Editor—A recent review in the British Journal of Anaesthesia described the impact of optimised, basic intraoperative infection control measures.1 Feedback is a critical implementation feature for prevention of bacterial transmission and associated surgical site infections,2 , 3 but the importance of feedback for viral pathogens is unknown. We have observed a low rate of Staphylococcus aureus [0% (0/108)] and severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) transmission [1% (1/108)] after implementation of recommended anaesthesia work area infection control measures.1, 2, 3, 4, 5 Residual contamination of operating room environmental sites other than the anaesthesia machine occurring after surface disinfection (13.5% without and 5.6% with ultraviolet irradiation-C [UV-C]) indicated a need for improvement.4 We aimed to assess residual environmental SARS-CoV-2 contamination with and without UV-C after implementation of feedback.1, 2, 3, 4
A post-implementation study involving 31 patients positive for SARS-CoV-2 within 90 days of surgery (Table 1 , baseline characteristics) was initiated 3 months after baseline analysis (November and December 2020) and completed over 4 months (March 24 to July 27, 2021) at the University of Iowa (Study Timeline, Supplementary Fig. S1).4 The study was approved by the Institutional Review Board (202005391) without requirement for informed, written patient consent, and was registered at clinical trials.gov (NCT04443803). We chose 90 days to study viral transmission because patients can remain positive or become re-infected for up to 90 days after diagnosis.6, 7, 8
Table 1.
Baseline characteristics of operating room environments.
| Characteristic | Baseline∗ (n=11) | After (n=31) | More cases with characteristic | Most cases without characteristic |
|---|---|---|---|---|
| Acute infection, n (%) | 5 (45) | 9 (29) | After (9 vs 5) | After (22 vs 6) |
| Vaccinated, n (%) | 0 (0) | 6 (19) | After (6 vs 0) | After (25 vs 11) |
| Age <18 yr | 0 (0) | 2 (6) | After (2 vs 0) | After (29 vs 11) |
| Age ≥50 yr | 7 (64) | 12 (39) | After (12 vs 7) | After (19 vs 4) |
| Age ≥65 yr | 4 (36) | 7 (23) | After (7 vs 4) | After (24 vs 7) |
| Female, n (%) | 7 (64) | 11 (35) | After (11 vs 7) | After (20 vs 4) |
| General anaesthesia, n (%) | 8 (73) | 29 (94) | After (29 vs 8) | After (3 vs 2) |
| Negative pressure OR, n (%) | 5 (45) | 10 (33) | After (10 vs 5) | After (21 vs 6) |
| Case duration ≥2 h | 6 (55) | 20 (65) | After (20 vs 6) | After (11 vs 5) |
| Case duration ≥3 h | 2 (18%) | 13 (42) | After (13 vs 2) | After (18 vs 9) |
∗Results published.4 Acute, ≤days from time of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) positivity to surgery.
Recommended infection control procedures were implemented in March 2020 (Perioperative COVID-19 Defense Strategy, https://vimeo.com/409005129/4e1f2a0711) for all operating rooms (ORs), and (UV–C; Helios, Surfacide, Waukesha WI, USA) was implemented for ORs exposed to patients with COVID-19 (Supplementary material).1, 2, 3 , 9, 10, 11, 12, 13, 14, 15, 16
The epidemiology of intraoperative SARS-CoV-2 transmission (Table 1) was observed in 11 ORs after implementation.4 Vascular care, hand hygiene, and anaesthesia machine cleaning procedures were implemented effectively based on a low S. aureus (<12.5%) and viral transmission rate.5 In contrast, there were many environmental sites with residual SARS-CoV-2 detection (Supplementary Table S2).4 There were multiple meetings with the anaesthesia department, perioperative medicine leadership, and environmental services leadership throughout February 2021 regarding the overall magnitude and locations of intraoperative environmental SARS-CoV-2 contamination.
Wipes prepared manually during the acute COVID-19 period via the addition of hydrogen peroxide (Oxivir Tb; Diversey, Fort Mill, SC, USA), an N-alkyl compound (Virex plus, Diversey), or an N-alkyl compound with one type of alcohol (Asepticare Tb + II; Ecolab, St. Paul, MN, USA) solutions to dry wipes were replaced by February 2021 with surface disinfection wipes containing didecyl dimethyl ammonium chloride along with ethyl and isopropyl alcohol (Sani-Cloth Prime Germicidal Wipe; PDI, Woodcliff Lak, NJ, USA).1, 2, 3 Wipes were used for routine between-case and terminal cleaning of the anaesthesia cart, equipment, surgical bed, mattress, and siderails, as supported by clinical trial results and reviews.2 , 17 , 18
The primary outcome was SARS-CoV-2 nucleic acid detection in frequently contaminated environmental sites after cleaning (after surface disinfection and after UV-C) including the top of the anaesthesia cart, anaesthesia cart handles, anaesthesia provider computer mouse, suction canister, circulating nurse computer mouse, surgical bed side, air return registers, walls, and floor at base of the bed.4 , 19 We also evaluated for viral infectivity by culture. Sample size was based on baseline viral detection results: 17/126 (13.5%) without vs 6/108 (5.6%) with UV-C.4 Comparing those two proportions using Fisher's exact test based on alpha=0.05 and 90% statistical power, there should be 297 locations sampled before and after UV-C, or a total of 594 locations. We compared the proportion of samples positive before feedback vs after feedback using Fisher's exact test.
A total of 31 operating room environments were enrolled and 587 samples were collected. Patient and procedural characteristics for the before and after periods are shown in Table 1. Sites involving SARS-CoV-2 nucleic acid or infectivity are shown in Supplementary Table S2. Whereas there was SARS-CoV-2 detected in 13.5% (17/126) of samples at baseline, there were 0% (0/587) with feedback resulting in process improvement (P<0.0001). Although there was no SARS-CoV-2 detected, there were more cases (compared with baseline period) with acute disease and more cases without acute disease, more patients without vaccination, and more patients with vaccination, etc. for the other eight characteristics in Table 1. We were unable to assess UV-C effect with zero viral nucleic acid detection and no positive viral cultures.
Feedback is an important implementation feature for an evidence-based, multifaceted intraoperative infection control programme derived from a solid foundation of published evidence involving bacterial pathogens.1, 2, 3 We learned in this study that feedback is also important for intraoperative control of SARS-CoV-2 disinfection. Feedback was remarkably practical, followed by only a change in surface disinfection wipes.
We characterised the baseline epidemiology of intraoperative SARS-CoV-2 transmission, identifying high-risk environmental locations,4 and leveraged that knowledge to test a data-driven process improvement strategy for environmental cleaning. The results can guide future research as the virus becomes endemic and preoperative testing is reduced. Future studies should use the reported model of intraoperative viral cross-contamination to assess the impact of intranasal povidone iodine on reduced aerosolisation of viral particles.17 Given the negligible viral transmission rate after implementation of recommended cleaning procedures including feedback,1 , 17 , 20 these findings should inspire implementation to improve patient and provider perioperative safety.
The validity of our findings is supported by a solid body of evidence for bacterial pathogens.1, 2, 3 , 9 , 11 The results were not explained by vaccination, the number of patients with active infection, use of negative pressure rooms, or procedure duration. The purpose of feedback is to provide the impetus for process improvement such as a change in cleaning procedures. We were unable to assess the impact of UV-C given the lack of viral detection by nucleic acid or culture. Although we were unable to confirm infectivity by viral culture in either cohort, this may have been related to disinfectant exposure and does not exclude the possibility of aerosolisation of live virus before sampling. In conclusion, evidence-based feedback is an important and practical component for prevention of intraoperative SARS-CoV-2 spread.
Acknowledgements
The authors acknowledge Vrunda M. Patel for her contributions to sample collection and administration of UV-C.
Footnotes
Declarations of interest
RWL received research funding from Sage Medical Inc., BBraun, Draeger, and Kenall, has one or more patents pending, and is a partner of RDB Bioinformatics, LLC, and 1055 N 115th St #301 (Omaha, NE, USA) a company that owns OR PathTrac, and has spoken at educational meetings sponsored by Kenall (AORN) and BBraun (APIC). FD is Director of the Division of Management Consulting of the University of Iowa Department of Anesthesia, which provides consultations to corporations, hospitals, and individuals. He receives no funds personally other than his salary and allowable expense reimbursements from the University of Iowa. His family and he have no financial holdings in any company related to his work. A list of all the Division's consults is available in his posted curriculum vitae at FranklinDexter.net/Contact_Info.htm. One of the donors, Gunner Lyslo, is CEO/founder and partner of Surfacide (Naperville, IL, USA), the company that makes the Helios® UV-C Disinfection System.
Funding
An unrestricted donation from Gunner Lyslo to the University of Iowa. US National Institutes of Health (Bethesda, MD, USA; grants P01 AI060699, R01 AI129269 to SP and AO).
Supplementary data to this article can be found online at https://doi.org/10.1016/j.bja.2022.04.018.
Appendix A. Supplementary data
The following is the Supplementary data to this article:
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