gms | German Medical Science

The vast field of anesthesia with its manifold tasks means that inevitably a range of diverse approaches are taken to infection prophylaxis. Set against a background where the prime focus is on the preservation of vital functions, infection control measures are assigned a minor role. It is alarming when anesthetists in a recent survey [1], just as in earlier years, were seen to be the specialists with the poorest rate of compliance with simple, really everyday rules of hygiene. This study had assessed activities carried out by doctors on patients and the associated infection control measures based on published guidelines in the light of conductance of obligatory measures such as hygienic hand disinfection or the wearing of gloves. With an average rate of 57% for hand disinfection in mandatory situations, also in the presence of known resistant bacteria, anesthetists scored only 23%. Why is that so?

The earlier guidelines governing infection control behavioral mechanisms advocated “hand washing” as a necessary measure. It is above all the anesthetist in the operating theater who cannot turn away from the patient following contamination in order to go to a washbasin situated outside the OR and spend the time there it takes to wash his hands. However, alcoholic products for hygienic hand disinfection are today standard practice and can be used in situ without a washbasin. The argument about the lack of facilities is generally no longer valid today. Likewise, the problem of skin irritation and drying is generally not a problem either since the incorporation of remoisturizing agents. And especially in the case of soap and also of alcohol, the mean exposure times at between 6 and 15 seconds, as borne out by studies, are relatively short for assured efficacy.

So if it is not the lack of facilities that is stopping anesthetists from taking hygienic measures, what is it then?

Unfortunately, infection prophylaxis is something to which the physician ascribes importance only when he sees the consequences of his actions, that is to say when he has to diagnose and treat infections in “his” patient as a result of his “failure” to adhere to infection control regulations. In intensive care medicine the implications of such experiences have been known for a long time now. The anesthetist in the intensive care unit, for example, admits a young, healthy but polytraumatized patient to his unit. Just a few days later he must concede that this patient who “only” suffered from tissue contusion and blood loss that warranted treatment, is now suddenly suffering from pneumonia that is posing a threat to this lung function. He treats the patient with antimicrobial chemotherapy. But soon the patient is exhibiting the entire clinical manifestations of sepsis. And it is not at all uncommon that colonization or infections with the same bacterium, which today will prove in most cases to be resistant to antibiotics, is seen in the immediate vicinity of this index case. Consistent infection control measures have not been taken at the bedside; this highlights the need for enlightenment and education of staff and serves as the basis for their involvement. In the past this was used, and even today is still used, as a motivation for hand disinfection.

Such measures can be taken much less easily in emergency medicine outside the hospital setting and in anesthesia in the operating theatre. The team treats the patient only for a very short period of time, ranging from minutes to a few hours, and then loses sight of the patient again. Rarely does the physician see how things turn out for the patient. Errors in infection prophylaxis relating to disinfection, in handling infusion solutions, dealing with arterial and central venous catheters do not have any perceptible consequences. “The threat posed to vital functions does not allow any time” said the emergency doctor. Often, there is a lack of facilities here, too. While there are gloves available, they are worn then to perform clean and unclean tasks on the patient without being changed, and thus ineffective. However, somewhere in the emergency chest there is a small bottle of alcoholic hand disinfectant. But in the concrete situation it cannot be reached. ”During the time elapsing from first administering the anesthetic until full narcosis is reached or in the case of intrasurgical bleeding, I’m feeling stressed and then have no time for hygiene” admits the anesthetist in the OR. Any danger posed to the patient, whose immune system has now been compromised by the operation, is viewed as a distant, theoretic and unimportant threat.

To improve this situation, the root cause of ignorance and thoughtlessness as regards hygiene must be addressed at present and in the future. Apart from general training and continuing education for correct conductance of hygienic measures and regarding the consequences of failure to observe the guidelines, the individual aspect of motivation must be addressed. Each individual professional administering treatment makes a difference for the patient. Each head physician and medical director makes a difference to the behavior of future anesthetists by acting as a role model. And within the hospital system the factors “overburdened personnel and time pressure” as the cause of inappropriate infection control must be clear. Today hygiene does not merely denote “clean working practices” and reduced patient morbidity. Today reduced infection rates mean reduced costs in the healthcare section and hence reserves for the future care of the population Today we know that hygienic practices when attending to the patient are not an onerous burden but that they pay off. We must only get around to implementing them.

Figure 1 [Fig. 1]

Specialist for Anaesthetics and General Intensive Care Medicine, sports physician, emergency doctor.

Werner Lingnau was reading medicine at the Leopold Franzens University in Innsbruck in Austria. 1983 her received his doctorate and started his education at the University Clinic for Anaesthetics and Intensive Care to become a specialist. For several months he moved to the „Onze Lieve Frowe Gasthuis” Clinic in Amsterdam to work with CP Stoutenbeek and then to the University of Texas (Medical Branch).

During his anaesthetical work Professor Lingnau became member of the Antibiotics Committee and the Drug Committee for all of the University clinics, furthermore Commissioner for Hygiene of the University Clinic for Anaesthetics and General Intensive Care Medicine in 1991. In this role he gets his hygiene education at the Royal College of Surgeons and at the King’s College Hospital in London.

1998 he habilitates in the special subject of Anaesthetics and General Intensive Care Medicine and receives the Venia legendi.

A lot of publications, articles for books, abstracts and 138 national and international „invited lectures” on the subjects of trauma, sepsis, multi-organ-collapse and infection prevention give proof of this wide range of competence.