In Depth:  New study slams anesthesiologists’ hand hygiene | Plastic Surgery Practice September 2014

By Amanda R. Kirzner, DO, MPH

A recent study in the American Journal of Infection Control found that anesthesia providers were neglecting to clean their hands during procedures at particularly high-risk times during the course of the surgery.

The study, while acknowledging that the current hand hygiene recommendations are for non-operating room environments, has provoked fear within the infection control community as lack of hand hygiene has been correlated with increased bacterial contamination, infection rates, and increased mortality among surgical patients.

There are approximately 157,000 surgical-site infections each year, according to the federal Centers for Disease Control and Prevention. Are your plastic surgery patients at risk?

They just may be, according to the new findings. Anesthesiologists in the new study were least likely to comply with hand hygiene recommendations during the first and last 20-minute time periods of a surgery: induction and emergence. Incidentally, these are the busiest and most critical times for the anesthesiologist.

“Complete compliance with hand hygiene practice as recommended by World Health Organization (WHO) guidelines would have consumed more than the 60 minutes available in each hour of anesthesia time, a fact that identifies a need to create more practical—but still effective—methods of controlling bacterial transmission in [anesthesia work environments],” conclude researchers from the Dartmouth-Hitchcock Medical Center in Lebanon, NH.


To arrive at their findings, the researchers videotaped anesthesia provider hand hygiene and hand contact with anesthesia work environment surfaces in randomly selected operating rooms. They followed WHO hand hygiene criteria, which include hand washing before touching a patient, before a clean procedure, after exposure to body fluids, after touching a patient, and after touching a patient’s surroundings. They found that induction and emergence appear to represent critical periods of environmental contamination.

Induction involves injecting various medications into a patient that literally stops them from breathing by paralyzing their muscles. Once they are paralyzed and not able to breathe, the anesthesiologist then puts the endotracheal tube down the patient’s throat. Before the tube is inserted, the anesthesiologist may do various things including trying to ventilate the patient, inserting an oral airway, and performing a direct laryngoscopy. All of these procedures may be necessary to intubate the patient correctly so that he or she can be placed on a ventilator.

Many of these high-stress, fast-paced procedures involve the anesthesiologist sticking their (gloved) hands into the patient’s mouth. During emergence, the anesthesiologist also sticks their hands into the patient’s mouth to remove the endotracheal tube. When a patient is not breathing and their airway is not secured, it would be impossible and impractical for an anesthesiologist to stop what they are doing and wash or sanitize their hands.

Still, the low hand hygiene compliance during these times caused sharp increases in bacterial contamination of the 20 most frequently touched objects during those time periods, the study showed. These include the bed, a pen, anesthesia cart second handle, anesthesia chair, and the right monitor screen button. There was an inverse correlation between provider hand hygiene compliance during induction and emergence from anesthesia (3.2% and 4.1%, respectively) and the magnitude of workspace surface contamination (103 and 147 CFU, respectively) at these time points, the study showed.

“Overall, these results suggest that increased frequency and quality of anesthesia work environments decontamination in addition to better hand hygiene compliance are indicated, especially during the induction and emergence phases of anesthesia,” the study authors conclude. “Effective interventions to prevent contamination by improving hand hygiene compliance may require development and implementation of novel approaches.”

Amanda R. Kirzner, DO, MPH, is currently completing her anesthesia residency in Farmington, Conn. She can be reached via [email protected].

Original citation for this article: Kirzner A. PSP special report: How safe is your OR? Plastic Surgery Practice. 2014;(8),38.