Correspondence  |   May 2009
Infection Control Practices by the Anesthesiologist
Author Affiliations & Notes
  • Randy W. Loftus, M.D.
  • *Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
Article Information
Correspondence   |   May 2009
Infection Control Practices by the Anesthesiologist
Anesthesiology 5 2009, Vol.110, 1191-1192. doi:
Anesthesiology 5 2009, Vol.110, 1191-1192. doi:
In Reply:—
We appreciate the thoughtful criticism provided by Drs. Neustein and Williams regarding our article entitled “Transmission of Pathogenic Bacterial Organisms in the Anesthesia Work Area.” They raise an interesting question regarding the likelihood of interinstitutional variability in infection control practices of anesthesia providers, a question inspired by our comment that “it is a reasonable assumption that the aseptic practice by anesthesia providers at our institution reflects practice elsewhere.”
In the 1970s, the Centers for Disease Control and Prevention initiated the National Nosocomial Infection Surveillance Study (NNIS) to continuously monitor infection control rates in hospitals across the United States. Data derived from the NNIS provided statistical evidence for the need to improve preventative measures and generated a set of guidelines for recognition and management of infection. Our statement was based on the NNIS quartile ranges of our institution, which suggest that our overall infection control practices are excellent; as good as or better than the majority. We are at the 50th percentile for new cases of Methicillin-resistant Staphylococcus aureus  and the 25 percentile for Vancomycin-resistant Enterococcus.  The NNIS is now known as the National Healthcare Safety Network, and it continues to serve as a reasonable comparative measure of interinstitutional infection control practices.1 
That being said, we agree that there is a possibility of both intra- and interinstitutional variability in infection control practices that would be unaccounted for by gross estimates as presented by NNIS quartile ranges. This could impact intraoperative bacterial transmission magnitude and patterns, making multiinstitutional studies evaluating intraoperative bacterial transmission an important consideration for further work in this area. We hope to address this important question with a recently funded study.
Interestingly, the infection control practices at Dartmouth-Hitchcock Medical Center largely reflect those at Mount Sinai. We too encourage designated dirty and clean areas in the anesthesia work area. The front area, the table connected to the anesthesia machine, is to remain clean (in theory), while the back of the medication cart is designated for placement of dirty health care tools into a disposable plastic bag. Like all infection control practices, there is not a 1:1 correlation with guidelines and actual practice.
The front area is decontaminated between patients with a quaternary ammonium compound, as described in our article, and similar to Mount Sinai, only items specific to the current patients are to be placed in this area. As reported in the manuscript, this is in addition  to terminal cleaning. We do not use a disposable sterile drape, an interesting caveat. Additional medications that have been prepared are also kept on the top of the anesthesia cart. Universal precautions, such as wearing a gown for patients in contact isolation, also apply at Dartmouth-Hitchcock Medical Center. We have various measures to control proper handling of controlled substances, an issue that is seemingly separate from infection control. All of our central lines are placed with central line dressings impregnated with chlorhexidine. Your investigation of stopcocks is interesting, timely, and in parallel with an ongoing study at our institution. In summary, based on the description which you provided of your infection control practices, the use of sterile drapes between patients serves as the only basis for variability in our infection control practices. Like use of gloves, this is unlikely to impact bacterial cross-contamination without intraoperative adherence to Centers for Disease Control and Prevention guidelines for hand hygiene. A more useful comparison for infection control practices at our respective institutions would be a report of hand hygiene compliance of anesthesia providers; the number one preventative measure for healthcare-associated infections.2 
*Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004. National Nosocomial Infections Surveillance System. Am J Infect Control 2004; 32:470–85
WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft). World Health Organization Health System Policies and Operations Evidence and Information for Policy. 2005. 9-13-2007