Epidemiology of Enterococcus , Staphylococcus aureus , Klebsiella , Acinetobacter , Pseudomonas , and Enterobacter Species Transmission in the Pediatric Anesthesia Work Area Environment With and Without Practitioner Use of a Personalized Body-Worn Alcohol Dispenser.

BACKGROUND: Personalized body-worn alcohol dispensers may serve as an important tool for perioperative infection control, but the impact of these devices on the epidemiology of transmission of high-risk Enterococcus , Staphylococcus aureus , Klebsiella, Acinetobacter , Pseudomonas , and Enterobacter (ESKAPE) pathogens is unknown. We aimed to characterize the epidemiology of ESKAPE transmission in the pediatric anesthesia work area environment with and without a personalized body-worn alcohol dispenser. METHODS: This controlled before and after study included 40 pediatric patients enrolled over a 1-year study period. Two groups of operating room cases were compared: (1) operating room cases caring for patients with usual care (December 17, 2019, to August 25, 2020), and (2) operating room cases caring for patients with usual care plus the addition of a personalized, body-worn alcohol hand rub dispenser (September 30, 2020, to December 16, 2020). Operating rooms were randomly selected for observation of ESKAPE transmission in both groups. Device use was tracked via wireless technology and recorded in hourly hand decontamination events. RESULTS: Anesthesia providers used the alcohol dispenser 3.3 ± 2.1 times per hour. A total of 57 ESKAPE transmission events (29 treatment and 28 control) were identified. The personalized body-worn alcohol dispenser impacted ESKAPE transmission by increasing the contribution of provider hand contamination at case start (21/29 device versus 10/28 usual care; relative risk, [RR] 2.03; 99.17% confidence interval [CI], 1.025-5.27; P = .0066) and decreasing the contribution of environmental contamination at case end (3/29 device versus 12/28 usual care; RR, 0.24; 99.17% CI, 0.022-0.947; P = .0059). ESKAPE pathogen contamination involved 20% (8/40) of patient intravascular devices. There were 85% (34/40) of preoperative patient skin surfaces contaminated with ≥1 (1.78 ± 0.19 [standard deviation {SD}]) ESKAPE pathogens. CONCLUSIONS: A personalized body-worn alcohol dispenser can impact the epidemiology of ESKAPE transmission in the pediatric anesthesia work area environment. Improved preoperative patient decolonization and vascular care are indicated to address ESKAPE pathogens among pediatric anesthesia work area reservoirs.

The dynamics and implications of bacterial transmission events arising from the anesthesia work area.

Health care-associated infections are a hospital-wide concern associated with a significant increase in patient morbidity, mortality, and health care costs. Bacterial transmission in the anesthesia work area of the operating room environment is a root cause of 30-day postoperative infections affecting as many as 16% of patients undergoing surgery. A better understanding of anesthesia-related bacterial transmission dynamics may help to generate improvements in intraoperative infection control and improve patient safety.

Hand hygiene knowledge and perceptions among anesthesia providers.

BACKGROUND: Health care worker compliance with hand hygiene guidelines is an important measure for health care-associated infection prevention, yet overall compliance across all health care arenas remains low. A correct answer to 4 of 4 structured questions pertaining to indications for hand decontamination (according to types of contact) has been associated with improved health care provider hand hygiene compliance when compared to those health care providers answering incorrectly for 1 or more questions. A better understanding of knowledge deficits among anesthesia providers may lead to hand hygiene improvement strategies. In this study, our primary aims were to characterize and identify predictors for hand hygiene knowledge deficits among anesthesia providers. METHODS: We modified this previously tested survey instrument to measure anesthesia provider hand hygiene knowledge regarding the 5 moments of hand hygiene across national and multicenter groups. Complete knowledge was defined by correct answers to 5 questions addressing the 5 moments for hand hygiene and received a score of 1. Incomplete knowledge was defined by an incorrect answer to 1 or more of the 5 questions and received a score of 0. We used a multilevel random-effects XTMELOGIT logistic model clustering at the respondent and geographic location for insufficient knowledge and forward/backward stepwise logistic regression analysis to identify predictors for incomplete knowledge. RESULTS: The survey response rates were 55.8% and 18.2% for the multicenter and national survey study groups, respectively. One or more knowledge deficits occurred with 81.6% of survey respondents, with the mean number of correct answers 2.89 (95% confidence interval, 2.78- 2.99). Failure of providers to recognize prior contact with the environment and prior contact with the patient as hand hygiene opportunities contributed to the low mean. Several cognitive factors were associated with a reduced risk of incomplete knowledge including providers responding positively to washing their hands after contact with the environment (odds ratio [OR] 0.23, 0.14-0.37, P < 0.001), disinfecting their environment during patient care (OR 0.54, 0.35-0.82, P = 0.004), believing that they can influence their colleagues (OR 0.43, 0.27-0.68, P < 0.001), and intending to adhere to guidelines (OR 0.56, 0.36-0.86, P = 0.008). These covariates were associated with an area under receiver operator characteristics curve of 0.79 (95% confidence interval, 0.74-0.83). CONCLUSIONS: Anesthesia provider knowledge deficits around to hand hygiene guidelines occur frequently and are often due to failure to recognize opportunities for hand hygiene after prior contact with contaminated patient and environmental reservoirs. Intraoperative hand hygiene improvement programs should address these knowledge deficits. Predictors for incomplete knowledge as identified in this study should be validated in future studies.

Transmission dynamics of gram-negative bacterial pathogens in the anesthesia work area.

BACKGROUND: Gram-negative organisms are a major health care concern with increasing prevalence of infection and community spread. Our primary aim was to characterize the transmission dynamics of frequently encountered gram-negative bacteria in the anesthesia work area environment (AWE). Our secondary aim was to examine links between these transmission events and 30-day postoperative health care-associated infections (HCAIs). METHODS: Gram-negative isolates obtained from the AWE (patient nasopharynx and axilla, anesthesia provider hands, and the adjustable pressure-limiting valve and agent dial of the anesthesia machine) at 3 major academic medical centers were identified as possible intraoperative bacterial transmission events by class of pathogen, temporal association, and phenotypic analysis (analytical profile indexing). The top 5 frequently encountered genera were subjected to antibiotic disk diffusion sensitivity to identify epidemiologically related transmission events. Complete multivariable logistic regression analysis and binomial tests of proportion were then used to examine the relative contributions of reservoirs of origin and within- and between-case modes of transmission, respectively, to epidemiologically related transmission events. Analyses were conducted with and without the inclusion of duplicate transmission events of the same genera occurring in a given study unit (first and second case of the day in each operating room observed) to examine the potential effect of statistical dependency. Transmitted isolates were compared by pulsed-field gel electrophoresis to disease-causing bacteria for 30-day postoperative HCAIs. RESULTS: The top 5 frequently encountered gram-negative genera included Acinetobacter, Pseudomonas, Brevundimonas, Enterobacter, and Moraxella that together accounted for 81% (767/945) of possible transmission events. For all isolates, 22% (167/767) of possible transmission events were identified by antibiotic susceptibility patterns as epidemiologically related and underwent further study of transmission dynamics. There were 20 duplicates involving within- and between-case transmission events. Thus, approximately 19% (147/767) of isolates excluding duplicates were considered epidemiologically related. Contaminated provider hand reservoirs were less likely (all isolates, odds ratio 0.12, 95% confidence interval 0.03-0.50, P = 0.004; without duplicate events, odds ratio 0.05, 95% confidence interval 0.01-0.49, P = 0.010) than contaminated patient or environmental sites to serve as the reservoir of origin for epidemiologically related transmission events. Within- and between-case modes of gram-negative bacilli transmission occurred at similar rates (all isolates, 7% between-case, 5.2% within-case, binomial P value 0.176; without duplicates, 6.3% between-case, 3.7% within-case, binomial P value 0.036). Overall, 4.0% (23/548) of patients suffered from HCAIs and had an intraoperative exposure to gram-negative isolates. In 8.0% (2/23) of those patients, gram-negative bacteria were linked by pulsed-field gel electrophoresis to the causative organism of infection. Patient and provider hands were identified as the reservoirs of origin and the environment confirmed as a vehicle for between-case transmission events linked to HCAIs. CONCLUSIONS: Between- and within-case AWE gram-negative bacterial transmission occurs frequently and is linked by pulsed-field gel electrophoresis to 30-day postoperative infections. Provider hands are less likely than contaminated environmental or patient skin surfaces to serve as the reservoir of origin for transmission events.

The epidemiology of Staphylococcus aureus transmission in the anesthesia work area.

BACKGROUND: Little is known regarding the epidemiology of intraoperative Staphylococcus aureus transmission. The primary aim of this study was to examine the mode of transmission, reservoir of origin, transmission locations, and antibiotic susceptibility for frequently encountered S aureus strains (phenotypes) in the anesthesia work area. Our secondary aims were to examine phenotypic associations with 30-day postoperative patient cultures, phenotypic growth rates, and risk factors for phenotypic isolation. METHODS: S aureus isolates previously identified as possible intraoperative bacterial transmission events by class of pathogen, temporal association, and analytical profile indexing were subjected to antibiotic disk diffusion sensitivity. The combination of these techniques was then used to confirm S aureus transmission events and to classify them as occurring within or between operative cases (mode). The origin of S aureus transmission events was determined via use of a previously validated experimental model and links to 30-day postoperative patient cultures confirmed via pulsed-field gel electrophoresis. Growth rates were assessed via time-to-positivity analysis, and risk factors for isolation were characterized via logistic regression. RESULTS: One hundred seventy S aureus isolates previously implicated as possible intraoperative transmission events were further subdivided by analytical profile indexing phenotype. Two phenotypes, phenotype P (patients) and phenotype H (hands), accounted for 65% of isolates. Phenotype P and phenotype H contributed to at least 1 confirmed transmission event in 39% and 28% of cases, respectively. Patient skin surfaces (odds ratio [OR], 8.40; 95% confidence interval [CI], 2.30-30.73) and environmental (OR, 10.89; 95% CI, 1.29-92.13) samples were more likely than provider hands (referent) to have phenotype P positivity. Phenotype P was more likely than phenotype H to be resistant to methicillin (OR, 4.38; 95% CI, 1.59-12.06; P = 0.004) and to be linked to 30-day postoperative patient cultures (risk ratio, 36.63 [risk difference, 0.174; 95% CI, 0.019-0.328]; P < 0.001). Phenotype P exhibited a faster growth rate for methicillin resistant and for methicillin susceptible than phenotype H (phenotype P: median, 10.32H; interquartile range, 10.08-10.56; phenotype H: median, 10.56H; interquartile range, 10.32-10.8; P = 0.012). Risk factors for isolation of phenotype P included age (OR, 14.11; 95% CI, 3.12-63.5; P = 0.001) and patient exposure to the hospital ward (OR, 41.11; 95% CI, 5.30-318.78; P < 0.001). CONCLUSIONS: Two S aureus phenotypes are frequently transmitted in the anesthesia work area. A patient and environmentally derived phenotype is associated with increased risk of antibiotic resistance and links to 30-day postoperative patient cultures as compared with a provider hand-derived phenotype. Future work should be directed toward improved screening and decolonization of patients entering the perioperative arena and improved intraoperative environmental cleaning to attenuate postoperative health care-associated infections.

The dynamics of Enterococcus transmission from bacterial reservoirs commonly encountered by anesthesia providers.

BACKGROUND: Enterococci, the second leading cause of health care-associated infections, have evolved from commensal and harmless organisms to multidrug-resistant bacteria associated with a significant increase in patient morbidity and mortality. Prevention of ongoing spread of this organism within and between hospitals is important. In this study, we characterized Enterococcus transmission dynamics for bacterial reservoirs commonly encountered by anesthesia providers during the routine administration of general anesthesia. METHODS: Enterococcus isolates previously obtained from bacterial reservoirs frequently encountered by anesthesiologists (patient nasopharynx and axilla, anesthesia provider hands, and the adjustable pressure-limiting valve and agent dial of the anesthesia machine) at 3 major academic medical centers were identified as possible intraoperative bacterial transmission events by class of pathogen, temporal association, and phenotypic analysis (analytical profile indexing). They were then subjected to antibiotic disk diffusion sensitivity for transmission event confirmation. Isolates involved in confirmed transmission events were further analyzed to characterize the frequency, mode, origin, location of transmission events, and antibiotic susceptibility of transmitted pathogens. RESULTS: Three hundred eighty-nine anesthesia reservoir isolates were previously identified by gross morphology and simple rapid tests as Enterococcus. The combination of further analytical profile indexing analysis and temporal association implicated 43% (166/389) of those isolates in possible intraoperative bacterial transmission events. Approximately, 30% (49/166) of possible transmission events were confirmed by additional antibiotic disk diffusion analysis. Two phenotypes, E5 and E7, explained 80% (39/49) of confirmed transmission events. For both phenotypes, provider hands were a common reservoir of origin proximal to the transmission event (96% [72/75] hand origin for E7 and 89% [50/56] hand origin for E5) and site of transmission (94% [16/17] hand transmission location for E7 and 86% [19/22] hand transmission location for E5). CONCLUSIONS: Anesthesia provider hand contamination is a common proximal source and transmission location for Enterococcus transmission events in the anesthesia work area. Future work should evaluate the impact of intraoperative hand hygiene improvement strategies on the dynamics of intraoperative Enterococcus transmission.

Frequently Touched Sites in the Intensive Care Unit Environment Returning 100 Colony-Forming Units per Surface Area Sampled Are Associated With Increased Risk of Major Bacterial Pathogen Detection.

BACKGROUND: A threshold for surface hygiene has not been defined for the healthcare arena. We aimed to identify the magnitude of bacterial contamination of frequently touched sites in the intensive care unit (ICU) environment that could be used to guide quality improvement initiatives. METHODS: Nineteen patients in a mixed ICU environment (providing care for medical and surgical patients) were followed from admission for 72 hours in 2010. Baseline cultures of frequently touched environmental sites were obtained at time zero following active decontamination and at 12, 24, 48, and 72 hours without further disinfection. We tested for an association of environmental reservoirs returning ≥ 100 colony-forming units (CFU) per surface area sampled with major bacterial pathogen detection. RESULTS: There were 446 ICU room, day, and reservoir combinations sampled from 19 patients. There were pathogens detected in 40% (79/199) of samples with ≥ 100 CFU vs. 14% (35/247) of samples returning < 100 CFU. The relative risk was 2.80 (95% CI: 1.97-3.98, P <0.0001). The odds ratio adjusted for time in hours was 3.11 (95% CI: 1.84-5.34, P < 0.0001). CONCLUSIONS: Frequently touched ICU environmental sites returning ≥ 100 CFU are associated with major bacterial pathogen detection. This threshold for surface hygiene can be used to ensure compliance with ICU environmental cleaning protocols and to guide quality improvement initiatives.

Reduction in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a passive catheter care system.

BACKGROUND: Bacterial contamination of intravascular devices has been associated with increased morbidity and mortality in various hospital settings, including the perioperative environment. Catheter hub disinfection has been shown in an ex vivo model to attenuate intraoperative injection of bacterial organisms originating from the anesthesia provider's hands, providing the impetus for improvement in intraoperative disinfection techniques and compliance. In the current study, we investigated the clinical effectiveness of a new, passive catheter care station in reducing the incidence of bacterial contamination of open lumen patient IV stopcock sets. The secondary aim was to evaluate the impact of this novel intervention on the combined incidence of 30-day postoperative infections and IV catheter-associated phlebitis. METHODS: Five hundred ninety-four operating room environments were randomized by a computer-generated list to receive either a novel catheter care bundle (HubScrub and DOCit) or standard caps in conjunction with a sterile, conventional open lumen 3-way stopcock set (24 inch with 3-gang 4-way and T-Connector). Patients underwent general anesthesia according to usual practice and were followed prospectively for 30 postoperative days to identify the development of health care-associated infections (HCAIs) and/or phlebitis. The primary outcome was intraoperative bacterial contamination of the primary stopcock set used by the anesthesia provider(s). The secondary outcome was the combined incidence of 30-day postoperative infections and phlebitis. RESULTS: Five hundred seventy-two operating rooms were included in the final analysis. Study groups were comparable with no significant differences in patient, provider, anesthetic, or procedural characteristics. The catheter care station reduced the incidence of primary stopcock lumen contamination compared with standard caps (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.63-0.98, P = 0.034) and was associated with a reduction in the combined incidence of HCAIs and IV catheter-associated phlebitis with and without adjustment for patient and procedural covariates (OR(adjusted) 0.589, 95% CI 0.353-0.984, P = 0.040). The risk-adjusted number needed to treat to eliminate 1 case of lumen contamination was 9 (95% CI 3.4-13.5) patients, whereas the risk-adjusted number needed to treat to eliminate 1 case of HCAI/catheter-associated phlebitis was 17 (95% CI 11.8-17.9) patients. CONCLUSION: Intraoperative use of a passive catheter care station significantly reduced open lumen bacterial contamination and the combined incidence of 30-day postoperative infections and phlebitis.

Multiple reservoirs contribute to intraoperative bacterial transmission.

BACKGROUND: Intraoperative stopcock contamination is a frequent event associated with increased patient mortality. In the current study we examined the relative contributions of anesthesia provider hands, the patient, and the patient environment to stopcock contamination. Our secondary aims were to identify risk factors for stopcock contamination and to examine the prior association of stopcock contamination with 30-day postoperative infection and mortality. Additional microbiological analyses were completed to determine the prevalence of bacterial pathogens within intraoperative bacterial reservoirs. Pulsed-field gel electrophoresis was used to assess the contribution of reservoir bacterial pathogens to 30-day postoperative infections. METHODS: In a multicenter study, stopcock transmission events were observed in 274 operating rooms, with the first and second cases of the day in each operating room studied in series to identify within- and between-case transmission events. Reservoir bacterial cultures were obtained and compared with stopcock set isolates to determine the origin of stopcock contamination. Between-case transmission was defined by the isolation of 1 or more bacterial isolates from the stopcock set of a subsequent case (case 2) that were identical to reservoir isolates from the preceding case (case 1). Within-case transmission was defined by the isolation of 1 or more bacterial isolates from a stopcock set that were identical to bacterial reservoirs from the same case. Bacterial pathogens within these reservoirs were identified, and their potential contribution to postoperative infections was evaluated. All patients were followed for 30 days postoperatively for the development of infection and all-cause mortality. RESULTS: Stopcock contamination was detected in 23% (126 out of 548) of cases with 14 between-case and 30 within-case transmission events confirmed. All 3 reservoirs contributed to between-case (64% environment, 14% patient, and 21% provider) and within-case (47% environment, 23% patient, and 30% provider) stopcock transmission. The environment was a more likely source of stopcock contamination than provider hands (relative risk [RR] 1.91, confidence interval [CI] 1.09 to 3.35, P = 0.029) or patients (RR 2.56, CI 1.34 to 4.89, P = 0.002). Hospital site (odds ratio [OR] 5.09, CI 2.02 to 12.86, P = 0.001) and case 2 (OR 6.82, CI 4.03 to 11.5, P < 0.001) were significant predictors of stopcock contamination. Stopcock contamination was associated with increased mortality (OR 58.5, CI 2.32 to 1477, P = 0.014). Intraoperative bacterial contamination of patients and provider hands was linked to 30-day postoperative infections. CONCLUSIONS: Bacterial contamination of patients, provider hands, and the environment contributes to stopcock transmission events, but the surrounding patient environment is the most likely source. Stopcock contamination is associated with increased patient mortality. Patient and provider bacterial reservoirs contribute to 30-day postoperative infections. Multimodal programs designed to target each of these reservoirs in parallel should be studied intensely as a comprehensive approach to reducing intraoperative bacterial transmission.

Prevention of intravenous bacterial injection from health care provider hands: the importance of catheter design and handling.

BACKGROUND: Device-related bloodstream infections are associated with a significant increase in patient morbidity and mortality in multiple health care settings. Recently, intraoperative bacterial contamination of conventional open-lumen 3-way stopcock sets has been shown to be associated with increased patient mortality. Intraoperative use of disinfectable, needleless closed catheter devices (DNCCs) may reduce the risk of bacterial injection as compared to conventional open-lumen devices due to an intrinsic barrier to bacterial entry associated with valve design and/or the capacity for surface disinfection. However, the relative benefit of DNCC valve design (intrinsic barrier capacity) as compared to surface disinfection in attenuation of bacterial injection in the clinical environment is untested and entirely unknown. The primary aim of the current study was to investigate the relative efficacy of a novel disinfectable stopcock, the Ultraport zero, with and without disinfection in attenuating intraoperative injection of potential bacterial pathogens as compared to a conventional open-lumen stopcock intravascular device. The secondary aims were to identify risk factors for bacterial injection and to estimate the quantity of bacterial organisms injected during catheter handling. METHODS: Four hundred sixty-eight operating room environments were randomized by a computer generated list to 1 of 3 device-injection schemes: (1) injection of the Ultraport zero stopcock with hub disinfection before injection, (2) injection of the Ultraport zero stopcock without prior hub disinfection, and (3) injection of the conventional open-lumen stopcock closed with sterile caps according to usual practice. After induction of general anesthesia, the primary anesthesia provider caring for patients in each operating room environment was asked to perform a series of 5 injections of sterile saline through the assigned device into an ex vivo catheter system. The primary outcome was the incidence of bacterial contamination of the injected fluid column (effluent). Risk factors for effluent contamination were identified in univariate analysis, and a controlled laboratory experiment was used to generate an estimate of the bacterial load injected for contaminated effluent samples. RESULTS: The incidence of effluent bacterial contamination was 0% (0/152) for the Ultraport zero stopcock with hub disinfection before injection, 4% (7/162) for the Ultraport zero stopcock without hub disinfection before injection, and 3.2% (5/154) for the conventional open-lumen stopcock. The Ultraport zero stopcock with hub disinfection before injection was associated with a significant reduction in the risk of bacterial injection as compared to the conventional open-lumen stopcock (RR = 8.15 × 10(-8), 95% CI, 3.39 × 10(-8) to 1.96 × 10(-7), P = <0.001), with an absolute risk reduction of 3.2% (95% CI, 0.5% to 7.4%). Provider glove use was a risk factor for effluent contamination (RR = 10.48, 95% CI, 3.16 to 34.80, P < 0.001). The estimated quantity of bacteria injected reached a clinically significant threshold of 50,000 colony-forming units per each injection series. CONCLUSIONS: The Ultraport zero stopcock with hub disinfection before injection was associated with a significant reduction in the risk of inadvertent bacterial injection as compared to the conventional open-lumen stopcock. Future studies should examine strategies designed to facilitate health care provider DNCC hub disinfection and proper device handling.

Effectiveness and feasibility of an evidence-based intraoperative infection control program targeting improved basic measures: a post-implementation prospective case-cohort study.

STUDY OBJECTIVE: A randomized controlled study demonstrated that an optimized intraoperative infection control program targeting basic preventive measures can reduce Staphylococcus aureus transmission and surgical site infections. In this study we address potential limitations of operating room heterogeneity of infections and compliance with behavioral interventions following adoption into clinical practice. DESIGN: A post-implementation prospective case-cohort study. SETTING: Twenty-three operating rooms at a large teaching hospital. PATIENTS: A total of 801 surgical patients [425 (53%) women; 350 (44%) ASA > 2, age 54.6 ± 15.9 years] were analyzed for the primary and 804 for the secondary outcomes. INTERVENTIONS: A multifaceted, evidence-based intraoperative infection control program involving hand hygiene, vascular care, and environmental cleaning improvements was implemented for 23 operating room environments. Bacterial transmission monitoring was used to provide monthly feedback for intervention optimization. MEASUREMENTS: S. aureus transmission (primary) and surgical site infection (secondary). MATERIALS AND METHODS: The incidence of S. aureus transmission and surgical site infection before (3.5 months) and after (4.5 months) infection control optimization was assessed. Optimization was defined by a sustained reduction in anesthesia work area bacterial reservoir isolate counts. Poisson regression with robust error variances was used to estimate the incidence risk ratio (IRR) of intraoperative S. aureus transmission and surgical site infection for the independent variable of optimization. MAIN RESULTS: Optimization was associated with decreased S. aureus transmission [24% before (85/357) to 9% after (42/444), IRR 0.39, 95% CI 0.28 to 0.56, P < .001] and surgical site infections [8% before (29/360) and 3% after (15/444) (IRR 0.42, 95% CI 0.23 to 0.77, P = .005; adjusted for American Society of Anesthesiologists' physical status, aIRR 0.45, 95% CI 0.25 to 0.82, P = .009]. CONCLUSION: An optimized intraoperative infection control program targeting improvements in basic preventive measures is an effective and feasible approach for reducing S. aureus transmission and surgical site infection development.

Hand contamination of anesthesia providers is an important risk factor for intraoperative bacterial transmission.

BACKGROUND: We have recently shown that intraoperative bacterial transmission to patient IV stopcock sets is associated with increased patient mortality. In this study, we hypothesized that bacterial contamination of anesthesia provider hands before patient contact is a risk factor for direct intraoperative bacterial transmission. METHODS: Dartmouth-Hitchcock Medical Center is a tertiary care and level 1 trauma center with 400 inpatient beds and 28 operating suites. The first and second operative cases in each of 92 operating rooms were randomly selected for analysis. Eighty-two paired samples were analyzed. Ten pairs of cases were excluded because of broken or missing sampling protocol and lost samples. We identified cases of intraoperative bacterial transmission to the patient IV stopcock set and the anesthesia environment (adjustable pressure-limiting valve and agent dial) in each operating room pair by using a previously validated protocol. We then used biotype analysis to compare these transmitted organisms to those organisms isolated from the hands of anesthesia providers obtained before the start of each case. Provider-origin transmission was defined as potential pathogens isolated in the patient stopcock set or environment that had an identical biotype to the same organism isolated from hands of providers. We also assessed the efficacy of the current intraoperative cleaning protocol by evaluating isolated potential pathogens identified at the start of case 2. Poor intraoperative cleaning was defined as 1 or more potential pathogens found in the anesthesia environment at the start of case 2 that were not there at the beginning of case 1. We collected clinical and epidemiological data on all the cases to identify risk factors for contamination. RESULTS: One hundred sixty-four cases (82 case pairs) were studied. We identified intraoperative bacterial transmission to the IV stopcock set in 11.5 % (19/164) of cases, 47% (9/19) of which were of provider origin. We identified intraoperative bacterial transmission to the anesthesia environment in 89% (146/164) of cases, 12% (17/146) of which were of provider origin. The number of rooms that an attending anesthesiologist supervised simultaneously, the age of the patient, and patient discharge from the operating room to an intensive care unit were independent predictors of bacterial transmission events not directly linked to providers. CONCLUSION: The contaminated hands of anesthesia providers serve as a significant source of patient environmental and stopcock set contamination in the operating room. Additional sources of intraoperative bacterial transmission, including postoperative environmental cleaning practices, should be further studied.

Life-threatening hyperkalemia from nutritional supplements: uncommon or undiagnosed?

Potassium chloride and other potassium compounds are used by the general public as salt substitutes, muscle-building supplements, and panacea. Severe hyperkalemia from oral potassium is extremely rare if kidney function is normal because of potassium adaptation. The oral potassium dose has to be large enough to overcome the normal renal excretory mechanisms to cause severe hyperkalemia. This occurs most commonly in patients with renal impairment or those who take potassium-sparing diuretics, angiotensin receptor blockers, or angiotensin-converting enzyme inhibitors. We present two unique cases of near-fatal hyperkalemia from nutritional supplements containing potassium. The first case was due to salt-substitute intake, whereas the second case was from a muscle-building supplement. Both patients suffered cardiac arrest, but were successfully resuscitated and survived. The acuity of intake and excessive quantity overwhelmed the kidneys' ability for adaptation. Potassium toxicity affects multiple organ systems and manifests in characteristic, acute cardiovascular changes with electrocardiographic abnormalities. Neuromuscular manifestations include general muscular weakness and ascending paralysis may occur, whereas gastrointestinal symptoms manifest as nausea, vomiting, paralytic ileus, and local mucosal necrosis that may lead to perforation. Once an urgent situation has been handled with intravenous push of a 10% calcium salt, short-term measures should be started with agents that cause a transcellular shift of potassium, namely, insulin with glucose, ß2-agonist, and NaHCO(3). Patients are unaware of these potentially serious adverse effects, and there are inadequate consumer warnings. Clinicians should be vigilant in monitoring potassium intake from over-the-counter supplements.

Perioperative Infection Transmission: the Role of the Anesthesia Provider in Infection Control and Healthcare-Associated Infections.

PURPOSE OF REVIEW: This review aims to highlight key factors in the perioperative environment that contribute to transmission of infectious pathogens, leading to healthcare-associated infection. This knowledge will provide anesthesia providers the tools to optimize preventive measures, with the goal of improved patient and provider safety. RECENT FINDINGS: Over the past decade, much has been learned about the epidemiology of perioperative pathogen transmission. Patients, providers, and the environment serve as reservoirs of origin that contribute to infection development. Ongoing surveillance of pathogen transmission among these reservoirs is essential to ensure effective perioperative infection prevention. SUMMARY: Recent work has proven the efficacy of a strategic approach for perioperative optimization of hand hygiene, environmental cleaning, patient decolonization, and intravascular catheter design and handling improvement protocols. This work, proven to generate substantial reductions in surgical site infections, can also be applied to aide prevention of SARS-CoV-2 spread in the COVID-19 era.

Reduction in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a novel device.

BACKGROUND: Hand hygiene is a vital intervention to reduce health-care associated infections, but compliance remains low. The authors hypothesized that improvements in intraoperative hand hygiene compliance would reduce transmission of bacteria to surgical patients and reduce the incidence of postsurgical healthcare-associated infections. METHODS: The authors performed a controlled before-and-after study over 2 consecutive months. One hundred fourteen operative cases were enrolled. Two predesignated sites on the anesthesia machine were selected, decontaminated, and cultured via aseptic technique. These sites and the peripheral intravenous stopcock were cultured again after completion of the surgery. The treatment phase used a novel personal hand-decontamination device capable of recording hand-decontamination events. RESULTS: There were no significant differences in patient location, age, or case duration and procedure type between groups. Use of the Sprixx GJ device (Harbor Medical Inc., Santa Barbara, CA) increased hourly hand decontamination events by 27-fold as compared with baseline rates (P < 0.002; 95% confidence interval, 3.3-13.4). Use of the device was associated with a reduction in contamination in the anesthesia work area and peripheral intravenous tubing. Intravenous tubing contamination was identified in 32.8% of cases in the control group versus 7.5% in the treatment group (odds ratio, 0.17; 95% confidence interval, 0.06-0.51; P < 0.01). Healthcare-associated infections rates were reduced in the device group (3.8%) as compared with the control group (17.2%) (odds ratio, 0.19; 95% confidence interval, 0.00-0.81; P = 0.02). CONCLUSIONS: Improved hand hygiene compliance through the use of a novel hand sanitation strategy reduces the risk of intraoperative bacterial transmission. The intervention was associated with a reduction in healthcare-associated infections.

Severe brachial plexopathy after an ultrasound-guided single-injection nerve block for total shoulder arthroplasty in a patient with multiple sclerosis.

DESPITE the known benefits of regional anesthesia for patients undergoing joint arthroplasty, the performance of peripheral nerve blocks in patients with multiple sclerosis (MS) remains controversial. MS has traditionally been described as an isolated disease of the central nervous system, without involvement of the peripheral nerves, and peripheral nerve blockade has been suggested to be safe. However, careful review of the literature suggests that MS may also be associated with involvement of the peripheral nervous system, challenging traditional teachings. There is a paucity of evidence with regard to safety in using peripheral nerve regional anesthesia in these patients. This makes it difficult to provide adequate "informed consent" to these patients. This case report describes a patient with MS who sustained a severe brachial plexopathy after a total shoulder arthroplasty during combined general anesthesia and interscalene nerve block.

Transmission of pathogenic bacterial organisms in the anesthesia work area.

BACKGROUND: The current prevalence of hospital-acquired infections and evolving amplification of bacterial resistance are major public health concerns. A heightened awareness of intraoperative transmission of potentially pathogenic bacterial organisms may lead to implementation of effective preventative measures. METHODS: Sixty-one operative suites were randomly selected for analysis. Sterile intravenous stopcock sets and two sites on the anesthesia machine were decontaminated and cultured aseptically at baseline and at case completion. The primary outcome was the presence of a positive culture on the previously sterile patient stopcock set. Secondary outcomes were the number of colonies per surface area sampled on the anesthesia machine, species identification, and antibiotic susceptibility of isolated organisms. RESULTS: Bacterial contamination of the anesthesia work area increased significantly at the case conclusion, with a mean difference of 115 colonies per surface area sampled (95% confidence interval [CI], 62-169; P < 0.001). Transmission of bacterial organisms, including vancomycin-resistant enterococcus, to intravenous stopcock sets occurred in 32% (95% CI, 20.6-44.9%) of cases. Highly contaminated work areas increased the odds of stopcock contamination by 4.7 (95% CI, 1.42-15.42; P = 0.011). Contaminated intravenous tubing was associated with a trend toward increased nosocomial infection rates (odds ratio, 3.08; 95% CI, 0.56-17.5; P = 0.11) and with an increase in mortality (95% CI odds ratio, 1.11-infinity; P = 0.0395). CONCLUSION: Potentially pathogenic, multidrug-resistant bacterial organisms are transmitted during the practice of general anesthesia to both the anesthesia work area and intravenous stopcock sets. Implementation of infection control measures in this area may help to reduce both the evolving problem of increasing bacterial resistance and the development of life-threatening infectious complications.

Frequency of Hand Decontamination of Intraoperative Providers and Reduction of Postoperative Healthcare-Associated Infections: A Randomized Clinical Trial of a Novel Hand Hygiene System.

BACKGROUND Healthcare provider hands are an important source of intraoperative bacterial transmission events associated with postoperative infection development. OBJECTIVE To explore the efficacy of a novel hand hygiene improvement system leveraging provider proximity and individual and group performance feedback in reducing 30-day postoperative healthcare-associated infections via increased provider hourly hand decontamination events. DESIGN Randomized, prospective study. SETTING Dartmouth-Hitchcock Medical Center in New Hampshire and UMass Memorial Medical Center in Massachusetts. PATIENTS Patients undergoing surgery. METHODS Operating room environments were randomly assigned to usual intraoperative hand hygiene or to a personalized, body-worn hand hygiene system. Anesthesia and circulating nurse provider hourly hand decontamination events were continuously monitored and reported. All patients were followed prospectively for the development of 30-day postoperative healthcare-associated infections. RESULTS A total of 3,256 operating room environments and patients (1,620 control and 1,636 treatment) were enrolled. The mean (SD) provider hand decontamination event rate achieved was 4.3 (2.9) events per hour, an approximate 8-fold increase in hand decontamination events above that of conventional wall-mounted devices (0.57 events/hour); P<.001. Use of the hand hygiene system was not associated with a reduction in healthcare-associated infections (odds ratio, 1.07 [95% CI, 0.82-1.40], P=.626). CONCLUSIONS The hand hygiene system evaluated in this study increased the frequency of hand decontamination events without reducing 30-day postoperative healthcare-associated infections. Future work is indicated to optimize the efficacy of this hand hygiene improvement strategy. Infect Control Hosp Epidemiol 2016;37:888-895.

Ketamine/propofol admixture (ketofol) is associated with improved hemodynamics as an induction agent: a randomized, controlled trial.

BACKGROUND: Critically ill patients may require emergent intubations, and the use of some induction agents can lead to undesirable effects on hemodynamics. The use of "ketofol" (ketamine/propofol admixture) may allow for improved hemodynamic control. The primary aim of this study was to assess the hemodynamic effects of "ketofol" in a fixed-dose combination during induction of general anesthesia in a controlled environment. METHODS: This was a randomized, double-blinded, placebo-controlled trial conducted at the Dartmouth Hitchcock Medical Center. American Society of Anesthesiology physical status I and II patients undergoing general anesthesia were randomly assigned to standardized induction with propofol alone or with "ketofol." Baseline noninvasive hemodynamic measurements were obtained and continuously monitored throughout the study period. Our hypothesis assumed that "ketofol" as an induction alternative would produce stable hemodynamics as referenced from baseline compared with propofol alone. The primary outcome was a systematic randomized assessment of changes in systolic blood pressure from baseline measurements for 30 minutes after induction. The primary comparisons were the frequency of a 20% change in systolic blood pressure at 5 minutes, 10 minutes, and 30 minutes after induction. RESULTS: Baseline patient demographics and intraoperative characteristics were equivalent in both groups. Propofol was more likely to generate a 20% reduction in systolic blood pressure from baseline at 5 minutes (48.8% vs. 12%, odds ratio: 6.87, 95% confidence interval: 2.07-26.15, p = < 0.001) and 10 minutes (67.4% vs. 39%, odds ratio: 3.24, 95% confidence interval: 1.21-8.75, p = < 0.01) as compared with "ketofol." This difference remained significant after adjustment for potentially confounding variables. CONCLUSION: "Ketofol" is associated with improved hemodynamic stability during the first 10 minutes after induction. Further study is needed to assess the efficacy of "ketofol" in critically ill patients and those with significant comorbidities. This combination has the potential to be used as an alternative agent for emergency induction during which time stable hemodynamics are desirable.

Reduction in ventilator associated pneumonia in a mixed intensive care unit after initiation of a novel hand hygiene program.

PURPOSE: Healthcare-associated infections (HCAIs) impact 10% of hospitalized patients. Some of these infections result from bacterial cross contamination and poor compliance with guidelines (Pittet D: Compliance with hand disinfection and its impact on hospital-acquired infections. J HospInfect 48 Suppl A:S40-S46, 2001); (Watanakunakorn C, Wang C, Hazy J: An observational study of hand washing and infection control practices by healthcare workers. Infect Control Hosp Epidemiol 19:858-860, 1998). Contamination of provider hands may be a modifiable risk factor. We instituted a novel multimodal system designed to improve hand hygiene by ICU providers. MATERIALS AND METHODS: A before and after study design was used to evaluate the impact on the incidence of CRBSI and VAP of a multi-modal program incorporating education, performance feedback, and a body worn hand hygiene device. Compliance was communicated quarterly. Primary outcomes were CRBSIs and VAPs per 1,000 line days or per 1,000 ventilator days and compliance rates. Secondary outcomes were hospital length of stay and mortality. RESULTS: A total of 1, 262 and 1,331 patients were evaluated during consecutive 12 month periods. VAP per 1000 vent days were significantly reduced after introduction of the program [3.7 vs. 6.9] P < .01. The reduction in CRBSI per 1000 line days was not significant [1.5 vs. 2.6], P = .09. Observed hand hygiene increased during the study period. There was no significant difference in mortality. CONCLUSIONS: A novel multi-modal hand hygiene system resulted in a reduction in VAP. Provider hand contamination during patient care in the ICU is a modifiable risk factor for reducing ventilator associated pneumonias.