Indications for hand and glove disinfection in Advanced Cardiovascular Life Support: A manikin simulation study

Abstract

Background and aim: There are no investigations on hand hygiene during cardiopulmonary resuscitation (CPR), even though these patients are at high risk for healthcare-associated infections. We aimed to evaluate the number of indicated hand hygiene per CPR case in general and the fraction that could be accomplished without delay for other life-saving techniques through standardized observations.

Materials and methods: In 2022, we conducted Advanced Cardiovascular Life Support (ACLS) courses over 4 days, practicing 33 ACLS case vignettes with standard measurements of chest compression fractions and hand hygiene indications. A total of nine healthcare workers (six nurses and three physicians) participated.

Results: A total of 33 training scenarios resulted in 613 indications for hand disinfection. Of these, 150 (24%) occurred before patient contact and 310 (51%) before aseptic activities. In 282 out of 310 (91%) indications, which have the highest impact on patient safety, the medication administrator was responsible; in 28 out of 310 (9%) indications, the airway manager was responsible. Depending on the scenario and assuming 15 s to be sufficient for alcoholic disinfection, 56-100% (mean 84.1%, SD ± 13.1%) of all indications could have been accomplished without delaying patient resuscitation. Percentages were lower for 30-s of exposure time.

Conclusion: To the best of our knowledge, this is the first study investigating the feasibility of hand hygiene in a manikin CPR study. Even if the feasibility is overestimated due to the study setup, the fundamental conclusion is that a relevant part of the WHO indications for hand disinfection can be implemented without compromising quality in acute care, thus increasing the overall quality of patient care.

Keywords: ACLS (Advanced Cardiovascular Life Support); BLS (Basic Life Support); CPR - cardiopulmonary resuscitation; glove disinfection; hand disinfection; hospital acquire infection; infection prevention; life support.

Figure 1

A prototypical ACLS training scenario with six members: the team leader (TL) and timekeeper (T) normally do not interact with the patient and do not perform invasive procedures. The compressor (C) and monitor/defibrillator (MD) may change roles and provide chest compressions to maintain cerebral and coronary perfusion. They also both typically do not perform invasive procedures. The monitor/defibrillation manager (MD) attaches electrodes to the patient's chest, analyses the ECG, and delivers shocks as indicated. The airway manager (A) ventilates with a bag valve mask, clears the airway if it is obstructed, and administers oxygen. If indicated, the airway manager places a supraglottic or endotracheal airway device. Hence, invasive procedures are sometimes performed by the airway manager or an assisting person (e.g., M or C), depending on the situation and crew resources. The medication administrator (IV) establishes intravenous or intraosseous access and prepares and administers medications according to the CPR or ROSC algorithm as identified and communicated by the team leader. The medication administrator is the person with the most expected invasive procedures and therefore the most hand hygiene indications. After each scenario, the roles were changed. It is noted that individuals are not wearing hospital clothing or personal protective equipment due to the training settings. N95 respirators were worn due to the COVID-19 pandemic. All depicted persons gave written informed consent for photography.

Figure 2

Different scenario types in ACLS courses typically last about 10–25 min each, including the briefing and debriefing. CA, cardiopulmonary arrest; VF, ventricular fibrillation; pVT, pulseless ventricular tachycardia; PEA, pulseless electrical activity; ROSC, return of spontaneous circulation; ACS, acute coronary syndrome.

Figure 3

WHO-2 indications for cases 1–33 with the scenarios: asystole (ASY), ventricular fibrillation (VF), pulseless ventricular tachycardia (PVT), bradycardia (BRA), unstable VT with a pulse (VT), supraventricular tachycardia (SVT), and pulseless electrical activity (PEA). Blue columns indicate the hand or glove disinfection indications that were feasible and orange for those that were not.