ANAESTHESIOLOGY PRACTICE IN THE PREVENTION OF

PERIOPERATIVE TRANSMISSION OF INFECTION AT THE

KENYATTA NATIONAL HOSPITAL

A DISSERTATION SUBMITTED IN PART FULFILLMENT OF THE

REQUIREMENTS FOR THE AWARD OF MASTER OF MEDICINE DEGREE IN
ANAESTHESIA

UNIVERSITY OF NAIROBI

DR. SHEILLA M.NZIOKA

©2014

i
DECLARATION
This dissertation is my original work and to my knowledge has not been presented for any award
in this university.

……………………………………….
Date…………………………………

Dr Sheilla Nzioka, MD (Wroclaw)

H58/64093/2010

Post Graduate student in Anaesthesia

College of Health Sciences, University of Nairobi

SUPERVISORS’APPROVAL

This dissertation has been submitted with approval of the following supervisors:

Dr.Charles Kabetu. MBChB (Nairobi) MMed (Anaesthesia) (Nairobi)

Chief Medical Specialist in Anaesthesiology /Critical Care
Kenyatta National Hospital.

Signed:…………………………………………... Date……………………

Dr.Thomas Chokwe BSc (Anat.) MBChB. MMed (Anaesthesia) (Nairobi)

Lecturer
Department of Anaesthesiology,University of Nairobi.
Consultant Anaesthesiologist, Kenyatta National Hospital.

Signed:.………………………………………….. Date………………………

ii
ACKNOWLEDGEMENTS

I would like to thank the God Almighty for keeping me in good health.

I would also like to thank my supervisors, Dr. Charles Kabetu and Dr. Thomas Chokwe for their
unwavering support throughout the collective process of the development of this dissertation.

I appreciate all those who willingly participated in the study.

iii
TABLE OF CONTENTS

DECLARATION .......................................................................................................................................................... II
SUPERVISORS’APPROVAL ..................................................................................................................................... II
ACKNOWLEDGEMENTS ......................................................................................................................................... III
TABLE OF CONTENTS ........................................................................................................................................... IV
ABSTRACT ............................................................................................................................................................... VI
LIST OF ABBREVIATIONS AND ACRONYMS .................................................................................................. VII
DEFINITION OF OPERATIONAL TERMS .......................................................................................................... VIII
CHAPTER 1: INTRODUCTION AND LITERATURE REVIEW ..............................................................................1
1.2JUSTIFICATION ......................................................................................................................................................7
1.2 STUDY OBJECTIVES ..............................................................................................................................................7
1.2.1 BROAD OBJECTIVE ............................................................................................................................................7
1.2.2 SPECIFIC OBJECTIVES ........................................................................................................................................7
1.3 RESEARCH QUESTION ..........................................................................................................................................8
CHAPTER 3: RESEARCH METHODOLOGY ...........................................................................................................9
3.1 STUDY DESIGN .....................................................................................................................................................9
3.2 STUDY SITE ..........................................................................................................................................................9
3.2 STUDY POPULATION .............................................................................................................................................9
INCLUSION CRITERIA ..................................................................................................................................................9
EXCLUSION CRITERIA .................................................................................................................................................9
3.4 SAMPLE SIZE DETERMINATION .............................................................................................................................9
3.5 DATA COLLECTION ............................................................................................................................................. 10
3.6 DATA PROCESSING AND ANALYSIS ..................................................................................................................... 11
3.7 ETHICAL CONSIDERATIONS ................................................................................................................................ 11
CHAPTER 4: RESULTS ............................................................................................................................................. 12
FIGURE 1: GENDER DISTRIBUTION OF PARTICIPANTS ............................................................................................... 12
FIGURE 2: PARTICIPANT AGE DISTRIBUTION............................................................................................................. 13
FIGURE 3: CADRE OF ANAESTHESIA PROVIDER ........................................................................................................ 13
FIGURE 4: COMPARISON OF AGE VERSUS CADRE OF ANAESTHESIA PROVIDER .......................................................... 14
FIGURE 5: YEARS OF PRACTICE IN THE FIELD OF ANAESTHESIOLOGY ...................................................................... 14
FIGURE 6: FREQUENCY OF SURGICAL MASK USE .................................................................................................... 15
FIGURE 7: LAST VACCINATION AGAINST HEPATITIS B............................................................................................. 15
FIGURE 8: FREQUENCY OF HME CHANGE................................................................................................................ 16
FIGURE 9: FREQUENCY OF CHANGING THE PATIENT’S DISPOSABLE BREATHING CIRCUIT ....................................... 17
FIGURE 10: FREQUENCY OF MAINTAINING THE ENDOTRACHEAL TUBE STERILE ..................................................... 18
TABLE 1: ADHERENCE TO VARIOUS HYGIENIC AND ASEPTIC PRACTICES .................................................................. 19
TABLE 2: CONDUCT OF ANAESTHESIA WITH REGARD TO INFECTIOUS DISEASES ....................................................... 19
FIGURE 11: PERCEIVED ANAESTHESIA ROLE IN TRANSMISSION OF INFECTIOUS AGENTS TO THE PATIENT ................ 20
CHAPTER 5: DISCUSSION ...................................................................................................................................... 21

iv
 5.1 PARTICIPANTS AND PROCEDURES ....................................................................................................................... 21
5.2 ADHERENCE TOHEALTHCARE-RELATED HYGIENE AND ASEPTIC PRACTICES ....................................................... 22
5.3 CONDUCT OF ANAESTHESIA WITH REGARD TO INFECTIOUS DISEASES .............................................................. 24
5.4 CLEANING AND DISINFECTING ANAESTHETIC EQUIPMENT ................................................................................ 24
CONCLUSION ........................................................................................................................................................... 25
RECOMMENDATIONS ............................................................................................................................................. 25
STUDY LIMITATIONS ............................................................................................................................................. 26
REFERENCES ............................................................................................................................................................ 27
APPENDICES ............................................................................................................................................................. 33
APPENDIX I: INFORMED CONSENT ................................................................................................................. 33
APPENDIX II:............................................................................................................................................................. 36
QUESTIONNAIRE……………… ............................................................................................................................. 36
APPENDIX III: GUIDELINES ................................................................................................................................... 40
APPENDIX IV: ETHICAL APPROVAL FROM KNH/UON ERC ........................................................................... 50
APPENDIX V: DECLARATION OF ORIGINALITY FORM .................................................................................. 52

v
ABSTRACT
Background: Anaesthesiologists play apivotal role in the prevention of nosocomial infections. In
anaesthetic practice, physiologic barriers are routinely breached, leading to patient contamination
with microorganisms and consequential development of infection. Hygiene practices of
professionals, proper cleaning of equipment and adequate sterile execution of invasive
procedures are among important aspects that reduce the risk of transmission of infections

Objective:The purpose of this study was to evaluate the degree to which anaesthesia providers
utilize appropriate hygiene techniques and anaesthetic equipment disinfection procedures for the
prevention of infection during the perioperative period at the Kenyatta National Hospital.

Design: This study was designed as a cross-sectional descriptive survey

Methodology:Data for the study was collected using a structured questionnaire distributed to
anaesthesia providers practicing in the Kenyatta National Hospital operating theatres. All
consenting anaesthesia providers were recruited into the study. Data was collected over a period
of 6 weeks at the main and satellite operating theatres in the Kenyatta National Hospital.
Analysis was done using the Statistical Package for Social Scientists (SPSS) software version
20.0. The results were presented in the form of charts, tables and graphs.

Results:A total of 85(83%) out of 102 anaesthesia providers participated in this study. Of the
four different cadres of anaesthesia providers at the Kenyatta National Hospital; consultant
anaesthesiologists were 29.4%, registered clinical officers in anaesthesia were 29.4%, registrars
in anaesthesia were 15.3% while clinical officer students in anaesthesia were 25.9% of the
participants. The distributed questionnaires were designed to assess the hygienic precautions
taken to reduce the potential for transmission of infectious agents to and from the patients under
their care. Face masks and gloves were always used by 65.9% and 23.5%, respectively, while
only 28.2% washed their hands between cases. 13.1% of the respondents had never received a
vaccination against hepatitis B. A higher proportion of anaesthetists continue to administer
anaesthesia despite suffering from respiratory (87.1%) than gastrointestinal (37.6%) infections.
Endotracheal tubes were maintained sterile by 36.5% whereas bacterial filters were used by
100% but changed after each case by 68.2%. On a scale of 0–10 (10 = significant) anaesthetists
rated their potential for transmitting or contributing to patient infection at a mean of 5.14
(standard deviation 2.65).

Conclusion:The results of this study show that, although anaesthesia providers at the Kenyatta
National Hospital are well aware of proper hygienic guidelines, their practice falls short of
accepted recommendations.

vi
List of Abbreviations and Acronyms

CDC – Centers for Disease Control

KNH – Kenyatta National Hospital

AIDS –Autoimmune deficiency syndrome

HIV – Human Immunodeficiency Virus

HBV - Hepatitis B Virus

Hep C – Hepatitis C

NHS – National Health Service

HME – Heat and Moisture Exchanger

AAGBI - Association of Anaesthetists of Great Britain and Ireland

SSD - Sterile Supplies Department

HCAI – Health Care Acquired Infection

HIS – Hospital Infection Society

TB - Tuberculosis

vii
Definition of Operational Terms

1. Anaesthesia Provider

Health care giver involved in perioperative care, development of an anesthetic plan, and the
administration of anesthetics this includes: consultant anaesthesiologists, registrars, registered
clinical officers and student clinical officers in the department of anaesthesiology

2. Anaesthesiologist

A doctor (with a degree of Bachelor of Medicine and Bachelor of Surgery or its equivalent) who
has specialized in the medical field of anaesthesiology. This could be a master of medicine in
anaesthesia, a post graduate diploma in anaesthesia or their equivalents.

3. Anaesthesiology

The medical specialty concerned with the pharmacological, physiological, and clinical basis of
anaesthesia, including resuscitation, intensive respiratory care and pain management.

4. Anaesthetic Circuitry/Anaesthetic breathing systems

An assembly of components which connects the patient’s airway to the anaesthetic machine
creating an artificial atmosphere, from and into which the patient breathes.

5. Antisepsis

Destruction of disease-causing microorganisms to prevent infection

6. Asepsis

The state of being free from living pathogenic organisms

viii
 7. Autoclave

A device used tosterilize equipment and supplies by subjecting them to high pressure saturated
steam at 121 °C for around 15–20 minutes depending on the size of the load and the contents.

8. Clinical officer

A mid-level practitioner of medicine in East Africa and parts of Southern Africa(with a Higher
National Diploma) who is qualified and licensed to perform general medical duties such as
diagnosis and treatment of disease and injury, ordering and interpreting medical tests, performing
routine medical and surgical procedures, and referring patients to other practitioners or licensed
within a medical specialty such as anaesthesiology.

9. Hospital Acquired Infection/Nosocomial Infection

An infection that first appears three days after a patient is admitted to a hospital or other health
care facility.

10. Registrar

A qualified medical doctor who, at the outset of her/his higher medical training is beginning to
specialize in a particular medical specialty and by the end of it will be looking at obtaining a
consultant post in that area.

11. Sterilize

To render sterile; to free from microorganisms.

ix
Chapter 1: Introduction and Literature Review

The cornerstones of modern surgery are the principles of antisepsis and asepsis. These
Were introduced more than a century ago; however patients still continue to be plagued by
postoperative wound infections. Although the mortality associated with postoperative sepsis has
been notably reduced, the morbidity and surgical failure caused by wound infections and sepsis
warrant further efforts to identify factors responsible and thereby reduce the rate of postoperative
infections.

In the USA, approximately 70% of all acute illness can be attributed to infectious agents. Of
these, nosocomial infections occur in approximately 5% of patients, increasing the average
hospital stay by 4 days and causing approximately 60,000 deaths per year. (1)

The role of the anaesthesiologist has now expanded to that of the “total perioperative physician”.
Therefore, there has been an increase in the number of invasive procedures performed by
anesthesiologists, resulting in an increase in the prevalence of emerging diseases. Hence
stringent attention to infection control practices is of utmost importance.

The practice of anaesthesiology has the potential for transmitting a number of infectious agents
to the patient, since it often requires breaching the body’s mechanical barriers. Placement of
intravenous and intra-arterial catheters, airway instrumentation, and mechanical ventilation all
(2)
provide potential vehicles for transmission of infection . The incidence of contact with blood
among anaesthetic personnel has been estimated to range from 8% for intramuscular injection to
87% for central venous catheter insertion; 98% of these incidents of blood contact can be
avoided by the use of gloves (3) .

The potential for nosocomial transmission of infection in anesthesiology practice is real, there is
however very little data to support a cause and effect relationship. Certain anaesthetic practices
have been implicated in the transmission of infections. The use of a common syringe for the
administration of drugs to more than one patient, for example, is a risky practice, even if a new
(4) (5)
sterile needle is used for each individual patient use . Froggatt et al. reported six patients
who contracted acute HBV infections from a reused syringe that had come in contact with a
contaminated stopcock from a hepatitis B carrier. A case of multiple patient-to patient

1
transmission of HIV in a private surgery clinic in Australia was described wherein the practice of
reusing syringes from a potentially contaminated multidose local anesthetic vial was implicated
(6,7) (8)
. Chant et al. also reported on an investigation of possible patient-to-patient transmission
of hepatitis C. In this case, transmission from the source patient to four other cases implicated
either a reused syringe or contaminated anesthetic circuitry.

In 2002, the Association of Anaesthetists of Great Britain and Ireland published guidelines to its
members regarding the occupational hazards of HIV and hepatitis B virus (HBV) infection 9.
These guidelines include recommendations to wear gloves during induction of anaesthesia,
inserting intravenous cannulae, setting up intravenous infusions and inserting and removing
airways and tracheal tubes. Where substantial spillage of blood may occur, as, for example, in
setting up an intra-arterial line, a plastic apron, mask and eye protection should be worn. Where
possible, nondisposable contaminated equipment should be autoclaved. Where this is not
possible the equipment should be thoroughly washed with detergent and left for a suitable period
in 2% freshly prepared glutaraldehyde or any other agent recommended by local infection
control policies 9.
Surveys from the CDC have implicated extrinsic contamination of propofol with cases of
(10)
postoperative infection . It is recommended that infusion solutions should be used on a one-
time, one patient basis. Studies show that contaminated infusions have resulted in bacterial and
fungal infections when used on more than one patient (10).

Although transmission of infection to a healthy patient is difficult, there are certain patient
populations that are readily predisposed to infection; Diabetic patients, elderly, obese, or burns
patients, or those with poor nutritional status (like alcoholics and drug abusers). Patients who
smoke may also have an increased incidence of pulmonary infections (11-13)

The anaesthesiologist today is faced with an increasing number of patients with

immunosuppressive diseases which may be acquired or congenital or who are on
immunosuppressive treatments for organ transplantation or malignancy. Infection is one of the
leading causes of morbidity and mortality in these patients. Many commonly used anaesthetics
(14-16)
are immunosuppressive and may compound the likelihood of pathogenic transmission .
Pneumonia, for example accounts for up to 40% of deaths among children and adults with cancer

2
(17,18)
and it has been estimated that 35% of renal transplant recipients develop pneumonia in the
first year after transplantation (19)

Multidose vials generally contain preservatives and, therefore, can be used on more than one
patient. However, the rubber septum should be cleaned with alcohol prior to each use. Vials that
are obviously contaminated should be discarded. Although transmission of infection by this route
is uncommon, there have been reports of viral and bacterial infections linked to contaminated
multidose vials (20, 21)

Adhering to simple hygienic practices could be the best approach in preventing perioperative
infections. For example, hand washing or the use of disposable gloves can prevent transmission
(22) (23)
of a number of pathogens . Gwaltney et al. showed that during experimental rhinovirus
infections, transmission of the virus occurs in 73% of cases via the hands and only 8% via
sneezing and coughing.

Wearing a face mask in surgical theatres is a controversial topic. Since its initial use by a
(24),
German surgeon in 1897 the surgical mask has been repeatedly modified, scrutinized and
(25)
criticized. Rogers recommended that surgeons, assisting nurses and anaesthetists should wear
masks. This was supported by increased rates of infection after major abdominal surgery when
(26)
surgeons and nurses did not wear masks . Masks, however, may not be necessary for theatre
(27,28)
staff who are not in close communication with the surgical field and the sterile instruments
(29)
especially in theatres with forced ventilation However, no member of the theatre staff can
exclude themselves completely from either the surgical site or the sterile instruments trolley.

(30)
Tunevall concluded that masks provide no benefit to patients. It is however, generally
recommended that masks should be used by people suffering from nasopharyngeal rhinoviral
infection, but it is more sensible to exclude them from the surgical suite. In addition rhinoviral
transmission has been shown to spread by hand-borne contamination, rather than by droplet
transfer; this again raises the question about the necessity for the mask (31). Nevertheless when no
mask was worn a significantly (p < 0.002) higher number of bacterial colonies were recoverable
than when a full mask was worn; mask placement, however, above or below the nose made no
significant difference to the mean colony counts (32).

3
 (33)
Heinsohn & Jewett recommended the proper use of respiratory protection equipment instead
of surgical masks because the latter do not offer adequate protection against aerosolized blood in
the operating room. Face masks do however decrease the spread of contaminated droplets by
filtration and alter the direction of dispersal from the upper respiratory tract during talking,
coughing and breathing. It is also recommended that masks should be removed and discarded
after use since they become wet and laden with micro-organisms. Standardized tests are therefore
needed to evaluate the ability of face masks to protect the user from a variety of particle sizes
and to quantify edge leakage (34).

Surveys were carried out in the late 90’s among consultant anaesthetists in the United Kingdom
and United States of America to assess the standards of hygiene and discipline and to highlight
areas of practice which may be less than optimal(9).The practice of reusing disposable plastic
syringes for different patients is still prevalent in North American theatres despite warnings
(35-37)
about the hazards . The use of a syringe for more than one patient was never (80%) and
rarely (13.1%) practiced, respectively, by the anaesthetists in United States of America. The
multiple use was mainly for total intravenous anaesthesia for which only the infusion line was
changed. The intravenous tubing, however, has been shown to have a significant contamination
rate in routine use; the rate decreasing as the distance from the intravenous catheter increases (38).
Tait & Tuttle (39) reported that 28% of anaesthetists in private practice frequently or always reuse
syringes for more than one patient compared with 7% in university practice (p < 0.01).

The contamination of anaesthesia equipment and the potential for nosocomial transmission has
(40)
long been a cause for concern. Indeed, as long ago as 1873, Skinner decried the use of the
same inhaler on successive patients without cleaning. The role of contaminated anesthesia
equipment in the development of postoperative infections is however controversial.

Although outbreaks of Pseudomonas aeruginosa infections have been described in patients

ventilated using a contaminated anesthesia machine, the use of disposable anaesthetic circuits
with bacterial filters has not been shown to improve the incidence of postoperative pulmonary
infections (41, 42). In addition, the administration of anesthesia to patients with documented Gram-
negative infections does not result in significant colonization of the anesthesia machine (43)

4
Blood and body fluid contamination of stopcocks, anesthesia machine working surfaces,
monitor cables, drawer handles, oximeter probes, and patient anesthesia records have all been
(44-46)
described, although their role in transmission of infection has not been established . It has
been shown that anaesthetic breathing systems can become contaminated with organisms from
the respiratory tract, especially with coughing (47-50) It is recommended that either an appropriate
filter should be placed between the patient and the breathing system, with a new filter being used
for each patient, or that a new breathing system be used for each patient, especially in paediatric
(51)
practice A contaminated reusable part of the breathing system can possibly result in HCV
(52)
infection However, the use of disposable anaesthetic circuits with bacterial filters has not
been shown to reduce the incidence of postoperative pulmonary infection.(53,54)

HBV and HIV are the most important viruses to which the anaesthetist is exposed and have long
been associated with anaesthetic practice. In the United Kingdom it was agreed that HIV- or
(51)
HBV-infected anaesthetists who are clinically well could continue in clinical practice . This
view was supported by the UK Health Departments' Advisory Panel on Health Care Workers
Infected with Blood Viruses with the exception of those procedures which involved skin
tunneling. Tait & Tuttle (39) reported a substantial alteration in practice by 58% of anaesthetists in
light of the AIDS epidemic, while practice was somewhat altered by 35.3%. Despite the
(9)
recommendations of The Association of Anaesthetists of Great Britain regarding infection
control of HIV and HBV and other nosocomial infections, these recommendations were not
strictly adhered to as shown in the survey done(55)

The practice of anaesthesiologists in the prevention of perioperative infection has been surveyed
in various countries;

El Mikatti et al(55)in 1997 did a survey among consultant anaesthetists in the North-West region
of the UK.Regarding the frequency of use of face masks, gloves and hand washing between
cases, there was no significant difference in the use of masks or frequency of hand washing
between consultants with respect to their seniority.All respondents claimed to clean/disinfect the
laryngoscope after each patient, with 59% using soap and water. 9.5% of respondents never used
multidose vials.One third of the respondents (33.3%) changed the disposable breathing circuit at
the end of the day or after an infected/high-risk patient, while 27% always changed it following a

5
known infected case. Only 1.3% of anaesthetists changed the breathing system after each case.
Bacterial filters were used by 17% and changed between cases by 7.2%.

Most anaesthetists in UK admitted anaesthetising patients whilst harboring respiratory tract

(94%), gastrointestinal (42.9%) and herpes simplex (32.6%) infections.Changing anaesthetic
practice in consideration of AIDS as a dangerous infectious disease was reported by 74.8% of the
respondents; 23.8% did not change their practice while 1.4% were not sure. Recognition of the
possibility of hepatitis B and C virus (HB/CV) infection changed anaesthetic practice in 68.8%
of the respondents; 28.8% did not change while 1.4% did not know.The anaesthetist's role in the
transmission of infectious agents to the patients was scored on a scale of 0–10 (10 = significant);
46.4% of the respondents rated it higher than 5, 4.9% perceived it as 0, while it was reported as
10 by only 3.5%. The modal score was 2 (25% of respondents

Tait and Tuttle et al(39) carried out a cross sectional descriptive study in the United States among
members of the American society of anaesthesiologists. 49% and 75.3% of respondents always
used gloves and masks, respectively, in their everyday practice. Only 58% of respondents stated
that they always washed their hands after every patient contact and 85% reported that they
always used aseptic technique while placing indwelling catheters. 20% of the respondents
reported frequently or always reusing syringes for more than one patient and 34.4% reported
never or rarely disinfecting the septum of multidose vials prior to use. The practice of reusing
syringes was significantly greater among private than university practitioners (P < 0.01). On a
scale of 0-10 (10 = high) anesthesiologists rated their potential for transmitting or contributing to
patient potential for transmitting or contributing to patient infection as 4.7

A study by Daniel Kishi et al(56)describing nosocomial infection prevention practices by

anaesthesiologists in a University Hospital in Brazil showed that the routine use of eye protection
was reported by 21.2% of anesthesiologists, while 95.2% always or frequently wear a surgical
mask; 96.3% wear general procedure gloves, while 84.1% use them for venous cannulation;
98.8% wear sterile gloves for the neuraxial block, and 87% wear them for peripheral nerve
blocks. Sterile technique including hand washing, mask, headwear, sterile gown, and sterile
glove was reported by 91.3% of anaesthesiologistNinety-five per cent of anaesthesiologists wash
their hands between cases, 89% wash their hands when removing the gloves, and 74.1% wash

6
their hands before a neuraxial block.The endotracheal tube is maintained sterile by 91.6% of
anesthesiologists, and 95.1% change the filter of the ventilation system between
patients.Prefilled propofol syringe was discarded at the end of each anesthesia by 98.8% of
anesthesiologists; however, 52.4% refill the propofol syringe for the same patient.A three-way
stopcock is used for intravenous infusion of drugs by 96.3%; however, only 30% reported
cleaning vials of drugs with alcohol for use in the neuraxial blocks, while 19.8% clean vials
before intravenous administration.

1.2Justification
The appearance of infection following anesthesia and surgery is a major source of morbidity and
mortality and therefore is an important indicator of the quality of health care in the perioperative
period.
Nosocomial infections are known to increase the average hospital stay and health costs.

There is a need to develop protocols for the department of anaesthesiology at the Kenyatta
National Hospital for the prevention of perioperative infections

There has been no similar study carried out in Kenya regarding practice of anaesthesia providers
in the prevention of perioperative infections.

The assessment of the current practice of anaesthesia providers in the Kenyatta National Hospital
in prevention of perioperative infection is paramount

1.2 Study Objectives

1.2.1 Broad Objective

Evaluate the degree to which anaesthesia providers in Kenyatta National Hospital utilize
appropriate hygienic techniques for the prevention of infection in the perioperative period.

1.2.2 Specific Objectives

1) To evaluate compliance of anaesthesia providers with healthcare-related personal
hygiene.

2) To assess the compliance of anaesthesia providers with anaesthetic equipment

disinfection procedures at the Kenyatta National Hospital.

3) To assess compliance of anaesthesia providers with the universal guidelines for the
prevention of occupational transmission of infectious diseases.

7
1.3 Research Question

Do anaesthesia providers at the Kenyatta National Hospital adhere to the recommended practices
related to the prevention of perioperative infections? (Appendix III)

8
Chapter 3: Research Methodology
3.1 Study design

This is a cross - sectional study

Data for the study was collected by the principal investigator using a structured questionnaire
(Appendix II) accompanied by a cover letter and consent form (Appendix I)

3.2 Study site

The survey was carried out at allthe main and satellite operating theatres in the Kenyatta
National Hospital.

3.2 Study population

The study population included the consultant anaesthetists, registrars, registered clinical officer
anaesthetists and student clinical officers in the department of anaesthesiology, Kenyatta
National Hospital.

Inclusion criteria
1. Consultant anaesthetists, part II registrars, registered clinical officer anaesthetists and part
II student clinical officers in the department of anaesthesiology, Kenyatta National
Hospital.

2. Those who gave informed consent to participate in the study.

Exclusion criteria
1.Those who declined consent to participate in the study.

2. Those not present in the period during which the study was conducted.

3. Part I registrars and part I student clinical officers in department of anaesthesia.

3.4 Sample size determination

The sample size was determined applying the following formula (Fisher et al, 1998).

n= z2p(1-p)
d2
Where:

n is the sample size.

z is the standard normal deviation at 95% confidence level.

9
p is the proportion in the targets population 50% (There is very little data to support a cause and
effect relationship in nosocomial transmission of infection in anaesthesiology practice, hence the
assumed incidence was 50%)

d is the target margin of error put at 0.05.

= 1.962*0.5(1-0.5)
0.052

n=392

Since the population is below 10,000, the following adjustment was done in calculating sample
size: N0

Where N is the total number of anaesthesia providers at the Kenyatta National Hospital (102)

n
N0 = 1+ n-1
N

392
1 + 392 - 1)
102

= 81

3.5 Data collection

The survey was done after the approval of Kenyatta National Hospital/University of Nairobi-
Ethics and Research committee over a period of 6 weeks. Details on the study were explained to
the anaesthesia providers by the principle researcher before handing the pretested questionnaires
to those that consented to the study. They were filled out and returned at the same sitting and the
filled out questionnaires checked for completeness.

The consent explanation form contained contacts of the principal investigator, his supervisor and
that of KNH/UON-ERC. It was made clear that the respondent was at liberty to contact any of

10
the contacts above and ask questions or seek any clarifications. This could be during the study
period or even thereafter.

3.6 Data processing and analysis

The completed questionnaires were checked to ensure each question had been filled out correctly
and that there were no gaps. The questionnaires were then numbered and coded for ease of
handling.

Data from structured questionnaires were entered, checked, cleaned and analyzed using
Statistical Package for Social Scientists (SPSS) version 20.0

Univariate analysis was performed in order to obtain descriptive statistics. Proportions, means
and standard deviations were determined during the analysis. The results are presented in form of
tables and charts. The T-test was used to calculate statistical values for continuous variables
whereas chi-square test was used for categorical variables in case of any relationship. Measures
of association were considered statistically significant when p value will be equal to or less than
0.05.

3.7 Ethical considerations

1. The study was undertaken after approval from the Kenyatta National Hospital – University of
Nairobi, Ethics and Research Committee.

2. Participants were assured that no harm will come to them as a result of participating in this
study. Additionally no direct benefits for participation.

3. All participants were informed of the purpose of the study and what it involved of them
through the Informed Consent Form that was affixed to the questionnaire.

4. The questions were answered voluntarily and anonymously. Confidentiality was maintained
throughout the study.

5. There were no cost implications to the participants of this study.

11
Chapter 4: Results
The following is a summary of the results.

Gender of participants

26% (22)

74% (63)

Male Female

Figure 1: Gender distribution of participants

Male participants were 74% and female participants were 26% of respondents.

12
 Age distribution
100.0
90.0
80.0
70.0
percentage %

60.0
50.0
40.0
30.0
20.0
10.0
0.0
20-30 31-40 41-50 51-60
age

Figure 2: Participant age distribution

Cadre of Respondent
Clinical officer student in anesthesia 25.9 (22)

Registrar in anaesthesia 15.3(13)

Cadre

Registered clinical office in

29.4(25)
anaesthesia

Consultant anaethesiologist 29.4(25)

0.0 20.0 40.0 60.0 80.0 100.0

Percentage % (n)

Figure 3: Cadre of anaesthesia provider

Four cadres of anaesthesia providers were surveyed; Consultants anaesthesiologists were 29.4%
of the respondents, registered clinical officers in anaesthesia were also 29.4%. Registrars in
anaesthesia were 15.3% and clinical officer students in anaesthesia formed 25.9% of the
respondents.

13
 Age Vs Cadre of anaesthesia provider

80.0%
69.2%
70.0%
59.1%
60.0% 52.0% 52.0%
50.0% 40.9% 36.0%
40.0% 30.8% 32.0%
30.0%
20.0% 16.0%
8.0%
10.0% 4.0%
0.0% 0.0% 0.0% 0.0% 0.0%
0.0%
20-30 31-40 41-50 51-60

Consultant anaethesiologist Registered clinical office in anaesthesia

Registrar in anaesthesia Clinical officer student in anesthesia

Figure 4: Comparison of age versus cadre of anaesthesia provider

Years of practice in anaesthesiology

Clinical officer student in anesthesia 90.9%

Registrar in anaesthesia 100.0% 0.0%

Registered clinical office in anaesthesia 20.0% 16.0% 48.0% 16.0%

Consultant anaethesiologist 12.0% 32.0% 40.0% 16.0%

0% 20% 40% 60% 80% 100%

0-5 years 5-10 years 10-15 years >15 years

Figure 5: Years of practice in the field of Anaesthesiology

The clinical officer students and registrars in anaesthesiology had mainly practiced for less than five
years, while the years of practice for the consultant anaesthesiologists and registered clinical officers in
anaesthesia varied widely.

14
 Surgical Mask Use
3.5%(3)

30.6%(26)

65.9% (56)

Rarely Frequently Always

Figure 6: Frequency of Surgical Mask Use

Surgical masks were always used by 65% of the participants, whereas 30.6% and 3.5%
frequently and rarely wore them.

Last Vaccination against Hepatitis B

100.0
90.0
80.0
Percentage % (n)

70.0
60.0
50.0
40.0 31.0 (26) (29.8(25)
30.0 26.2(22)
20.0 13.1(11)
10.0
0.0
<1 year ago 1-5 years >5 years Never
Year

Figure 7: Last Vaccination against Hepatitis B

15
 Change the patient's HME

Both only after infected or high risk patient and at the

12.9 (11)
end of the day

At the end of the day 15.3 (13)

Only after infected or high risk patient 3.5(3)

After each patient 68.2(58)

0.0 20.0 40.0 60.0 80.0 100.0

percentage % (n)

Figure 8: Frequency of HME Change

Most (68.2%) of the anaesthesia providers change the HME after each patient, 15.3% at the end
of the day and 12.9% both only after infected or high risk patient and at the end of the day.

16
 100.0 Change the patient's disposable breathing circuit
90.0
80.0
70.0
percentage%

60.0
50.0
40.0 31.8 (27)
30.0 24.7 (21)
17.6 (15)
20.0 14.1(12) 11.8 (10)
10.0
0.0
After each patient Only after infected At the end of the Both only after Other
or high risk patient day infected or high
risk patient and At
the end of the day

Figure 9: Frequency of Changing the Patient’s Disposable Breathing circuit

The breathing circuit was changed by 31.8% of the respondents at the end of the day, 24.7%
changed after each patient, 14.1% changed the breathing circuit only after an infected or high
risk patient, 11.8% changed the breathing circuit both after an infected or high risk patient and at
the end of the day. 17.6% of the respondents cited other reasons for change of the breathing
circuit.

17
 Maintain the endotracheal tube sterile
100.0

90.0

80.0

70.0
Percentage % (n)

60.0

50.0

40.0 36.5 (31)

29.4 (25) 27.1 (23)
30.0

20.0

10.0
.
7 1 (6)

0.0
Never Rarely Frequently Always

Figure 10: Frequency of Maintaining the Endotracheal Tube Sterile

While intubating, the endotracheal tube was always maintained sterile by 36.5% of the
respondents, 29.4%, 27.1%,7.1% respectively never, frequently and rarely maintained the
endotracheal tube sterile.

18
 Table 1: Adherence to various hygienic and aseptic practices
Never % Rarely% Frequently% Always%
(n) (n) (n) (n)

Wear gloves 0 10.6 (9) 52.9 (45) 23.5 (20)

Scrub before giving spinal or epidural 28.2 (24) 40.0(34) 10.6 (9) 21.2 (18)

Use aseptic technique when placing 15.3 (13) 21.2 (18) 23.5 (20) 40.0 (34)
indwelling catheter

Wipe the rubber septum of a 8.3 (7) 28.6 (24) 29.8 (25) 33.3 (28)
multidose vial with alcohol prior to
use

Share syringe between multiple 49.4 (42) 24.7 (21) 22.4 (19) 3.5 (3)
patients

Table 2: Conduct of anaesthesia with regard to infectious diseases

Yes % (n) No % (n)

Knowingly administered anaesthesia while infected with a 87.1(74) 12.9(11)

respiratory infection

Knowingly administered anaesthesia while infected with a 37.6 (32) 61.2(53)

gastrointestinal infection

Change of conduct if patient is HIV positive 24.7(21) 72.9(64)

Change of conduct if patient has Hepatitis B or C 81.9(70) 18.1(15)

19
Figure 11: Perceived anaesthesia role in transmission of infectious agents to the
patient

20
Chapter 5: Discussion

Given the impact of perioperative infection on both the society and economy, it is essential that
anaesthesiologists and other operating room personnel use appropriate precautions to reduce the
potential for transmission of infectious agents to the patients under their care. This study was
carried out to evaluate the degree to which anaesthesia providers in Kenyatta National Hospital
utilize appropriate hygienic techniques for the prevention of infection in the perioperative
period. It sought toassess their compliance with the universal guidelines for the prevention of
occupational transmission of infectious diseases and to highlight the areas of practice which may
be less than optimal.

5.1 Participants and procedures

A total of 85(83%) anaesthesia providers participated in this study. Compared to other studies;
such as that of Tait et al.(39) in the United States, with 44% of participation, El Mikatti et al.(54)in
(55)
the United Kingdom, with 68%, and Daniel Kishi et al. in Brazil, with 75%, the participation
of anaesthesia providers in the present study can be considered favorable.

There are four different cadres of anaesthesia providers at the Kenyatta National Hospital. All
were included in this study as they are actively involved in the provision of anaesthesia in the
Kenyan hospital setting. Consultants anaesthesiologists were 29.4% of the respondents,
registered clinical officers in anaesthesia were also 29.4%. Registrars in anaesthesia were 15.3%
while clinical officer students in anaesthesia formed 25.9% of the respondents.Male participants
were 74% and female participants were 26% of respondents which represents a male to female
ratio of 3:1 which is reflective of the general distribution of anaesthesia providers at the Kenyatta
National Hospital.

The seniority of the anaesthesia providers was recorded; 16% each of the consultants and
registered clinical officers in anaesthesia had been practicing anaesthesiology for more than 15
years. 40% of consultants had been in the field between 10-15 years, 48% of the registered
clinical officers in anaesthesia had been practicing for 10-15 years. 32% of the consultants
compared to 16% of the registered clinical officers in anaesthesia had been in the post for 5-10

21
years while all the registrars as well as the clinical officer students in anaesthesia had been
practicing for less than 5 years.

5.2 Adherence tohealthcare-related hygiene and aseptic practices

Washing hands between cases, a simple procedure that can prevent transmission of
microorganisms with the best cost/benefit relationship, was reported by 71.7% of
anaesthesiologists in the present study, compared to 95.1% in Brazil (Daniel Kishi et al.55) and
83.9%, in the United Kingdom (El Mikatti et al.54).

Regarding the neuraxial block, 63.5% report using aseptic technique prior to administering the
block. Higher proportions were reported in Brazil 98.8 %( Daniel Kishi et al.55) and New
Zealand99.3 %( Ryan et al.56) indicating suboptimal practice at the Kenyatta national hospital in
comparison to the fore mentioned countries. Adherence to the practice of handwashing is lower
before neuraxial blocks (31.8%) compared to 74.1% in Brazil.(Daniel Kishi et al.55) According
to a recent recommendation of the ASA (American Society of Anaesthesiologists), before a
neuraxial block, one should wash his/her hands, wear sterile gloves, cap, and mask covering the
mouth and nose, besides using individual packages in skin preparation, and remove all
jewelry.(57)

In this study there was significant difference in the use of aseptic technique prior to placing
indwelling catheters among the different cadres (p<0.025) 46.2% registrars compared to 16%
consultant anaesthesiologists,16% registered clinical officers and 27.3% clinical officer students
frequently used the aseptic technique. The difference was also significant among the different
age groups (p<0.005). 47.1% of the age group between 41-50 years never used aseptic technique
in comparison with 0% 20-30 years, 9.3% 31-40 years and 16.7% 51-60 years

Surgical masks were used by 96.5% of the respondents, this is similar to the American study of
Tait et al.(39) (94.9%) and the Brazilian study of Daniel Kishi et al (55)95.2%but higher than that
of the United Kingdom 68.3% (El Mikatti et al.54). The high level of compliance with wearing of
surgical masks in the Kenyatta National Hospital may probably be attributed to the use of
disposable surgical masks which are affordable and always readily available at the main entrance
to all operating theatres.

22
The practice of reusing disposable plastic syringes for different patients is still prevalent in
Kenyatta national hospital operating theatres despite warnings about the hazards. Reusing
syringes between patients is an unacceptable practice(38), even if needles are changed.
Microorganisms can be introduced into the syringe during a plunger shaft pull (58)or by otherwise
passing through the syringe barrel(59). In this study, sharing of syringes between multiple patients
was practiced by 25.9% of the anaesthesia providers, whereas 49.4% and 24.7% respectively
never and rarely shared a syringe. There was no significant difference in the sharing of syringes
between patience with regard to the cadre (p>0.1) or the age group (p>0)In the study by El
Mikatti et al.(54)(UK) 80% of the respondents never reused syringes whereas in a study carried
out in Taiwan by Richard C.H et al less than 6% of anaesthesiologists and nurse anaesthetists
reported frequently or always reusing syringes(60).

In thepresent study 76.4% wore gloves, compared to 96.3% in the study of Daniel Kishi et
al.(55)(Brazil) and 84.2% in the study of Ryan et al.(56) (New Zealand). Gloves being perforated
or torn duringprocedures is a common occurrence. It has been shown that most nosocomial
infections in intensive care units and post-anaesthesia care units are caused by cross
contamination from microorganisms carried on the hands of health care workers(61,62) with the
improvements in hand hygiene practices having anoticeably positive effect on nosocomial
infection rates(63,64).

The results of this study suggest ineffective care with airways contamination, since only 63.6%
of anaesthesiologists try to maintain the endotracheal tube sterile, and 68.2% change the filter of
the ventilation system between patients. This care was considerable lower in the study of El
Mikatti et al.(54) (UK - 7.2%). However an improvement of practice in the last decade was
(55)
reflected in the study of Daniel Kishi et al (Brazil – 91.6%) andRyan et al.(56)(New Zealand -
97.1%)

(65)
Hemingway et al. has shown that cleaning the exterior of vials with alcohol can reduce
contamination of the contents however, most anaesthesiologists donot clean vials before using
them, which increases the risks of drug contamination. 33.3% of the respondents always wiped
the rubber septum of a multidose vial with alcohol prior to use. There was significant difference
among the different cadres (p<0.035), 54.5% clinical officer students always wiped the rubber

23
septum with alcohol prior to use, compared to 20% consultant anaesthesiologists, 33.3%
registered clinical officers and 23.1% registrars. There was no significance (p<0.5) with regard to
the different age groups.

5.3 Conduct of Anaesthesia With Regard to Infectious Diseases

The observation that 87.1% of anaesthesia providers administer anaesthesia while harboring an
infection of the respiratory tract is perhaps not surprising this however does not imply that the
practice results in transmission of the infection to the patient.

Among the participants, a significant 13.1% had never received any vaccination against HBV.
This is despite the knowledge that in terms of risk, HBV is the most important virus to which the
(51)
anaesthetist is exposed to, and it has long been associated with anaesthetic practice . The
recommended hepatitis B vaccine dosage for all healthcare workers at the Kenyatta National
Hospital is administered as a three-dose series on a 0, 1 and 6 month schedule.However, there
was a change in conduct when administering anaesthesia to a patient who is HIV positive or has
(54)
HB/CV (24.7% and 81.9%, respectively). The study by El Mikatti et al showed that most
anaesthetists have changed their practice in recognition of the risks from HIV and HB/CV (74%
(39)
and 68.8%, respectively). Tait & Tuttle reported a substantial alteration in practice by 58% of
anaesthetists in light of the AIDS epidemic, while practice was somewhat altered by 35.3%.

5.4 Cleaning and Disinfecting Anaesthetic Equipment

With respect to changing the patient’s disposable breathing circuit, Tait & Tuttle (39)reported that
88.4% of their respondents, compared with 24.7% in the present study, always changed it after
each patient use. The breathing circuit was changed at the end of the day by 31.8% of the
anaesthetists reporting in the present study compared with 3.2% in the North American study.
Most (68.2%) of the anaesthesia providers change the HME after each patient, 15.3% at the end
of the day . The filter was changed between cases by 7.2% of the respondents in the study by El
(54)
Mikatti et al. (UK), but it is likely that, in the years since the study was done, the use of
bacterial filters has increased.

24
Cleaning and sterilizing anaesthetic equipment is another issue of importance when it comes to
infection control. Guidelines for infection Control in Anaesthesiawere published by the
Association of Anaesthetists of Great Britain and Ireland (Appendix III).The CDC has also
published guidelines on procedures for disinfecting anaesthetic equipment. Both publications put
emphasis on items used in the respiratory tract, such as the anaesthesia breathing circuit, face
mask, laryngoscope blade, endotracheal tube, and oral airway, whichshould be disposed of after
use or else undergo high-level disinfection between patients.

CONCLUSION
1) The compliance of anaesthesia providers with healthcare – related personal hygiene in
most aspects is well below that which is recommended.

2) There is low compliance with regard to disinfection reusable anaesthetic equipment

3) Most anaesthetists are aware of the occupational hazards; however they do not strictly
follow the recommended universal guidelines for the prevention of occupational
transmission of infectious diseases

RECOMMENDATIONS

Anaesthetic department should have a written protocol for hygienic standards and discipline in
the operating theatres.

Appropriate training and education of all anaesthetic personnel should be done routinely.

Precautions against the transmission of infection between patient and anaesthetist or between
patients should be a routine part of anaesthetic practice. In particular, anaesthetists must ensure
that hand hygiene becomes an indispensable part of their clinical culture.

Anaesthetic equipment is a potential vector for transmission of disease. Policies should be

documented to ensure that recommended decontamination practices are followed and audited for
all reusable anaesthetic equipment.

25
STUDY LIMITATIONS
The study was carried out in only one hospital in Kenya; thus the results are not generalized to
the overall anaesthesiology practice in Kenyan hospitals.

There was potential for self report bias, this is because the study was based on self reporting
therefore dependent on the respondents’ honesty.

26
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32
APPENDICES
APPENDIX I: INFORMED CONSENT

ANAESTHESIOLOGY PRACTICE IN THE PREVENTION OF PERIOPERATIVE

TRANSMISSION OF INFECTION AT THE KENYATTA NATIONAL HOSPITAL

Introduction
I am Dr. Sheilla Nzioka, a third year resident in the Master of Medicine in Anaesthesia program
at The University of Nairobi. I am conducting a survey on anaesthesiology practice in the
prevention of perioperative transmission of infection at the Kenyatta National Hospital as part of
my post-graduate program requirements. I will strive to answer any queries that may arise before
and during the course of the intended study.

Purpose of the research

The objective of this survey is to determine the practice of anaesthesia providers in the
prevention of perioperative transmission of infection among anaesthesia providers at the
Kenyatta National Hospital

Research Intervention

This research will not involve any interventions

Participant selection

Consultant anaesthetists, registrars, registered clinical officers student clinical officers in the
department of anaesthesiology, Kenyatta National Hospital

Voluntary Participation

Your participation in this research is entirely voluntary. No monetary payment will be given or
asked for participating in this survey. You are free to withdraw from the study at any point
during the study without any adverse consequences to you.

33
Duration

The research is intended to take place over a period of six weeks. During that time questionnaires
will be administered to all consenting participants.

Risks

By participating in this research you will not be exposed to any risk.

Benefits

There are no known benefits from the study to the participants however knowledge gathered
will be helpful in understanding practice in the prevention of perioperative transmission of
infection at the Kenyatta National Hospital. The study findings will be presented to the
KNH/UON ethics and research committee and the department of anaesthesia and used to make
recommendations on prevention of perioperative infections.

Confidentiality

The information that I collect from this research project will be kept confidential. Any
information about you will have your initials to which a serial number will be assigned instead of
your name.

Whom to Contact

If you have any questions you may ask them now, during the period of the study or even after the
study is over. If you wish to ask questions later, please use the contacts below:

Dr. Sheilla Nzioka (Researcher) –0713737431tsheilla@yahoo.co.uk

Dr. Thomas Chokwe (Supervisor) –0722528237 tmchokwe@gmail.com

Dr. Charles Kabetu (Supervisor) – 0722512205 ckabetu@gmail.com

KNH/UON-ERCuonknh_erc@uonbi.ac.ke , www.uonbi.ac.ke/activities/KNHUoN

34
INFORMED CONSENT FORM

I have read the foregoing information. I have had the opportunity to ask questions about it and
any questions that I have asked have been answered to my satisfaction. I hereby consent to
participate in this research.

Serial no. of Participant:…………

Date: …………………….

Statement by the researcher

I confirm that the participant was given an opportunity to ask questions about the study, and all
the questions asked by the participant have been answered correctly and to the best of my ability.
I confirm that the individual has not been coerced into giving consent, and the consent has been
given freely and voluntarily.

Name of Researcher…………………………………………………….

Signature: …………………………..…. Date: ……………………

35
APPENDIX II:

QUESTIONNAIRE
Date………………

ANAESTHESIOLOGY PRACTICE IN THE PREVENTION OF PERIOPERATIVE

TRANSMISSION OF INFECTION AT THE KENYATTA NATIONAL HOSPITAL

These Questions Relate to the Anesthesiologist’s Role in Limiting the Transmission of Any
Type of Infectious Agent to the Patient
1. Bio data

a) Gender (please underline) i)male ii)female

b) Age (years) …………..
c) Cadre:
i) Consultant anaesthesiologist
ii) Registered clinical officer in anaesthesia
iii) Registrar in anaesthesia
iv) Clinical officer student in anaesthesia

2. How long have you been practicing in the field of anaesthesiology?

a) 0–5 years
b) 5–10 years
c) 10–15 years
d) > 15 years.

3. Do you always wear surgical masks?

a) Yes
b) No
c) On surgeon's request.

4. Do you always wear gloves?

a) Yes
b) No

36
 c) Change them between cases: Yes/No.

5. Do you wash your hands between cases?

a) Yes
b) No

6. Do you scrub before giving spinal or epidural (vs. wearing sterile gloves)?

a) No
b) Yes

7. Do you use aseptic technique when placing an indwelling cannula?

a) Never
b) Rarely
c) Frequently
d) Always.

8. Do you wipe the rubber septum of a multidose vial with alcohol prior to use?

a) Yes
b) No

9. Do you share syringes between multiple patients when administering drugs

a) Yes
b) No

10. Have you ever knowingly administered anaesthesia while infected with:

a) A respiratory infection (cold, influenza, etc.)

1. Yes
2. No

b) A gastrointestinal infection

37
11. Do you change your conduct if you know a patient is HIV positive?

a) Yes
b) No
Comments………….

12. Do you change your conduct if you know a patient has hepatitis B or C?

a) Yes
b) No
Comments………….

13. When did you last get vaccinated against Hepatitis B?

a)<1 year ago

b) 1-5 years ago

c)> 5yrs ago

d) Never

14. Do you change the patient's disposable breathing circuit?

a) After each patient

b) Only after infected or high-risk patient
c) At the end of the day
d) Both (b) and (c)
e) Other (please explain)

15. Do you change the patient’s HME?

a) After each patient

b) Only after infected or high-risk patient
c) At the end of the day
d) Both (b) and (c)
e) Other (please explain).

38
16. Do you try to maintain the tracheal intubation tube sterile?
a) Never
b) Rarely
c) Frequently
d) Always

17. Are laryngoscope blades cleaned/ disinfected?

a) After each patient
b) Only after an infected or high-risk patient
c) At the end of the day
d) Other (please explain).

18. How are laryngoscope blades usually cleaned/ disinfected?

a) Wiped with a clean cloth

b) Rinsed under running water
c) Washed with a soap and water
d) Wiped with an alcohol swab
e) Cleaned with disinfectant/germicidal agent

19. After administering anaesthesia, is the anaesthesia machine ever wiped

a) Never
b) Rarely
c) Frequently
d) Always.

20. On a scale of 0 (none) to 10 (significant), how do you perceive the anaesthetist's role in
transmission of infectious agents to the patient (please circle)?

None Significant

0 1 2 3 4 5 6 7 8 9 10

39
APPENDIX III: GUIDELINES
Infection Control in Anaesthesia
Association of Anaesthetists of Great Britain and Ireland

This is a consensus document produced by expert members of a Working Party established by

the Association of Anaesthetists of Great Britain and Ireland (AAGBI)

Summary
(1) A named consultant in each department of anaesthesia should liaise with Trust Infection
Control Teams and Occupational Health Departments to ensure that relevant specialist standards
are established and monitored in all areas of anaesthetic practice.
(2) Precautions against the transmission of infection between patient and anaesthetist or between
patients should be a routine part of anaesthetic practice. In particular, anaesthetists must ensure
that hand hygiene becomes an indispensable part of their clinical culture.
(3) Anaesthetists must comply with local theatre infection control policies including the safe use
and disposal of sharps.
(4) Anaesthetic equipment is a potential vector for transmission of disease. Policies should be
documented to ensure that nationally recommended decontamination practices are followed and
audited for all reusable anaesthetic equipment.
(5) Single use equipment should be utilized where appropriate but a sterile supplies department
(SSD) should process reusable items.
(6) An effective, new bacterial ⁄ viral breathing circuit filter should be used for every patient and
a local policy developed for the re-use of breathing circuits in line with manufacturer’s
instructions. The AAGBI recommends that anaesthetic departments should consider changing
anaesthetic circuits on a daily basis in line with daily cleaning protocols.
(7) Appropriate infection control precautions should be established for each anaesthetic
procedure, to include maximal barrier precautions for the insertion of central venous catheters,
spinal and epidural procedures and any invasive procedures in high risk patients.

Standard precautions
Precautions are recommended for all patients regardless of their diagnosis or presumed infectious
status and must be implemented when there is a possibility of contact with:

40
1 Blood.
2 All other body fluids.
3 Non-intact skin.
4 Mucous membranes.
Preventative measures should be based on the likelihood of an infectious agent being present, the
nature of the agent and the possibility of dispersion, e.g. splashing. A standard set of precautions
should be established for every invasive procedure (see below) with additional risk assessment of
each patient to determine extra and specific precautions that may be appropriate.

Hand hygiene
Anaesthetists must ensure that good hand hygiene becomes an indispensable part of their clinical
culture. Hand-mediated transmission is the major contributing factor to infection associated with
healthcare. Effective hand decontamination immediately before every episode of direct patient
contact will result in a significant reduction in the transfer of potential pathogens and a decrease
in the incidence of preventable HCAI At the start of every session, and when visibly soiled or
potentially contaminated, hands must be washed with liquid soap and water. When there is no
soiling, the Hand Hygiene Liaison Group advocates that staff should use an antimicrobial hand
rub between patients or activities as this is effective and quicker. Antimicrobial hand rub is not
effective in preventing cross infection with Clostridium difficile.
Gloves
Sterile gloves must be worn for invasive procedures and contact with sterile sites. Non-sterile
examination gloves must be worn for contact with mucous membranes, non-intact skin and all
activities that carry a risk of exposure to blood, body fluids, secretions and excretions. All blood
and body fluids, substances, secretions and excretions may be considered to be potentially
infective regardless of the perceived risk of the source. They should be put on immediately
before an episode of patient contact and removed as soon as the activity is completed, and before
contact with fomites, including curtains, pens, clinical notes, keyboards and telephones. Gloves
should be changed between patients and between different procedures on the same patient.

41
Facemasks
The use of facemasks to decrease the incidence of postoperative wound infection has been
questioned. However, masks with a face shield should be worn when there is a risk of blood,
body fluids, secretions and excretions splashing into the face and eyes. Masks must also be worn
by anaesthetists when carrying out a sterile procedure under full aseptic conditions. Correctly
fitting facemasks may also give some protection to the anaesthetist against inhaling infected
droplets from the respiratory tracts of patients with infectious respiratory diseases.
Theatre caps
Theatre personnel in most UK operating theatres wear disposable headgear although there is
little evidence for the effectiveness of this practice except for scrub staff in close proximity to the
operating field. However, theatre caps should be worn in laminar flow theatres during prosthetic
implant operations.
Theatre suits and gowns
The skin of staff working in the operating theatre is a major source of bacteria that have the
potential for being dispersed into the air. Clean theatre suits should be available for all staff in
theatre. Full body, fluid-repellent gowns should be worn where there is a risk of extensive
splashing of blood, body fluids, secretions and excretions.
Sterile gowns should be worn when invasive procedures are undertaken. Disposable plastic
aprons are often worn on wards in situations where there is a risk of physical soiling of clothing
in order to prevent transmission of infection between patients
Shoes and overshoes
Special footwear should be worn in the operating department and cleaned if contaminated or
after every use. Trusts should ensure that a system for cleaning theatre footwear is in place in
each theatre suite. Plastic overshoes may increase bacterial contamination of floors and, in
addition, hands become contaminated when overshoes are put on or removed. Their use is not
recommended.
Movement within the theatre complex
To reduce airborne contamination, general traffic in and out of the operating theatre itself should
be kept to a minimum. Doors should be kept closed to ensure the efficiency of the ventilation
system. Moving patients on their beds into the operating theatre may increase the bacterial count

42
on floors. The use of separate trolleys from ward to transfer area and transfer area to table has
not been shown to have benefit although this practice continues in many operating areas.
Order of patients
There should be a written hospital policy requiring accurate printed theatre lists to be available
prior to the scheduled date. ‘Dirty cases’, i.e. patients likely to disperse microbes of particular
risk to other patients, should be identified before surgery and theatre staff should be notified.
These patients should be scheduled last on an operating list to minimize risk. Where this is not
possible, the Hospital Infection Society (HIS) advises that a
Plenum-ventilated operating theatre should require a minimum of 15 min before proceeding to
the next case after a ‘dirty’ operation. Appropriate cleaning of the operating theatres between all
patients should be undertaken. Whenever there is visible contamination with blood or other body
materials, the area must be disinfected with sodium hypochlorite (according to local protocols)
and then cleaned with detergent and water. Floors of the operating room should be disinfected at
the end of each session.
Safe use and disposal of sharps
• Sharps must not be transferred between personnel and handling should be kept to a minimum.
• Needles must not be bent or broken prior to use or disposal.
• Needles and syringes must not be disassembled by hand prior to disposal.
• Needles should not be recapped or resheathed.
• Used sharps must be discarded into an approved sharps container at the point of use.
• The sharps container should be sealed and disposed of safely by incineration when about two-
thirds full or in use for more than four weeks, whichever is sooner
• Blunt aspirating needles should be used for drawing up drugs.
Preventing contamination of drugs
Syringes and needles are sterile, single-use items and, after entry or connection to a patient’s
vascular system or attachment to infusions, a syringe and needle should be considered
contaminated and used only for that patient. A syringe must not be used for multiple patients
even if the needle is changed. Before use, prepared syringes and needles should be stored in a
clean container and syringes capped to avoid contamination.
After use or at the end of the anaesthetic, all used syringes with needles should be discarded into
an approved sharps container. Care must be taken when drawing up drugs. Single use ampoules

43
should be discarded after the required amount of drug is drawn up and not re-used for subsequent
patients. Ampoules can be kept for identification purposes and discarded at the end of the list.
Multiple-use ampoules are not recommended.
All infusions, administration sets or items in contact with the vascular system or other sterile
body compartments are for single-patient use. An aseptic technique should be used when
preparing infusions and breaks ⁄ taps in lines should be kept to a minimum. Injection ports should
be maintained with a sterile technique, kept free of blood and covered with a cap when not in
use.
Connections and injection ports in intravenous lines should be kept to a minimum. Three-way
taps should be avoided if practicable..
Anaesthetic equipment and infection control
Items of anaesthetic equipment may become contaminated either by direct contact with patients,
indirectly via splashing, by secretions or from handling by staff.
Contamination is not always visible and all used pieces of equipment must be assumed to be
contaminated and disposed of or, if reusable, undergo a process of decontamination. There is a
need to designate a person who is responsible for ensuring equipment cleanliness
Single-use equipment
Where appropriate, single-use disposable equipment will remove the difficulties of re-use and
decontamination procedures. The use of such equipment is to be encouraged. However, there are
problems of cost, storage and disposal of single-patient use devices and for some equipment
there is no feasible disposable alternative.
Packaging should not be removed until the point of use for infection control, identification,
traceability in the case of a manufacturer’s recall, and safety.
Decontamination
Decontamination is a combination of processes including cleaning, disinfection and ⁄ or
sterilisation used to make a re-usable item safe to be handled by staff and safe for further use on
patients. Effective decontamination of re-usable devices is essential in reducing the risk of
infection. It is recommended that each department identifies a designated consultant who, in
conjunction with the appropriate bodies in their Trust, will develop specific guidelines for
anaesthetic practice which satisfy national recommendations and that these practices are audited
on a regular basis.

44
Decontamination processes
Cleaning – removal of foreign material from an item. This usually involves washing with a
detergent to remove contamination followed by rinsing and drying. All organic debris, e.g.
blood, tissue or body fluids, must be removed before disinfection or sterilisation, as its presence
will inhibit disinfectant or sterilant from contacting microbial cells
Low Level Disinfection – kills most vegetative bacteria (except TB and endospores), some fungi
and some viruses using disinfectants such as sodium hypochlorite, 70% alcohol and
chlorhexidine.

High Level Disinfection – kills vegetative bacteria (not all endospores), fungi and viruses. With
sufficient contact time (often several hours), these high level disinfectants may produce
sterilisation, e.g. the use of aldehydes, peracetic acid and chlorine dioxide.
Sterilisation – A process used to render an object free from viable micro-organisms, including
all bacteria, spores, fungi and viruses, with techniques such as autoclaving.

Risk assessment
The choice of equipment and ⁄ or the level of cleanliness ⁄ disinfection ⁄ sterility required of re-
usable items may be assessed against the risk posed to patients of transmission of infection
during any procedure in which the equipment is employed. It has been proposed by the MHRA
Microbiology Advisory Committee that three levels should be considered:
1 High Risk – the device will penetrate skin or mucous membranes enter the vascular system or a
sterile space – these devices require sterilisation.
2 Intermediate Risk – the device will be in contact with intact mucous membranes or may
become contaminated with readily transmissible organisms – these devices require high level
disinfection or sterilisation.
3 Low Risk – the device contacts intact skin or does not contact patient directly – these devices
require low level disinfection or cleaning.

45
Infection control policy
Anaesthetic face masks
These items are frequently contaminated by secretions from patients and have been implicated in
causing cross infection .These items should be single-use.

Airways and tubes

Oral airways, nasal airways and tracheal tubes should be of single-use type since they readily
become contaminated with transmissible organisms and blood . Ideally, supraglottic airways
should be of the single patient use type but the re-usable design is in common use and many
anaesthetists perceive it as being less traumatic. Therefore, a supraglottic airway designed for
repeated use should be sterilised no more often than the manufacturer recommends. A
supraglottic airway used for tonsillectomy or adenoidectomy should not be used again. The
AAGBI recommends single-use supraglottic airways.

Catheter mounts – angle pieces

It is recommended that these items are single-patient use type.

Anaesthetic breathing systems

The AAGBI has previously recommended that ‘an appropriate filter should be placed between
the patient and the breathing circuit (a new filter for each patient)’

Anaesthetic machines
Routine daily sterilisation or disinfection of internal components of the anaesthetic machine is
not necessary if a bacterial ⁄ viral filter is used between patient and circuit. However,
manufacturers’ cleaning and maintenance policies should be followed, and bellows,
unidirectional valves and carbon dioxide absorbers should be cleaned and disinfected
periodically. All the surfaces of anaesthetic machines and monitors should be cleaned on a daily
basis with an appropriate disinfectant or immediately if visibly contaminated.

46
Laryngoscopes
Blades are regularly contaminated with blood, indicating penetration of mucous membranes,
which places these items into a high-risk category. Proper cleaning of laryngoscope blades is of
great importance before decontamination ⁄ sterilisation, particularly of residue around light
sources or articulated sections. Although repeated autoclaving may affect the function of
laryngoscopes, the Working Party recommends that re-usable laryngoscope blades should be
sterilised by an audited SSD between patients, following the manufacturers’ instructions.
There are an increasing number of inexpensive, single use laryngoscope blades and handles of
improving design available, and their use is to be encouraged.
Traditional blades should be available at all times in case difficulty is encountered.
Laryngoscope handles also become contaminated with micro-organisms and blood during use,
and they should be washed ⁄ disinfected and, if suitable, sterilised by SSDs after every use.
Anaesthetists should wear gloves during intubation and place used instruments in a designated
receptacle to prevent contamination of surfaces, pillows and drapes.

Bougies
Re-use of these items has been associated with cross infection. Manufacturers recommend that a
gum elastic bougie may be disinfected up to five times between patients and stored in a sealed
packet. It is preferable that alternative single-use intubation aids are employed when possible.

Surfaces
The surfaces of anaesthetic machines and monitoring equipment, especially those areas which
are likely to have been touched by the gloved hand that has been in contact with blood or
secretions, should be regarded as contaminated and should be cleaned at the earliest opportunity,
probably between patients. Local policies should be in place to ensure that all equipment that
touches intact skin, or does not ordinarily touch the patient at all, is cleaned with a detergent at
the end of the day or whenever visibly contaminated. This includes non-invasive blood pressure
cuffs and tubing, pulse oximeter probes and cables, stethoscopes, electrocardiographic cables,
blood warmers etc., and the exterior of anaesthetic machines and monitors. Items such as
temperature probes should be for single patient use.

47
Oxygen masks and tubing
Single-patient use products should be used.

Resuscitation equipment
Single-patient use equipment should be kept in a sealed package or should be resterilised
between patients according to the manufacturer’s instructions. All training equipment should be
handled similarly.

Infection control precautions for anaesthetic procedures

Carrying out procedures in an operating theatre does not pose a lower risk of infection than other
hospital locations and the risk of infection depends on the procedure and on the level of barrier
protection rather than the surrounding environment

Maximal barrier precautions

Maximal barrier precautions involve full hand washing, the wearing of sterile gloves and gown, a
cap, mask and the use of a large sterile drape. The skin entry site should be cleaned with an
alcoholic chlorhexidine gluconate solution or alcoholic povidone-iodine solution .The antiseptic
should be allowed to dry before proceeding.
Certain invasive anaesthetic procedures require this optimum aseptic technique:
• Insertion of central venous catheters.
• Spinal, epidural and caudal procedures.

Other barrier precautions

Certain invasive procedures do not require full barrier precautions as above but nevertheless
demand appropriate aseptic techniques. Such precautions involve the wearing of sterile gloves
and use of small drapes, although similar attention is required to hand washing and skin
preparation.
These procedures include:
• Peripheral regional blocks.
• Arterial line insertion.

48
Peripheral venepuncture or intramuscular injection in low-risk patients will involve hand
washing, non-sterile gloves and skin preparation with propyl alcohol. Peripheral intravenous
catheters are a significant source of nosocomial bacteraemias and care is required.

High-risk patients
Certain patients may be especially vulnerable to infection, e.g. the immunocompromised, or offer
particularly high risk of transmitting infection, e.g. tuberculosis and HIV. For the
immunocompromised, maximal barrier precautions are required for all invasive procedures and
similarly, where there is a high infection risk, staff should concentrate not only on preventing
cross-infection between patients but in protecting themselves by ensuring compliance with all
precautions.

49
APPENDIX IV: ETHICAL APPROVAL FROM KNH/UON ERC

50
51
APPENDIX V: DECLARATION OF ORIGINALITY FORM

52