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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

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.

(2)

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

4

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.

(3)

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.

7

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.

8

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.

(4)

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

10

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.

11

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

(5)

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

13

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

14

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?

(6)

Case Study 1:

What was the breach?

Sharing syringes between multiple patients

16

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?

(7)

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

19

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.

20

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

(8)

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

22

when it is actually single-use

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?

23

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

(9)

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

25 Macedo 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

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

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.

(10)

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

28

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

29

Case Study 2:

What was the breach?

Using IV bag of fluid as a common source for

multiple patients

30

(11)

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)?

31

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)?

32

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

(12)

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

34

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

35

(13)

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.

37

Pictures from Investigations

38

(14)

Pictures from Investigations

40

Opened,

 

unlabeled

 

vials

 

ready

 

for

 

use

 

on

 

next

 

patient

 

left

 

unattended

 

in

 

an

 

exam

 

room

Pictures from Investigations

41

Used

 

needle

Full

 

sharps

 

container

Pictures from Investigations

42

“Clean”

(15)

43

“flu

 

vaccine”

 

syringe

 

with

 

1

ml

 

of

 

fluid

Pictures from Investigations

44

Medication

 

vial

 

stored

 

in

 

refrigerator

 

with

 

staff

 

food

Pictures from Investigations

Single

dose

 

vial

 

of

 

propofol with

 

vented

 

spike

 

for

 

use

 

on

 

multiple

 

(16)

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

46

One & Only Campaign

Educational Materials

47

Resources

Centers for Disease Control and Prevention:

Injection Safety Website

http://www.cdc.gov/injectionsafety/

(17)

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

49

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

50

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

(18)

References

52

Case/Outbreak Reports: Bacterial Contamination

Abe K et al. Outbreak of Burkholderia cepacia bloodstream infection at an outpatient hematology and oncology practice. ICHE2007;28:1311-1313. Cohen AL et al. Outbreak of Serratia marcescens bloodstream and central

nervous system infections after interventional pain management procedures. Clin J Pain2008;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.

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. MMWR2005;54:220-223.

Farkas K, Jermendy G. Transmission of hepatitis B infection during home blood glucose monitoring. Diabetic Medicine 1997;14:263.

53

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.

(19)

55

Medication handling

Bennett SN et al. Post-operative infections traced to contamination of an intravenous anesthetic, propofol. NEJM1995;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. CID2010;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. AIM2005;142:898-903. Samandari T et al. A large outbreak of hepatitis B virus infections associated

with frequent injections at a physician’s office. ICHE2005;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 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.

56

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 Technol2009;3(2):283-288.

Klonoff DC, Perz JF. Assisted monitoring of blood glucose: Special safety needs for a new paradigm in testing glucose.

(20)

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.Lancet1981;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. JID2010:201 (15 June);1859-1866

Doerrbecker J et al. Inactivation and survival of hepatitis C virus on inanimate surfaces. J ID2011:204(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 Epidemiol2007;28:519-524 Paintsil E et al. Survival of hepatitis C virus in syringes: Implication for

transmission among injection drug users. JID2010:202(1 October);984-990

58

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

(21)

This program has been recorded and will be

available for on demand viewing within 1 week

at: http://www.empirestatephtc.org/events.cfm

References

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