Following the WFSA World Hand Hygiene Day webinar, experts address the most common questions on perioperative hand hygiene and infection prevention.
Hand hygiene is one of the simplest and most effective measures to prevent healthcare-associated infections. To mark World Hand Hygiene Day, WFSA hosted the webinar ‘Resource-Stratified Approaches to Hand Hygiene in the Perioperative Environment’, bringing together experts to discuss practical strategies for improving infection prevention in anaesthesia practice across diverse healthcare settings.
During the webinar, participants from around the world shared questions about the challenges they face in everyday clinical practice. Members of the WFSA Safety and Quality Committee have prepared responses to the most frequently asked questions, providing practical, evidence-informed guidance that can be adapted across a range of clinical settings.
Why These Questions Matter
The practice of anaesthesia is continually evolving. Anaesthesia professionals perform many tasks within a short period of time to optimise patient care. Unfortunately, their hands can also transmit pathogens from patients to equipment in the anaesthesia workspace, creating reservoirs of microorganisms that may then be transmitted to other patients. Disinfecting hands with alcohol-based hand sanitiser is one of the most effective measures to break this cycle of transmission and help prevent healthcare-associated infections.
Integrating robust hand hygiene practices into routine anaesthesia care can be challenging. For many anaesthesia professionals, the greatest difficulty is knowing exactly when, and remembering, to perform hand hygiene during a busy clinical workflow. The questions submitted during the WFSA webinar also highlight additional challenges, including limited access to soap, alcohol-based hand sanitiser, sterilisation equipment and other essential resources in many healthcare settings.
Although these challenges differ from one setting to another, the goal remains the same: reducing the transmission of pathogens and improving patient safety. Every anaesthesia professional must consider their own circumstances and identify practical strategies that make the best use of the resources available.
Expert Q&A
The questions submitted during the webinar covered a wide range of practical topics, from cleaning laryngoscopes and maintaining aseptic technique to improving hand hygiene compliance and adapting infection prevention practices in resource-limited environments.
Read the expert responses 👇
Is there any protocol to clean laryngoscope sets after intubation?
When resources allow, laryngoscopes sets should be both cleaned and sterilized [1]. Laryngoscope blades are considered semi-critical items because they contact mucus membranes of the patient. Cleaning requires both soap and water and a brush or a device to provide a scrubbing effect to remove mucus and bacterial biofilm. Cleaning does not provide sterilization. Autoclaving the blades will sterilize them if an autoclave is available. Placing the laryngoscope in boiling water after cleaning for 20 minutes won’t kill bacterial spores but does kill most microorganisms providing low-level disinfection [2].
Just as we need to think about how to clean and sterilize a laryngoscope blade, we need to consider how to prevent the bacteria on a used blade from transmitting to the anaesthesia workspace. Hand hygiene is indicated after handling a used laryngoscope.
- Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008
- Rowinski A, von Schreeb J. Decontamination of Surgical Instruments for Safe Wound Care Surgeries in Disasters: What are the Options? A Scoping Review. Prehosp Disaster Med. 2021;36(5):645-650. doi:10.1017/S1049023X2100090X
How to perform good aseptic technique for ultrasound-guided nerve block anaesthesia in clinical practice?
Ultrasound guided nerve blocks present challenges for maintenance of aseptic technique. Ultrasound gel spreads across the field as an image is obtained. In high resource settings, a sterile field can be created with a dedicated kit. Sterile ultrasound gel can be used along with a sterile plastic sheath to protect the ultrasound probe from contamination. The ASRA Pain Medicine consensus guidelines can be helpful here [1]. Provenzano DA, Hanes M, Hunt C, Benzon HT, Grider JS, Cawcutt K, Doshi TL, Hayek S, Hoelzer B, Johnson RL, Kalagara H, Kopp S, Loftus RW, Macfarlane AJR, Nagpal AS, Neuman SA, Pawa A, Pearson ACS, Pilitsis J, Sivanesan E, Sondekoppam RV, Van Zundert J, Narouze S. ASRA Pain Medicine consensus practice infection control guidelines for regional anesthesia and pain medicine. Reg Anesth Pain Med. 2025 Jul 17:rapm-2024-105651. doi: 10.1136/rapm-2024-105651. Epub ahead of print. PMID: 39837579.
Can you provide the link for the 5 Moments of Hand Hygiene for Anaesthesia?
The World Health Organization has many good resources. Please see their five moments campaign.
Is soap better than chlorhexidine?
Soap and water are effective cleaners that reduce surface contamination and bacterial counts. Chlorhexidine is a broad-spectrum antimicrobial chemical that sticks well to skin and provides additional disinfection. For routine cleaning of hands, soap and water or an alcohol-based hand scrub are recommended. For disinfecting the hands of providers before surgery or disinfecting the skin of patients before a procedure, chlorhexidine is superior.
Is an apron necessary during intubation and IV cannulation in the operating theatre, in addition to hand hygiene?
Adding a protective gown, sometimes called an apron, to peripheral IV placement or intubation does not usually add extra protection for the patients or the providers. If the patients have a particularly resistant organism, or a transmissible infection, a gown could be added. However, for routine care, adding an apron is not recommended.
How can infection prevention protocols be adapted to ensure effective hand hygiene for anaesthesia teams working in resource limited and space constrained perioperative environments?
Limited resources will affect what anaesthesia professionals are able to do for their patients. Even in limited resource settings, anaesthesiologists can strive to ensure that potential pathogen reservoirs (for instance, the APL valve on the anaesthesia machine) are decontaminated as often as possible, and patients are protected from pathogens.
Space is a concern for all anaesthesiologists. Often, we work in a small space, and leaving the area of the anaesthesia machine takes effort and time. Therefore, it makes sense to bring a bottle of alcohol-based hand sanitizer into the anaesthesia workspace, so that hands can be disinfected without having to leave the anaesthesia area. Some have found success with mounting a bottle of hand sanitizer on an IV pole. Other studies have shown a body-worn device to be helpful. Alcohol based sanitizer should be a minimum standard.
Could you share with us any guidelines about infection prevention of anaesthesia provide used in the Operating Theatre (OT)?
There are many great resources that provide guidance to help prevent pathogen transmission in the operating theatre/room.
This article in the APSF Newsletter provides some general guidance.
The Society for Healthcare Epidemiology of America also has guidelines that are helpful.
Could you share specific initiatives in your local institution in improving hand hygiene compliance, and how did you sustain those changes over time?
Hand Hygiene projects are sometimes similar to weeding a garden. If the effort in keeping hand hygiene a priority decreases then the unwanted lapses in hand hygiene return like weeds to the untended garden. We have had success in getting institutional leaders to voice that hand hygiene is a priority. We have also had success (in the ICU) in getting providers to recognize behavioural queues like crossing the threshold of the room needs to trigger the behaviour of hand hygiene. We continue to look for the projects that will lead to the right dose of hand hygiene.
Training, Education, Monitoring and feedback are the necessary steps to implement hand hygiene or any practice. WHO has also encouraged locally produced Alcohol-based Hand Rubs (ABHRs) for hand hygiene. Bedside or pocket-sized ABHR dispensers may help to promote to practice “Five Moments” of hand hygiene during perioperative period. Where ABHR production or procurement is not feasible, ensuring functioning sinks, soap, and clean water at every care point is the minimal requirement.
To what extent do medical gloves replace hand hygiene and should hand disinfection still be performed before and after glove use?
Both gloves and clean hands have better bacterial counts than are seen with hands that have not been disinfected with alcohol [1]. Glove provide some protection against pathogen transmission from patients to providers. However, both gloved hands and ungloved hands can move pathogens around within the anaesthesia work area. Hands without gloves are easy to disinfect with alcohol-based hand sanitizer. Gloves can also be treated this way, but alcohol can cause the material of the glove to fail. So, whether gloves are used, or not, anaesthesia professionals must consider how they are preventing pathogens from moving around within the anaesthesia workspace. Frequent disinfection when working in the anaesthesia area is required.
So, medical gloves are not considered as a replacement of the hand hygiene practices. Hand disinfection before and after glove use may help in reducing the cross contaminations.
Some behavioural triggers that can prompt hand hygiene are:
- Entering or Exiting a Room
- Finishing airway management and moving to vascular access
- Before any block or procedure
- Putting on gloves
- Preparing to access medications or intravenous fluids
- Administering medications
- When finished accounting for urine output
- Touching floor, self, or cell phone
- Paul G, Bobic R, Dawud J, et al. Bacterial contamination of nonsterile gloves versus hands after hand hygiene. Am J Infect Control. 2021;49(11):1392-1394. doi:10.1016/j.ajic.2021.04.002
Do you use chlorhexidine for your lumbar puncture?
My practice is to disinfect the skin with chlorhexidine in 70% alcohol before lumbar puncture, spinal, or epidural anaesthesia. There are several case reports of terrible injuries relating to chlorhexidine getting into the neuraxial space. There are several precautions that I take to try and minimize any potential issues. First, I use chlorhexidine in an applicator, rather than open chlorhexidine. Some case reports of open chlorhexidine splashing into anaesthesia or being drawn up for injection make me feel that open chlorhexidine should not be on the same sterile field as the procedural equipment. Second, I make sure that the chlorhexidine in alcohol dries before I put up any type of drape. I don’t want to trap any liquid under the drape that could get onto the equipment later. Third, I make sure that I know where the chlorhexidine might come out of any air holes in the applicator, and I never shake the applicator because that causes the chlorhexidine to leak out. Finally, I try to avoid touching the needle with fingers that might have residual chlorhexidine on them. For the record, I think similar precautions should be taken by those who use other agents to disinfect the surface, like iodine or alcohol.
Allowing a minimum of 2 min of contact time prior to the procedure is helpful for adequate asepsis and probably takes care of alcohol evaporation.
Stinner DJ, Krueger CA, Masini BD, Wenke JC. Time-dependent effect of chlorhexidine surgical prep. J Hosp Infect. 2011 Dec;79(4):313-6. doi: 10.1016/j.jhin.2011.08.016. Epub 2011 Oct 15. PMID: 22000737.
We thank everyone who participated in the webinar and submitted questions. We also thank the WFSA Safety and Quality Committee for sharing their expertise and helping advance this important conversation on patient safety through effective hand hygiene.
