title: Performance of aseptic technique during neuraxial analgesia for labor before and after the publication of international guidelines on aseptic technique.
abstract: BACKGROUND
  Aseptic technique and handwashing have been shown to be important factors in perioperative bacterial transmission, however compliance often remains low despite guidelines and educational programs. Infectious complications of neuraxial (epidural and spinal) anesthesia are severe but fortunately rare. We conducted a survey to assess aseptic technique practices for neuraxial anesthesia in Israel before and after publication of international guidelines (which focused on handwashing, jewelry/watch removal and the wearing of a mask and cap).
  
  
  METHODS
  The sampling frame was the general anesthesiology workforce in hospitals selected from each of the four medical faculties in Israel. Data was collected anonymously over one week in each hospital in two periods: April 2006 and September 2009. Most anesthesiologists received the questionnaires at departmental staff meetings and filled them out during these meetings; additionally, a local investigator approached anesthesiologists not present at these staff meetings individually. Primary endpoint questions were: handwashing, removal of wristwatch/jewelry, wearing mask, wearing hat/cap, wearing sterile gown; answering options were: "always", "usually", "rarely" or "never". Primary endpoint for analysis: respondents who both always wash their hands and always wear a mask ("handwash-mask composite") - "always" versus "any other response". We used logistic regression to perform the analysis. Time (2006, 2009) and hospital were included in the analysis as fixed effects.
  
  
  RESULTS
  135/160 (in 2006) and 127/164 (in 2009) anesthesiologists responded to the surveys; response rate 84% and 77% respectively. Respondents constituted 23% of the national anesthesiologist workforce. The main outcome "handwash-mask composite" was significantly increased after guideline publication (33% vs 58%; p = 0.0003). In addition, significant increases were seen for handwashing (37% vs 63%; p = 0.0004), wearing of mask (61% vs 78%; p < 0.0001), hat/cap (53% vs 76%; p = 0.0011) and wearing sterile gown (32% vs 51%; p < 0.0001). An apparent improvement in aseptic technique from 2006 to 2009 is noted across all hospitals and all physician groups.
  
  
  CONCLUSIONS
  Self-reported aseptic technique by Israeli anesthesiologists improved in the survey conducted after the publication of international guidelines. Although the before-after study design cannot prove a cause-effect relationship, it does show an association between the publication of international guidelines and significant improvement in self-reported aseptic technique.
authors.affiliation: Department of Anesthesiology, Shaare Zedek Medical Center, Jerusalem, Israel.
authors.forename: Alex
authors.initials: A
authors.lastname: Ioscovich
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel.
authors.forename: Elyad M
authors.initials: EM
authors.lastname: Davidson
authors.affiliation: Department of Anesthesiology, Rabin Medical Center, Petach Tikva, Israel.
authors.forename: Sharon
authors.initials: S
authors.lastname: Orbach-Zinger
authors.affiliation: Department of Anesthesiology, Soroka Hospital, Ben Gurion University, Beer Sheva, Israel.
authors.forename: Zvia
authors.initials: Z
authors.lastname: Rudich
authors.affiliation: Department of Anesthesiology, Western Galilee Hospital, Nahariyah, Israel.
authors.forename: Simon
authors.initials: S
authors.lastname: Ivry
authors.affiliation: Department of Health Promotion, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.
authors.forename: Laura J
authors.initials: LJ
authors.lastname: Rosen
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel.
authors.forename: Alexander
authors.initials: A
authors.lastname: Avidan
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel.
authors.forename: Yehuda
authors.initials: Y
authors.lastname: Ginosar