Best Infection Control Practices for ID, SC, and IM Injections

Recommendations of the SIGN Working Group on Best Practices

Geneva, 19-20 October 2000

SIGN 2001

Injection Safety Standards:Background

• No prior agreement on what is a “safe injection”.

• Review of training materials showed many dangerous or questionable practices being promoted. Research does not exist to support many common practices (e.g. aspiration).

• This group focused on actions of the injector that could spread infection.

A “Best Practices” Document

• “Best” = pose minimum risk of disease transmission based on current evidence.

• Countries modify, or accept “best” practices based on risks and cost of adopting practices in their programs.

Process for Development of Best Practices for Infection Control

• Broke an injection into a series of steps • Conducted a literature review • Drafted and discussed the document • Revised draft for public comments • Availability of a final document

Categories of Evidence 1, 2 or 3

1 Strongly recommended and supported by research with appropriate study design and analysis.

2 Strongly recommended on the basis of strong theoretical rationale and suggestive, descriptive evidence.

3 Recommended on the basis of expert consensus and theoretical rationale.

Four Scientifically-Supported Practice Areas

• Use of sterile injection equipment for each injection

• Preventing contamination of equipment and medication

• Preventing needlesticks by disposal at point of use

• Preventing contact or access to used needles– reduces re-use– reduces needlesticks

Issues Where Firm Conclusions Could not Be Reached

• Use of engineered technology

• Hand hygiene

• Use of gloves for providing injections

• Swabbing vials or ampoules

• Skin preparation prior to injection

Use Simple Sheets to Help Discuss Practices

• Don’t expect guidelines or posters alone to change

behavior

• People do things for a reason. Explore why.

• Knowledge is necessary but not sufficient to change

practices.

Different Areas Have Different Problem Practices

• Decanting• Aspiration• Dosing• Loading more than one dose in a syringe• Placing syringes in disinfectant prior to re-use• Storing syringes wet• Placing a finger over the needle site

Use a Syringe and Needle with Proof of Sterility for Each Injection (1)

• Inspect packaging or sterilization monitors.

• Use syringes with quality controls that staff and parents can see.

If Single-Use Equipment is Unavailable… (1)

• Sterilize only equipment designed for steam-sterilization.

• Decontaminate syringes to make them safe to handle.

• Clean all visible dirt from syringes, remove plunger, flush needle, take apart.

• Use sterilization monitors.• This critical task requires

supervision and appropriate pay.

Prepare Injections in a Clean Area (2)

• Do not work in an area where blood, contaminated items or body fluids are or may be present.

• Water is available• Soap is available • Freshly prepared bleach and

water or environmental disinfectant (not skin cleaner)

•

Use Single-Dose Vials if Possible (2)

• Single dose vials pose a lower risk for disease transmission.

• The risks of using single-dose vials will increase in programs where syringes are used more than once, and if reconstituted vaccine vials are not strictly discarded after 6 hours.

Use Tools or Barriers to Open Glass Vials (2)

• Staff frequently cut themselves opening glass vials. This is painful and contaminates the ampoule and work area.

• Purchase vials that do not need to be broken to open.

Follow Product-Specific Recommendations for Use, Storage and

Handling (3)• Discard reconstituted

vaccines that do not contain preservatives within 6 to avoid sepsis or toxic shock

• Never use normal saline or water in place of diluent.

• Avoid freezing vaccines

Discard Needles that Have Touched Non-Sterile Surfaces (3)

• If if touched, discard.

Position Patients Prior to Injection (2)

• Anticipate and take measures to prevent sudden patient movement during and after injection.

• This may require making chairs available, revising clinic flow or reassigning staff.

Avoid Recapping and Manipulation of Needles (1)

• Reducing contact and manual handling of used syringes reduces needlesticks.

Questions and Comments?

• Contact the SIGN Secretariat for copies of images, materials and to share materials.

SIGN@who.ch Safe Injection Global Network

World Health Organization Avenue Appia 20

Geneva 27 Switzerland 1211

Fax 41-22-791-4836