Safe Injection Safe Injection PracticesPractices

• Confirmed patient-to-patient Confirmed patient-to-patient transmission of transmission of blood borne blood borne

& other pathogens & other pathogens in US healthcarein US healthcare facilitiesfacilities

• Transmission have been linked to Transmission have been linked to unsafe injectionunsafe injection practices practices

SITUATION

Past Decade, USPast Decade, US•> 35 reported outbreaks of viral hepatitis > 35 reported outbreaks of viral hepatitis among patients among patients

• > 250 confirmed cases since 2008> 250 confirmed cases since 2008

•Outbreaks linked to unsafe injection practices Outbreaks linked to unsafe injection practices

•> 90,0000 patient notifications re: potential > 90,0000 patient notifications re: potential exposures to blood borne pathogensexposures to blood borne pathogens

BACKGROUND

Mar 2012 Mar 2012

•Orthopedic clinic-DEOrthopedic clinic-DE•7 patients / 5 same procedure date7 patients / 5 same procedure date•All admitted to hospital for Rx of septic arthritis All admitted to hospital for Rx of septic arthritis or bursitis or bursitis • 6 pts. and 1 HCW had MSSA w/ indistinguishable 6 pts. and 1 HCW had MSSA w/ indistinguishable

PFGE typePFGE type•Reuse of single-dose vials of bupivacaine for Reuse of single-dose vials of bupivacaine for multiple patientsmultiple patients

Apr 2012 Apr 2012 •Outpatient Pain Management clinic – AZOutpatient Pain Management clinic – AZ•3 patients / same procedure date 3 patients / same procedure date • 1 Pt. developed MRSA mediastinitis & 1 Pt. developed MRSA mediastinitis &

bacteremia bacteremia •2 Epidural steroid injections / 1 stellate ganglion 2 Epidural steroid injections / 1 stellate ganglion block block • Contrast medium drawn up in procedure roomContrast medium drawn up in procedure room• Change in vial size due to drug shortagesChange in vial size due to drug shortages

BACKGROUND

•Unsafe injection practices place Unsafe injection practices place patients at riskpatients at risk• Use of single-dose vials for multiple Use of single-dose vials for multiple

patientspatients

• Contamination of multi-use vials & Contamination of multi-use vials & containers via reuse of containers via reuse of needles/syringesneedles/syringes

•Other related consequences Other related consequences include:include:• Negative media Negative media • Malpractice suits Malpractice suits • Disciplinary action by licensing Disciplinary action by licensing

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ASSESSMENT

•Variable practices exist and may differ Variable practices exist and may differ between health care facilities / settings between health care facilities / settings

•Healthcare facilities MUST develop Healthcare facilities MUST develop processes to processes to • Assure policies/protocols set clear expectations Assure policies/protocols set clear expectations

• Assess existing practicesAssess existing practices

• Evaluate existing products Evaluate existing products

• Educate and train staff on safe injection Educate and train staff on safe injection

practices practices

ASSESSMENT

Assure policies/protocols set clear expectationsAssure policies/protocols set clear expectations

RECOMMENDATIONS Injection Practices

1. Aseptic technique is used to avoid contamination of sterile injection equipment.2. Used syringes, needles and cannulas are discarded at the point of use in an approved sharps container immediately after

use.3. Single-dose vials are used whenever possible and discarded immediately after use on a single patient. 4. Medications are not administered from a syringe to multiple patients, even if the needle or cannula on the syringe is

changed. 5. Needles, cannulae, and syringes are sterile, single-use items and should not be reused for another patient or to access a

medication or solution that might be used for a subsequent patient. 6. A syringe or needle/cannula is considered contaminated once it has been used to enter or connect to a patient's

intravenous infusion bag or administration set. 7. Medication is not prepared in one syringe to transfer to another syringe.8. A sterile syringe and needle/cannula is always used when entering a vial--never one that has been used on another

patient.9. Vials are discarded 28 days after opening, unless specified by the manufacturer, or sooner if sterility is questioned or

compromised.10. Multi-dose vials are not kept in the immediate patient treatment area and are stored in accordance with the

manufacturer's recommendations. 11. A needle, cannula, or spike device is never left inserted into a medication vial rubber stopper because it leaves the vial

vulnerable to contamination. 12. Fluid infusion and administration sets (i.e., intravenous bags, tubing, and connectors) are used for one patient only and

discarded appropriately after use. 13. Bags or bottles of intravenous solution are not used as a common source of supply for multiple patients.14. Once IV solution bags have been spiked; administration must begin within 1 hour.15. All opened vials, IV solutions and prepared or opened syringes that were used in an emergency situation are discarded.

Assess Existing PracticesAssess Existing Practices

RECOMMENDATIONS

TIPS

•Include all settings where injections may be administered

•Targeted audits/mock surveys

•Annual IP Program Review

Evaluate Existing Products Evaluate Existing Products

RECOMMENDATIONS

TIPS

•Work closely with Pharmacy

•Targeted audits/mock surveys

• Single dose vials whenever possible

• If not possible, review alternatives• Use multi-dose vial as single-dose vial• Can Pharmacy support drawing doses

in controlled setting (e.g. in pharmacy under laminar hood)?

Educate and train staff on safe injection practicesEducate and train staff on safe injection practices

RECOMMENDATIONS

http://www.cdc.gov/injectionsafety/1anOnly.html

1.1. CDC -The One & Only Campaign - Injection CDC -The One & Only Campaign - Injection SafetySafety

2.2. HICPAC. 2007 Guideline for Isolation HICPAC. 2007 Guideline for Isolation Precautions: Preventing Transmission of Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Infectious Agents in Healthcare Settings. June 2007June 2007

3.3. Sue Dill Calloway. Safe Injection Practices Sue Dill Calloway. Safe Injection Practices Presentation. 2012 Presentation. 2012

4.4. MMWR. Invasive Staphylococcus aureus MMWR. Invasive Staphylococcus aureus Infections Associated with Pain Injections Infections Associated with Pain Injections and Reuse of Single-Dose Vials — Arizona and Reuse of Single-Dose Vials — Arizona and Delaware, 2012. July 13, 2012 / and Delaware, 2012. July 13, 2012 / 61(27);501-50461(27);501-504

References

Questions for the CHAIN Gang??