VOLUME 32, ISSUE 1

The Society for Healthcare Epidemiology of America (SHEA) recently issued an expert guidance with the goal of improving infection prevention in the operating room anesthesia work area1. The entire document is very detailed and I recommend that every anesthesiologist review its content. Hospital administrators and regulatory agencies will likely use this document to dictate new policies and protocols that affect our daily work. For many of us, this has directly impacted the way we practice and may lead to increased costs, delayed room turnover, decreased operating room efficiency, and increased duration of anesthesia time. The document was approved by the SHEA Guidelines Committee and Board of Trustees, the American Academy of Anesthesiology Assistants, the American Association of Nurse Anesthetists, the Association of Perioperative Registered Nurses, and the Anesthesia Patient Safety Foundation. The American Society of Anesthesiologists (ASA) was involved in the creation of these guidelines, however, certain qualifications were noted in the letter of support from former ASA President Dr. James Grant2. This will be discussed below.

Many of the recommendations are important and self-explanatory: proper use of hand hygiene before, during and after patient care; availability of alcohol-based hand rub dispensers at all locations where we practice; double gloving during airway management to avoid soiling nearby workspaces; and proper cleaning of anesthesia machines and workspaces between cases1.

The SHEA recommends disinfection of all injections ports with sterile alcohol-based disinfectant prior to each use, or using sterile isopropyl alcohol containing caps to cover the ports continuously1. In addition, they recommend wiping medication vials’, rubber stoppers, and necks of ampules with 70% alcohol wipes prior to vial access and medication withdrawal1. The SHEA recommends full maximal barrier precautions including sterile gowns and large sterile drape during insertion of central venous catheters and axillary/femoral arterial lines1. For more peripheral arterial lines, a minimum of cap, mask sterile gloves and small sterile fenestrated drape is recommended1.

The controversy begins when the guidelines address medications drawn up into syringes in preparation for anesthetic care. The guidelines cite the current version of United States Pharmacopeia (USP) Chapter 797, which recommends that the use of provider-prepared sterile injectable drugs commence within 1 hour of preparation1. This practice greatly affects our normal workflow, limiting our ability to properly prepare for surgical cases in advance due to the “1 hour rule”. In Dr. Grant’s letter of support with qualifications, he notes the expected revision of the USP Chapter 797 coming up at the end of 2019, which will clearly distinguish between “compounding” and “administration” of medications, which is what takes place under our care in the operating room2. What is more confusing is that The Joint Commission does not require labeling provider-prepared injectable drugs for “immediate use”, provided the medications are administered within 24 hours of preparation. Moreover, the Food and Drug Administration recommendations for drugs such as propofol state a 12-hour expiration time after being drawn up into a syringe1. Needless to say, this will continue to be a hot topic of discussion and contention between hospital administrators, regulatory agencies, and anesthesiologists to determine clear and evidence-based guidelines for these practices.

One final change in practice sparked by these new guidelines stems from the recommendation to minimize the time between the spiking of intravenous fluid bags and administration of medications. The SHEA recommendation is to administer intravenous fluids as soon as possible after spiking of the bag, though no specific time limits have been identified in the literature1. It also defers to hospital protocols as to whether or not the advanced set-up of these materials in preparation for emergent procedures complies with these recommendations. Regulatory agency surveyors have mandated that some hospitals, including my own, not allow preparation of intravenous fluids in advance of potential emergent surgery. This has affected our ability to quickly respond in these emergent situations.

There is no question that we have an important role in the prevention and reduction of hospital acquired infections. Timely administration of perioperative antibiotics, maintenance of normothermia, blood glucose control, and hand washing are all ways in which we can help decrease infection risks3. Physician anesthesiologists’ direct involvement in the development of enhanced recovery after surgery and fast-track surgery protocols shows our commitment to improving the quality of care in the perioperative setting. A recent study showed that our active efforts can help reduce hospital-acquired infections4. Our specialty must be actively involved in quality improvement research going forward to find out which changes to our workflow actually lead to improved outcomes and reduction in hospital-acquired infections.