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Anesthesia providers play a crucial role in preventing surgical site infections. In this episode, we dive into the critical topic of infection control with the distinguished Dr. Cherie Burke, Program Director at Loyola University in New Orleans.
Dr. Burke, with her extensive background as a CRNA and a PhD in nursing, brings her expertise to the forefront as she discusses how anesthesia providers can both cause and prevent infections in the operating room.
Drawing from the AANA’s infection control standards, Dr. Burke offers invaluable insights and practical advice on hand hygiene, proper syringe use, and more to ensure patient safety and reduce infection rates. Tune in to learn how you can be a part of the change in infection control practices.
Learn More about the Loyola University New Orleans Anesthesia Program: https://www.loyno.edu/academics/colleges/loyola-online/doctor-nursing-practice-online-hybrid-options
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AANA Infection Control Policy Updates And What You Need To Know With Dr. Cherie Burke Program Director At Loyola University New Orleans
Welcome back to the show, future CRNA. I’m so excited for this episode. We have never talked about it on the show, which is infection control and how anesthesia providers can cause and prevent surgical site infections. It’s taught by the one and only breath of fresh air, Dr. Cherie Burke. Dr. Cherie Burke is the Program Director at Loyola University in New Orleans. She started there in 2021 as the Director of School Nursing.
She has been practicing clinically as a CRNA. She also has a PhD from Duquesne University in Pittsburgh. She received her doctorate and nursing practice from La Salle University and her Master’s in the Science of Nursing is from DeSales University in Center Valley, PA. Her CRNA education was obtained by the Frank J. Tornetta School of Anesthesia. Dr. Burke received her BSN from Wilkes University.
Dr. Burke has been working with New Orleans as the program director for the nurse anesthesia program. However, she has experience as the program director of Rush University’s nurse anesthesia program. She has also taught across degrees at St. Joseph College of Maine and Rutgers University Nurse Anesthesia program.
Dr. Burke completed a postdoctoral patient safety fellowship with the Veterans Administration at Philadelphia’s VA Hospital and the University of Pennsylvania Simulation Center. Dr. Burke has been an active member of the American Association of Nurse Anesthetists and serves on both the national and state level. Her research interests include patient safety and infection prevention. She’s an expert on this topic. I’m excited for you to tune in. Let’s go ahead and get into the episode.
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Welcome, I’m Dr. Cherie Burke. I’m the Founding Director of the Loyola New Orleans Nurse Anesthesia Program and I’m here to talk to you about hospital-acquired infections. I want to talk about anesthesia’s role in preventing, mitigating, as well as contributing to hospital-acquired infections. My topic is we all have been slimed. Now what are we going to do about it? We have to do better.
We’ll refer to the AANA’s infection control standards and guidelines. The literature is pretty much full of documentation. Infection control is a problem for patient safety. My two areas of research interest are patient safety, medication safety, and infection control. We know that hand contamination of anesthesia providers is an important risk factor for intraoperative bacterial infections.
The transmission of pathogenic bacterial organisms in the anesthesia work area can be a contributing factor. As well as multiple reservoirs that contribute to interoperative bacterial transmission. Those are those multiple-stop cocks in different injection sites. We’re going to talk a little bit about the literature, the studies, and how we can do better.
Infection Control
What’s all the fuss? Let’s talk about that. We know that there are about 40 million patients admitted to US hospitals every year. Five to 10% of those patients will develop the hospital-acquired infection and 90,000 of these patients will die. The cost of treating hospital-acquired infections is astronomical. We know that the Centers for Disease Control has a whole bunch of information about hospital-acquired infections and these things have to be reported.
There was an article in the New England Journal of Medicine in 2018 about the changes in the prevalence of hospital-acquired infections. It’s a big problem and a big cost. If you’re the one patient or your family member is the one patient who winds up with a hospital-acquired infection, it could be quite devastating. Chuck Biddle as a CRNA and PhD. He used to be the Editor of the AANA Journal. He is a brilliant educator. He says, “Absence of evidence is not as evidence of absence.” Meaning we don’t see patients postoperatively.
We encounter patients for a very short and limited time. We see them that day, they’re having their surgery and go home. If they wind up with a hospital-acquired infection, that doesn’t always get back to us. The surgeons are caring for them. We have to be aware that even though we can’t see it, it doesn’t mean it doesn’t exist.
Transmission of pathogenic bacterial organisms in the workstation, this study looked at 61 operating rooms. They were randomly selected. What they did is they looked at the sterile IV stopcock where we inject our medication and two sites on the anesthesia machine. The APL valve, which is what we call our pop-off valve, it’s what we regulate to give positive pressure ventilation and our flow meter controls, which is where we turn on our oxygen and our nitrous oxide in those types of things.
What they looked at was the presence of a positive culture on a previously sterile stopcock set. The secondary outcome was the number of colonies per surface area sampled on the machine. They identified the species and the antibiotic susceptibility of these organisms. What they found is quite shocking. There are all the organisms that they found, whether it was on the stop cock, the APL valve, or the flow meters but this is very scary. We need to realize that these things are occurring in our work environment.
Retrospectively, a chart review was done post-op day of 30. They revealed a non-significant increase in nosocomial infection rates but a significant increase in mortality. Those who got an infection had a much higher risk of mortality with their contaminated stop cocks. Five of 20 patients with contaminated stopcocks developed nosocomial infections and five of 41 patients, 12% without stopcock contamination developed nosocomial infections.
Hand Washing
Another big deal, 2 of 3 patients, 66% associated with the transmission of a multi-drug resistant organism to the anesthesia work area and/or the peripheral intravenous tubing died in the intensive care unit. That is scary. We know their formal guidelines for hand washing. The same advice was in the 1840s and we are still dealing with this now.
Recent studies show that healthcare workers averaged less than 50% compliance with hand-washing guidelines. In the operating room, there’s a little bit more of a challenge to wash your hands. This is a great article by Ray Roy, who was the Chair of Wake Forest University, Department of Anesthesia when I worked there.
He wrote this article, “We’ve all been slimed. Now what are we going to do about it?” That’s where we still need to pick this up a little bit more. We know that 20% of healthcare providers are persistent asymptomatic carriers of staph aureus. Thirty percent of us are intermittent carriers and because we’re constantly shedding our bacteria from our biofilms, our cells, our hair, and everything, we, as patients and as healthcare providers, contaminate every operating room we enter.
AANA Infection Control: We, as patients and as healthcare providers, contaminate every operating room we enter.
We should know that our personal slime may be attributed to other people’s infections. What can we do to prevent these surgical site infections? There’s been a lot in the literature and some of these are old articles, but the thing is, we haven’t made any progress on hand contamination of anesthesia providers, important risk factors, systematic breakdown, and hand washing compliance. They instituted an institutional change, which made a big difference.
Increased hand washing by anesthesia providers decreased the risk of hospital-acquired infections. As Dr. Roy says, “If we accept that we’re all slimed by our personal bacteria, constantly contaminating our environment and causing some surgical site infections, then we must also accept responsibility for reducing our personal contributions to surgical site infections.” The obvious answer is simple hand washing.
The AANA Scope & Standard for Anesthesia Practice
I will tell you some other obvious things that are occurring that can be causing this. You all know these standard precautions. They’re on all the time on the ICU doors but they’re not enough in the operating room. The AANA adopted, expanded, and revised infection control guidelines in January of 2022. If you go to the AANA website or google AANA infection control guidelines, you’ll see the safe injection guidelines for needle and syringe use and infection prevention control and anesthesia care but we’ll review some of the highlights.
The AANA scope and standard for anesthesia practice, safe practices for needle and syringe use. They say that CRNAs and other healthcare providers need to take necessary precautions to minimize the effect of infection on themselves and their patients. We have to act and practice in accordance with the professional standards established by the profession. If you have a patient who develops some unique bacterial infection or viral infection and they contribute it to you, they ask you, “Did you follow these standards?” You didn’t. You’re in breach of our practice guidelines.
We follow the CDC’s one and only campaign for safe injection practices. These things all came out of the fact that bad things happened. There was an endoscopy center in Las Vegas where nurse anesthetists were providing anesthesia and they would take a dispensing pin, as we call them. They would put it in the propofol and would draw off many syringes from there.
One day, someone must have gone back with the dirty syringe and drawn off there and contaminated it. There were upwards of hundreds of people who were exposed to hep-C. Very bad. That was before they even had anything to treat hep-C. We are encouraged to consult the position, and safe practices for needle and syringe uses and follow these standards. What’s going on? Preventing the transmission of infectious diseases involves many considerations and best practices.
The following statements reflect the current safe practice for needle and syringe use by nurse anesthetists or nurse anesthesiologists. Never administer medications from the same syringe to multiple patients, even if the needle has changed. I know that sounds silly, but honestly, in the late ‘80s and early ‘90s, that was done. Never reuse a needle even on the same patient. Once a needle’s been used and we’re going to talk about IM. We’re talking about IV, inserting into the IV port.
That was before we had needleless. Some places may still have the rubber things where you can put a needle in, but we don’t have needleless injection ports. Needles are single-use devices. When we’re injecting a dose of medication from a syringe into an intravenous port, the needle may enter the port only once, then it must be discarded. If you drop 250 mics of fentanyl, 5 CCs and you give 50 mics. You still have 40 and you used a needle. You have to change that needle. You can’t stick it in the port again.
You should never refill a syringe once it’s been used even for the same patient. Basically, if we had a syringe and it had 50 milligrams and 5 ml of Rocuronium. People would take that syringe, put a clean needle on it, draw up again, and use the same syringe for the entire case. They might use that three times. The problem is the internal barrel of that syringe is considered contaminated.
It’s touching different places on the anesthesia workstation and the anesthesia machine. It becomes contaminated once it goes through, so you must discard the syringe. You’ll see anesthesia providers who will use a 50 CC syringe for infusing propofol. We have infusion pumps that are syringe pumps. They’ll put a stopcock right at the hub of the syringe where it connects with the infusion tubing. What they’ll do is they’ll drop another 20 CCs or 30 CCs of propofol from a vial. They’ll turn the stopcock, and shoot it back into that 50 CC syringe. Now the plunger is moving back up and it’s contaminated. We know that propofol has no antimicrobial in it. We’ve got even bigger problems there. This is still a real problem in anesthesia.
Anesthesia Medication Expiration Times
Expiration times for medication; first of all, medications should be drawn up as close as possible to the time being administered. First thing in the morning, you should not drop five syringes of Succinylcholine, Lidocaine, Decadron, and Zofran. You drop for that specific patient that you’re going to be caring for. This environment is not always obtainable by anesthesia practitioners in the OR suite to use the hand Sanitizers or to do it within one hour.
You must be very cognizant of how you’re doing it and you’re keeping clean from dirty and your hands are clean when doing this. In addition, we must label our preparations with the medication name concentration and the time that it was prepared. We in anesthesia are the prescriber, the dispenser, and the administrator. We’ve now taken out the nurse who’s checking the order. We’ve taken out the pharmacist who’s going to get the medication ready and double-check the order.
AANA Infection Control: We in anesthesia are the prescriber, the dispenser, and the administrator.
You as the nurse who receives the medication from the pharmacy, check it for the third time. We’ve cut out all of those people. What you’ll find is most anesthesia providers will put labels on their syringes, but they won’t date, time, and put their name or initials on it. It’s very important that you do that. You’ll see them do it with propofol because unlike in the ICU, propofol must be discarded within six hours of being opened even if you’re hanging a thousand milligrams and a hundred CC vials. You’re going to use it slowly for intravenous anesthesia during the procedure.
If the procedure goes twelve hours and that same vial is hanging. You must take it down after six hours. One of the things that anesthesia providers don’t always do is all medications in the perioperative setting are single-use vials. Not multidose vials. If you open a vial of labetalol, it’s 30 ml, a bottle of labetalol and you only draw out 5 CCs, 25 milligrams. You must discard that labetalol at the end of that case for that patient.
I had an anesthesiologist when I was doing a case, and we were emerging, the patient was hypertensive. I was with a registered nurse anesthesiology resident and he stuck the rocuronium syringe in the labetalol vial, drew out five ml, and gave it. Now, I said to the resident afterward, “Did you see what he did?” They said, “Yes, he gave labetalol.” I said, “Did you see what he used to give the labetalol?” They said, “No.” If they had put that labetalol vial back in the anesthesia cart, we could have contaminated future patients. These things happen.
In addition, the rubber stopper, when you flip off the plastic lid on any medications. It should be disinfected with 70% isopropyl alcohol before accessing. That is not always done in anesthesia. In addition, your stopcock, as well as your injection site should be scrubbed with alcohol before injecting. If your patient is coding, you have to give that perforin. All bets are off. Most times, we have the time to swab and scrub those injection sites. I do and you should.
Despite having this knowledge, we continue to see unacceptable practices in our setting. This was a very interesting study done by Kelly Ford back in 2013 when she was a student at Accela School of Nurse Anesthesia in Western Pennsylvania. She sent out a questionnaire to SRNAs. This would be a great scholarly project for someone thinking about a scholarly project to redo this and see if we’re doing any better.
These are the questions she asked, “Have you ever administered medications from the same syringe to multiple patients?” Sadly, fourteen of her respondents, 4%, said yes. Have you ever reused a needle on the same patient? Fifty-nine or 80% said yes. Have you ever refilled a syringe once it’s been used, even for the same patient? This includes the syringe on propofol infusions. Eighty-two percent said yes. Have you ever reused infusion or IV administration sets on more than one patient? The fact that two said yes concerns me, seriously.
Have you ever reused a syringe or needle to withdraw medication from a multidose vial? Twenty-two percent, yes. Have you ever re-entered a single-used medication, vial and pill, or solution to prepare doses for multiple patients, even if the needle and syringe are clean? Forty-nine percent yes. Have you ever witnessed a CRNA do any of the prior six activities? This is what’s scary, 81% said yes. Have you ever been asked or instructed by a CRNA to do these prior activities? Fifty-eight percent said yes.
Clean Equipment
We have to do better. I want you, as providers, to be the change we need to see. Even if someone asks you to do something, you should be able to say, “My faculty member told us that this is against the AANA infection control policies. We must adhere to all the AANA policies. I’m just going to do this real quick.” That’s all you have to say. It’s helping to educate them.
We have to do better. We, as providers, need to be the change we need to see. Share on XPer the CDC, we have to cleanse all lines, ports and stop cocks with alcohol prior to entry for 30 seconds. They did a study and they saw that there was a significant difference between 15 and 30 seconds of scrubbing the hub but not much difference between 30 and 60. They came up with 30. When you flip the top off of those vials, you must scrub the rubber stopper. Glass ampules should be cleaned with alcohol before popping the glass ampule.
Do not draw fluid. You will see anesthesia providers do this. They’ll stick a syringe into the port on the IV and draw fluid out of it or from the stopcock and draw tubing up to into it to dilute or flush or what have you. Use individually wrapped saline syringes and flushes as dilutants and as flushes. There are good reasons to be doing this.
Once you enter those little stoppers on the IV fluid, you are allowing bacteria to get in there. When you get those bags from the pharmacy and they’ve mixed drugs into 250 bags of fluid. They put a little protector over there to keep microbial agents. We get aerosolization in the operating room. Blood gets sprayed up and irrigation fluid. It’s very important. to remember this. Hand hygiene is most important. You should not wear rings or jewelry to the operating room.
I leave my rings at home. Remember that we must use soap and water if our patient has C-diff. You need to rub your hands for fifteen seconds. We have the hand sanitizers on our anesthesia carts. People just aren’t using them. The recommendation by the AANA is to double glove when you’re about to intubate and remove the outer glove before you touch your anesthesia bag or your flow meters or your vaporizers.
The other nice thing is if you have a second glove on and for some reason, you didn’t get the intubation into the trachea and went to the esophagus. You have to open the mouth. Again, you have another clean glove on. It’s much quicker. If you did use your second glove, you would take that off before touching anything. We need to make sure that we keep our contaminated equipment on the anesthesia machine shelf and keep grossly contaminated equipment covered with an impermeable cover and keep all of our clean equipment back on our back cart where we set up.
Do not mix clean and dirty. Always monitor your environment and clean up. If you notice something on it, we have the microbial wipes there. Wipe them down. I start every day in the morning with a pair of gloves and microbial wipes. I clean my anesthesia machine and my anesthesia work setting prior to starting. I know that I’m starting with a clean environment, then I draw my medications up and I do all those things. In some places, the anesthesia techs are very good. In other places, maybe not so good, or maybe housekeeping. They don’t understand the importance of everything in doing this.
One of the other things I’d like to say is that arterial line insertions should be done with an aseptic sterile technique. You’re supposed to clean the site and infiltrate with local anesthesia. You need to prep and drape sterile. Use sterile gloves, a sterile field, and a sterile catheter. It’s very important. You will see people do this with regular latex gloves. Not a good idea.
Remember, everything gets contaminated. Look and look again. If it’s something that you wouldn’t want for you or your family member, don’t let it happen to your patients. The World Health Organization talks about five moments of hand hygiene. The other thing is that they also talk about how the increase in glove use has unfortunately caused a decrease in hand hygiene among anesthesia providers. They recommend that gloves should be worn during exposure and removed then hand sanitize if you put new gloves on. In addition, another opportunity for improvement is the IV port decontamination. They say at least 10 to 15 seconds to fully decontaminate the port. The CDC recommends 30.
Lastly, increased environmental cleaning is very important to prevent these infections. Mobile phones, we use them for everything. We use them as our calculators, to communicate with other providers, and things like that. Mobile phone contamination rate of 94.5 % with 37.7% having methicillin-resistant strains. Very scary. Eighty-seven percent of the bacterial load reduction after decontaminating with 70% isopropyl alcohol between every case if you’ve touched your phone, which we do. You need to decontaminate your phone.
In addition, you’re putting it right up here by your face. Very scary. There was a small study that I thought was very fascinating. They looked at the adverse effects of noise in the operating room. We play music and there’s a lot of talking. What they found was that the higher the noise level, the higher the risk of surgical site infection. It wasn’t the noise that caused the infection, but if the scrub person accidentally hit something with the instrument then proceeded to pass it. There was more of a breakdown.
People were less engaged and less able to hear. They don’t recommend having a lot of ancillary noise in the operating room. I haven’t sold that to too many people. Though it’s a very long day, if you don’t have a little music, but it shouldn’t be at decibels that’ll make you deaf. How much are we to blame? I would venture to say we probably are involved in the increase in surgical site infections and there’s a lot we can do to do better. I know all of you when you become CRNAs will remember these things. Do not become complacent.
Loyola University Of New Orleans
A little bit about Loyola University of New Orleans, where I’m the founding Director of the nurse anesthesia program. We are the second program in the country to offer a CRNA program and a dual CRNA adult, general, acute care, and PI program. We have sixteen first-year students of the 1611 who opted for the dual. It is a 36-month program, whether you’re a CRNA or a dual student and you culminate with your DNP.
All of our clinical sites are within three hours of the Greater New Orleans area. Most of them are within an hour. We offer open houses in the fall. Our applicants open in Nursing CAS on September 1st and they close on December 15th. We then select interview candidates to interview in February and within a week of the interview, we will let you know if you’ve been accepted. We are a small program. Only 24 students. We don’t want to be a mega school.
We know that you have a choice where you go. I know that you’re applying to many programs. What I want you to do is I want you to attend many open houses. We offer ours virtually, as well as we offer one in person. You need to find a place where you feel that it’s going to be a good fit for you for 36 months. We hope that that will be Loyola. You can opt into the dual program up until the third semester.
Once the third semester starts, that’s when you start your first adult year or acute care NP course and practicum. If you start out as a dual student and after the first two semesters say, “I don’t want to do this.” At any time you can opt out of it. We are what we call an integrated program meaning that you’ll start with us. We have everyone move to New Orleans at the beginning of the program because there’s a lot to learn from the upper cohorts.
We’ll have journal clubs. We’ll have bonding and mentoring going on. All the first-semester courses are offered asynchronously online. Those are your DNP courses and the first advanced path that all APRN students take. The second semester you start into nurse anesthesia courses. Those courses are in-person and on campus with the faculty. You’ll continue to have DNP, advanced pharmacotherapeutics, and advanced health assessment online asynchronously. That’s how we do it.
Every one of our students starts clinical in the first semester. In their second year, we integrate you into clinical slowly two days a week for the first two semesters of the second year then full-time for the third semester of the second year, first and second semester of the third year. We then bring you back down and slow you down that last semester and your sixth semester in the program to get you prepared for your certification exams. I hope that you found this interesting. We would love to hear from you. You’ll be able to find us in Nursing CAS for applications. Thank you.
Important Links
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Learn More about the Loyola University New Orleans Anesthesia Program: https://www.loyno.edu/academics/colleges/loyola-online/doctor-nursing-practice-online-hybrid-options
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