Participants should be able to: -Apply infection control principles to protect themselves and their patients -Select anesthesia equipment and supplies that reduce vulnerability to supply chain interruptions during a pandemic

1. © U N I V E R S I T Y O F U T A H H E A L T H
INFECTION CONTROL CONSIDERATIONS
FOR COVID-19: LESSONS LEARNED
HARRIET W. HOPF, MD
PROFESSOR OF ANESTHESIOLOGY & BIOENGINEERING
UNIVERSITY OF UTAH
66th Annual Update in Anesthesiology February 2021

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DISCLOSURES
• Paid consultant for Ambu, Inc., which
manufactures anesthesia circuits and filters

3. © U N I V E R S I T Y O F U T A H H E A L T H
LEARNING OBJECTIVES
• Participants should be able to:
– Apply infection control principles to
protect themselves and their
patients
– Select anesthesia equipment and
supplies that reduce vulnerability to
supply chain interruptions during a
pandemic

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HISTORY OF INFECTION CONTROL
Alexander JW. Ann Surg 201:423-428, 1985

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THE CHALLENGE
Alexander JW. Ann Surg 201:423-428, 1985

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PROGRESS
• HAI prevalence
– 2011: 4.0%
– 2015: 3.2%
• SSI & UTI
Zimlichman et al. JAMA Intern Med. 173:2039-46, 2013.
Magill et al. NEJM 379:1732-44, 2018.

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PRESENT DAY
• Persistent focus on better antisepsis
– Small potential incremental impact
– Drives use of single use disposables
• Introduced w/o evidence of benefit
• Distracts from higher yield approaches
– Strengthen host defenses
– Non-scrubbed personnel actions to
reduce cross-transmission
Hopf, et al. Inflammation, Wound Healing, & Infection. In Barash P,
et al. (Eds.), Clinical Anesthesia 8th
Edition

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HIGH YIELD APPROACHES
• Clean hands
• Clean work area
• Clean medications & administration
• Antibiotics
• Attention to physiology
http://jamanetwork.com/journals/jamasurgery/fullarticle/2623725

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AND THEN CAME COVID-19
• COVID-19 pandemic reframed:
– patient safety patient & personal safety
• Increased focus on PPE & prevention
of cross-transmission may have side
benefits on HAI & public health
– Will impact be sustained long term?

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LESSONS FROM COVID-19

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PUBLIC HEALTH MEASURES WORK
Influenza-Associated Hospitalization
Weekly Incidence Rate- Utah
https://www.cdc.gov/flu/weekly/index.htm
https://bit.ly/2MLRjv9

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INTUBATION BOXES…
Dr. Hsien Yung Lai

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INTUBATION BOXES…DON’T
https://www.fda.gov/media/141415/download

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MORE AEROSOLS, MORE DIFFICULT INTUBATION
https://doi.org/10.1111/anae.15188

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ANESTHESIA CIRCUIT FILTERS
• Protect machine, patient, and personnel from
respiratory organisms
• Both electrostatic & mechanical pleated are effective
• Viral/Bacterial Filtration Efficiency: % blocked or
captured
– VFE >99.99% = 1 particle in 10,000 will pass through
– Filters in series increase both efficiency & resistance
• Heat & Moisture Exchangers are not filters, but can be
combined with filters
• Standard High Efficiency Particulate Airway (HEPA)
filters block 0.3 micron particles (99.97% efficiency)
https://www.apsf.org/faq-on-anesthesia-machine-use-protection-and-
decontamination-during-the-covid-19-pandemic/

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FILTER PLACEMENT
https://www.apsf.org/faq-on-anesthesia-machine-use-protection-and-
decontamination-during-the-covid-19-pandemic/

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PPE: LEVELS OF PROTECTION
• Blood and body fluids
– Hand hygiene
– Gloves
– Surgical mask
– Eye protection
– (Gown)
• Aerosol-generating
– Respirator mask (N95, PAPR, CAPR, elastomeric)
https://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/standard-precautions.html

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RESPIRATOR MASKS
• Good seal required
• Formal fit testing for each
brand / model annually
– Up to 10% fail the next year
• Seal check required each time
a respirator mask is donned
https://blogs.cdc.gov/niosh-science-blog/2020/03/16/n95-preparedness/

19. © U N I V E R S I T Y O F U T A H H E A L T H
WHEN IS A RESPIRATOR MASK REQUIRED?
• Patients w/ known or suspected COVID-19
• When you are (potentially) exposed to
aerosols
– Extubation, aerodigestive cases, intubation,
suctioning, supplemental oxygen, coughing
• Recommendations continue to evolve:
– PPE supply
– Data on modes of transmission
– Prevalence

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WHY DO I WEAR AN N95 ALL DAY IN THE OR?
• While all patients are tested:
– Test is single point in time
– False positives
• Rapid test designed to detect symptomatic infection
– High local prevalence (15-20% + tests)
– Some HCW to HCW transmission
• More convenient than storing
– Top of head / around neck facilitate cross-transmission

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What caused PPE shortages?

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INCREASING RELIANCE ON SINGLE USE DISPOSABLES
• Perception of reduced infection risk
– Evidence does not support perception
• Perception of reduced cost
– Per unit acquisition lower; more expensive long term
• Reduced institutional complexity
– No need to staff & manage cleaning & storage
– Lack of existing reprocessing facilities & lack of space
• Reduced liability from human error
• Reduced chance of accreditor citation
• More profitable for manufacturers
– Default is SUD
– Reprocessing not considered in design
MacNeill, Hopf, et al. Health Affairs 2020; doi: 10.1377/hlthaff.2020.01118

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COVID-19 & LINEAR SUPPLY CHAIN VULNERABILITY
• PPE demand skyrocketed
• Just-in-time supply ran out
quickly & could not be
replenished
– Resource delivery,
manufacturing, & product
shipment all interrupted and
delayed
https://www.uschamberfoundation.org/blog/post/circular-
economy-toolkit-small-businesses

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RESPONSE TO DISRUPTION: CIRCULAR ECONOMY
• Emphasis on cloth &
surgical masks
• Prolonged use, re-use, &
reprocessing of PPE
• Transition to reusables
• Expansion of local
manufacturing capacity
• Innovation
– Elastomeric masks
– Snuba masks

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IMPLICATIONS FOR THE FUTURE
• U.S. Healthcare industry:
• 8% of US greenhouse gas emissions
• 5.9 million tons solid waste/year; ~1/3 from OR
• Public health harm equivalent to that of medical errors
• SUDs increase resource use, pollution, & waste
• Climate change likely to cause more frequent
disruption of linear supply chains
• Transition to more circular economy will reduce
environmental impact, cost, & vulnerability of supply
chain
@ H a r r i e t H o p f M D # c l i n i c a l l y s u s t a i n a b l e
Chung & Meltzer, JAMA 302 (18): 1970-2; 2009
Eckelman & Sherman PLoS ONE 2016; 11: e0157014
Eckelman & Sherman Am J Public Health 2018; 108:S120-S122

26. © U N I V E R S I T Y O F U T A H H E A L T H
SUMMARY
• Infection control measures have dual benefit in
protecting both patients & health care professionals
• Single-use disposables have few advantages, but
increase cost, environmental impact, and supply
chain vulnerability
• Reversion to a more circular economy requires
commitment, regulatory changes, and more
comprehensive assessment of costs & benefits
– The COVID-19 pandemic underscored the importance
and urgency of this effort