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Hand Hygiene and Relearning Lessons From the Past

2019; Lippincott Williams & Wilkins; Volume: 129; Issue: 6 Linguagem: Inglês

10.1213/ane.0000000000004303

1526-7598

Kevin T. Riutort, Sorin J. Brull, Richard C. Prielipp,

Surgical site infection prevention

See Articles, p 1443, p 1549, p 1557, p e182 Clean hands are the single most important factor in preventing the spread of pathogens and antibiotic resistance in health care settings. —Centers for Disease Control and Prevention “Clean Care is Safer Care” is not a choice but a basic right. Clean hands prevent patient suffering and save lives. —World Health Organization Two million hospitalized patients develop health care–associated infections (HCAIs) annually, contributing to over 90,000 deaths each year in the United States.1 The source of these HCAIs is multifactorial, but there is increasing evidence that a significant fraction of these infections originate while patients are in the operating room—and routine anesthesia practices may contribute to these infections.2,3 For instance, contaminated hands of anesthesia providers are significant sources of operating room contamination,3 and although the surrounding patient environment may also be a significant source, bacterial contamination of provider hands contributes to intravenous (IV) line stopcock bacterial transmission, which is associated with increased patient mortality.4 Meanwhile, there is no debate about the profound consequences of HCAIs that include increased costs, selection pressure for drug-resistant organisms, patient and family dissatisfaction, significant morbidity and mortality, and potential liability. Surgical site infections (SSIs) are especially relevant because they account for 20% or more of all HCAIs. Indeed, SSIs afflict 1%–3% of all surgical patients, increasing the hospital length of stay from 3 to 10 days and increasing mortality from 2- to 10-fold.1 Of course, SSIs are just 1 of the 4 most common types of HCAIs that include catheter-associated urinary tract infection (CAUTI), central line–associated bloodstream infection (CLABSI), and ventilator-associated pneumonia (VAP). Overuse or misuse of antibiotics is an additional risk factor for all infections.5 How can anesthesia practices contribute to HCAIs? Observed risk factors for poor hand hygiene include status as a physician, working as an anesthesia provider, short duration of care, and interruption in patient care activities.2,3 A recent study identified bacterial contamination of drugs and drug syringes during routine administration of anesthesia in the operating room. Over 6% of microbial filters placed in standard IV tubing of anesthetized patients were contaminated with Staphylococcus, Corynebacterium, and Bacillus species.6 Equally alarming, 2.4% of fluid samples from the residual drug within syringes at the end of surgical cases grew these same and additional organisms. The Figure shows the working surface of an anesthesia machine during the midpoint of a routine anesthetic at a major teaching hospital and illustrates how syringes and medications could become contaminated.Figure.: Intraoperative photograph of an anesthesia work surface during the maintenance phase of a general anesthetic at a major teaching hospital. Note the uncapped syringes and Luer-lock plug (circled highlights) in close proximity to the patient’s “used” airway equipment. This image illustrates how easily our “routine habits” might create unintended infectious risks during what undoubtedly constitutes common and well-intended practices.As anesthesiologists, the 2 biggest contributors to HCAIs are right in front of us—our hands.3 The interactions among anesthesia professionals and operating room equipment, the anesthesia machine, monitor surfaces, computers and keyboards, vascular catheters, stopcocks, and IV tubing were documented during 8 hours of operating room observation. Anesthesia providers, on average, touched these surfaces 1132 times, completed 66 stopcock injections, and inserted 4 vascular catheters.2 Unfortunately, appropriate hand hygiene preceded only a small fraction of these actions. Birnbach et al7 expanded on these observations using a fluorescent dye technique to illustrate how anesthesia providers’ gloved hands contaminate the local anesthesia work surfaces within 6 minutes after a routine anesthetic induction and endotracheal intubation. Of particular concern, there was 100% contamination of the IV hub, anesthesia circuit, and anesthesia cart. In addition, there was compelling evidence that even unused syringes in our work environment get contaminated. Of course, the concept that hand hygiene contributes to patient well-being is not new. In 1847, Ignaz Philipp Semmelweis introduced hand hygiene on an obstetric ward of Vienna General Hospital. Although his efforts reduced maternal mortality by 90%, his attempts to institute hand hygiene elsewhere were met with fierce resistance by the medical establishment and ultimately led to his leaving Vienna. One hundred fifty years later, according to the World Health Organization (WHO), “[a]dherence of HCWs to recommended hand hygiene procedures has been reported with very variable figures, in some cases unacceptably poor…”8 An audit of perioperative hand hygiene from 2 university hospitals during 2018 is reported in Table 1 (R. C. Prielipp, MD, MBA, FCCM, University of Minnesota, Minneapolis, MN, personal communication, 2018) and affirms the “variable” and “unacceptable” level of compliance decried in the WHO statement.Table 1.: Audit of Hand Hygiene for All Perioperative Providers During an 8-Month Period in 2018 at 2 University Hospitals Examining Care in the Pre-/Postoperative Areas and in the Operating RoomsBoth the Centers for Disease Control and Prevention (CDC) and the WHO have published protocols for hand hygiene as shown in Table 2.8 Most hospital systems will adopt some variant of these 2 protocols, which are said to be functionally comparable, despite suggestions that the WHO 6-step technique may be microbiologically more effective in reducing the mean hand bacterial count.9Table 2.: WHO 5 Moments for Hand HygieneWhy is routine hand hygiene so critical? Bacteria counts on the hands range from 40,000 to 4 million colony-forming units per square centimeter.9 These organisms consist of both resident and transient flora. The transient flora is responsible for most HCAIs.10 Transmission occurs either when a health care worker’s hands contact organisms directly on the patient or when organisms shed onto inanimate objects in the vicinity of a patient. If the organism is capable of surviving for at least a few minutes on the hands of personnel, and if hand hygiene is inadequate, the caregiver will contaminate the physical surroundings and other patients, repeating the cycle.11 Efforts to interrupt this contamination cycle have provided momentum for the WHO to make hand hygiene a top priority since 2009 and are the focus of the WHO First Global Patient Safety Challenge: “Clean Care is Safer Care.” What should anesthesia providers do? We know that alcohol-based hand rubs (ABHRs) have fast disinfectant onset and readily kill Gram-positive/Gram-negative bacteria, mycobacteria, viruses, and fungi (the notable exception is spore-forming pathogens such as Clostridiumdifficile). However, ABHRs do not have persistent activity and “must be reapplied” between patient and surface contacts. Thus, the 2 articles by Birnbach et al12,13 and 1 by Segal et al,14 which have been identified as an Infection Disease “bundle” by the Editor-in-Chief for this issue of the Journal, are especially welcome because they address the most critical component for implementation of reliable hand hygiene in the operating room: health care provider participation. However, as Birnbach et al12 highlight, the prevalence of skin problems and complaints in health care workers after repeated use of ABHR may be as high as 40%.15 While previous research suggested that the irritant potential of commonly used alcohols in hand antiseptics is generally low,15 the incidence of irritant contact dermatitis following the WHO hand hygiene protocol was unknown. Birnbach et al12 had volunteer subjects apply ABHR to their hands every 15 minutes over 8 hours. This was repeated for 5 days for a total of 160 exposures, with independent verification of compliance. The volunteers were critically evaluated at both the beginning and the end of the 5-day period; nearly two-thirds of them experienced discomfort with the process, and 80% of volunteers reported that the frequency of hand hygiene interfered with other tasks. Indeed, strict compliance with WHO Five Moments Hand Hygiene protocols would require even more frequent application of ABHR than that addressed by Birnbach et al7 because anesthesiologists touch operating room surfaces up to 150 times during induction and maintenance of anesthesia.2 Aside from concerns over irritant contact dermatitis, another reason for lack of adherence to hand hygiene is the interruption of patient care activities at key times. We know that as clinical tasks become more intensive and production pressure increases, compliance with hand hygiene decreases. Thus, another approach might be considered. A second article by Birnbach et al12 examines the durability of commonly used nitrile gloves after multiple applications of ABHR to the gloves themselves. This novel approach, while uncommon, is currently used “usually or always” by 9% of anesthesia professionals and appears to be scientifically sound.16 Repeated application of disinfectant to gloves (rather than bare hands), 15 times over 2 hours, did not interrupt the structural or tactile integrity of nitrile gloves. Left untested, however, is the core (and we think, reasonable) assumption that application of ABHR to gloves is efficacious in breaking the chain of cross contamination by touch in the perioperative period. Physical audits of hand hygiene such as those reported in Table 1 are labor intensive, time consuming, and may be prone to the Hawthorne effect. A simple, reliable, and more cost-effective solution is reported by Segal et al.14 The authors measured the weight of the ABHR container before and after surgery as a surrogate for the frequency of ABHR use. The weight-based estimate of hand hygiene episodes has a high coefficient of agreement with observed episodes of hand hygiene utilization, and importantly, the median hand hygiene use actually increased compliance by 1–5 applications per hour after implementation of the weight-based monitoring process. Future work still needs to refine the effectiveness of this process to address the issue of potential work-arounds, as well as to document the durability of the improvements in hand hygiene. Thus, a systems approach to monitor hand hygiene may be as simple as integrating a scale (indicating either tare weight or calibrated to number of hand hygiene applications) to our disinfectant dispenser as a means of both providing real-time measurable feedback to the user as well as monitoring the system as a whole. Clinicians may encounter misguided concerns over the potential flammability of ABHRs used in the operating room environment. During a recent Society for Healthcare Epidemiology of America (SHEA) Webinar, 16% of the participants reported that ABHRs were PROHIBITED from the operating rooms due to concerns of fire (R. C. Prielipp, MD, MBA, FCCM, University of Minnesota, Minneapolis, MN, personal communication, 2019). The Federal Aviation Administration examined the general flammability characteristics of ABHR (hand “sanitizers”) used in lavatories of commercial airlines and found that “burning hand sanitizer presents no significant risk to commercial transport aircraft fire safety”. The National Fire Protection Association (NFPA) has recently published the 2018 Codes and Standards, which specifically address the appropriate use and placement of ABHR dispensers to mitigate the potential for flammability.17 Finally, an extensive review of fires related to the ABHR use found 7 nonsevere incidents that occurred during 25,038 hospital-years of use. All incidents were caused “by individual human actions and not by technical failure,”18 underscoring the safety of ABHR use in hospitals. Thus, ABHR should be available inside and immediately outside of every operating room and anesthetizing site. Finally, anesthesia providers should be aware that the SHEA has issued a comprehensive expert guidance on how hospitals may reduce infections associated with anesthesiology procedures and equipment in the operating room. The guidance, published in December 2018 in Infection Control & Healthcare Epidemiology,16 recommends numerous steps to improve infection prevention through increased hand hygiene, environmental disinfection, and other process improvements (including better equipment design) directly applicable to current anesthesia practice. Semmelweis died in 1865, 5 years after publishing his seminal work, “Die Ätiologie, der Begriff und die Prophylaxis des Kindbettfiebers” (“The Etiology, Concept, and Prophylaxis of Childbed Fever”). His doctrine of hand-chlorine wash was rejected throughout Europe by the 19th century medical establishment (among those, ironically, the great pathologist, Rudolph Virchow). In the 21st century, a seemingly simple task of hand hygiene in the operating still proves burdensome, and its neglect is costly. Were he to peer into the perioperative arena of our current hospitals and observe our actions, would he be satisfied with our progress? DISCLOSURES Name: Kevin T. Riutort, MD, MS. Contribution: This author helped research, review, and write the manuscript. Conflicts of Interest: None. Name: Sorin J. Brull, MD, FCARCSI (Hon). Contribution: This author helped research, review, and write the manuscript. Conflicts of Interest: S. J. Brull is a Director and shareholder, Senzime AB (publ), Uppsala, Sweden; member of Scientific Advisory Boards, The Doctors Company (Napa, CA), ClearLine MD (Woburn, MA), and NMD Pharma (Aarhus, Denmark); and has intellectual property assigned to Mayo Clinic. Name: Richard C. Prielipp, MD, MBA, FCCM. Contribution: This author helped research, review, and write the manuscript. Conflicts of Interest: R. C. Prielipp is a member of the Speakers Bureau for Merck & Co, Kenilworth, NJ, and a consultant for Fresenius Kabi USA, LLC, Lake Zurich, IL. This manuscript was handled by: Tong J. Gan, MD.