Hand Hygiene and Anesthesiology. L. Silvia Munoz-Price, MD*wz. David J. Birnbach, MD, MPHwy

Transcription

1 Hand Hygiene and Anesthesiology L. Silvia Munoz-Price, MD*wz University of Miami Miller School of Medicine Jackson Memorial Hospital Miami, Florida David J. Birnbach, MD, MPHwy University of Miami Miller School of Medicine Miami, Florida Background Even though hand hygiene in hospitals is currently considered as the standard of clinical care, the history behind this practice is relatively recent. The practice of hand hygiene among health care workers was first proposed by Ignaz Philipp Semmelweis ( ). 1 He was an assistant professor of Medicine, at a time when puerperal fever was a common cause of maternal mortality. While working at a maternity clinic in Austria, he witnessed physicians and medical students moving between the anatomy laboratory and the labor ward. In 1847, Dr Semmelweis found that an intervention consisting of hand disinfection of the hands of medical staff with a chlorinated lime solution between performing autopsies and providing maternal care at the delivery suite decreased puerperal fever from 16% to 3%. Semmelweis s discovery of the importance of hand disinfection was quite revolutionary for his time, but like many new ideas, not embraced by the medical establishment. His results were dismissed and disregarded by many of his peers. In his subsequent quest to change hand hygiene behaviors of physicians, he felt increasingly frustrated and ostracized. Eventually, his conduct deteriorated and the diagnosis of insanity was made. This chapter in the history of hand hygiene comes to a sad end. In 1865, Dr Semmelweis was committed to a mental institution, dying 14 days after being institutionalized. A sorrowful introduction, indeed, to the important subject of hand hygiene compliance among physicians and an example of just how difficult it is to change the culture of nonadherence to hand hygiene among hospital staff. FROM THE DEPARTMENTS OF *MEDICINE; wepidemiology AND PUBLIC HEALTH; yanesthesiology INTERNATIONAL ANESTHESIOLOGY CLINICS Volume 51, Number 1, r 2013, Lippincott Williams & Wilkins AND zjackson MEMORIAL HOSPITAL REPRINTS: L.SILVIA MUNOZ-PRICE, MD, PPW L-302, 1611 NW 12TH AVENUE, MIAMI, FL SMUNOZPRICE@MED.MIAMI.EDU 79

2 80 Munoz-Price and Birnbach Currently, we have strong evidence of the clinical importance of hand hygiene in health care settings; nevertheless, compliance with hand hygiene among health care providers is still poor, even though hand hygiene is a relatively easy and inexpensive intervention. The lack of adherence to guidelines for appropriate hand hygiene in hospitals is a major public health concern. 2 Estimates suggest that nurses are more compliant than physicians, but rates for all health care workers are appallingly low. This is not only a problem for physicians who have been in practice for many years and have developed bad habits. 3 For example, a recent report found a hand hygiene compliance of only 38% of new medical school graduates about to start their internships. 4 During the past decade, there has been an increase in public awareness and transparency requirements of preventable events during hospitalizations. 5 Despite this public awareness and the dramatic rise in newspaper and magazine articles about health care associated infections (HAI), hand hygiene rates have not dramatically increased. Hospitalacquired infections constitute one of these preventable or never events. Moreover, hospitals are now mandated by the Centers for Medicare and Medicaid to report central line associated bloodstream infections and selected surgical site infections (eg, colon surgeries, hysterectomies, and cesarean delivery) 6 ; these requirements are expected to expand to all other hospital-acquired infections in the near future. Moreover, hospital-acquired infection rates have now started to be used by the government and patients as indicators of hospital performance and a potential impact factor for hospital reimbursements. Although potentially a source of misinformation when relying on administrative data, hospital report cards are now commonplace and the consumer can type in the hospital name and almost instantly receive information regarding infection rates at any particular hospital. 7 There is no debate that is of major importance to implement measures to ensure patient safety in our health care institutions and one cannot improve safety without addressing hand hygiene and hospital-acquired infections. Hand hygiene compliance can be increased in several ways. 3 These interventions include education of the health care workers so that they understand the importance of appropriate hand hygiene, system change (making hand hygiene easy, increasing availability of alcohol-based products), incentivizing of those who comply, or sanction for those who do not. Last, new technology to help identify hand hygiene compliance or to produce a forced functionality (eg, restricted entry into intensive care units or operating rooms until alcohol-based hand rub is delivered to the hands of the health care worker) is being introduced. In this paper, we aim to review some of the relevant literature dealing with the clinical importance of hand hygiene in hospitals, the moments in which it should be performed, and the compliance with hand hygiene among health care providers. We will also discuss the

3 Hand Hygiene and Anesthesiology 81 environment as a bacterial reservoir and the role that health care providers play in the infection control chain during their daily activities. We will also place emphasis on literature concerning the operating room environment and demonstrate how the anesthesiologist can become a key player in infection prevention. The Underlying Problem: Hospital-acquired Infections and Multidrug-resistant Organisms HAIs are the most common adverse events during hospital stay. 8 In 2002, 1.7 million patients suffered from HAIs in the United States. The term HAI is synonymous with hospital-acquired or nosocomial infections. The mortality associated with these events was estimated to be 6%, totaling 99,000 attributable deaths. 8 Similarly, according to the Hospital in Europe Link for Infection Control through Surveillance, the annual number of HAIs in Europe is in the range of 3 million cases with approximately 50,000 related deaths. 9 The attributable cost of HAIs vary depending on the source. One estimate of costs are $34,670 for surgical site infections, $29,156 for central line associated bloodstream infections, and $28,508 for ventilator-associated pneumonias. 10 Furthermore, of 1391 patients admitted to a Chicago health care facility during the year 2000, 13.5% patients developed infections with antimicrobial-resistant organisms. The attributable costs of these infections ranged between $18,588 and $29,069 per infection, with a total societal cost of up to 15 million US dollars. 11 Similarly, the attributable mortality found by the same authors has been estimated at 6.5%, translating to patients with antimicrobial-resistant infections twice as likely to die as patients without antimicrobial-resistant infections. 11 Similarly, length of hospital stay has been found to increase by 8.1 days among patients who developed HAIs, 12 with infections at multiple sites and lower respiratory tract infections having the highest incremental increase of 15 and 8 days, respectively. 12 Just as with hospital costs, infections caused by antimicrobial-resistant organisms were associated with longer length of stays than infections caused by susceptible organisms (additional 6.4 to 12.7 d). 11 Role of Hand Hygiene in Hospital-acquired Infections and Multidrug-resistant Organisms Transmission of resistant organisms through the hands of health care workers has been previously well documented A well-known study by Duckro et al 14 showed that health care workers were responsible for transferring vancomycin-resistant enterococci from a positive source (patient or surroundings) to a previously negative site in >10% of observed contacts. A similar study by Barker et al 20 showed

4 82 Munoz-Price and Birnbach transmission of norovirus through a contaminated health care worker s hand to up to 7 different surfaces. Furthermore, an increased compliance with hand hygiene has been associated with reductions of hospital-acquired infections and decreased transmission of multidrug-resistant organisms. Similarly, Pessoa-Silva et al 21 described a reduction in the risk of infections among very low birth weight neonates after an improvement in hand hygiene compliance from 42% to 55% in a neonatal intensive care unit. Although the ultimate goal among infection preventionists, hand hygiene compliance does not need to go to 100% to see dramatic improvements in clinical outcomes. At the University of Geneva Hospitals, Pittet et al 22 described a reduction of hospital-acquired infections from 16.9% to 9.9% after increasing the compliance with hand hygiene from 48% to 66% (P < 0.001). Moreover, bundle interventions put in place to halt outbreaks of multidrug-resistant organisms tend to include hand hygiene campaigns. Moments of Hand Hygiene In 2009, the World Health Organization (WHO) released a comprehensive set of guidelines on hand hygiene in health care. 3 This document describes in detail the Five moments for hand hygiene 23 that are becoming better known in the United States. Most of this section and the next 2 (unless noted) were obtained from the WHO paper, and we encourage the reader to review this landmark paper for further details. 3 The Five moments for hand hygiene consist of: Moment #1 Before patient contact Moment #2 Before a clean procedure Moment #3 After body fluid exposure Moment #4 After patient contact Moment #5 After contact with the patient s surrounding (Fig. 1). A key concept for health care providers is that these 5 moments can occur multiple times within a single patient encounter. An example would be a provider entering a patient s room, (moment #1) touching the patient s hand, (moment #2) infusing an intravenous medication through an intravenous hub, touching the Foley catheter (moments #3 and 1) touching the patient s arm (moment #4), charting on the bedside table (moment #5) and leaving the room. Note that the moments are not dependent on entering or leaving the patient s room but rather dependant on the interactions with the patients and the surroundings. In the example provided, moments #3 and 1 fuse into only 1 episode of hand disinfection. In addition, given the high number of opportunities for hand hygiene within a patient s zone, it is key to have alcohol hand sanitizer in close proximity to the bed (eg, on top of the bedside table) so that the flow of patient care is not interrupted.

5 Hand Hygiene and Anesthesiology 83 Figure 1. Elsevier. My Five Moments of Hand Hygiene. Reprinted from Sax et al 23 with permission from There is a second major set of hand hygiene guidelines compiled by the Centers for Disease Control and Prevention (CDC) back in ; these guidelines are slightly different than the WHO s. According to the CDC, the indications for hand hygiene include: before direct contact with a patient (WHO s moment #1), before donning sterile gloves when placing a central line (WHO s moment #2), before inserting any kind of device such as Foley catheter or central line catheter (WHO s moment #2), after contact with body fluids (WHO s moment #3), after contact with intact skin, and after removing gloves (WHO s moment #4). It is of note that the CDC guidelines specify a hand hygiene moment in relation to glove usage. This is an important concept given that gloves provide a sense of security to the provider, which is partially the case for the provider but not necessarily for the patients. Gloves have been associated with lower hand hygiene compliance by health care workers given that they become a second skin; however, gloves cannot be disinfected unless exchanged. Just as provider s hands, gloves will get contaminated after contact with the patient s skin, devices, or environment. By wearing 1 set of gloves throughout patient care (going from patient to surfaces and vice versa), health care workers spread organisms across surfaces. Thus, removal of gloves and hand disinfection is expected by the WHO every time one of the 5 moments occurs. 3 This is particularly relevant to anesthesiologists and nurse anesthetists who currently wear 1 pair of gloves for prolonged periods of time. In addition, not all patient contacts require gloves but rather only contacts with potential exposure to body fluids or during the care of patients on contact isolation. It is important to highlight that gloves do not preclude hand contamination. Studies performed with vancomycin-resistant

6 84 Munoz-Price and Birnbach enterococci and Acinetobacter baumannii showed bacterial contamination of hands in up to a third of instances after removing gloves used during contact with contaminated patients. 25,26 For the anesthesiologist, wearing gloves is not a substitute for appropriate hand hygiene, because glove breakage occurs, and there is also a real incidence of contamination during glove removal. For example, Korniewicz et al 27 demonstrated that 34% of gloves that had passed a watertight test still allowed Serratia marscescens penetration when worn by volunteers. Olsen et al 28 reported that health care workers were only aware of glove leakage in 22% of the times that it had occurred. As to choice of gloves, Muto et al 29 reported that leakage rates were far greater for examination gloves than for surgical gloves. Educational programs about the need for hand hygiene despite use of gloves have been successfully implemented to intensive care unit staff and should be considered for operating room staff as well. 30 Contrary to the CDC guidelines, the WHO guidelines require hand hygiene after contact with patient s surroundings. As we will discuss later in the manuscript, the hospital environment serves as an important bacterial reservoir and can contaminate provider s hands as heavily as after contact with patient s body surfaces. 14 This is particularly relevant to the operating room. As will be discussed later in this paper, the myth that the operating room is a sterile environment and that therefore hand hygiene is not important to those in that environment is not based on scientific data. On the basis of the current hand hygiene guidelines for outside the operating rooms and despite the uncertainty on how frequently hand hygiene should be performed by anesthesiologists in the operating room, we would advocate these minimum standards of practice: On entering and leaving the operating rooms Before contact with the patient After contact with the patient Before any invasive procedure such as placing vascular lines, neuraxial blocks, or intubating a patient After contact with the airway Before accessing intravenous catheters After contact with the floor or with things that have been in contact with the floor After removing gloves Hand Hygiene Products There are 2 main categories of hand disinfectant products: soaps and alcohol-based products. Soaps are available as either plain or antimicrobial formulations, with plain soaps being less effective than antimicrobial soaps. Needless to say, water alone is not an effective agent for decreasing

7 Hand Hygiene and Anesthesiology 85 bacterial loads.despite this,we have observed some medical students and residents who put their hands under running water without use of soap and consider that they have satisfied the requirements for hand hygiene. 31 This is another example of a situationthatcanbeaddressedthrough improved educational programs at various levels of training. Antimicrobial soaps can contain different active ingredients such as iodophors, chlorhexidine, chloroxylenol, hexachlorophene, triclosan, and quaternary ammoniums. The onset and duration of activity of antimicrobial soaps will largely depend on the type of active ingredient; however, to maximize its effectiveness, the process of hand disinfection with soap and water should take at least 40 to 60 seconds. It is important to underscore that water temperature is not a relevant factor for the removal of organisms from the skin. Therefore, hot water temperatures should be discouraged, as they increase skin irritation and dryness without further effectiveness. In addition, soap and water should not be used concomitantly with alcohol-based products as the combination promotes skin irritation without improving disinfection. Alcohol formulations can contain 1 or 2 of the 3 main types of alcohols: ethanol, isopropanolol, or n-propanol, with n-propanol being the most active of the 3 and ethanol the least active. It is unclear what the optimal volume of alcohol hand sanitizer should be for optimal hand disinfection. However, as a general rule, enough volume should be applied so that hands are still wet after rubbing them for 10 to 15 seconds. Regarding effectiveness, waterless alcohol-based solutions are superior to plain soap and water for hand disinfection. Furthermore, alcohol products decrease bacterial counts to a greater degree than antiseptic soaps. Alcohol-based solutions also have a faster onset of action than antiseptic soap and water. Alcohols have a broad range of bactericidal activity against Gram-positive, Gram-negative, viral, tuberculous, and fungal organisms; however, they have almost no activity against spores. This is especially important when dealing with patients who are suspected of having Clostridium difficile infections, as will be discussed in further detail later in this paper. The concentration of alcohol is also an important factor on the degree of skin disinfection, being the most effective concentrations between the range of 60% and 80% (percentage of volume). Interestingly, formulations with alcohol concentrations above 80% have a paradoxical reduction in hand disinfecting activity, probably due to the fact that alcohol requires water to denature proteins. Alcohol products for disinfection of health care worker s hands are available in 3 main presentations: liquid, gels, and foams. At this time, it is not clear which of the 3 formulations is the most effective within health care settings. Many hospitals, however, are now favoring foam preparations, as they are associated with less spillage. All hand hygiene products can cause skin reactions and irritation. However, despite general beliefs to the contrary, alcohol-based products

8 86 Munoz-Price and Birnbach are better tolerated by the skin than soap and water. This is in part due to the concomitant use of emollients in the alcohol products. The skin irritation observed with alcohol is directly proportional to the concentration of alcohol and more frequent with n-propanol and isopropanolol. Allergic reactions to hand hygiene products are uncommon, but when present they are usually caused by a delayed hypersensitivity to either the fragrances or preservatives. Alcohol-based antiseptics are more effective, better tolerated, and easier to use than soap and water. Therefore, whenever a health care provider has the option to choose between alcohol hand sanitizers and antiseptic soap and water, he or she should opt for alcohol hand sanitizers. There are 2 situations where soap and water are preferred, which include the presence of soiled hands, or while providing care to patients with suspected C. difficile infections. To increase the compliance with hand hygiene, alcohol products should be readily available and in close proximity to the bedside or operating room table. This proximity to the bedside also decreases the time spent going back and forth from the patient zone to the location of the alcohol dispenser. Jewelry constitutes an additional barrier to hand hygiene. Studies have shown that the degree of hand contamination with pathogenic bacteria is independently associated with the number of rings worn, especially with voluminous rings and while using non alcohol-based products for hand hygiene. Similarly, artificial fingernails can harbor Gram-negative organisms regardless of hand disinfection and have been linked with outbreaks in the intensive care units. Therefore, the use of artificial fingernails should be prohibited during patient care. Fresh nail polish has not been linked to increased carriage of organisms, but chipped nail polish might cause an increased risk of contamination. It is recommended that natural nails should be kept at no >¼ inch length. Alcohol-based products are flammable and therefore should be stored away from high temperatures of flames. In 2003, Boyce and Pearson 32 found no fire reports in a survey of 798 facilities. Another study described the experience of 788 German hospitals (25,038 hospital-years). They found 7 episodes of minor fires associated with either lightening cigarettes or candles immediately after using the alcohol hand sanitizer. 33 There does not seem to be any clinical risk associated to the current use of these alcohol-based products in operating rooms and intensive care units. Compliance With Hand Hygiene Among Health Care Providers (and in Particular Anesthesiologists) Health care workers clean their hands on average of 5 to 42 times per shift and 1.7 to 15.2 times per hour. Nurses are the group of providers with the highest hand hygiene compliance. Among medical

9 Hand Hygiene and Anesthesiology 87 specialties, pediatric providers have the best performance being intensive care unit workers the worst performers, especially while performing contaminated procedures. Interestingly, intensive care units have the highest number of hand hygiene indications per hour. Other indicators of poor hand hygiene performance include being a physician, being a nurse assistant, a physiotherapist or technician, male sex, understaffing conditions, wearing gloves during patient care, and working in intensive care units, emergency care, or being an anesthesiologist. 3 Despite the fact that exposure to blood and body fluids is common among anesthesiologists, 34 hand hygiene compliance among anesthesiologists while providing care in the operating rooms is especially low. Koff et al 35 observed baseline frequencies of hand hygiene to be under once an hour (mean ± SD: 0.15 ± 0.05 hand disinfections per hour). This frequency increased to 7.1 disinfections per hour after providing a personal dispenser alcohol hand sanitizer. 35 A more recent study performed in the Netherlands found similar frequencies of hand hygiene. 36 These investigators performed 60 hours of observations in the operating rooms (28 surgeries) finding a mean of 0.14 disinfections per hour. Compliance with hand hygiene during postanesthesia care has also been found to be suboptimal. Pittet et al 37 evaluated 1091 opportunities for hand hygiene among 187 patients during postanesthesia care. They found an average hand hygiene compliance of 19.6% with even lower compliances during busy periods of care. 37 It has been reported that a large number of anesthesiologists are approaching retirement age. 38 This may be an explanation for some of the reticence of current anesthesiologists to change their hand hygiene behaviors and may also present an opportunity for a paradigm change as new trainees join the work force. This, however, suggests that hand hygiene compliance must become a part of resident education and appropriately emphasized by those who are teaching them. As part of educational programs to underscore the importance of hand hygiene, it may be particularly useful to highlight the benefit of physician safety. Methicillin-resistant Staphylococcus aureus (MRSA) infection can cause severe health problems in health care workers that may lead to longterm incapacity. In addition, the risk of transporting pathogens to the home environment should also be emphasized. 39 In addition to their work in operating rooms, anesthesiologists are taking a more active role in duties throughout the hospital. As Fleisher 40 stated, anesthesiologists are increasingly being asked to provide anesthesia or heavy sedation for patients undergoing procedures outside the operating room. In addition, anesthesiologists are actively involved in numerous activities that can impact hand hygiene compliance. They include work in the postanesthesia care unit, intensive care units, teaching medical students, residents and nurse anesthetists, acute and chronic pain management, radiologic imaging, emergency airway management,

10 88 Munoz-Price and Birnbach gastrointestinal procedures, including endoscopies, obstetric anesthesia, and analgesia. In each of these settings, the anesthesiologist can play a large role in not only their own hand hygiene but in changing the safety culture so that other health care workers also comply with current recommendations. The American Society of Anesthesiologists Committee on Occupational Health Task Force on Infection Control 41 has stated that the following are areas for which anesthesiologists may affect outcome: MRSA infection, surgical site infections, central line associated bloodstream infections (including compliance with insertion checklist), ventilator-associated pneumonia, and central line insertion practice compliance. All of these events are directly or indirectly impacted through hand hygiene of health care providers. Many anesthesiologists expect to be allowed to practice without constraints to individual autonomy or mode of practice. It has been suggested, however, that strategies for control of spread of infection in hospitals may require constraints to individual autonomy or freedom of movement. 42 That change may occur through devices that only allow entrance to operating rooms once alcohol hand rub has been provided or through radio frequency and infrared technology that recognizes identities of individuals and hand hygiene rates and alarms when hand hygiene is not performed. 4 Perhaps it will be as simple a solution as bright warning lights when entering a patient room or operating room. 43 The Hospital Environment On the basis of increasing numbers of published scientific manuscripts, we now know that the hospital environment is a major reservoir of multidrug-resistant organisms ,26 These organisms include MRSA, vancomycin-resistant enterococci, C. difficile, and A. baumannii. Huang et al 44 reported a 40% higher likelihood of acquiring MRSA linked to having a prior hospital room occupant MRSA positive. Similarly, contamination of the gloved hands of nurses after touching body surfaces of MRSA-positive patients was just as frequent as after touching only contaminated patient s room environment (58% vs. 42%). 18 Even seemingly innocuous surfaces and devices (such as stethoscope used to verify proper endotracheal tube placement) can be a source of bacterial contamination in the operating room. 45,46 Recent studies show that environmental contamination is present even in areas previously thought to be sterile, such as the operating rooms. Loftus et al 47 described bacterial transmission from patients in the operating room to the environment in 89% of instances. The same authors described transmission of organisms to intravenous stopcocks in 11.5% of their patients, with half of them linked to the anesthesia providers. 35 In addition, we recently found that pathogenic organisms

11 Hand Hygiene and Anesthesiology 89 were present in 16.6% of ready to use operating room surfaces. 48 Furthermore, Jefferson et al 49 evaluated 71 operating rooms across 6 acute care hospitals and found an average daily cleaning rate of 25% of the objects monitored. Similar findings were described by our group, with a baseline cleaning rate of 47% at baseline that increased to 82% after feedback and education were implemented. 48 However, no studies have been performed clearly linking poor hand hygiene compliance during the anesthesia care in the operating room and higher incidence of subsequent hospital-acquired infections. It does make sense, however, to speculate that poor hand hygiene practices in the operating room can potentially be a factor in the development of postoperative infections, particularly in high-risk patients who will be in the intensive care units setting postoperatively. Conclusions Hand hygiene is one of the most effective and most affordable interventions aimed at decreasing both hospital-acquired infection rates and transmission of multidrug-resistant organisms. Even though there is a large body of evidence showing its effectiveness, compliance with hand hygiene among health care providers is poor. Various factors are believed to affect compliance including performing in intense patient care activities or having certain specialties such as anesthesiology. Multiple factors make the daily anesthesia work environment an ideal setting for transmission of pathogenic organisms. These factors include confined workspace for extended periods of time, high intensity work with manipulation of multiple environmental objects, low frequency of hand hygiene, and unreliable environmental cleaning. We believe that anesthesiologists, especially while providing care in the operating room, might play an important role in the infection control chain. Until more evidence is available, more clear guidance should be provided on the frequency of hand hygiene required while in the operating room. The authors declare that they have nothing to disclose. References 1. Ignaz Semmelweis. From Wikipedia. June 2, Available at: Accessed June 11, Burke JP. Infection control a problem for patient safety. N Engl J Med. 2003;348: WHO Guidelines on hand hygiene in health care first global patient safety challenge clean care is safer care. Available at: _eng.pdf. Accessed June 2, 2012.

12 90 Munoz-Price and Birnbach 4. Gluck PA, Nevo I, Lenchus JD, et al. Factors impacting hand hygiene compliance among new interns: findings from a mandatory patient safety course. J Grad Med Educ. 2010;2: Milstein A. Ending extra payment for never events stronger incentives for patients safety. N Engl J Med. 2009;360: Hospital-acquired conditions (HAC) in acute inpatient prospective payment system (IPPS) hospitals. May Available at: Accessed June 11, Glance LG, Dick AW, Osler TM, et al. Accuracy of hospital report cards based on administrative data. Health Serv Res. 2006;41: Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating health care-associated infections and deaths in U.S. hospitals, Public Health Rep. 2007;122: Hospital in Europe Link for infection control through surveillance. Available at: Accessed June 11, The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention. March pdf. Accessed June 11, Roberts RR, Hota B, Ahmad I, et al. Hospital and societal costs of antimicrobialresistant infections in a Chicago teaching hospital: implications for antibiotic stewardship. Clin Infect Dis. 2009;49: Roberts RR, Scott RD 2nd, Hota B, et al. Costs attributable to healthcare-acquired infection in hospitalized adults and a comparison of economic methods. Med Care. 2010;48: Hayden MK, Bonten MJ, Blom DW, et al. Reduction in acquisition of vancomycinresistant enterococcus after enforcement of routine environmental cleaning measures. Clin Infect Dis. 2006;42: Duckro AN, Blom DW, Lyle EA, et al. Transfer of vancomycin-resistant enterococci via health care worker hands. Arch Intern Med. 2005;165: Hota B. Contamination, disinfection, and cross-colonization: are hospital surfaces reservoirs for nosocomial infection? Clin Infect Dis. 2004;39: Otter JA, Yezli S, French GL. The role played by contaminated surfaces in the transmission of nosocomial pathogens. Infect Control Hosp Epidemiol. 2011;32: Bhalla A, Pultz NJ, Gries DM, et al. Acquisition of nosocomial pathogens on hands after contact with environmental surfaces near hospitalized patients. Infect Control Hosp Epidemiol. 2004;25: Boyce JM, Potter-Bynoe G, Chenevert C, et al. Environmental contamination due to methicillin-resistant Staphylococcus aureus: possible infection control implications. Infect Control Hosp Epidemiol. 1997;18: Munoz-Price LS, Weinstein RA. Acinetobacter infection. N Engl J Med. 2008;358: Barker J, Vipond IB, Bloomfield SF. Effects of cleaning and disinfection in reducing the spread of Norovirus contamination via environmental surfaces. J Hosp Infect. 2004;58: Pessoa-Silva CL, Hugonnet S, Pfister R, et al. Reduction of health care associated infection risk in neonates by successful hand hygiene promotion. Pediatrics. 2007;120:e382 e Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet. 2000;356: Sax H, Allegranzi B, Uc kay I, et al. 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.

13 Hand Hygiene and Anesthesiology Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/ APIC/IDSA Hand Hygiene Task Force. October 25, Available at: Accessed June 5, Tenorio AR, Badri SM, Sahgal NB, et al. Effectiveness of gloves in the prevention of hand carriage of vancomycin-resistant enterococcus species by health care workers after patient care. Clin Infect Dis. 2001;132: Morgan DJ, Rogawski E, Thom KA, et al. Transfer of multidrug-resistant bacteria to healthcare workers gloves and gowns after patient contact increases with environmental contamination. Crit Care Med. 2012;40: Korniewicz DM, Laughon BE, Butz A, et al. Integrity of vinyl and latex procedure gloves. Nurs Res. 1989;38: Olsen RJ, Lynch P, Coyle MB, et al. Examination gloves as barriers to hand contamination in clinical practice. JAMA. 1993;270: Muto CA, Sistrom MG, Strain BA, et al. Glove leakage rates as a function of latex content and brand: caveat emptor. Arch Surg. 2000;135: Fitzpatrick M, Everett-Thomas R, Nevo I, et al. A novel educational programme to improve knowledge regarding health care-associated infection and hand hygiene. Int J Nurs Pract. 2011;17: Shekhter I, Nevo I, Fitzpatrick M, et al. Creating a common patient safety denominator: the interns course. J Grad Med Educ. 2009;1: Boyce JM, Pearson ML. Low frequency of fires from alcohol based hand rub dispensers in healthcare facilities. Infect Control Hosp Epidemiol. 2003;24: Kramer A, Kampf G. Hand rub-associated fire incidents during 25,038 hospital-years in Germany. Infect Control Hosp Epidemiol. 2007;28: Chakravarthy M. Enhanced risk of needlestick injuries and exposure to blood and body fluids to cardiac anesthesiologists: need for serious introspection. Ann Card Anaesth. 2010;13: 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: Krediet AC, Kalkman CJ, Bonten MJ, et al. Hand-hygiene practices in the operating theatre: an observational study. Br J Anaesth. 2011;107: Pittet D, Stéphan F, Hugonnet S, et al. Hand-cleansing during postanesthesia care. Anesthesiology. 2003;99: Birnbach DJ, Bucklin BA, Dexter F. Impact of anesthesiologists on the incidence of vaginal birth after cesarean in the US; role of anesthesia availability, productivity, guidelines, and patient safety. Semin Perinatol. 2010;34: Haamann F, Dulon M, Nienhaus A. MRSA as an occupational disease: a case series. Int Arch Occup Environ Health. 2011;84: Fleisher LA. Anesthesia outside the operating room. Foreword. Anesthesiol Clin. 2009;27:xiii. 41. Recommendations for infection control for the practice of anesthesiology Available at: joyqfptjwmcwtdemn2rsrvje7w5iairpt3qshdqu7gd3ag5mmdbmgckrtzm5acqkz46e/use ofsyringesamericansocietyofanethesiologists.pdf. Accessed June 11, Millar M. Do we need an ethical framework for hospital infection control? J Hosp Inf. 2009;73: Nevo I, Fitzpatrick M, Thomas RE, et al. The efficacy of visual cues to improve hand hygiene compliance. Simul Healthc. 2010;5: Huang SS, Datta R, Platt R. Risk of acquiring antibiotic-resistant bacteria from prior room occupants. Arch Intern Med. 2006;166:

14 92 Munoz-Price and Birnbach 45. Cohen HA, Amir J, Matalon A, et al. Stethoscopes and otoscopes a potential vector of infection? Fam Pract. 1997;14: Vajravelu RK, Guerrero DM, Jury LA, et al. Evaluation of stethoscopes as vectors of Clostridium difficile and methicillin-resistant Staphylococcus aureus. Infect Control Hosp Epidemiol. 2012;33: Loftus RW, Muffly MK, Brown JR, et al. Hand contamination of anesthesia providers is an important risk factor for intraoperative bacterial transmission. Anesth Analg. 2011;112: 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: Jefferson J, Whelan R, Dick B, et al. A novel technique for identifying opportunities to improve environmental hygiene in the operating room. AORN J. 2011;93: