Circulation 122,210 • Volume 35, No. 1 • February 2020   Issue PDF

Balancing Sustainability and Infection Control: The Case for Reusable Laryngoscopes

Diane Gordon, MD; Jodi D. Sherman, MD; Richard Beers, MD; Harriet W. Hopf, MD
Summary: 

The recent APSF Newsletter articles on infection prevention by Drs. Prielipp, Birnbach, Schaffzin, Johnston, and Munoz-Price advocate for expanded decontamination procedures for re-usable laryngoscope handles. The authors argue that, in light of their expanded reprocessing recommendations, the most cost-effective option is the nationwide adoption of single-use disposable (SUD) laryngoscopes. Evidence to support expanded reprocessing procedures for laryngoscope handles is lacking. Disposable laryngoscope handles, each of which has lithium batteries, a light source, and plastic and metal, substantially increase medical waste and environmental harm. A true cost-benefit analysis favors reprocessing re-usable laryngoscope handles in accordance with current CDC recommendations.

In their articles in the October issue of the APSF Newsletter, Drs. Prielipp, Birnbach, Schaffzin, Johnston, and Munoz-Price outline a comprehensive approach to infection control by anesthesia professionals.1,2 We agree with most of their recommendations, including frequent hand hygiene, cleaning the intravenous hub before injection, aseptic practices during medication preparation and administration, and decontaminating environmental surfaces.3 We respectfully disagree, however, with the authors’ conclusion that single-use disposable (SUD) laryngoscopes are cost-effective compared to reusable laryngoscopes.

The authors’ begin by calling for expanded reprocessing procedures for reusable laryngoscope handles. Implementing these expanded procedures would require disassembly and transport of the handles to a central reprocessing area. The authors go on to state that, “the cost of reprocessing reusable laryngoscopes to this new standard is substantial.” As a result of their “new standard,” the authors endorse “adopting single-use products [i.e., disposable laryngoscopes]” because they “may actually be quite cost favorable.”1,2

Requiring that laryngoscope handles undergo high-level disinfection is contrary to the recommendations of the Centers for Disease Control and Prevention (CDC) (https://www.cdc.gov/infectioncontrol/guidelines/disinfection/rational-approach.html)

While laryngoscope blades are properly required to undergo central reprocessing, we contend that the evidence does not support subjecting handles to the same standard. Laryngoscope handle contamination with primarily normal skin flora is well-documented.4-6 However, to our knowledge, there has not been a documented case of a hospital-associated infection transmitted by either laryngoscope handles or blades that were reprocessed as per current CDC guidelines.

We agree that laryngoscope handles should undergo a verifiable low-level disinfection process for surface decontamination just as any other environmental surface, and that blades should remain wrapped until their use on a patient.

Cost-benefit calculations must include assessment of environmental harms and medical waste costs. The World Health Organization (WHO) endorses this approach; in its World Health Report, WHO “strongly advocates the assessment of population-wide risks…in strategies for risk reduction.” Each disposable laryngoscope handle contains lithium batteries, a light source, and metal and plastic that are rarely effectively recycled at present. Anesthesia professionals have a duty to consider the harm to global health associated with the manufacturing, packaging, transport, and disposal of these single-use items.7

In a recent comprehensive life-cycle analysis, a compelling case is made for reusable laryngoscopes on the basis of patient safety, environmental impact, and cost.4 When all costs were compared, reusable laryngoscopes were 10-fold less expensive than SUD laryngoscopes, and greenhouse gas emissions were 16–25 times less.4,8 Several studies suggest that disposable laryngoscopes have not been shown to provide superior reliability or intubating conditions compared with reusable laryngoscopes.4,8-9

Without evidence of benefit, broad implementation of disposable laryngoscopes would substantially increase (and already has) anesthesia-related costs and pollution. Anesthesia professionals, as leaders in patient safety, have a duty to use evidence-based data to minimize the incidence and impact of adverse outcomes.9,10 In its broadest context, this includes adverse outcomes that impact public health.

 

Dr. Gordon is assistant professor of Anesthesiology at the University of Colorado and member of the ASA Environmental Task Force.

Dr. Sherman is associate professor of Anesthesiology, and of Epidemiology (Environmental Health Sciences), at the Yale School of Medicine, New Haven, CT, and member of the ASA Committee on Equipment and Facilities, and the Committee on Occupational Health and Safety. Dr. Sherman is also co-chair of the ASA Subcommittee on Environmental Health.

Dr. Beers is professor of Anesthesiology at the State University of New York, Upstate Medical Center and chair, ASA Committee on Occupational Health and Safety. Dr. Hopf is professor of Anesthesiology and adjunct professor of Biomedical Engineering at the University of Utah, Salt Lake City, UT, and a member of the ASA Committee on Equipment and Facilities.

Dr. Sherman has received a speaking honorarium from Getinge USA. Drs. Gordon and Beers have no disclosures.

References

  1. Prielipp RC, Birnback DJ. Health care-associated infections: a call to anesthesia professionals. APSF Newsletter. 2019;34:29–32.
  2. Schaffzin J, Johnston L, Munoz-Price LS. The hospital epidemiologist’s perspective on the anesthesia operating room work area. APSF Newsletter. 2019;34:37–39.
  3. Munoz-Price LS, Bowdle A, Johnston BL, et al. Infection prevention in the operating room anesthesia work area. Infect Cont Hosp Ep. 2019;40:1–17.
  4. Sherman JD, Raibley LA, Eckelman M. Life Cycle assessment and costing methods for device procurement: comparing reusable and single-use disposable laryngoscopes. Anesth Analg. 2018;127:434–43.
  5. Call TR, Auerback FJ, Riddell SW, et al. Nosocomial contamination of laryngoscope handles: challenging current guidelines. Anesth Analg. 2009;109:479–83.
  6. Negri de Sousa AC, Levy CE, Freitas MIP. Laryngoscope blades and handles as sources of cross-infection: an integrative review. J Hosp Infect. 2013;83:269–275.
  7. Chapter 2: Defining and assessing risks to health. In: The World Health Report 2002: reducing risks, promoting healthy life. Geneva: World Health Organization, 2002, pp. 7–27.
  8. Sherman JD. Reusable vs disposable laryngoscopes. APSF Newsletter. 2019;33:91.
  9. Sherman JD, Hopf HW. Balancing infection control and environmental protection as a matter of patient safety: the case of laryngoscope handles. Anesth Analg. 2018;127:576–579.
  10. Watts, N. et al. The 2019 report of the Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate. Lancet. November 13, 2019 https://doi.org/10.1016/S0140-6736(19)32596-6