Subrahmanyam Radhakrishna | University Hospitals Coventry & Warwickshire, UK
Editor’s note: we are pleased to start a new series of short clinical studies with significant importance to our routine in the operating room and outside it. The ESA Newsletter invites our readers to contribute to this new idea by sending the results of their clinical research which could have an impact of our professional activity.
Hand contamination in the anaesthetic induction room
Dr.S.Radhakrishna1, Dr.C.Vaidyanath2, Dr.M.Sharma2
1 Consultant Anaesthetist, 2 ST7 Anaesthetic Registrar
University Hospitals Coventry & Warwickshire, Coventry, U.K
Correspondence to: Dr.S.Radhakrishna (firstname.lastname@example.org)
Cross contamination in the hospital is of prime importance to all the heath care trusts concerned. Though a lot of steps have been taken across various sites in the hospital to bring about a reduction, cross contamination in the anaesthetic induction room has surprisingly been missed1, 2. This observational study tries to identify the gaps in the existing practice. Though a larger study may be required to determine the extent of the problem we have tried to highlight the key areas of concern and have made suggestions to minimise this risk.
Cross contamination is an ever-growing cause for concern in the hospitals. While the problem has been identified and addressed in important locations in the hospitals like the wards, operating theatres and the intensive care units, cross contamination still remains an issue in the anaesthetic induction room. This observational study was conducted to get an insight into the hand contamination practices of anaesthetists in the anaesthetic induction rooms in various hospitals across the United Kingdom. We also attempted to find ways of eliminating these practices so that it could lead to reduction in cross contamination. Anaesthetists unknowingly could be a cause of cross-contamination and may carry body fluids from one patient to another. We list here the different ways in which cross-contamination may occur and would like to suggest methods to minimise this cross-contamination.
The observational study was initially conducted at University Hospitals of Coventry and Warwickshire (UHCW). Anaesthetists were observed during routine induction of general anaesthesia at UHCW. The study was registered with the clinical audit department in the hospital. We applied for Ethical committee approval but as this was an observation of routine existing practice the Ethics Committee deemed committee approval unnecessary. The study was carried out in the main operating theatres and in day surgery theatres. Permission was taken from the anaesthetists prior to the study but they were not told which aspect of their practice was being studied. This was done so that we did not in any way influence their routine practice, which would have prejudiced the main purpose of this observation. This data was then recorded on the data collection sheet.
To observe the existing practice across the United Kingdom, a similar data collection sheet was distributed to various UK hospitals using Survey Monkey. The audit lead or designated people were requested to collect the data through the AAGBI (Association of Anaesthetists of Great Britain and Ireland) linkman. The results were collected and fed in electronically into the Survey Monkey website by each department audit lead. Our team processed the collected data and the results are given below.
The survey had a reasonable response from the AAGBI linkman in various hospitals across UK who undertook the survey in their respective hospitals. There could have been a perception amongst anaesthetists that the data may be used against them. This could have contributed to refusal to participate in some other hospitals, despite a clear statement that the data would not identify any individual or hospital.
Thus on combining the data from all the hospitals we had a total of 108 observations. This data though was sufficient to illustrate the potential problem of cross contamination caused by anaesthetic practice across the United Kingdom.
In 88 cases (81%) the anaesthetist had worn gloves while in 20 cases (19%) the anaesthetist did not wear any gloves at all. Only thirty-three anaesthetists (31%) changed the gloves between the cases. On sixty-three occasions (58%) the anaesthetist’s gloves were contaminated with either blood or saliva. The gloves were contaminated with blood on twenty-six observed cases (24%) while it was contaminated with saliva on thirty-seven cases (34%); Figure 1. It is thus evident that there was considerable contamination that occurred in the anaesthetic induction room. On twenty-five occasions (40%) out of the sixty-three observed, the contaminated gloves were carried into theatre.
The items most frequently touched with the contaminated gloves are listed below: –
Anaesthetic Machine, Circuit, Flow meter, Drip set, Arterial line, Anaesthetic chart, Patient notes, Flow control knobs, Reservoir bag, Vaporiser, BP connection tube, Airway, Swabs and Endotracheal tube.
The Association of Anaesthetists of Great Britain and Ireland (AAGBI) published their recommendations in a document entitled ‘Infection control in Anaesthesia’ in October 20083. The AAGBI made the following recommendations:
Disposable items such as masks, airways, Laryngoscopes and catheter mounts are for single use only.
Breathing circuits are recommended as single use by manufacturers but are generally used for a whole list, with a bacterial filter inserted between the patient and the circuit. The bacterial filter is changed between the cases and not the whole circuit. The AAGBI is not opposed to this practice
The re-use of bougies has been associated with cross infection. Manufacturers recommend that these can be disinfected up to 5 times between patients. It is preferable to make them single use items.
The surfaces of anaesthetic machines and monitoring equipment should be cleaned between patients and immediately where necessary.
These recommendations do not cover areas identified in this audit where anaesthetists do not regularly use or change gloves and contaminate a whole set of objects in the anaesthetic room and possibly in the theatres4. There is a serious risk of cross contamination here5. Decontamination of the machine and equipment between cases was not a routine practice in most of the hospitals studied. There was no written hospital policy about hand decontamination in anaesthetic room in any of the hospitals studied. As is evident from the data presented here, there has been complete confidentiality and no hospital or individual has been identified.
This project should prompt a larger study to determine the extent of the problem and find local remedies to minimise the contamination. The AAGBI should further explore methods to look into this and to ensure increased compliance.
We would like to make a few suggestions to minimise this contamination. Trainees in anaesthetics develop their skills in cannulation & airway management in the anaesthetic induction room. A junior trainee may not necessarily be adept in avoiding contact with body fluids including blood during these procedures. Hence it is important to change gloves between each anaesthetic procedure and always change gloves before entering theatres from the anaesthetic room. Hence change of gloves after insertion of cannula, change of gloves after intubation and change again before transfer to theatre. This must apply to all staff members in the induction room who have been involved in the care of the patient. We also recommend use of disposable items wherever feasible and to clean anaesthetic machine and all the equipment’s between the cases.
These procedures must be incorporated into the early stages of teaching of trainee anaesthetists to evolve good anaesthetic practice for the immediate future.
We would like to thank the AAGBI and all the linkmen for helping us with the distribution and collation of the data required for the study.
1. Teare L, Cookson B, Stone S. Hand hygiene. British Medical Journal 2001; 323: 411–12.
2. Kristensen M, Sloth E, Jensen TK. Relationship between anaesthetic procedure and contact of anesthesia personnel with patient body fluids. Anesthesiology 1990; 73: 619–24.
3. Infection control in anaesthesia, Anaesthesia 2008, 63:1027-36.
4. Guidelines on infection control in anaesthesia, ANZCA PS28, 2013.
5. Infection prevention and control, NICE clinical guidelines, 2012.
Total number of observations [n = 108]; ( ) No gloves worn [20/108]; ( ) Gloves contaminated with blood [26/108]; ( ) Gloves contaminated with saliva [37/108] and ( ) Gloves not contaminated [25/108].