IPAC in the OR for Anesthesia:

A review and a proposal Chris Wherrett, MD, FRCPC

(Updated Nov 13, 2011)

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Objectives

1. To review practical infection control issues related to routine practice in Anesthesia

2. To present a proposal for:1. Routine best practice 2. Contact precautions cases3. Syringe handling

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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

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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

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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.

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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.

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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.

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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.

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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

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Time for formal proposal

• Still open to feedback• Aim to have full support at implementation• Ongoing project• Allow for individual preferences where reasonable

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Consultation to date

• Dept rounds x2• Dept working group• Bonnie Dove• Infection control• Infectious Diseases• Kent Woodhall• Natalie Clavel• Civic colleagues

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Proposals routine best practice

1. Routine best practice

2. Contact Precautions

3. Safe injection practices

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The Airway Tray

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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.

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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.

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• If used airway equipment is placed on anesthesia machine it will need additional cleaning at end of case – Mention at debriefing

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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

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If contamination occurs:

• Virox it yourself if possible• Or, mention to circulating nurse• Mention at debriefing

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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.

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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

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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.

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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.

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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

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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.

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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

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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.

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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)

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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

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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.

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Contact Precautions

• Perioperative policy last updated 2004 • Presentation by Dr. McKenna two years ago

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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

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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

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• 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

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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.”

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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.

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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.

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PERIPHERY

• Everything else

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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

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Room preparation

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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

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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.

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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.

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If a second person is present

• (e.g. RT, Resident)• One person should work in the island zone and the

other the periphery

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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

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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

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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.

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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.

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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.

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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.”

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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.

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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.

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• 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.

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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.

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