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Dyeing to Find Out How an “AWEsim” Bundle Can Impact Anesthesia Work Environment Contamination

Simpao, Allan F. MD, MBI*; Rehman, Mohamed A. MD

doi: 10.1213/ANE.0000000000003323
Editorials: Editorial

From the *Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania

Department of Anesthesiology, Johns Hopkins All Children’s Hospital, St Petersburg, Florida.

Accepted for publication January 30, 2018.

Funding: Departmental.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Allan F. Simpao, MD, MBI, Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, and Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104. Address e-mail to

In this issue of Anesthesia & Analgesia, Porteous et al1 present a novel prospective study of how the implementation of an “AWEsim” (Anesthesia Work Environment Simulation) infection prevention bundle reduced anesthesia work environment contamination in a simulation setting.

Health care–associated infections remain a significant cause of patient morbidity and mortality despite local and national efforts to identify and address sources of contamination.2 Recently published studies have shed light on the contamination that occurs in the anesthesia work environment and interventions such as sheathing the laryngoscope and wearing 2 sets of gloves have been suggested to reduce contamination.3,4 Meanwhile, bundling of evidence-based interventions has been shown to reduce health care–associated infections in a variety of health care settings.5–8 The authors should be commended for prospectively measuring the impact of an intervention bundle on anesthesia work environment contamination, as there exists scant research on this phenomenon.

The authors explored the impact of an intervention bundle in the safe, controlled environment of a simulation setting. The nonrandomized simulation scenario, crossover design study was thoughtfully designed and well conducted, with a diverse group of anesthesia provider subjects and a relevant application of the dye detection process that has been described in previous studies.2,3,9 The bundle included evidence-based practices that have been shown to reduce contamination: double gloving before intubation, confining airway equipment to a single area, and increased hand hygiene.2,3,10 The study’s major finding was that after establishing a baseline contamination rate in 1 simulation scenario, the use of the intervention bundle in a second scenario reduced anesthesia work environment contamination by 27%.

Porteous et al1 state clearly the limitations of their study. Clinicians’ behavior certainly differs in the simulated environment, and the inorganic tracer that the authors used to measure contamination does not behave exactly like a pathogenic organism would in an actual anesthesia work environment. Subjects were not randomized to start with the intervention scenario because of the risk of informing their behavior; the authors admit that a parallel group study design would have been more appropriate to control for this confounder. However, the study’s methodology leaves key questions unanswered. Keyboards and smartphones are a major source of contamination and health care–associated infections, yet the authors did not incorporate them into their study.11,12 Furthermore, what are the real-world practices of anesthesia providers while in the operating room? What is the true biological contamination rate of the anesthesia work environment during actual clinical practice? What impact does an infection control bundle have in a real-world anesthesia work environment? How would one implement and sustain such an effort? And most of all, what impact does an infection control bundle have on actual health care–associated infections?

There certainly exists a chasm between Porteous et al’s1 findings and a sustained, positive impact of an “AWEsim” bundle on health care–associated infections. What message can clinicians take from Porteous et al’s1 report of their “AWEsim” findings? How can anesthesia providers improve their own infection control practices at their institutions? Most clinicians have neither the time nor resources to conduct a sophisticated simulation study across their anesthesia group as Porteous et al1 did. However, all providers can take the time to examine their own approach to infection control and improve their understanding of the dynamics and implications of contamination in the anesthesia work area.13 Emulating the authors by implementing a similar bundle in daily practice does not seem out of the question for most anesthesia practices. Double gloving, improved hand hygiene, and designated airway equipment areas are relatively easy to implement. Other measures, such as covering the anesthesia workspace with a physical barrier, might be useful additions to a bundle aimed to reduce health care–associated infection rates by decreasing the initial contamination after airway management.14 Addressing the issue of health care–associated infections requires a systematic, institution-wide approach, and all anesthesia providers who wish to provide optimal patient care should question how their own clinical practices might contribute to this complication.

While Porteous et al’s1 study leaves many relevant clinical questions unanswered, the study still serves as an encouraging stepping stone toward future efforts designed to answer these questions. The study provides powerful visual evidence of the impact that anesthesia providers’ poor adherence to infection control practices can have on contamination in their work environment. That this contamination occurred in a simulation setting—where providers might exhibit greater nonchalance in their approach to hygiene—does not render the study’s findings clinically irrelevant. Porteous et al’s1 findings highlight the danger of such laxity in a real-world setting, and the potential positive impact that a bundle of infection control practices might have on a lackadaisical approach to contamination in the anesthesia work environment.

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Name: Allan F. Simpao, MD, MBI.

Contribution: This author helped write the article.

Name: Mohamed A. Rehman, MD.

Contribution: This author helped write the article.

This manuscript was handled by: Maxime Cannesson, MD, PhD.

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1. Porteous GH, Bean HA, Woodward CM, et al. A simulation study to evaluate improvements in anesthesia work environment contamination after implementation of an infection prevention bundle. Anesth Analg. 2018;127:662–670.
2. Bratzler DW, Hunt DR. The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery. Clin Infect Dis. 2006;43:322–330.
3. Birnbach DJ, Rosen LF, Fitzpatrick M, Carling P, Arheart KL, Munoz-Price LS. Double gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the operating room. Anesth Analg. 2015;120:848–852.
4. Birnbach DJ, Rosen LF, Fitzpatrick M, Carling P, Arheart KL, Munoz-Price LS. A new approach to pathogen containment in the operating room: sheathing the laryngoscope after intubation. Anesth Analg. 2015;121:1209–1214.
5. Pellegrini JE, Toledo P, Soper DE, et al. Consensus bundle on prevention of surgical site infections after major gynecologic surgery. Anesth Analg. 2017;124:233–242.
6. Pincock T, Bernstein P, Warthman S, Holst E. Bundling hand hygiene interventions and measurement to decrease health care-associated infections. Am J Infect Control. 2012;40:S18–S27.
7. Clarke K, Tong D, Pan Y, et al. Reduction in catheter-associated urinary tract infections by bundling interventions. Int J Qual Health Care. 2013;25:43–49.
8. Bert F, Giacomelli S, Amprino V, et al. The “bundle” approach to reduce the surgical site infection rate. J Eval Clin Pract. 2017;23:642–647.
9. Birnbach DJ, Rosen LF, Fitzpatrick M, Carling P, Munoz-Price LS. The use of a novel technology to study dynamics of pathogen transmission in the operating room. Anesth Analg. 2015;120:844–847.
10. Loftus RW, Muffly MK, Brown JR, et al. Hand contamination of anesthesia providers is an important risk factor for intraoperative bacterial transmission. Anesth Analg. 2011;112:98–105.
11. Fukada T, Iwakiri H, Ozaki M. Anaesthetists’ role in computer keyboard contamination in an operating room. J Hosp Infect. 2008;70:148–153.
12. Brady RR, Wasson A, Stirling I, McAllister C, Damani NN. Is your phone bugged? The incidence of bacteria known to cause nosocomial infection on healthcare workers’ mobile phones. J Hosp Infect. 2006;62:123–125.
13. Loftus RW, Koff MD, Birnbach DJ. The dynamics and implications of bacterial transmission events arising from the anesthesia work area. Anesth Analg. 2015;120:853–860.
14. Hunter S, Katz D, Goldberg A, et al. Use of an anaesthesia workstation barrier device to decrease contamination in a simulated operating room. Br J Anaesth. 2017;118:870–875.
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