and process
Expansion of service lines- Total Joint/ Prosthetics/implants

19. Anesthesiologist role in SSI reduction
Antimicrobial prophylaxis
Temperature regulation:
Hypothermia causes vasoconstriction, decrease in tissue perfusion
Inhibits destruction of bacteria by neutrophils
Alters drug metabolism and coagulation, increase in cardiac events
CMS recommends intraoperative warming for cases greater than one hour
Glucose Control:
Hyperglycemia associated with neutrophil dysfunction
Decreased local immune response
Very tight glucose control is associated with increased mortality ( < )
Anesthesia Work Space/Environment
Safe Injection Practices
Stewardship

20. Perioperative Transmission of Infection: Implications for the Anesthesiologist
Perioperative physicians- increase in exposures and invasive procedures
How can the anesthesiologist minimize bidirectional transmission of infection between patient and physician
Infectious agent requires a portal of entry
Typically respiratory tract with ET tubes, contamination of equipment or airborne pathogens
Blood stream via direct contact with blood or blood products, indwelling catheters
Skin and mucous membranes: direct contact with infectious lesion, surgery, and trauma

21. There were other areas where the fluorescnet dye was also found
There were other areas where the fluorescnet dye was also found.: Look at the stars….

22. HCA- Infections Can the Anesthesia Provider be at Fault
HCA- Infections Can the Anesthesia Provider be at Fault? Richard Prielipp MD MBA and David Birnbach MD MPH, APSF Newsletter February 2018
Surgical Site Infections account for 20% of all HCAI
6% of microbial filters placed in standard IV tubing of anesthetized patients were contaminated- S. Capitis, S. Hemolyticus, Corynebacterium and Bacillus
8 hour case: anesthesia provider touched surfaces 1,132 times, 66 stopcock injections, inserted 4 vascular catheters- hand hygiene was poor and only used in small fraction of encounters
Forced Air warmers- one study suggested increased risk- FDA in 2017 unable to identify an associated between FAW and SSI

23. Safe Injection Practices and Medication Safety Multiple Standards related to safe injection practices (SIP) and medication safety high levels of deficiencies this year.
Multi-dose vials were accessed in patient care areas. ( National SIP guideline recommendations are that multi-dose vials be accessed in a clean area, away from patient care
The organization’s policies were not followed
USP 797 guidelines ( for splitting single dose vials) were not followed
Multi-dose vials were not wiped with alcohol before being accessed
Anesthesia providers carried capped syringes in their pockets
A list of look-alike, sound-alike medications were not posted/present
Pre-drawn syringes were not labeled.
Medications with similar names were stored next to each other.

24. Examining the Source and the BACTERIAL Reservoir(s)
Anesthesia provider hands are frequently contaminated with major bacterial pathogens before patient care.
The contaminated hands of anesthesia providers before patient care serve as a significant source of patient environmental and stopcock set contamination in the OR.
Recommendations include:
Simple introduction of the closed system injection ports (instead of open stopcocks).
Disinfect the port prior to each injection (not disinfecting the port prior to injection increases the rate of infections when compared to open stopcock). Clean needleless connectors, including open systems, with 70% isopropyl alcohol before access and to provide interim protection from bacterial transmission during subsequent use

25. Anesthesia Provider Hand Hygiene?
Fukada et al examined bacterial contamination on the hands of anesthesiologists during general anesthetic cases and found the hands were heavily contaminated with bacterial pathogens. This was evident throughout all phases of anesthesia care. Many of us have been shown to be particularly non compliant with hand hygiene.
In 1996, Tait and Tuttle reported that 95% of Anesthesia providers reported washing their hands after caring for “high-risk” patients, but only 58% washed their hands in “low-risk” situations.
These studies were done in an era where less attention was paid to Infection control.
Fukada et al, Bacterial Contamination of Anesthesiologist’s Hands and the Efficacy of Handwashing, Masui 1996:45:
Tait, A., Tuttle, D. Infection Control Precautions and Anesthesia; Anesthesia and Analgesia; Feb 1996 Vol 82; page 428

26. Double gloves to prevent ANESTHESIA WORK ENVIRONMENT Contamination
The difference in the rate of contamination between anesthesiology residents who wore single gloves versus those with double gloves was clinically and statistically significant. The number of sites that were contaminated in the operating room when the intubating resident wore single gloves was ± 1.4 (mean ± SE); the number of contaminated sites when residents wore double gloves was 5.0 ± 0 .7 (P < 0.001).
The results of this study suggest that when an anesthesiologist wears 2 sets of gloves during laryngoscopy and intubation and then removes the outer set immediately after intubation, the contamination of the intraoperative environment is dramatically reduced.
One of the mian things that Id like you to get out of this talk is that double gloving makes a big difference: Study done wth residents: Difference of 5 vs 20 contaminated sites after laryngoscopy and intubation.
Birnbach et al, Double Gloves: A Randomized Trial to Evaluate a Simple
Strategy to Reduce Contamination in the Operating Room Anesth Analg 2015;120:848–52

27. ANESTHESIA WORK ENVIRONMENT ANESTHESIA MACHINE
Albrecht and Dryden identified that contaminated anesthesia machines can indeed transmit bacteria to patients.
Several investigators have used laboratory models to confirm this mechanism, they found that without an in-line circuit filter in place, bacterial organisms were universally transmitted to the patient circuit, with the greatest density of organisms lodged closest to the patient.
They also found that the anesthetic gas (halothane/sevo/iso) and soda lime were ineffective at preventing bacterial transfer.
Multiple studies have subsequently demonstrated the efficacy of in- line circuit filters in prevention of bacterial transfer to the patient circuit.
Anestghesia machines have long been looked at as potential sources of contamination. Soda lime and anesthetic gases are ineffective in preventing bacterial transfers. The most effective way to do that is by the use of an in-line filter on the anesthesia circuit.
Albrecht WH, Dryden GE. Five-year experience with the development of an
individually clean anesthesia system. Anesth Analg 1974;53:24–8
Berry et al An alternative strategy for infection control of
anesthesia breathing circuits: a laboratory assessment of the
Pall HME Filter.Anesth Analg 1991;72:651–5

28. Anesthesia Work Environment: laryngoscopy
Blades & Handles: Residual contamination of these airway devices associated with suboptimal disinfection practices has been linked to infectious outbreaks.
Additional work has confirmed the need for better disinfection of laryngoscope handles in today’s OR environment.
Many practice locations have gone to disposable blades and at a minimum reprocess them in a sterile manner.
Let’s talk about laryngoscopy: It is safe to say that Blades and handle can certainly be a source of cross contamination, and several studies have shown that they are nor properly disinfected between patients.
Foweraker JE. The laryngoscope as a potential source of cross-
infection. J Hosp Infect 1995;29:315–6
---
Call et Al, Nosocomial contamination of laryngoscope handles:
challenging current guidelines. Anesth Analg 2009;109:479–83

29. Anesthesia Work Environment- Infection Prevention Assistance
Laryngoscope sterilization Options
Circuit and Filter Options

30. Reduction and Elimination
Setting the goals
Education and understanding of infection transmission
Realization of poor practice habits
Willingness to change and adapt to culture of the facility
Accountability- all parties- consider punitive options for failure to adopt best practices
Fines, Privileges, peer pressure
Positive feedback and reinforcement?

31. Education and Understanding of the Issues
CREATING A CULTURE
Education and Understanding of the Issues
Set the expectations
Define the responsibilities
Define the process
Evaluate, reinforce, analyze
Leadership

32. ANESTHESIA INFECTION PREVENTION CHECKLIST
OR :__________________SUITE___________OBSERVER:___________________________
NAME:________________________________DATE:________________TIME:___________
MET
NOT MET
MEASURE
Hands are washed prior to entering the OR
Hand hygiene performed:
prior to accessing/preparing clean supplies/medications
prior to gloving and when removing gloves
between dirty and clean steps of a procedure
Full barrier protection is worn for central line insertions and Central Line bundle is followed and documented
Gloves are worn when inserting IVs
LMA/laryngoscopes are handled with gloves (hands sanitized first)
Gloves are removed after inserting or removing LMA/laryngoscope
Cover jackets are buttoned to the top and are removed at end of case when there is patient contact or contact with body substances
Hair and head jewelry are totally covered by cap; no rings present, mask tied
Medications are drawn up and labeled at time of procedure
Used medication vials are stored on top of medication cart during procedure and discarded prior to next case
Medication labels are stored in a clean location
Unused medications (drawn up syringes) are not transferred for use on next case
IV ports and medication stoppers are disinfected prior to entering
IV tubing does not hang below level of knees
CHG/alcohol prep used for skin prior to IV insertion
Single use items (medications/supplies) are discarded between patients
Topical ointments/tape are dispensed in a clean manner to avoid contamination
Sprays are handled in a clean manner to avoid contamination
Set up changed between patients (new towel)
Items dropped on floor are discarded
Medication/anesthesia cart surfaces and drawer handles are disinfected between patients
Keyboard and mouse are disinfected between patients
Medications for next case are drawn up over a clean towel after hand hygiene performed, placed in ziplock bag and stored in anesthesia cart drawer.

33. Outline of Recommendations for Infection Control: Anesthesiology
Prevention of Nosocomial Infections in Patients
Disinfection of equipment
Preventing Contamination of Medications
Prevention Of Infection during insertion of Central Lines/Indwelling
Protection of the Immunosuppressed patient
Prevention of transmission of TB (not so much these days)
Prevention of Occupational Transmission to MDs/Staff
Standard Precautions: examples include handwashing, use of barriers, avoid needlesticks, avoid personnel with cutaneous lesions
Hepatitis B vaccine
Influenza Vaccine
Smoke evacuation during laser or ESU

34. Clinical Applications of Infection Control: Scenarios Presented
Timing of Surgical Antibiotic Prophylaxis and the risk of Surgical Site infection, does it really matter?
Normothermia?
The anesthesiologist and team’s role in Maintaining a sterile surgical field?
I took my scrubs home and came back?
Should you compromise safe injection practices in times of drug shortages?
Terminal cleaning? What does that really mean?

35. Timing of Surgical Antibiotic Prophylaxis and the risk of SSI, does it really matter?
JAMA Surg 2013
32,459 operations, prophylactic ABX, median of 28 minutes prior to surgical incision, 1497 cases (4.6%) developed an SSI
ABX within 60 minutes prior to incision but not after incision, higher SSI rates
No increase in SSI was shown for patients receiving ABX after incision
Conclusion: No significant association between prophylactic antibiotic timing and SSI was observed; risk varies by patient and procedure factors as well as antibiotic properties
While adherence to the timely prophylactic ABX measure is not bad care, little evidence to suggest it is better care
Stewardship

36. Look What we have Created!

37. Temperature control: Normothermia
Expansion of service lines to include Implants/prosthetics/etc.
Total Joint Programs
Temperature control options and guidelines- American Society of Anesthesiologists and CMS-
Forced air warmers:
Discussion with respect to infection control and FDA
Current outcomes and data
Airflow caused by forced air warmers- counteracted by downward laminar flow- no final conclusions

38. Maintaining a Sterile operative field: Team approach
Avoiding SSI and sterile field
Exclude patients with prior infections
Stop patient tobacco use
Apply sterile dressing hours
Shower with antiseptic soap
Areas of focus in the OR
Involve all the team members
Follow same practices daily
Wear a mask and cover hair, keep OR doors closed
Reduce traffic to OR and in the “sterile field”
Face the sterile field at all times
Confirm sterility of all surgical instruments, indicators, and inspect trays
Maintaining a Sterile operative field: Team approach
-SCIP measures
-IHI: institute for Healthcare Improvement (SSI prevention)
Antibiotic prophylaxis
MD/ glycemic control
Avoid Shaving Operative site

39. I took my scrubs home and Came back to work?
Should we be allowed to wear scrubs in public?
Short answer is yes, not a public safety issue as there is no evidenced based research to support banning scrubs outside of the OR
Scrubs have short sleeves and allow HCW to wash their hands thoroughly
Wearing scrubs outside of the OR is more of an aesthetic issue and poor form professionally?
To minimize infection we wash hands, mask faces, and change clothes; no logic to return back with same scrubs or attire
What about non sterile workplace environments? Endo centers ?

40. Should you consider compromising safe injection practices in times of drug shortages?
Ethical dilemma
Risk vs. reward
Standard of care vs. Compassionate care
Split vials of fentanyl?
Split vials of versed?
Draw up two syringes of Propofol?

41. Rational Approach to Disinfection and Sterilization
30 years plus ago, Earle H. Spaulding
Classification scheme is clear and logical
Critical Items: confer a high rate of Infection: objects that enter sterile tissue or the vascular system must be sterile!
Semicritical Items: contact mucous membranes or non-intact skin; this category respiratory therapy and anesthesia equipment, endoscopes: Minimally require high-level disinfection using chemical disinfectants
Noncritical Items: come in contact with intact skin but not mucous membranes, examples include bedpans, BP cuffs, bed rails, bedside tables, etc. : virtually no risk has been documented for transmission of agents to patients through noncritical items.

42. Evolution of Behavioral Sciences in Infection Control
Seto in application of behavioral sciences in timely and crucial for the continuing practice of hospital infection control
Social Power- defined as the potential ability of an influencing agent to change:
The cognitions
Attitudes
Behaviors

43. Six bases for Social Power French and Raven -1959
Coercive Power – ability of the Influencing agent to mediate punishment for the target
Reward Power- the ability to mediate rewards
Legitimate Power- target’s acceptance of a role relationship with the influencing agent that obligates the target to comply with agent’s request
Expert Power- the target’s attribution of superior knowledge or ability of the agent
Referent Power- the target’s utilization of others as a frame of reference to evaluate his or her behavior
Informational Power- the persuasiveness of the information communicated by the agent to the target

45. Implementation Science
Embraced by Infection Preventionists
Define technical components while also focusing on the adaptive ones (how to adapt or tailor the intervention given the context)
Collaborating with organizational behaviorists, social scientists and each other to develop role of context
Establishing a research network to find out what works, how and where
Determining how to “institutionalize” change while avoiding the over adoption of fads
Identifying funders (CDC/NIH/AHRQ)- those to invest in understanding implementation science using infection prevention as clinical model

46. Learning Objectives
Define the term infection control and healthcare associated infection as it relates to the perioperative setting while focusing on the anesthesiologist’s role and impact.
Discuss various techniques and creative tools (checklist) to enhance workplace compliance in reducing or eliminating undesirable anesthesia practices that contribute to common HCAIs.
Review and present clinical case scenarios to illustrate and show differences before and after implementing an action plan for infection control.

47. Infection Control In Anesthesia
Stanford R. Plavin MD
Ambulatory Anesthesia Partners

49. References
Guide to Infection control in the Hospital- International Society for Infectious Diseases, Chapter 22 , February 2018
Bratzler DW, Dellinger EP, Olsen KM, et al, Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery, AM J Health syst Pharm 2013; 70 (3):
Allegranzi B, Zayed B, Bischoff P, et al, Surgical Site Infections 2. New WHO Recommendations on Intraoperative and Postoperative Measures for Surgical Site Infection Prevention ; an Evidence Based Global Perspective. Lance Infect Dis 2016;16(12)
Berrios-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease control and Prevention Guideline for the Prevention of Surgical Site Infection, JAMA surgery 2017; 152(8)784-92
Anesthesia and Analgesia; numerous articles, April 2015, volume 120, Number 4
References included within text
Infection control Today- June p 14-19,
CDC.gov website
Infection Control and Hospital Epidemiology (2019),40,1-17 ( SHEA Expert Guidance)- Infection Prevention in the Operating room anesthesia work area
JAMA Surg 2017; 152 (8): Clinical Review and Education