Frequency of Interactions and Hand Disinfections among Anesthesiologists While Providing Anesthesia Care in the Operating Room: Induction versus Maintenance Author(s): L. Silvia Munoz-Price MD PhD, Bobbie Riley MD, Shawn Banks MD, Scott Eber MD, Kristopher Arheart EdD, David A. Lubarsky MD MBA and David J. Birnbach MD MPH Source: Infection Control and Hospital Epidemiology, Vol. 35, No. 8 (August 2014), pp. 1056-1059 Published by: Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/677154 Accessed: 16-06-2015 19:42 UTC
Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at http://www.jstor.org/page/ info/about/policies/terms.jsp JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact [email protected].
Cambridge University Press and The Society for Healthcare Epidemiology of America are collaborating with JSTOR to digitize, preserve and extend access to Infection Control and Hospital Epidemiology.
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This content downloaded from 142.58.129.109 on Tue, 16 Jun 2015 19:42:51 UTC All use subject to JSTOR Terms and Conditions
infection control and hospital epidemiology
august 2014, vol. 35, no. 8
concise communication
Frequency of Interactions and Hand Disinfections among Anesthesiologists While Providing Anesthesia Care in the Operating Room: Induction versus Maintenance L. Silvia Munoz-Price, MD, PhD;1,2,3 Bobbie Riley, MD;2 Shawn Banks, MD;2 Scott Eber, MD;2 Kristopher Arheart, EdD;3,4 David A. Lubarsky, MD, MBA;2 David J. Birnbach, MD, MPH2,3
We evaluated the behaviors of anesthesiologists during induction and maintenance of anesthesia. Contacts with surfaces occurred a mean (Ⳳstandard error) of 154.8 Ⳳ 7.7 and 60 Ⳳ 3.1 times per hour during induction and maintenance, respectively (P ! .0001). Hand hygiene events were 1.8 Ⳳ 0.27 per hour during induction versus 1.19 Ⳳ 0.27 during maintenance (P p .018). Infect Control Hosp Epidemiol 2014;35(8):1056-1059
During the past few years, the operating room (OR) and its potential role in the spread of multidrug-resistant pathogens has been the focus of a handful of studies, especially within the anesthesia literature.1-3 There is now evidence that horizontal transmission of pathogens occurs between the anesthesia environment and patients3 and that OR surfaces are infrequently disinfected.4,5 Additionally, contamination of patients’ intravascular devices during surgery has been recently associated with increased postoperative infections and mortality.3 However, the interactions of anesthesia providers with the patient and the environment throughout a surgical case are not well characterized. Understanding the behavioral patterns of current hand hygiene is essential, because this would allow us to tailor hand hygiene guidelines to anesthesiologists in the OR. We recently described the behaviors of anesthesia providers during 8 hours of observations, in which over 1,000 objects were touched and anesthesiology hands were disinfected on only 13 occasions.6 This study aims to quantify and compare the frequency of interactions with both the environment and patients as well as the frequency of hand hygiene among anesthesia providers during the phases of induction and maintenance.
methods This observational study was performed at a 1,000-bed teaching hospital, which has an annual volume of approximately 18,000 surgical procedures a year. The observations were per-
formed in the main general ORs (n p 30), where daily anesthesia care is provided by both anesthesiology house staff and certified nurse anesthetists under the direct supervision of attending anesthesiologists. During a surgical procedure, we observed only the “primary anesthesia provider,” who was defined as the person who remained in the OR throughout the case. This study was reviewed and approved by the University of Miami’s institutional review board, which waived informed consent. Using simple randomization, an OR was selected among those scheduled that day. If the primary anesthesia provider in the OR selected had been previously observed, randomization was repeated until a provider not previously observed was obtained. A single observer (B.R.) performed all observations. Observations started at the time of entry of the patient with the primary anesthesia provider and concluded upon exit of the patient or after 120 minutes of surgery (whichever occurred first). The observer remained within a few feet of the primary anesthesia provider and did not disclose the purpose of the project. Observations were recorded in 5-minute intervals starting at the time that the patients entered the OR. Data collected included the number of environmental contacts and hand hygiene of the primary anesthesia provider. Contacts were defined as any surface (patient’s body surfaces or objects) touched by the primary anesthesia provider. Additionally, “anesthesia-ready” time (the time when the surgical procedure can start) was recorded. The period of induction was defined as the time from patient’s entry to the OR until anesthesia-ready time. Similarly, maintenance was defined as the period from anesthesia-ready time until the end of the observation. Other variables collected included sex and level of training of the provider, and both the type of surgical procedure and the patient’s American Society of Anesthesiologists classification. Statistical Analysis We used hierarchical linear modeling (proc glimmix) to analyze counts of either hand hygiene or environmental contacts (in fixed 5-minute intervals). The independent variables (counts) of the model were clustered within 5-minute intervals within the periods of induction or maintenance. These analyses were performed as repeated measures within each subject (primary anesthesia provider). Variables kept in the final model were selected in a stepwise fashion on the basis of their level of significance (P ! .05). Poisson regression using third-degree polynomials was used for modeling the number of contacts throughout surgery. A subanalysis using Poisson regression evaluated the number of hand hygiene events per 100 hand hygiene opportunities. For this analysis, hand hygiene opportunities per time period were calculated by aggregating the contacts with airways, intravenous hubs,
This content downloaded from 142.58.129.109 on Tue, 16 Jun 2015 19:42:51 UTC All use subject to JSTOR Terms and Conditions
anesthesia contacts and hand disinfection
1057
table 1. Characteristics of the Primary Anesthesia Providers and Surgical Procedures Variable
No. (%) of cases
Sex of healthcare provider (n p 30) Female Male Training/profession (n p 30) CRNA PGY-2 PGY-3, PGY-4, fellows Type of surgical procedure (n p 29) Intra-abdominal Vascular Thoracic Extremities/orthopedic Spinal surgery Intracranial surgery Urologic/gynecologic Ear, nose, and throat Other (hernia repairs, breast, hemorrhoid) ASA classification of the patient (n p 30) 0 1 2 3 4 5
18 (60) 12 (40) 11 (36.7) 6 (20.0) 13 (43.3) 4 3 4 1 6 5 1 5
(13.8) (10.3) (13.8) (3.4) 0 (20.7) (17.2) (3.4) (17.2)
3 8 6 1 8 4
(10.0) (26.7) (20.0) (3.3) (26.7) (13.3)
note. ASA, American Society of Anesthesiologists; CRNA, certified registered nursing anesthetist; PGY, postgraduate year.
patient surfaces, and objects on the floor. All analyses were performed using SAS version 9.2 (SAS).
results A total of 30 anesthesia providers were observed while providing anesthesia in the OR (Table 1). The median durations of induction and maintenance observed were 25.5 minutes (range, 8–60 minutes) and 73 minutes (range, 35–100 minutes), respectively (Table 2). On average, only the initial 40% of the surgical procedures were observed (range, 16%– 100%; Table 2). The mean number (Ⳳstandard error [SE]) of contacts of anesthesiologist hands per hour during induction was 154.8 Ⳳ 7.7, compared with 60 Ⳳ 3.1 contacts per hour during maintenance (P ! .0001; Table 3). The continuous pattern of contacts over time based on induction or maintenance is
depicted in Figure 1. The number of hand hygiene events per hour during the induction was 1.8 Ⳳ 0.27 versus 1.19 Ⳳ 0.27 contacts per hour during maintenance (P p .018; Table 3). Multivariate analysis found the hand hygiene frequency to be associated with both induction and level of training, with senior house staff demonstrating the highest frequency (P p .002; Table 3). Additionally, we determined the mean number (ⳲSE) of hand hygiene events per 100 hand hygiene opportunities to be 4.0 Ⳳ 1.0 and 9.0 Ⳳ 2.0 for both induction and maintenance, respectively (P ! .001).
discussion This study describes and compares the behavior of anesthesia providers during induction and maintenance of anesthesia in the OR. We found that the frequency of their contacts with both the environment and patients was significantly higher
table 2. Timing of Observations Variable Induction time, minutes Maintenance observed, minutes Total duration of the surgical procedure, minutes Proportion of the surgical procedure observed
Median
Minimum
Maximum
25.5 73 240 0.4
8 35 60 0.16
60 100 594 1.0
note. Median, minimum, and maximum represent the summary statistics in minutes for all the observations. The proportion of the surgical procedure observed was calculated for each observation, dividing the number of minutes observed by the total duration in minutes of the surgical procedure.
This content downloaded from 142.58.129.109 on Tue, 16 Jun 2015 19:42:51 UTC All use subject to JSTOR Terms and Conditions
1058
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august 2014, vol. 35, no. 8
table 3. Effect of Covariates on Frequency of Environmental Contacts and Hand Hygiene Events Variable Environmental contacts Induction Maintenance Hand hygiene events Induction Maintenance Sex Female Male Level of training CRNA PGY-2 PGY-3,4,5 Type of surgeryc 1 2 3 ASA classification 0–1 2–3 4–5
Univariate analysis, mean Ⳳ SEa 154.8 Ⳳ 7.7 60 Ⳳ 3.1 2.28 Ⳳ 0.54 1.45 Ⳳ 0.34
P
Multivariable analysis, mean Ⳳ SEa
!.0001
NA NA
.013
1.84 Ⳳ 0.43 1.19 Ⳳ 0.27
P
.017
.899 1.74 Ⳳ 0.25 1.84 Ⳳ 0.64 .002b
.002 0.89 Ⳳ 0.32 0.98 Ⳳ 0.45 3.58 Ⳳ 0.88
0.91 Ⳳ 0.33 1.01 Ⳳ 0.46 3.54 Ⳳ 0.88 .166
0.99 Ⳳ 0.47 2.52 Ⳳ 0.69 1.27 Ⳳ 0.62 .316 2.33 Ⳳ 1.33 1.25 Ⳳ 0.41 2.5 Ⳳ 0.89
note. ASA, American Society of Anesthesiologists classification of patients; CRNA, certified registered nursing anesthetist; NA: not applicable; PGY, postgraduate year; SE, standard error. a Mean environmental contacts per hour or mean hand hygiene events per hour Ⳳ SE. b Statistical differences between subgroups were as follows: CRNAs versus PGY-2s, P p .866; CRNAs versus PGY-3,4,5, P p .002; PGY-2 versus PGY-3,4,5, P p .016. c For the univariate analysis, surgeries were categorized into 3 groups on the basis of their complexity in regard to anesthesia care. Group 1 included extremities/orthopedic; ear, nose, and throat; and other surgeries (hernia repairs, breast, and hemorrhoids). Group 2 included intra-abdominal, vascular, thoracic, cardiac, and urologic/gynecologic. Group 3 included spinal and intracranial surgeries.
during the induction than during maintenance. Similarly, the frequency of hand hygiene was higher during induction, but this difference was less than 1 additional hand disinfection over the course of an hour. Based on current guidelines, it is uncertain what the optimal hand hygiene frequency should be among anesthesiologists in the OR.7 The World Health Organization’s “Five Moments for Hand Hygiene”8 are relatively easy to follow outside the OR; nevertheless, when we tried to extrapolate them to anesthesia providers in the ORs, we discovered that these guidelines were not logistically feasible, especially during induction. Thus, hand hygiene recommendations should be tailored for anesthesia providers in the OR and may involve other solutions, including wearing double gloves during induction9 or performing hand hygiene every 5–10 minutes after an automatic prompt rather than after specific contacts. Ideally, these guidelines should have a reasonable expectation for hand hygiene frequency during both induction and maintenance without interfering with anesthesiologists’ workflow or impacting patient safety.
Limitations of this study include being a single-center experience and having an observer next to the anesthesia provider. However, a Hawthorne effect is unlikely, because the frequency of hand hygiene was markedly low, as previously reported.10,11 Additionally, our sample size was small, although we were still able to determine differences between induction and maintenance. Also, this study was performed chronologically after a randomized crossover trial using a device to increase hand hygiene in our ORs; this difference in timing could have potentially affected the behavior of house staff as they progressed in their training. In conclusion, we describe a high number of contacts of anesthesiologists with the anesthesia work environment and patients’ body surfaces during both the induction and maintenance of anesthesia. The lack of tailored hand hygiene guidelines during anesthesia care in the OR makes changing behavior among providers particularly challenging. Therefore, more clear and reasonable expectations are urgently needed. Given the major overlap between anesthesia providers, environmental contamination and disinfection, and in-
This content downloaded from 142.58.129.109 on Tue, 16 Jun 2015 19:42:51 UTC All use subject to JSTOR Terms and Conditions
anesthesia contacts and hand disinfection
1059
figure 1. Anesthesiology contacts per 5-minute intervals during induction and maintenance. Predicted contacts per 5-minute intervals were obtained using Poisson negative binomial regression and second-degree polynomials. Number of contacts are depicted in 5-minute intervals. Onset for induction was entry to the operating room. Onset for maintenance was “anesthesia-ready” time. Triangles indicate observed number of contacts during induction. Dashed line indicates predicted number of contacts during induction. Rhomboids indicate observed number of contacts during maintenance. Solid line indicates the predicted number of contacts during maintenance.
fection control behaviors, we suggest crafting these guidelines as a collaborative effort between anesthesiology, hospital epidemiology, and infection control representatives.
4.
5.
acknowledgments Potential conflicts of interest. All authors report no conflicts of interest relevant to this article. All authors submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and the conflicts that the editors consider relevant to this article are disclosed here. Affiliations: 1. Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; 2. Department of Anesthesiology, University of Miami Miller School of Medicine, Miami, Florida; 3. Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida; 4. Division of Biostatistics, University of Miami Miller School of Medicine, Miami, Florida. Address correspondence to L. Silvia Munoz-Price, MD, Park Plaza West L-302, 1611 NW 12th Avenue, Miami, FL 33136-1096 ([email protected]). Received November 4, 2013; accepted March 18, 2014; electronically published June 20, 2014. 䉷 2014 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2014/3508-0018$15.00. DOI: 10.1086/677154
6.
7.
8.
9.
references 1. Loftus RW, Koff MD, Burchman CC, et al. Transmission of pathogenic bacterial organisms in the anesthesia work area. Anesthesiology 2008;109:399–407. 2. Loftus RW, Brindeiro BS, Kispert DP, et al. Reduction in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a passive catheter care system. Anesth Analg 2012;115:1315–1323. 3. Loftus RW, Brown JR, Koff MD, et al. Multiple reservoirs con-
10.
11.
tribute to intraoperative bacterial transmission. Anesth Analg 2012;114:1236–1248. Jefferson J, Whelan R, Dick B, Carling P. A novel technique for identifying opportunities to improve environmental hygiene in the operating room. AORN J 2011;93:358–364. Munoz-Price LS, Birnbach DJ, Lubarsky DA, et al. Decreasing operating room environmental pathogen contamination through improved cleaning practice. Infect Control Hosp Epidemiol 2012;33:897–904. Munoz-Price LS, Lubarsky DA, Arheart K, et al. Interactions between anesthesiologists and the environment while providing anesthesia care in the operating room. Am J Infect Control 2013; 41:922–924. American Society of Anesthesiologists Committee on Occupational Health Task Force on Infection Control. Recommendations for infection control for the practice of anesthesiology, 2013. http:// www.asahq.org/For-Members/About-ASA/ASA-Committees /Committee-on-Occupational-Health.aspx. Accessed October 29, 2013. Sax H, Allegranzi B, Uckay I, Larson E, Boyce J, Pittet D. “My five moments for hand hygiene”: a user-centred design approach to understand, train, monitor and report hand hygiene. J Hosp Infect 2007;67:9–21. Birnbach DJ, Rosen LF, Fitzpatrick M, Carling P, Arheart KL, Munoz-Price LS. Double gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the operating room. Anesth Analg 2014 [Epub ahead of print]. Koff MD, Loftus RW, Burchman CC, et al. Reduction in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a novel device. Anesthesiology 2009;110: 978–985. Krediet AC, Kalkman CJ, Bonten MJ, Gigengack AC, Barach P. Hand-hygiene practices in the operating theatre: an observational study. Br J Anaesth 2011;107:553–558.
This content downloaded from 142.58.129.109 on Tue, 16 Jun 2015 19:42:51 UTC All use subject to JSTOR Terms and Conditions
Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at http://www.jstor.org/page/ info/about/policies/terms.jsp JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact [email protected].
Cambridge University Press and The Society for Healthcare Epidemiology of America are collaborating with JSTOR to digitize, preserve and extend access to Infection Control and Hospital Epidemiology.
http://www.jstor.org
This content downloaded from 142.58.129.109 on Tue, 16 Jun 2015 19:42:51 UTC All use subject to JSTOR Terms and Conditions
infection control and hospital epidemiology
august 2014, vol. 35, no. 8
concise communication
Frequency of Interactions and Hand Disinfections among Anesthesiologists While Providing Anesthesia Care in the Operating Room: Induction versus Maintenance L. Silvia Munoz-Price, MD, PhD;1,2,3 Bobbie Riley, MD;2 Shawn Banks, MD;2 Scott Eber, MD;2 Kristopher Arheart, EdD;3,4 David A. Lubarsky, MD, MBA;2 David J. Birnbach, MD, MPH2,3
We evaluated the behaviors of anesthesiologists during induction and maintenance of anesthesia. Contacts with surfaces occurred a mean (Ⳳstandard error) of 154.8 Ⳳ 7.7 and 60 Ⳳ 3.1 times per hour during induction and maintenance, respectively (P ! .0001). Hand hygiene events were 1.8 Ⳳ 0.27 per hour during induction versus 1.19 Ⳳ 0.27 during maintenance (P p .018). Infect Control Hosp Epidemiol 2014;35(8):1056-1059
During the past few years, the operating room (OR) and its potential role in the spread of multidrug-resistant pathogens has been the focus of a handful of studies, especially within the anesthesia literature.1-3 There is now evidence that horizontal transmission of pathogens occurs between the anesthesia environment and patients3 and that OR surfaces are infrequently disinfected.4,5 Additionally, contamination of patients’ intravascular devices during surgery has been recently associated with increased postoperative infections and mortality.3 However, the interactions of anesthesia providers with the patient and the environment throughout a surgical case are not well characterized. Understanding the behavioral patterns of current hand hygiene is essential, because this would allow us to tailor hand hygiene guidelines to anesthesiologists in the OR. We recently described the behaviors of anesthesia providers during 8 hours of observations, in which over 1,000 objects were touched and anesthesiology hands were disinfected on only 13 occasions.6 This study aims to quantify and compare the frequency of interactions with both the environment and patients as well as the frequency of hand hygiene among anesthesia providers during the phases of induction and maintenance.
methods This observational study was performed at a 1,000-bed teaching hospital, which has an annual volume of approximately 18,000 surgical procedures a year. The observations were per-
formed in the main general ORs (n p 30), where daily anesthesia care is provided by both anesthesiology house staff and certified nurse anesthetists under the direct supervision of attending anesthesiologists. During a surgical procedure, we observed only the “primary anesthesia provider,” who was defined as the person who remained in the OR throughout the case. This study was reviewed and approved by the University of Miami’s institutional review board, which waived informed consent. Using simple randomization, an OR was selected among those scheduled that day. If the primary anesthesia provider in the OR selected had been previously observed, randomization was repeated until a provider not previously observed was obtained. A single observer (B.R.) performed all observations. Observations started at the time of entry of the patient with the primary anesthesia provider and concluded upon exit of the patient or after 120 minutes of surgery (whichever occurred first). The observer remained within a few feet of the primary anesthesia provider and did not disclose the purpose of the project. Observations were recorded in 5-minute intervals starting at the time that the patients entered the OR. Data collected included the number of environmental contacts and hand hygiene of the primary anesthesia provider. Contacts were defined as any surface (patient’s body surfaces or objects) touched by the primary anesthesia provider. Additionally, “anesthesia-ready” time (the time when the surgical procedure can start) was recorded. The period of induction was defined as the time from patient’s entry to the OR until anesthesia-ready time. Similarly, maintenance was defined as the period from anesthesia-ready time until the end of the observation. Other variables collected included sex and level of training of the provider, and both the type of surgical procedure and the patient’s American Society of Anesthesiologists classification. Statistical Analysis We used hierarchical linear modeling (proc glimmix) to analyze counts of either hand hygiene or environmental contacts (in fixed 5-minute intervals). The independent variables (counts) of the model were clustered within 5-minute intervals within the periods of induction or maintenance. These analyses were performed as repeated measures within each subject (primary anesthesia provider). Variables kept in the final model were selected in a stepwise fashion on the basis of their level of significance (P ! .05). Poisson regression using third-degree polynomials was used for modeling the number of contacts throughout surgery. A subanalysis using Poisson regression evaluated the number of hand hygiene events per 100 hand hygiene opportunities. For this analysis, hand hygiene opportunities per time period were calculated by aggregating the contacts with airways, intravenous hubs,
This content downloaded from 142.58.129.109 on Tue, 16 Jun 2015 19:42:51 UTC All use subject to JSTOR Terms and Conditions
anesthesia contacts and hand disinfection
1057
table 1. Characteristics of the Primary Anesthesia Providers and Surgical Procedures Variable
No. (%) of cases
Sex of healthcare provider (n p 30) Female Male Training/profession (n p 30) CRNA PGY-2 PGY-3, PGY-4, fellows Type of surgical procedure (n p 29) Intra-abdominal Vascular Thoracic Extremities/orthopedic Spinal surgery Intracranial surgery Urologic/gynecologic Ear, nose, and throat Other (hernia repairs, breast, hemorrhoid) ASA classification of the patient (n p 30) 0 1 2 3 4 5
18 (60) 12 (40) 11 (36.7) 6 (20.0) 13 (43.3) 4 3 4 1 6 5 1 5
(13.8) (10.3) (13.8) (3.4) 0 (20.7) (17.2) (3.4) (17.2)
3 8 6 1 8 4
(10.0) (26.7) (20.0) (3.3) (26.7) (13.3)
note. ASA, American Society of Anesthesiologists; CRNA, certified registered nursing anesthetist; PGY, postgraduate year.
patient surfaces, and objects on the floor. All analyses were performed using SAS version 9.2 (SAS).
results A total of 30 anesthesia providers were observed while providing anesthesia in the OR (Table 1). The median durations of induction and maintenance observed were 25.5 minutes (range, 8–60 minutes) and 73 minutes (range, 35–100 minutes), respectively (Table 2). On average, only the initial 40% of the surgical procedures were observed (range, 16%– 100%; Table 2). The mean number (Ⳳstandard error [SE]) of contacts of anesthesiologist hands per hour during induction was 154.8 Ⳳ 7.7, compared with 60 Ⳳ 3.1 contacts per hour during maintenance (P ! .0001; Table 3). The continuous pattern of contacts over time based on induction or maintenance is
depicted in Figure 1. The number of hand hygiene events per hour during the induction was 1.8 Ⳳ 0.27 versus 1.19 Ⳳ 0.27 contacts per hour during maintenance (P p .018; Table 3). Multivariate analysis found the hand hygiene frequency to be associated with both induction and level of training, with senior house staff demonstrating the highest frequency (P p .002; Table 3). Additionally, we determined the mean number (ⳲSE) of hand hygiene events per 100 hand hygiene opportunities to be 4.0 Ⳳ 1.0 and 9.0 Ⳳ 2.0 for both induction and maintenance, respectively (P ! .001).
discussion This study describes and compares the behavior of anesthesia providers during induction and maintenance of anesthesia in the OR. We found that the frequency of their contacts with both the environment and patients was significantly higher
table 2. Timing of Observations Variable Induction time, minutes Maintenance observed, minutes Total duration of the surgical procedure, minutes Proportion of the surgical procedure observed
Median
Minimum
Maximum
25.5 73 240 0.4
8 35 60 0.16
60 100 594 1.0
note. Median, minimum, and maximum represent the summary statistics in minutes for all the observations. The proportion of the surgical procedure observed was calculated for each observation, dividing the number of minutes observed by the total duration in minutes of the surgical procedure.
This content downloaded from 142.58.129.109 on Tue, 16 Jun 2015 19:42:51 UTC All use subject to JSTOR Terms and Conditions
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august 2014, vol. 35, no. 8
table 3. Effect of Covariates on Frequency of Environmental Contacts and Hand Hygiene Events Variable Environmental contacts Induction Maintenance Hand hygiene events Induction Maintenance Sex Female Male Level of training CRNA PGY-2 PGY-3,4,5 Type of surgeryc 1 2 3 ASA classification 0–1 2–3 4–5
Univariate analysis, mean Ⳳ SEa 154.8 Ⳳ 7.7 60 Ⳳ 3.1 2.28 Ⳳ 0.54 1.45 Ⳳ 0.34
P
Multivariable analysis, mean Ⳳ SEa
!.0001
NA NA
.013
1.84 Ⳳ 0.43 1.19 Ⳳ 0.27
P
.017
.899 1.74 Ⳳ 0.25 1.84 Ⳳ 0.64 .002b
.002 0.89 Ⳳ 0.32 0.98 Ⳳ 0.45 3.58 Ⳳ 0.88
0.91 Ⳳ 0.33 1.01 Ⳳ 0.46 3.54 Ⳳ 0.88 .166
0.99 Ⳳ 0.47 2.52 Ⳳ 0.69 1.27 Ⳳ 0.62 .316 2.33 Ⳳ 1.33 1.25 Ⳳ 0.41 2.5 Ⳳ 0.89
note. ASA, American Society of Anesthesiologists classification of patients; CRNA, certified registered nursing anesthetist; NA: not applicable; PGY, postgraduate year; SE, standard error. a Mean environmental contacts per hour or mean hand hygiene events per hour Ⳳ SE. b Statistical differences between subgroups were as follows: CRNAs versus PGY-2s, P p .866; CRNAs versus PGY-3,4,5, P p .002; PGY-2 versus PGY-3,4,5, P p .016. c For the univariate analysis, surgeries were categorized into 3 groups on the basis of their complexity in regard to anesthesia care. Group 1 included extremities/orthopedic; ear, nose, and throat; and other surgeries (hernia repairs, breast, and hemorrhoids). Group 2 included intra-abdominal, vascular, thoracic, cardiac, and urologic/gynecologic. Group 3 included spinal and intracranial surgeries.
during the induction than during maintenance. Similarly, the frequency of hand hygiene was higher during induction, but this difference was less than 1 additional hand disinfection over the course of an hour. Based on current guidelines, it is uncertain what the optimal hand hygiene frequency should be among anesthesiologists in the OR.7 The World Health Organization’s “Five Moments for Hand Hygiene”8 are relatively easy to follow outside the OR; nevertheless, when we tried to extrapolate them to anesthesia providers in the ORs, we discovered that these guidelines were not logistically feasible, especially during induction. Thus, hand hygiene recommendations should be tailored for anesthesia providers in the OR and may involve other solutions, including wearing double gloves during induction9 or performing hand hygiene every 5–10 minutes after an automatic prompt rather than after specific contacts. Ideally, these guidelines should have a reasonable expectation for hand hygiene frequency during both induction and maintenance without interfering with anesthesiologists’ workflow or impacting patient safety.
Limitations of this study include being a single-center experience and having an observer next to the anesthesia provider. However, a Hawthorne effect is unlikely, because the frequency of hand hygiene was markedly low, as previously reported.10,11 Additionally, our sample size was small, although we were still able to determine differences between induction and maintenance. Also, this study was performed chronologically after a randomized crossover trial using a device to increase hand hygiene in our ORs; this difference in timing could have potentially affected the behavior of house staff as they progressed in their training. In conclusion, we describe a high number of contacts of anesthesiologists with the anesthesia work environment and patients’ body surfaces during both the induction and maintenance of anesthesia. The lack of tailored hand hygiene guidelines during anesthesia care in the OR makes changing behavior among providers particularly challenging. Therefore, more clear and reasonable expectations are urgently needed. Given the major overlap between anesthesia providers, environmental contamination and disinfection, and in-
This content downloaded from 142.58.129.109 on Tue, 16 Jun 2015 19:42:51 UTC All use subject to JSTOR Terms and Conditions
anesthesia contacts and hand disinfection
1059
figure 1. Anesthesiology contacts per 5-minute intervals during induction and maintenance. Predicted contacts per 5-minute intervals were obtained using Poisson negative binomial regression and second-degree polynomials. Number of contacts are depicted in 5-minute intervals. Onset for induction was entry to the operating room. Onset for maintenance was “anesthesia-ready” time. Triangles indicate observed number of contacts during induction. Dashed line indicates predicted number of contacts during induction. Rhomboids indicate observed number of contacts during maintenance. Solid line indicates the predicted number of contacts during maintenance.
fection control behaviors, we suggest crafting these guidelines as a collaborative effort between anesthesiology, hospital epidemiology, and infection control representatives.
4.
5.
acknowledgments Potential conflicts of interest. All authors report no conflicts of interest relevant to this article. All authors submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and the conflicts that the editors consider relevant to this article are disclosed here. Affiliations: 1. Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; 2. Department of Anesthesiology, University of Miami Miller School of Medicine, Miami, Florida; 3. Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida; 4. Division of Biostatistics, University of Miami Miller School of Medicine, Miami, Florida. Address correspondence to L. Silvia Munoz-Price, MD, Park Plaza West L-302, 1611 NW 12th Avenue, Miami, FL 33136-1096 ([email protected]). Received November 4, 2013; accepted March 18, 2014; electronically published June 20, 2014. 䉷 2014 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2014/3508-0018$15.00. DOI: 10.1086/677154
6.
7.
8.
9.
references 1. Loftus RW, Koff MD, Burchman CC, et al. Transmission of pathogenic bacterial organisms in the anesthesia work area. Anesthesiology 2008;109:399–407. 2. Loftus RW, Brindeiro BS, Kispert DP, et al. Reduction in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a passive catheter care system. Anesth Analg 2012;115:1315–1323. 3. Loftus RW, Brown JR, Koff MD, et al. Multiple reservoirs con-
10.
11.
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