Reproduced from American Society of Anesthesiologists Task Force on Latex Sensitivity of the Committee on Occupational Health of Operating Room Personnel: Natural Rubber Latex Allergy: Considerations for Anesthesiologists. Available at http://ecommerce.asahq.org/publicationsAndServices/latexallergy.pdf. Accessed October 30, 2012.
J. Noise Pollution
1. OSHA has determined that the maximum level for safe noise exposure is 90 dB for 8 hours (ventilators, suction equipment, music, and conversation produce background noise at a level of 75 to 90 dB).
2. Mental efficiency, short-term memory, and the ability to multitask and perform complex psychomotor tasks are all diminished by exposure to excess noise. Noise also interferes with the ability to hear alarms (MRI suites, music).
II. Ergonomics and Human Factors
A. Human factor analysis (ergonomics) is the study of the interaction between humans and machines and the impact of equipment design on their use. The work performed by an anesthesiologist shares many of the characteristics found in other high-risk industries (aviation, nuclear power, oil exploration), including the intricacy of the tasks, a narrow margin of error, and vulnerability to human error.
1. A number of human factor difficulties exist in anesthesiologists’ workplaces (e.g., anesthesia equipment is often poorly designed or positioned, anesthesia monitors are frequently placed so that the anesthesiologist’s attention is directed away from the patient and surgical field).
2. The ability to sustain complex monitoring tasks, such as maintaining vigilance and to respond to critical incidents, is vulnerable to the distractions created by poor equipment design or placement.
3. Even the alarms that have been developed with the specific goal of augmenting the task of vigilance can have considerable drawbacks (e.g., alarms are nonspecific and can be a source of frustration and confusion, susceptible to many artifacts and false-positives that can cause “alarm fatigue” and distract the observer from more clinically significant information).
a. It is not unusual for distractive alarms to be ignored or inactivated.
b. A positive trend that is emerging in alarm technology is the development of “knowledge-based alarms” that can integrate information from more than one monitor and suggest a list of diagnostic and therapeutic possibilities.
4. The potential for disaster as a result of poor communication has been well illustrated in a number of airline catastrophes. The possibility for miscommunication and resultant accident is heightened in OR, where, in contrast to the structure inherent in an airline crew, there is an absence of a well-defined hierarchical organization with overlaps in areas of expertise and responsibility. Poor communication can lead to conflict and compromised patient safety and has been identified as a root cause of many anesthesia-related sentinel events.
III. WORK HOURS, NIGHT CALL, AND FATIGUE
A. A circadian pattern of alertness and sleep is a fundamental element of healthy human physiology. Individuals with sleep deprivation (obstructive sleep apnea, disruptive work schedules) also think and move more slowly and make more mistakes.
B. In general, workers who are sleep deprived experience a decrement in performance and are at greater risk of committing workplace errors. The changes resulting from sleep deprivation bear a striking similarity to those seen with alcohol intoxication. A number of reports have also identified sleep deprivation as a causative factor in errors occurring in the health care industry.
C. A number of specific consequences of sleep deprivation have the potential to adversely impact the conduct of a safe anesthetic, including impaired cognition, short-term memory, and clinical decision making; prolonged reaction time; and reduced attention, vigilance and performance.
D. There is an apparent disparity between reports of fatigue-related performance impairment and the failure to conclusively link these with medical errors or adverse outcomes.
E. In 2000, the Accreditation Council for Graduate Medical Education (ACGME) established the first set of standards to limit resident duty hours (revised by the ACGME in 2011). This statement recognizes that these restrictions on duty periods apply only to trainees and that work hours in medical practice remain unregulated. Prolonged work hours and sleep deprivation are ubiquitous components of many anesthesiologists’ professional lives.
IV. INFECTIOUS HAZARDS
A. Anesthesia personnel are at risk for acquiring infections from patients and from other personnel.
B. OSHA Standards, Standard Precautions, and Transmission-Based Precautions
1. The major features of universal precautions have been synthesized into “Standard Precautions” that should be applied to all patients.
2. Standard precautions include the appropriate application and use of hand washing, personal protective equipment (PPE), and respiratory hygiene and cough etiquette.
a. Gloves may be all that is necessary during many procedures that involve contact with mucous membranes or oral fluids (e.g., routine endotracheal intubation, insertion of a peripheral intravenous catheter).
b. Additional personal protection (gown, mask, face shield) may be required during endotracheal intubation when the patient has hematemesis or during bronchoscopy or endotracheal suctioning.
3. The institution’s employee health service is required to obtain and record a contagious disease history from new employees and provide immunizations and annual PPD (purified protein derivative) skin testing. In addition, the employee health service must have protocols for dealing with workers exposed to contagious diseases and those percutaneously or mucosally exposed to the blood of patients infected with HIV or hepatitis B or C virus.
C. Respiratory viruses account for half or more of all acute illnesses and are usually transmitted by small particle aerosols produced by coughing, sneezing, or talking (influenza, measles) or large droplets produced by coughing or sneezing that can contaminate the donor’s hands or inanimate surface.
1. Anesthesia personnel who routinely care for patients in high-risk influenza groups should be immunized annually (October or November).
2. Human respiratory syncytial virus (HRSV) is the most common cause of serious bronchiolitis and lower respiratory tract disease in infants and young children worldwide.
a. HRSV may also be a significant cause of illness in healthy elderly patients and those with chronic cardiac or pulmonary disease.
b. Careful hand washing and the use of standard precautions have been shown to reduce HRSV infection in hospital personnel.
3. Severe acute respiratory syndrome (SARS) typically presents with a fever greater than 38.0°C followed by symptoms of headache, generalized aches, and cough. Severe pneumonia may lead to acute respiratory distress syndrome and death.
D. DNA Viruses
1. Herpes simplex viruses (HSV-1, HSV-2; Herpesvirus hominis) produce a variety of infections involving mucocutaneous surfaces, the central nervous system, and sometimes visceral organs (corneal blindness).
a. Exposure to HSV at mucosal surfaces or abraded skin allows entry of the virus and initiation of viral replication.
b. The primary infection with HSV type 1 is usually clinically unapparent but may involve severe oral lesions, fever, and adenopathy.
2. Varicella-zoster virus (VZV) causes varicella (chickenpox) and zoster (shingles).
a. Most adults in the United States have protective antibodies to VZV.
b. All employees with negative titers should be restricted from caring for patients with active VZV infection and should be offered immunization with two doses of the live, attenuated varicella vaccine.
c. Susceptible personnel with a significant exposure to an individual with VZV infection are potentially infective from 10 to 21 days after exposure and should not have contact with patients during this period. They should be offered vaccination within 3 to 5 days of the exposure because it might modify the severity as well as the duration of the disease.
E. Viral Hepatitis
1. The most common forms of viral hepatitis are type A (infectious hepatitis), type B (HBV, serum hepatitis), and type C (HCV, non-A, non-B hepatitis), which is responsible for most cases of parenterally transmitted hepatitis in the United States. All types of viral hepatitis produce clinically similar illnesses (asymptomatic to fulminate and fatal infections, subclinical to chronic persistent liver disease with cirrhosis and hepatocellular carcinoma). The greatest risks of occupational transmission to anesthesia personnel are associated with HBV and HCV.
2. Hepatitis A virus is the cause of about 20% to 40% of viral hepatitis in adults in the United States (usually a self-limited illness, and no chronic carrier state exists).
a. Spread is predominantly by the fecal–oral route, either by person-to-person contact or by ingestion of contaminated food or water.
b. Immune globulin provides protection against hepatitis A through passive transfer of antibodies and is used for postexposure prophylaxis.
3. Hepatitis B virus is a significant occupational hazard for nonimmune anesthesiologists and other medical personnel who have frequent contact with blood and blood products.
a. The incidence of acute hepatitis B in the United States declined nearly 80% and is attributable to effective vaccination programs as well as universal precautions in needle use.
b. Acute HBV infection may be asymptomatic and usually resolves without significant hepatic damage (<1% of acutely infected patients develop fulminate hepatitis)
c. Approximately 10% become chronic carriers of HBV (serologic evidence for >6 months). Within 2 years, half of the chronic carriers resolve their infection without significant hepatic impairment. Chronic active hepatitis, which may progress to cirrhosis and is linked to hepatocellular carcinoma, is found most commonly in individuals with chronic viral infection for more than 2 years.
d. Anesthesia personnel are at risk for occupationally acquired HBV infection as a result of accidental percutaneous or mucosal contact with blood or body fluids from infected patients.
e. Hepatitis B vaccine is the primary strategy to prevent occupational transmission of HBV to anesthesia personnel.
4. Hepatitis C virus causes most cases of parenterally transmitted non-A, non-B hepatitis (NANBH) and is a leading cause of chronic liver disease in the United States. Although antibody to HCV (anti-HCV) can be detected in most patients with hepatitis C, its presence does not correlate with resolution of the acute infection or progression of hepatitis, and it does not confer immunity against HCV infection.
a. Of those who develop chronic hepatitis, 20% will develop cirrhosis over the following 20 to 30 years, and 1% to 2% of those will be diagnosed with hepatocellular carcinoma.
b. The greatest risk of occupational HCV transmission is associated with exposure to blood from an HCV-positive source.
c. There is no vaccine or effective postexposure prophylaxis available to prevent HCV infection, and the use of immune globulin is no longer recommended after a known exposure. Prevention of exposure remains the primary strategy for protecting HCW against HCV infection.
F. Pathogenic Human Retroviruses (human T lymphotropic viruses [HTLV-1, HTLV-2] and Human Immunodeficiency Viruses [HIV-1, HIV-2])
1. HIV infection/AIDS is a global pandemic (33.3 millions infected worldwide, 1.1 million in the United States of whom 21% are unaware of their infection).
2. The initial infection with HIV begins as a mononucleosis-like syndrome with lymphadenopathy and rash. Within a few weeks, an antibody may be detected by an enzyme immunoassay or rapid HIV antibody test, but a positive result must be confirmed using Western blot or immunofluorescent assay. After a variable length period of asymptomatic HIV infection, there is an increase in viral titer and impaired host immunity, resulting in opportunistic infections and malignancies characteristic of AIDS.
3. The risk of infection with HIV in the United States via transfused screened blood currently is approximately 1 per 1.5 million units.
4. Risk of Occupational HIV Infection. The risk of HIV transmission after skin puncture from a contaminated needle or a sharp object is 0.3% and after a mucous membrane exposure it is 0.09% if the injured or exposed person is not treated within 24 hours with antiretroviral drugs.
a. Anesthesia personnel are frequently exposed to blood and body fluids during invasive procedures such as insertion of vascular catheters, arterial punctures, and endotracheal intubation.
b. Although many exposures are mucocutaneous and can be prevented by the use of gloves and protective clothing, these barriers do not prevent percutaneous exposures such as needle-stick injuries, which carry a greater risk for pathogen transmission.
c. The risk of HIV transmission from HCW medical personnel to patient is extremely low.
5. Postexposure Treatment and Prophylactic Antiretroviral Therapy. Based on the nature of the injury, the exposed worker and the source individual should be tested for serologic evidence of HIV, HBV, and HCV infection. If the source patient is found to be HIV positive, the employee should be retested for HIV antibodies at 6 and 12 weeks and at 6 months after exposure, although most infected people are expected to undergo seroconversion within the first 6 to 12 weeks.
a. Clinicians should consider potential occupational exposures to HIV as an urgent situation to ensure timely postexposure management and possible administration of postexposure antiretroviral prophylaxis (PEP).
b. If a decision is made to offer PEP, US Public Health Service guidelines recommend either a combination of two nucleoside analogue reverse transcriptase inhibitors given for 4 weeks for less severe exposures or a combination of two nucleoside analogue reverse transcriptase inhibitors plus a third drug given for 4 weeks for more severe exposures.
c. For consultation on the treatment of occupational exposures to HIV and other bloodborne pathogens, the clinician managing the exposed patient can call the National Clinicians’ Post-Exposure Prophylaxis Hotline (PEPline) at 888-448-4911.
G. Prion Diseases
1. Prions (from protein + infection) are composed of misfolded protein without nucleic acid. They are responsible for the transmissible spongiform encephalopathies (bovine spongiform encephalopathy or “mad cow disease” in cattle and Creutzfeldt-Jakob disease in humans). All are untreatable and fatal.
2. When a prion enters a healthy organism, it provides a template to guide the misfolding of normal protein into the extremely stable prion form (effective prion decontamination is difficult because it relies on protein hydrolysis or reduction or destruction of protein tertiary structure).
H. Tuberculosis (TB) is most commonly transmitted from a person with infectious pulmonary TB to others by aerosolized droplet nuclei via coughing, sneezing, or speaking (most infectious patients have cavitary pulmonary disease). Effective prevention of spread to HCWs requires early identification of infected patients and immediate initiation of airborne infection isolation.
1. Elective surgery should be postponed until infected patients have had an adequate course of chemotherapy. If surgery is required, bacterial filters (high-efficiency particulate air [HEPA] filters) should be used on the anesthetic breathing circuit for patients with TB. Patients must undergo recovery in a room that meets all the requirements for airborne precautions.
2. Routine periodic screening of employees for TB should be included as part of a hospital’s employee health policy.
I. Viruses in Smoke Plumes. Smoke vacuuming systems as well as PPE should be used when HCWs are in proximity to surgical smoke. OR personnel working in the vicinity of the laser plume should wear gloves, goggles, and high-efficiency filter masks.
V. EMOTIONAL CONSIDERATIONS
A. Stress (occupational) occurs when the demands of a job exceed the capabilities or resources of the worker and can result in poor mental and physical health, industrial accidents, and injury. Common stress-related illnesses include mood and sleep disturbances; disrupted relationships with family and friends; and various types of gastrointestinal, musculoskeletal, and cardiovascular disease.
1. Anesthesiology is a stressful occupation. The OR imposes a background of chronic low-level stress that is frequently interrupted by acute episodes of extreme stress.
2. Specific stressors reported by anesthesiologists include the unpredictability of the work, the need for sustained vigilance during long intervals, production pressure, fear of litigation, difficult interpersonal relations, and economic uncertainties.
B. Burnout is a clinical syndrome that is characterized by physical and emotional exhaustion, poor judgment, cynicism, guilt, feelings of ineffectiveness, and a sense of depersonalization in relationships with coworkers or patients.
1. Burnout primarily affects workers such as physicians and nurses whose jobs require intense interactions with individuals who have great physical and emotional needs.
2. Commonly cited causes of burnout among health care providers are increased production requirements, excessive bureaucracy and regulation, long hours of work, lack of control of one’s schedule, decreasing reimbursement, a rapidly expanding base of medical knowledge, and difficulty balancing personal and professional lives.
C. Substance Use, Abuse, and Addiction
1. It is estimated that 20 million Americans abuse substances and 5 million are addicted (continue to use the substance despite unsuccessful attempts to control its use, the need for larger amounts of the substance, symptoms of withdrawal, and the need to spend increasing amounts of time seeking the substance).
2. Approximately 10% to 12% of physicians will develop some form of substance abuse disorder during their careers. (They tend to abuse different substances than the general public and are less likely to abuse tobacco or illicit drugs and more likely to self-medicate with prescription drugs such as opioids and propofol.)
3. Recent studies report a disproportionately high prevalence of substance abuse among both resident and practicing anesthesiologists. (Substance abuse is considered by many authorities to be the number one occupational hazard of anesthesiology.)
4. Anesthesiologists are unique among physicians because they frequently prescribe as well as personally administer these highly addictive psychoactive drugs. In contrast, physicians in most other specialties prescribe medications while other personnel administer them.
5. The recidivism rate among the general population approaches 60% for patients who have been treated for addiction. Physicians are highly motivated, and in general, the prognosis for doctors’ recovery exceeds that of the general public.
D. Mortality Among Anesthesiologists. There have been a number of conflicting reports regarding the average longevity of anesthesiologists. Recent reports have failed to find any increase in cancer risk among anesthesiologists, but a consistent finding of increased numbers of drug-related deaths and suicide.
E. Suicide
1. Several reports have singled out anesthesiologists as being particularly vulnerable, but this conclusion has been questioned.
2. Stress resulting from a malpractice lawsuit, may have a direct causative association with suicide.
3. Substance abuse among anesthesia personnel is another potential contributor to the increased suicide rate. Drug abuse is among the highest causes of death and the most frequent method of suicide among anesthesiologists.
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