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Your Best Shot: Training Your Staff to

Give Safe InjectionsEmily 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

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Program Guidelines No Sound? Make sure your computer speakers/ sound

is turned on! You may have to turn up the volume.

If you experience any technological problems during the program, try exiting and logging in again.

This program will be recorded and available for on demand viewing within 1 week.

Contact info: coned@albany.edu / 518-402-0330

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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 coned@albany.edu

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Click here to submit a question

Questions & Answers at end of program

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 ofstaff 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 providersand 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 ofUnsafe Injection Practices?

Using the same syringe to administer medication to more than one patient, even if the needleis 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.

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Source: CDC Injection Safetyhttp://www.cdc.gov/injectionsafety/

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 abouther 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 What went wrong?

Root cause Why did it go wrong?

Barrier(s) to correct procedure What contributed to the breach? What could have been done to stop it?

Sequelae (potential or actual) 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?17

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 actionsagainst 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 consequencesof 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

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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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For use by one patient multiple times, not for multiple patients

Why Case Studies?

Staff may not realize that insulin pens are really syringes with removable needles

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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

25Macedo de Oliveira, et al. Ann Int Med 2005;142:898-903

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

26Macedo 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

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“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 testingneedle reuse

Clinic affiliated with hospital

MD (fellow)

Inadequate med prep area Dialysis facility MD (renal), Nursing

Improper storage ofinjection equipment

Private practice MD (dermatology), Nursing

IV tubing reuse Hospital (2) Nursing35

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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 itthis 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

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Opened, unlabeled vials ready for use on next patient left unattended in an exam room

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Pictures from Investigations

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Used needle

Full sharps container

Pictures from Investigations

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“Clean”

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Pictures from Investigations

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“flu vaccine” syringe with 1‐ml of fluid

Pictures from Investigations

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Medication vial stored in refrigerator with staff food

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Pictures from Investigations

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Single‐dose vial of propofol with vented spike for use on multiple patients

ResourcesNYS One & Only Campaign Partner Website http://www.oneandonlycampaign.org/partner/new-york

Healthcare provider andpatient 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/Isolation2007.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/blood-glucose-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/PostmarketDrugSafetyInformationforPatientsandProviders/DrugSafetyInformationforHeathcareProfessionals/ucm133352.htm

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References

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Case/Outbreak Reports:

Bacterial ContaminationAbe 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. NEJM2001;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

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Medication handlingBennett 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;25:576-583.

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. Gastroenterology2010;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.

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 multidosevials 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 Anaesth1990;37:156-9.

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ReferencesGuidelines/Recommendations

Thompson ND et al. Nonhospital health care-associated hepatitis B and C virus transmission: United States, 1998-2008. Ann Intern Med2009;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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ReferencesEnvironmental 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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Click here to submit a question

Questions?

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 coned@albany.edu

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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

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