Transcript Your Best Shot: Training Your Staff to Give Safe Injections Emily Lutterloh, MD, MPH Director, Bureau of Healthcare Associated Infections, NYSDOH and Ernest J.

Your Best Shot:
Training Your Staff to
Give Safe Injections
Emily Lutterloh, MD, MPH
Director, Bureau of Healthcare Associated Infections, NYSDOH
and
Ernest J. Clement, RN, MSN, CIC
Epidemiologist/Infection Preventionist,
Bureau of Healthcare Associated Infections, NYSDOH
Program Sponsors

New York State Department of Health

Empire State Public Health Training Center

University at Albany, School of Public Health
2
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
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
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
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
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
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Questions & Answers
at end of program
Click here to
submit a question
Program Goal
To provide safe injection practices information
and resources that can be incorporated into
patient safety and infection control staff
education activities.
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Program Objectives



Identify five components of an effective safe
injections case study used as part of
staff training.
Identify one to three disciplines within the
learner’s institution or practice setting that
could benefit from safe injection education.
Identify four resources the learner could use as
part of a safe injections training program in
their facility.
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What is Injection Safety?

A safe injection prevents:
Harms such as needlestick injuries
 Transmission of infectious diseases between
patients and between healthcare providers
and patients


A safe injection does not:
Harm the patient
 Expose the provider to any avoidable risks
 Result in waste that is dangerous
for the community.

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What are Some Examples of
Unsafe Injection Practices?



Using the same syringe to administer medication to
more than one patient, even if the needle
is changed.
Accessing a medication vial with a syringe that has
already been used to administer medication to a patient
and then using medication from that vial for other
patients.
Accessing a bag of IV fluid with a syringe that has
already been used to flush a patient's IV catheter and
then using the same bag as a common source of IV
flush for more than one patient.
Source: CDC Injection Safety
http://www.cdc.gov/injectionsafety/
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Myths & Facts I


Myth
Changing the needle makes
a syringe safe for re-use
Syringes can be reused as
long as injection is given
through an intervening
length of tubing
Fact


Once used, both needle and
syringe are contaminated and
must be discarded.
Microscopic backflow into the
syringe can occur when
removing the needle.
Everything from the IV bag to
the patient's IV catheter is a
single, interconnected unit.
Distance from patient, gravity,
or infusion pressure do not
ensure syringe won’t be
contaminated
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Myths & Facts II


Myth
No visible blood in IV
tubing or syringe means the
equipment is safe for reuse.
Single-dose vials with large
volumes that appear to
contain multiple doses can
be used for more than one
patient.


Fact
HBV, HCV, and HIV can be
present in sufficient quantities
to produce infections without
visible blood.
Single-dose vials should not be
used for more than one patient
regardless of vial size or
volume.
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Case Study 1:
Sharing syringes between patients



New nursing graduate just off orientation
Working on the night shift
Needleless system and pre-filled saline syringes
for flushing IV lines
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Case Study 1:
Sharing syringes between patients


Staff noticed used saline flush syringes lying on
medication cart
During orientation there was no improper use of
saline syringes observed
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Case Study 1:
Sharing syringes between patients

The facility interviewed the nurse about
her practices
Concern about re-use of the syringes
 Nurse could not say syringes were never shared
between patients



The facility decided to notify patients
Over 200 patients recommended to be tested for
HBV, HCV, and HIV
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Five Components of an Effective
Safe Injection Case Study

Infection control breach


Root cause



What contributed to the breach?
What could have been done to stop it?
Sequelae (potential or actual)


Why did it go wrong?
Barrier(s) to correct procedure


What went wrong?
What harm was done?
Corrective Actions


How can patient harm be mitigated?
How can similar breaches be prevented in the future?
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Case Study 1:
What was the breach?

Sharing syringes between multiple patients
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Case Study 1:
What was the root cause?

Unclear, possibilities include:
•
Nursing education and/or orientation might not have
included safe injection procedures
•
•
Taught what to do but not what not to do and why?; lack of
awareness of written procedures?
Belief in myths regarding the potential for syringe
contamination
•
e.g., myths about lack of contamination if no back pressure on
plunger, no aspiration, no needle, injection into IV tubing, etc.?
Syringes used for flushing contained more saline than
needed for task?
• Pressure to conserve resources?
•
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Case Study 1:
Were there barriers to performing
the correct procedure?

None identified, possibilities include:
Lack of appropriate supplies?
 Lack of understanding of supply acquisition?
 Difficult or inconvenient to obtain supplies?

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Case Study 1:
What are the sequelae?
Potential cross-contamination between patients
(e.g. bacteria, bloodborne viruses)
 Disciplinary action against healthcare provider
(loss of employment, potential actions
against license)
 Lawsuits
 Negative press
 Loss of trust in healthcare by consumers

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Case Study 1:
What are some potential
corrective actions?
Include safe injection practices education in
basic nursing education and facility orientation
programs.
 Incorporate injection safety competencies into
evaluations.
 Instruct what to do, and what not to do.

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Why Case Studies?

Connecting to real-life situations adds impact


Audiences may relate to clinical scenarios
Knowing the recommendations may not always
translate into correct clinical practice
Need to bridge the gap between general
recommendations and specific daily practice
 Examples may help
 Important to understand consequences
of unsafe practice

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Why Case Studies?

Large volume vials

Everyone knows single use means for one patient
only, but staff using a large volume vial of
medication may assume it is multi-use
when it is actually single-use
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Why Case Studies?
We all know that reusing a syringe on another
patient is wrong, even if there is no needle or the
needle is changed. Everyone knows this… right?
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Why Case Studies?
Staff may not realize that insulin pens are really
syringes with removable needles
For use by one
patient multiple
times, not for
multiple patients
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Case Study 2:
IV Bag as Common Source of Flush

Nebraska, September 2002
Four patients diagnosed with HCV
 Cluster reported by a gastroenterologist to
Nebraska Department of Health
 All patients had received cancer chemotherapy at
one clinic
 All had HCV genotype 3a

Macedo de Oliveira, et al. Ann Int Med 2005;142:898-903
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Case Study 2:
IV Bag as Common Source of Flush

Clinic independently owned and operated
within a hospital complex
Approximately 500 patients per month
 One oncologist, a registered nurse, a certified
nurse assistant, and a secretary

Macedo de Oliveira, et al. Ann Int Med 2005;142:898-903
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Case Study 2:
IV Bag as Common Source of Flush

Epi investigation revealed
No active infection control program
 RN responsible for all central venous catheter
(CVC) care, medication administration, and blood
collection

Reused disposable syringes to withdraw saline solution
from 500-ml bags (potentially used for 25-50 patients)
after withdrawing blood from central venous catheters
 Hospital and clinic notified of infection control concerns
in February and April 2001.

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Case Study 2:
IV Bag as Common Source of Flush


RN dismissed for infection control breaches in
July 2001 (19 mos prior to outbreak
identification)
Physician oversight of practices
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Case Study 2:
IV Bag as Common Source of Flush


Investigators reviewed records of 367 patients
treated at the clinic between March 2000 and
July 2001
99/367 HCV positive
95/99 (96%) had detectable virus (genotype 3a)
 All 99 had CVC flushes on the same days as one
patient with prior history of HCV (genotype 3a)
 Only 20 exhibited clinical signs of HCV
 2/99 spontaneously cleared HCV

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Case Study 2:
What was the breach?

Using IV bag of fluid as a common source for
multiple patients
“Single dose container”
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Case Study 2:
What was the root cause?
Unclear,
•
possibilities include:
High volume clinic with one RN?
 Pressure
to cut corners related to high through-put in the
clinic (trying to save time, resources, etc.)?
Lack of sufficient oversight of professional staff?
• Belief in myths regarding the potential for syringe
contamination (e.g., no visible blood = no
contamination)?
•
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Case Study 2:
Were there barrier(s) to the
correct procedure?

None identified, possibilities include:

Lack of appropriate supplies (e.g., vials of normal
saline for flushing IVs)?
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Case Study 2:
What were the sequelae?
Spread of HCV to multiple patients and deaths
related to HCV
 Disciplinary action against healthcare providers
(loss of employment, loss of license)

Clinic
voluntarily closed October 2002
(1 month after outbreak identification)
Lawsuits
 Negative press
 Loss of trust in healthcare by consumers

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Case Study 2:
What are some corrective actions?


Establish and maintain an effective infection
control program
Include safe injections in infection control
training upon hire and at least annually thereafter



Include examples pertinent to audience’s practice
Monitor the practice of those under your
supervision
Have a mechanism to recognize and address
infection breaches in a timely manner
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Examples of Investigations
Related to Unsafe Injections
Investigation
Practice Setting
Professions Involved
Sharing insulin pens
Acute (3) and long term
care (1) facilities
Nursing
Sharing diabetes care
equipment without
appropriate reprocessing
Long term psychiatric care
facility,
Adult care facility
Nursing
Reusing contaminated
multi-use vials
Pain management clinic
MD (anesthesia)
Flu vaccine syringe reuse
Private practices (3)
MD (1 OB/GYN, 2 GP)
Allergy skin testing
needle reuse
Clinic affiliated with
hospital
MD (fellow)
Inadequate med prep area Dialysis facility
MD (renal), Nursing
Improper storage of
injection equipment
Private practice
MD (dermatology),
Nursing
IV tubing reuse
Hospital (2)
Nursing
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Excuses for Unsafe Injections
We all know not to re-use needles. What’s the big fuss?
 My colleagues all do it like this, so it must be okay.
 That’s just something the government bureaucrats tell us
to do, but no one really does it.
 That’s not how I trained.
 It’s wasteful and expensive; I can’t afford it.
 You can’t really transmit hepatitis that way!
 The policies in place when I came here say to do it
this way, so it must be okay.

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Pictures from Investigations
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Pictures from Investigations
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Pictures from Investigations
Opened,
unlabeled vials
ready for use on
next patient left
unattended in an
exam room
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Pictures from Investigations
Used needle
Full sharps
container
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Pictures from Investigations
“Clean”
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Pictures from Investigations
“flu vaccine”
syringe with
1-ml of fluid
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Pictures from Investigations
Medication vial stored
in refrigerator with
staff food
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Pictures from Investigations
Single-dose vial
of propofol with
vented spike for
use on multiple
patients
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Resources
NYS One & Only Campaign Partner Website
http://www.oneandonlycampaign.org/partner/ne
w-york
Healthcare provider and
patient education materials
 Newsletter and links to recent alerts and advisories
regarding safe injections

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One & Only Campaign
Educational Materials
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Resources
Centers for Disease Control and Prevention:
Injection Safety Website
http://www.cdc.gov/injectionsafety/
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Resources
CDC: Guideline for Isolation Precautions:
Preventing Transmission of Infectious Agents in
Healthcare Settings, 2007
http://www.cdc.gov/hicpac/pdf/isolation/Isolatio
n2007.pdf
 Contains recommendations for safe injection
practices with references
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Resources
CDC: Recommended Practices for Preventing
Bloodborne Pathogen Transmission during
Blood Glucose Monitoring and Insulin
Administration in Healthcare Settings
http://www.cdc.gov/injectionsafety/bloodglucose-monitoring.html#Recommended
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Resources
US Food and Drug Administration (FDA) Information for Healthcare Professionals: Risk
of Transmission of Blood-borne Pathogens from
Shared Use of Insulin Pens
http://www.fda.gov/Drugs/DrugSafety/Postmark
etDrugSafetyInformationforPatientsandProviders
/DrugSafetyInformationforHeathcareProfessiona
ls/ucm133352.htm
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References
Case/Outbreak Reports:
Bacterial Contamination
Abe K et al. Outbreak of Burkholderia cepacia bloodstream infection at an
outpatient hematology and oncology practice. ICHE 2007;28:1311-1313.
Cohen AL et al. Outbreak of Serratia marcescens bloodstream and central
nervous system infections after interventional pain management
procedures. Clin J Pain 2008;24:374-380
Groshskopf LA et al. Serratia liquefaciens Bloodstream Infections from
contamination of epoetin alfa at a hemodialysis center. NEJM
2001;344:1491-1497.
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References
Diabetes Testing
Centers for Disease Control and Prevention. Notes from the field: Deaths from
acute hepatitis B virus infection associated with assisted blood glucose
monitoring in an assisted-living facility – North Carolina, August-October
2010. MMWR 2011;60:182.
Centers for Disease Control and Prevention. Transmission of hepatitis B virus
among persons undergoing blood glucose monitoring in long-term-care
facilities–Mississippi, North Carolina, and Los Angeles County, California,
2003-2004. MMWR 2005;54:220-223.
Farkas K, Jermendy G. Transmission of hepatitis B infection during home
blood glucose monitoring. Diabetic Medicine 1997;14:263.
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References
Diabetes Testing (continued)
Gotz HM, et.al. A cluster of hepatitis B virus infections associated with
incorrect use of a capillary blood sampling device in a nursing home in the
Netherlands, 2007. Eurosurveillance 2008;13:1-5.
Polish LB, et al. Nosocomial transmission of hepatitis B virus associated with
a spring-loaded finger-stick device. N Engl J Med 1992;326:721-5.
Stapleton J. Transmission of hepatitis B during blood glucose monitoring.
JAMA 1985;253:3250.
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References
Medication handling
Bennett SN et al. Post-operative infections traced to contamination of an
intravenous anesthetic, propofol. NEJM 1995;333:147-154.
Comstock RD et al. A large nosocomial outbreak of hepatitis C and hepatitis B
among patients receiving pain remediation treatments. ICHE 2004;25:576583.
Fischer GE et al. Hepatitis C virus infections from unsafe injection practices at an
endoscopy clinic in Las Vegas, Nevada, 2007-2008. CID 2010;51:267-273.
Gutelius B et al. Multiple clusters of hepatitis virus infections associated with
anesthesia for outpatient endoscopy procedures. Gastroenterology
2010;139:163-170.
Macedo de Oliveira A et al. An outbreak of hepatitis C virus infections among
outpatients at a hematology/oncology clinic. AIM 2005;142:898-903.
Samandari T et al. A large outbreak of hepatitis B virus infections associated
with frequent injections at a physician’s office. ICHE 2005;26:745-750.
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References
Contamination of syringes/blood glucose equipment:
Hughes RR. Syringe contamination following intramuscular and subcutaneous
injections. J R Army Med Corps 1948;87:156-68.
Louie RF, Lau MJ, Lee JH, et al. Multicenter study of the prevalence of blood
contamination on point-of-care glucose meters and recommendations for
controlling contamination. Point of Care 2005;4:158-163.
Lutz CT, Bell CE Jr, Wedner HJ, Krogstad DJ. Allergy testing of multiple
patients should no longer be performed with common syringes. N Engl J
Med 1984;310:1335-7.
Plott RN, Wagner RF Jr, Tyring SK. Iatrogenic contamination of multidose
vials in simulated use: a reassessment of current patient injection technique.
Arch Dermatol 1990;126:1441-4.
Trepanier CA, Lessard MR, Brochu JB, Denault PH. Risk of cross infection
related to the multiple use of disposable syringes. Can J Anaesth
1990;37:156-9.
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References
Guidelines/Recommendations
Thompson ND et al. Nonhospital health care-associated hepatitis B and C
virus transmission: United States, 1998-2008. Ann Intern Med
2009;150:33-39.
Thompson ND, Perz JF. Eliminating the blood: Ongoing outbreaks of hepatitis
B virus infection and the need for innovative glucose monitoring
techniques. J Diabetes Sci Technol 2009;3(2):283-288.
Klonoff DC, Perz JF. Assisted monitoring of blood glucose: Special safety
needs for a new paradigm in testing glucose.
J Diabetes Sci Technol 2010;4(5):1027-1031
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References
Environmental survival of hepatitis viruses
Alfurayh O. et al. Hand contamination with hepatitis C virus in staff looking after
hepatitis C-positive hemodialysis patients. Am J Nephrol 2000;20:103-106.
Bond WW, Favero MS, Petersen NJ, et al. Survival of hepatitis B virus after
drying and storage for one week. Lancet 1981;1(8219):550-1.
Ciesek S et al. How stable is the hepatitis C virus (HCV)? Environmental
stabilityof HCV and its susceptibility to chemical biocides. JID 2010:201 (15
June);1859-1866
Doerrbecker J et al. Inactivation and survival of hepatitis C virus on inanimate
surfaces. J ID 2011:204(15 December);1831-1838.
Kamili S et al. Infectivity of hepatitis C virus in plasma after drying and storing at
room temperature. Infect Control Hosp Epidemiol 2007;28:519-524
Paintsil E et al. Survival of hepatitis C virus in syringes: Implication for
transmission among injection drug users. JID 2010:202(1 October);984-990
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Questions?
Click here to
submit a question
Handouts & CEs

http://www.empirestatephtc.org/events.cfm
 View and print handouts
 CME, CNE, CECHs credits
 evaluation and post-test required
 Viewing
as a group?
 Please submit sign in sheet via fax
518-402-1137 or email
[email protected]
60
Thank you!!
This program has been recorded and will be
available for on demand viewing within 1 week
at: http://www.empirestatephtc.org/events.cfm
61