Poor anaesthetist hygienic practices — a problem across all grades of anaesthetist

The recent article by El Mikatti and colleagues regarding anaesthetic hygienic practices highlighted poor compliance of consultant anaesthetists with Association of Anaesthetists' guidelines (Anaesthesia 1998; 54: 13–18). This is not unique to the consultant grade, but applies across all grades of anaesthetist. The guidelines published by the Association of Anaesthetists in 1992 and updated in 1996 are widely available and include the routine use of gloves, eye protection and mask and gown wearing [1]. These have been emphasised in the light of a growing rate of undiagnosed HIV infection and hepatitis C infection in the population. The incidence of HIV in a high-risk population has been reported as high as 9.9% with lower rates in a young, general-risk population of 0.18–0.23% (The Unlinked Anonymous HIV Prevalence Monitoring Programme in England and Wales, 1995). An incidence as high as 1.79% has been reported in patients attending an inner London Accident and Emergency department [2]. A survey of anaesthetists' working practices and attitudes to HIV infection was carried out in 1992 and demonstrated a low rate of routine universal precautions among anaesthetists of all grades [3]. In particular, only 16% routinely wore gloves during invasive vascular procedures and 35% resheathed needles that had been in contact with a patient's bodily fluids. El Mikatti and colleagues report a similar low rate of 14.5% always wearing gloves. During 1997 and 1998, we carried out a five hospital-wide audit to assess anaesthetic practice in line with recommendations. This involved three teaching hospitals and two large district general hospitals in the south-east of England. Eighty anaesthetists of all grades were questioned about their knowledge of the Association guidelines and their current practice. This represented a random selection across all grades who were available to be questioned. The sample included 34 consultants, 29 specialist registrars and 13 senior house officers, with four of other grades. In total, only 49% knew the published guidelines. According to grade, this represented 67% of consultants and 30% of trainees. Routine glove wearing was still low at 29%. Again this was across all grades, with a trainee rate of 35%. The most frequently cited reason was a loss of ‘feel’ (86%), with 9% claiming that they were not easily available and 10% unconcerned. Few anaesthetists routinely wore eye protection for vascular procedures (4% — allowing for spectacle wearers) or masks and gowns (7.5%). Most would not resheath used needles (74%). Despite these figures, 77% would change their practice with a known HIV-positive patient: most notably and universally wearing gloves. In addition, 32% were in favour of routine screening for HIV infection in all surgical patients. This compares with 50% of respondents in the survey in 1992. It would seem that practice has not altered considerably since guidelines have been introduced and this applies equally across grades. The value of simple precautions has been well documented. Of those advised, routine glove wearing is simple and perhaps of most documented benefit. Their regular use reduces the incidence of needlestick injury and overall percutaneous injury [4]. This is widely accepted, judging by the number of anaesthetists who would change their practice with a known HIV-positive patient. It is disappointing that all grades are equally at fault. It might be argued that established behaviour is more difficult to change, but it would seem that trainees are learning similar patterns of practice. In the light of these findings it is perhaps timely and prudent to once again raise this issue and re-emphasise the value of simple precautions in every day practice.