- Email: [email protected]
Safe Injection Practices: Keeping Safety In and the “Bugs” Out
DANGER ZONE
SAFE INJECTION PRACTICES: KEEPING SAFETY IN AND THE “BUGS” OUT Author: Susan Paparella, MSN, RN, Horsham, PA Section Editor: Susan Paparella, MSN, RN
Earn Up to 8 CE Hours. See page 599.
The Problem
A recent online survey of more than 5,000 health care practitioners revealed an alarming lapse in basic infection control practices associated with the use of syringes, needles, multiple-dose vials, single-use vials, and flush solutions.1 Although the majority of nurses and other health care practitioners appear to be following infection control practices consistent with current recommendations, some respondents showed a general lack of awareness about safe injection practices and harbored misconceptions about injection safety that are clearly placing patients at risk for transmission of blood-borne diseases.1 This research was published in an article entitled “Injection practices among clinicians in United States health care settings” in the December 2010 issue of the American Journal of Infection Control (http://www.ajicjournal.org/ article/S0196-6553(10)00853-9/fulltext). The Institute for Safe Medication Practices (ISMP) has long been concerned about a variety of unsafe injection practices that have been described in its national medicaSusan Paparella, Member, Bux-Mont Chapter, is Vice President at the Institute for Safe Medication Practices (ISMP*), Horsham, PA, and a member of the Advisory Committee for the Institute for Quality, Safety, and Injury Prevention. *ISMP is a nonprofit organization that works closely with health care practitioners, consumers, hospitals, regulatory agencies, and professional organizations to educate caregivers about preventing medication errors. ISMP is the premier international resource on safe medication practices in health care institutions. If you would like to report medication errors to help others, E-mail us at: [email protected] or call (800)FAIL-SAF(e). This Medication Error Reporting Program keeps information confidential and secure. We will include only the level of detail that the reporter wishes in our publications. For correspondence, write: Susan Paparella, MSN, RN, Vice President, ISMP; E-mail: [email protected]. J Emerg Nurs 2011;37:564-6. Available online 1 September 2011. 0099-1767/$36.00 Copyright © 2011 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: 10.1016/j.jen.2011.07.012
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JOURNAL OF EMERGENCY NURSING
tion error reporting program and observed by its consulting team in hospitals across the United States.2 These unsafe practices already have resulted in patient harm. In June 2000, ISMP reported on a hepatitis C outbreak from three patients resulting from the use of a contaminated multi-dose vial of 0.9% sodium chloride injection. In 2003, Staphylococcus aureus was found in the wounds of 5 patients treated at the same location, reportedly transmitted through the use of a multi-dose lidocaine vial.3 The Extent of the Problem
The respondents in the aforementioned study reported that they were performing the following actions: 1. Using the same syringe to re-enter a multi-dose vial several times (15%); some respondents reported reusing this vial for other patients (7%) 2. Using a common bag or bottle of intravenous solution to obtain a “flush” dose or for drug diluents for multiple patients (9%) 3. Using single-dose vials for multiple patients (6 %) 4. Reusing a syringe for more than one patient after changing the needle (1%)1,4,5
The survey by Pugliese et al.1 revealed comments by the participants (more than 85% were nurses) that clearly demonstrated a general lack of awareness and some misperceptions regarding safe injection practices. For example, although most survey respondents suggested that the reuse of syringes is “appalling,” other practitioners were unaware that pathogenic contaminants can enter a syringe and be transmitted to the next patient, even after applying a clean needle. Cases of this nature have been reported frequently in the literature. In 2009, more than 2000 insulin-dependent diabetic patients from a U.S. Army hospital were placed at risk for acquiring blood-borne diseases when staff reused insulin pens between patients after only changing the needle.6 At least 2 other studies have shown that biological contamination of insulin can occur in up to half of all reused insulin pen cartridges.4
VOLUME 37 • ISSUE 6
November 2011
Paparella/DANGER ZONE
In these cases and in the survey, staff believed that changing a needle on a syringe was enough to protect patients against disease transmission.1 The use of a common intravenous solution bag to fill flush syringes for more than one patient also has been observed in organizations across the United States. Emergency departments are no exception. Some survey respondents had the misperception that as long as they “always used a clean syringe” and discarded the solution after 24 hours, they maintained a safe environment for the patient.1 Unfortunately, limiting use of the bag to 24 hours does not prevent pathogen transmission. A contaminated flushing solution could result very quickly in serious widespread transmission of pathogens throughout any department. Nursing staff in some facilities express a misunderstanding about the difference between single-use and multi-dose vials. Frequently, topical anesthetic multi-dose vials are used in the emergency department, and often they are used with multiple patients. Often the unsafe practice of re-entry with the same syringe and needle into a multi-dose vial after use on a patient is not overt but more likely to occur during a single procedure, such as bedside suturing. It is common for multi-dose vials to have a bacteriostatic agent in the vial; however, this agent will not destroy the bacteria, nor do these vials contain any agents with antiviral or antifungal properties.4 On a similar note, practitioners often do not recognize or understand that single-dose vials do not contain any type of preservative. Once opened and accessed for use with a single patient, these vials should be disposed of immediately, regardless of the amount of product remaining in them. All of the above risky practices have been specifically prohibited by the Centers for Disease Control and Prevention (CDC), and for good reason.7 All these practices have been directly associated with serious disease transmission. According to reports from the CDC, more than 50 outbreaks of hepatitis B, hepatitis C, and HIV have occurred in the past 10 years that have required notice to more than 125,000 potentially exposed patients, and more than 600 patients subsequently became infected. It also is the concern of the authors of this study1 that the full extent of any disease transmissions may go unrecognized for years as patients remain asymptomatic or have mild symptoms.4 What Can I Do?
Safety-minded organizations such as Premier’s Safety Institute and regulatory agencies such as the Food and Drug Administration, CDC, and The Joint Commission
November 2011
VOLUME 37 • ISSUE 6
all recently have stepped up activities to raise awareness about this important topic. Best practices in this situation call for all practitioners to follow the Safe Injection Practice recommendations put forth by the CDC, which can be found at http://www.cdc.gov/injectionsafety/unsafe Practices.html.8 The One & Only Campaign—one needle, one syringe, ONLY ONE time—that is led by the CDC and the Safe Injection Practice Collation offers free posters and educational brochures for both health care providers and patients. A free short training video on the topic is available at http://oneandonlycampaign.org/.9 Most importantly, you can help all practitioners understand that any form of syringe and/or needle reuse between patients is dangerous practice and puts patients at risk. Ideally, prefilled syringes should be used whenever possible for flushing intravenous sites and ports to avoid the risk of using a contaminated flush bag or vial. Begin to limit the use of multi-dose vials to single patients. Although disposing of multi-dose vials after one use be difficult for some frugal users, keep in mind that the cost of a new vial per patient (unless it is a medication that is very difficult to obtain or expensive) is certainly less when compared with an outbreak in your facility. If multi-dose vials must be saved and reused for more than one patient, both the needle and the syringe must be sterile and strict attention must be given to aseptic technique.4 Last, but certainly not least, share this information with your ED colleagues, including attending physicians, residents, interns, physician assistants, nurse practitioners, and clinical pharmacists. Help everyone make the right choices when it comes to safe injection practices. REFERENCES 1. Pugliese G, Gosnell C, Bartley JM, Robinson S. Injection practices among clinicians in United States health care settings. Am J Infect Control. 2010;38:789-98. 2. Institute for Safe Medication Practices. Medication Error Reporting Program confidential database (accessed July 2011). Horsham, PA: Institute for Safe Medication Practices. 3. Institute for Safe Medication Practices. Patient safety movement calls for the reexamination of multidose vial use. Hepatitis B outbreak related to multiple dose heparin vials should serve as a wakeup call. ISMP Medicat Saf Alert. 2000;5(12):1-2. 4. Institute for Safe Medication Practices. Perilous infection control practices with needles, syringes, and vials suggest stepped-up monitoring is needed. ISMP Medicat Saf Alert. 2010;15(24):1-2. 5. Institute for Safe Medication Practices. Safe injection practices: A call to action (live Webinar held). Horsham, PA: Institute for Safe Medication Practices; 2011. 6. Institute for Safe Medication Practices. Hazard alert: reuse of insulin pen for multiple patients risks transmission of bloodborne disease. ISMP Medication Safety Alert. 2009 Feb 12;1.
WWW.JENONLINE.ORG
565
DANGER ZONE/Paparella
7. Centers for Disease Control and Prevention. Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings 2007. www.cdc.gov/hicpac/2007IP/2007isolationPrecautions. html. Accessed August 8, 2011. 8. Centers for Disease Control and Prevention. Preventing unsafe injection practices. http://www.cdc.gov/injectionsafety/unsafePractices.html. Accessed August 8, 2011.
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JOURNAL OF EMERGENCY NURSING
9. Centers for Disease Control and Prevention. The One & Only Campaign. http://oneandonlycampaign.org/. Accessed July 15, 2011.
Submissions to this column are encouraged and may be sent to Susan Paparella, MSN, RN [email protected]
VOLUME 37 • ISSUE 6
November 2011
SAFE INJECTION PRACTICES: KEEPING SAFETY IN AND THE “BUGS” OUT Author: Susan Paparella, MSN, RN, Horsham, PA Section Editor: Susan Paparella, MSN, RN
Earn Up to 8 CE Hours. See page 599.
The Problem
A recent online survey of more than 5,000 health care practitioners revealed an alarming lapse in basic infection control practices associated with the use of syringes, needles, multiple-dose vials, single-use vials, and flush solutions.1 Although the majority of nurses and other health care practitioners appear to be following infection control practices consistent with current recommendations, some respondents showed a general lack of awareness about safe injection practices and harbored misconceptions about injection safety that are clearly placing patients at risk for transmission of blood-borne diseases.1 This research was published in an article entitled “Injection practices among clinicians in United States health care settings” in the December 2010 issue of the American Journal of Infection Control (http://www.ajicjournal.org/ article/S0196-6553(10)00853-9/fulltext). The Institute for Safe Medication Practices (ISMP) has long been concerned about a variety of unsafe injection practices that have been described in its national medicaSusan Paparella, Member, Bux-Mont Chapter, is Vice President at the Institute for Safe Medication Practices (ISMP*), Horsham, PA, and a member of the Advisory Committee for the Institute for Quality, Safety, and Injury Prevention. *ISMP is a nonprofit organization that works closely with health care practitioners, consumers, hospitals, regulatory agencies, and professional organizations to educate caregivers about preventing medication errors. ISMP is the premier international resource on safe medication practices in health care institutions. If you would like to report medication errors to help others, E-mail us at: [email protected] or call (800)FAIL-SAF(e). This Medication Error Reporting Program keeps information confidential and secure. We will include only the level of detail that the reporter wishes in our publications. For correspondence, write: Susan Paparella, MSN, RN, Vice President, ISMP; E-mail: [email protected]. J Emerg Nurs 2011;37:564-6. Available online 1 September 2011. 0099-1767/$36.00 Copyright © 2011 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: 10.1016/j.jen.2011.07.012
564
JOURNAL OF EMERGENCY NURSING
tion error reporting program and observed by its consulting team in hospitals across the United States.2 These unsafe practices already have resulted in patient harm. In June 2000, ISMP reported on a hepatitis C outbreak from three patients resulting from the use of a contaminated multi-dose vial of 0.9% sodium chloride injection. In 2003, Staphylococcus aureus was found in the wounds of 5 patients treated at the same location, reportedly transmitted through the use of a multi-dose lidocaine vial.3 The Extent of the Problem
The respondents in the aforementioned study reported that they were performing the following actions: 1. Using the same syringe to re-enter a multi-dose vial several times (15%); some respondents reported reusing this vial for other patients (7%) 2. Using a common bag or bottle of intravenous solution to obtain a “flush” dose or for drug diluents for multiple patients (9%) 3. Using single-dose vials for multiple patients (6 %) 4. Reusing a syringe for more than one patient after changing the needle (1%)1,4,5
The survey by Pugliese et al.1 revealed comments by the participants (more than 85% were nurses) that clearly demonstrated a general lack of awareness and some misperceptions regarding safe injection practices. For example, although most survey respondents suggested that the reuse of syringes is “appalling,” other practitioners were unaware that pathogenic contaminants can enter a syringe and be transmitted to the next patient, even after applying a clean needle. Cases of this nature have been reported frequently in the literature. In 2009, more than 2000 insulin-dependent diabetic patients from a U.S. Army hospital were placed at risk for acquiring blood-borne diseases when staff reused insulin pens between patients after only changing the needle.6 At least 2 other studies have shown that biological contamination of insulin can occur in up to half of all reused insulin pen cartridges.4
VOLUME 37 • ISSUE 6
November 2011
Paparella/DANGER ZONE
In these cases and in the survey, staff believed that changing a needle on a syringe was enough to protect patients against disease transmission.1 The use of a common intravenous solution bag to fill flush syringes for more than one patient also has been observed in organizations across the United States. Emergency departments are no exception. Some survey respondents had the misperception that as long as they “always used a clean syringe” and discarded the solution after 24 hours, they maintained a safe environment for the patient.1 Unfortunately, limiting use of the bag to 24 hours does not prevent pathogen transmission. A contaminated flushing solution could result very quickly in serious widespread transmission of pathogens throughout any department. Nursing staff in some facilities express a misunderstanding about the difference between single-use and multi-dose vials. Frequently, topical anesthetic multi-dose vials are used in the emergency department, and often they are used with multiple patients. Often the unsafe practice of re-entry with the same syringe and needle into a multi-dose vial after use on a patient is not overt but more likely to occur during a single procedure, such as bedside suturing. It is common for multi-dose vials to have a bacteriostatic agent in the vial; however, this agent will not destroy the bacteria, nor do these vials contain any agents with antiviral or antifungal properties.4 On a similar note, practitioners often do not recognize or understand that single-dose vials do not contain any type of preservative. Once opened and accessed for use with a single patient, these vials should be disposed of immediately, regardless of the amount of product remaining in them. All of the above risky practices have been specifically prohibited by the Centers for Disease Control and Prevention (CDC), and for good reason.7 All these practices have been directly associated with serious disease transmission. According to reports from the CDC, more than 50 outbreaks of hepatitis B, hepatitis C, and HIV have occurred in the past 10 years that have required notice to more than 125,000 potentially exposed patients, and more than 600 patients subsequently became infected. It also is the concern of the authors of this study1 that the full extent of any disease transmissions may go unrecognized for years as patients remain asymptomatic or have mild symptoms.4 What Can I Do?
Safety-minded organizations such as Premier’s Safety Institute and regulatory agencies such as the Food and Drug Administration, CDC, and The Joint Commission
November 2011
VOLUME 37 • ISSUE 6
all recently have stepped up activities to raise awareness about this important topic. Best practices in this situation call for all practitioners to follow the Safe Injection Practice recommendations put forth by the CDC, which can be found at http://www.cdc.gov/injectionsafety/unsafe Practices.html.8 The One & Only Campaign—one needle, one syringe, ONLY ONE time—that is led by the CDC and the Safe Injection Practice Collation offers free posters and educational brochures for both health care providers and patients. A free short training video on the topic is available at http://oneandonlycampaign.org/.9 Most importantly, you can help all practitioners understand that any form of syringe and/or needle reuse between patients is dangerous practice and puts patients at risk. Ideally, prefilled syringes should be used whenever possible for flushing intravenous sites and ports to avoid the risk of using a contaminated flush bag or vial. Begin to limit the use of multi-dose vials to single patients. Although disposing of multi-dose vials after one use be difficult for some frugal users, keep in mind that the cost of a new vial per patient (unless it is a medication that is very difficult to obtain or expensive) is certainly less when compared with an outbreak in your facility. If multi-dose vials must be saved and reused for more than one patient, both the needle and the syringe must be sterile and strict attention must be given to aseptic technique.4 Last, but certainly not least, share this information with your ED colleagues, including attending physicians, residents, interns, physician assistants, nurse practitioners, and clinical pharmacists. Help everyone make the right choices when it comes to safe injection practices. REFERENCES 1. Pugliese G, Gosnell C, Bartley JM, Robinson S. Injection practices among clinicians in United States health care settings. Am J Infect Control. 2010;38:789-98. 2. Institute for Safe Medication Practices. Medication Error Reporting Program confidential database (accessed July 2011). Horsham, PA: Institute for Safe Medication Practices. 3. Institute for Safe Medication Practices. Patient safety movement calls for the reexamination of multidose vial use. Hepatitis B outbreak related to multiple dose heparin vials should serve as a wakeup call. ISMP Medicat Saf Alert. 2000;5(12):1-2. 4. Institute for Safe Medication Practices. Perilous infection control practices with needles, syringes, and vials suggest stepped-up monitoring is needed. ISMP Medicat Saf Alert. 2010;15(24):1-2. 5. Institute for Safe Medication Practices. Safe injection practices: A call to action (live Webinar held). Horsham, PA: Institute for Safe Medication Practices; 2011. 6. Institute for Safe Medication Practices. Hazard alert: reuse of insulin pen for multiple patients risks transmission of bloodborne disease. ISMP Medication Safety Alert. 2009 Feb 12;1.
WWW.JENONLINE.ORG
565
DANGER ZONE/Paparella
7. Centers for Disease Control and Prevention. Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings 2007. www.cdc.gov/hicpac/2007IP/2007isolationPrecautions. html. Accessed August 8, 2011. 8. Centers for Disease Control and Prevention. Preventing unsafe injection practices. http://www.cdc.gov/injectionsafety/unsafePractices.html. Accessed August 8, 2011.
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JOURNAL OF EMERGENCY NURSING
9. Centers for Disease Control and Prevention. The One & Only Campaign. http://oneandonlycampaign.org/. Accessed July 15, 2011.
Submissions to this column are encouraged and may be sent to Susan Paparella, MSN, RN [email protected]
VOLUME 37 • ISSUE 6
November 2011