“ “Refuse to infuse” Refuse to infuse” Injection Safety for Injection Safety for Infection PreventionInfection Prevention

2011 Puget Sound APIC Conference2011 Puget Sound APIC ConferenceSept 30 and Oct 1, 2011Sept 30 and Oct 1, 2011

Lou Hilken, RN, MN, ICP, CICLou Hilken, RN, MN, ICP, CICProvidence St. Peter Hospital, Olympia WAProvidence St. Peter Hospital, Olympia WA

Current ScoreboardCurrent Scoreboard

UW – 31UW – 31

Seahawks – 13Seahawks – 13

Olympia High School - Olympia High School - 2424

Patient w/o injection Patient w/o injection related infection – related infection – allall

Cal 23Cal 23

Cardinals – 10Cardinals – 10

Mt. Tahoma – 0Mt. Tahoma – 0

Pathogens - 0Pathogens - 0

Refuse to infuse, so patients Refuse to infuse, so patients don’t losedon’t lose

Disclosure: several slides were obtained or adapted Disclosure: several slides were obtained or adapted from: from:

A “Never” Event: Unsafe Injection PracticesA “Never” Event: Unsafe Injection PracticesJoseph Perz DrPH MA, Arjun Srinivasan MD, Priti Patel MD Joseph Perz DrPH MA, Arjun Srinivasan MD, Priti Patel MD MPHMPHPrevention and Response Branch Division of Healthcare Prevention and Response Branch Division of Healthcare Quality Promotion: Centers for Disease Control and Quality Promotion: Centers for Disease Control and PreventionPrevention

Injection SafetyInjection SafetyMelissa Schaefer, MDMelissa Schaefer, MD

Division of Healthcare Quality Promotion Centers for Division of Healthcare Quality Promotion Centers for Disease Control and PreventionDisease Control and Prevention

Learning objectivesLearning objectives

1.1. Describe safe injection, infusion and Describe safe injection, infusion and medication vial practices to minimize medication vial practices to minimize cross contamination and infection cross contamination and infection outbreaks.outbreaks.

2.2. Discuss situations that led to break in Discuss situations that led to break in sterile technique and infection related sterile technique and infection related to medication administration.to medication administration.

3.3. Identify potential practice changes in Identify potential practice changes in your Ambulatory Surgery Center (ASC) your Ambulatory Surgery Center (ASC) to further reduce infection risk.to further reduce infection risk.

Success StrategiesSuccess Strategies

Know the game and rules Know the game and rules Learn from past lossesLearn from past losses Implement a solid game planImplement a solid game plan Work with your coaches Work with your coaches

Know the game and the Know the game and the rulesrules

Injection SafetyInjection Safety

Measures taken to perform injections in a Measures taken to perform injections in a safe manner for patients and providers . safe manner for patients and providers .

Prevent transmission of infectious Prevent transmission of infectious diseases from: – Patient to patient; diseases from: – Patient to patient; Patient to provider; and Provider to Patient to provider; and Provider to patient . patient .

http://www.cdc.gov/ncidod/dhqp/injectionSafetyFAQs.htmlhttp://www.cdc.gov/ncidod/dhqp/injectionSafetyFAQs.html

What do your injection What do your injection practices look like?practices look like?

Multidose vialsMultidose vials Single dose vialsSingle dose vials Pre-drawn medsPre-drawn meds Needle/syringe managementNeedle/syringe management EnvironmentEnvironment

CMS Injection Practice CMS Injection Practice ExpectationsExpectations

Needles are used for only one patient.Needles are used for only one patient. Syringes are used for only one patient.Syringes are used for only one patient. Medication vial are always entered with a Medication vial are always entered with a

new needle and syringe.new needle and syringe. Predrawn meds are labeled with time of Predrawn meds are labeled with time of

draw, initials of person drawing, med, draw, initials of person drawing, med, strength, expiration date or time.strength, expiration date or time.

Single use med vials are used for only one Single use med vials are used for only one patient.patient.

CMS expectationsCMS expectations

Manufactured prefilled syringes are used Manufactured prefilled syringes are used for only one patient.for only one patient.

Bags of IV solutions are used for only one Bags of IV solutions are used for only one patient.patient.

Medication administration tubing and Medication administration tubing and connectors are used for only one patient.connectors are used for only one patient.

All sharps are disposed of in a puncture-All sharps are disposed of in a puncture-resistant sharps container.resistant sharps container.

Sharps containers are replaced when the Sharps containers are replaced when the fill line is reached.fill line is reached.

CMS expectationsCMS expectations

Additional breaches in injection practices, not Additional breaches in injection practices, not captured by the previous questions above.captured by the previous questions above.

Multi-dose injectable medications are used for Multi-dose injectable medications are used for only one patient, if NO thenonly one patient, if NO then Rubber spectum disinfectedRubber spectum disinfected Vial dated and discard appropriatelyVial dated and discard appropriately Location of storage and access of medLocation of storage and access of med Sharp disposalSharp disposal Other breaches not covered aboveOther breaches not covered above

www.cms.gov/manuals/www.cms.gov/manuals/downloads/downloads/

som107_exhibit_351.pdfsom107_exhibit_351.pdf

Gain from Losses…Gain from Losses…

CDC and state and local health departments have CDC and state and local health departments have investigated an increasing number of outbreaksinvestigated an increasing number of outbreaks Unsafe injection practicesUnsafe injection practices Other breaches in very basic infection controlOther breaches in very basic infection control Detection is haphazardDetection is haphazard

Outbreaks are occurring across the healthcare Outbreaks are occurring across the healthcare spectrumspectrum Ambulatory, home and long-term care Ambulatory, home and long-term care

settingssettings Infection control programs and oversightInfection control programs and oversight

Growing ConcernGrowing Concern

Unsafe Injection related Unsafe Injection related outbreaksoutbreaks

> 35 nation wide in past decade> 35 nation wide in past decade

~ 100,00 patients exposed to viral ~ 100,00 patients exposed to viral hepatitishepatitis

More than 500 infectedMore than 500 infected

Bacterial Outbreaks due to Bacterial Outbreaks due to Unsafe Injection PracticesUnsafe Injection Practices

Pain Clinic – 7 cases – Serratia marcescensPain Clinic – 7 cases – Serratia marcescens Spinal injections; all patients hospitalizedSpinal injections; all patients hospitalized

Cohen, AL et al. Clin J Pain 2008; 24(5): 374-380Cohen, AL et al. Clin J Pain 2008; 24(5): 374-380

Primary care clinic – 5 cases – S. aureusPrimary care clinic – 5 cases – S. aureus Joint injections; all patient hospitalizedJoint injections; all patient hospitalized Kirschke DL et al. CID 2003;36:1369-1373. Kirschke DL et al. CID 2003;36:1369-1373.

Storage of multidose vials and preparation of injections in same area that used needles and syringes were dismantled and discarded

FACT: injection preparation on surfaces where contaminated substances are handled can lead to the spread of infections

Ref: Samandari et al. ICHE 2005; 26: 745-750

Photo: Don Weiss / NYCDOHMH

Tallis, GF et al, Journal of Viral Tallis, GF et al, Journal of Viral Hepatitis, 2003, 10, 234-239Hepatitis, 2003, 10, 234-239

Hepatitis C transmission post arthoscopy Hepatitis C transmission post arthoscopy Same patient, same needle/syringe Same patient, same needle/syringe

combo used to draw addition medicationcombo used to draw addition medication Remainder Propofol and Fentanyl used Remainder Propofol and Fentanyl used

on next patienton next patient

Oklahoma Pain Remediation Oklahoma Pain Remediation ClinicClinic

Anesthetist filled single syringe with sedation Anesthetist filled single syringe with sedation medication to treat up to 24 sequential patientsmedication to treat up to 24 sequential patients Administered through heparin locksAdministered through heparin locks

Lookback investigation for entire two year time Lookback investigation for entire two year time period of clinic operationperiod of clinic operation Serologic results for 795/908 (88%) patientsSerologic results for 795/908 (88%) patients

71 (9%) clinic-associated HCV infections71 (9%) clinic-associated HCV infections 31 (4%) clinic-associated HBV infections31 (4%) clinic-associated HBV infections

US $25 million settlementUS $25 million settlement

Comstock et al. ICHE, 2004, 25:576-583

Common ThemesCommon Themes

Investigations were resource-intensive and disruptiveInvestigations were resource-intensive and disruptive Notification, testing, and counseling of hundreds of patientsNotification, testing, and counseling of hundreds of patients

Delayed recognition and missed opportunitiesDelayed recognition and missed opportunities Prolonged transmissionProlonged transmission Growing reservoirs of infected patientsGrowing reservoirs of infected patients

IC programs lacking or responsibilities unclearIC programs lacking or responsibilities unclear Clinic space rented from a hospital (NE)Clinic space rented from a hospital (NE) Contractors (NYC and OK)Contractors (NYC and OK)

Entirely preventableEntirely preventable Standard precautions + Standard precautions + aseptic techniqueaseptic technique

MMWR 2003 52:901-6 / CID 2004; 38:1592–8

Practice findingsPractice findings

Syringe reuseSyringe reuse Multidose vials in the immediate patient treatment Multidose vials in the immediate patient treatment

areaarea Contamination of vials and IV bags with previously Contamination of vials and IV bags with previously

used syringeused syringe Using single-dose medications for more than one Using single-dose medications for more than one

patient. patient. Purchase vials containing quantities in excess of Purchase vials containing quantities in excess of

those needed for a single patient – Mistaken belief those needed for a single patient – Mistaken belief that they can be used in a multi-dose fashion. that they can be used in a multi-dose fashion.

Failure to follow basic infection safety for preparing Failure to follow basic infection safety for preparing and administering medsand administering meds

Mistaken beliefs about syringe Mistaken beliefs about syringe reusereuse

““But I can prevent of infection But I can prevent of infection transmission by…”transmission by…” Changing the needle onlyChanging the needle only Injecting through intervening lengths of Injecting through intervening lengths of

IV tubingIV tubing Presence of Check valvePresence of Check valve Maintaining pressure on the plunger to Maintaining pressure on the plunger to

prevent backflowprevent backflow

ASC Infection ControlASC Infection Control 68 ASC in 3 states surveyed68 ASC in 3 states surveyed Hand hygiene, equipment reprocessing, Hand hygiene, equipment reprocessing,

environmental cleaning, handling of blood environmental cleaning, handling of blood glucose monitoring equipment and injection glucose monitoring equipment and injection safety and medication handling reviewedsafety and medication handling reviewed

28% of ASC had Injection safety lapse28% of ASC had Injection safety lapse Primary offense - Single dose vials Primary offense - Single dose vials

(without preservative) used on multiple (without preservative) used on multiple patients cases including saline bagspatients cases including saline bags

JAMA, June, 2010-Vol 303, No.22JAMA, June, 2010-Vol 303, No.22

Implement a solid game Implement a solid game planplan

Work with your coachesWork with your coaches

APIC position paperAPIC position paper

Unresolved issues Unresolved issues Beyond use date for multidose vialsBeyond use date for multidose vials

USP <797> 28 days after initial penetrationUSP <797> 28 days after initial penetration Center for disease control (CDC) supports Center for disease control (CDC) supports

manufacture’s guidelinesmanufacture’s guidelines USP <797> one hour limit for USP <797> one hour limit for

Compounding-Sterile Preparation (CSP)Compounding-Sterile Preparation (CSP)

Drill #1Drill #1

Drill #2Drill #2

APIC supported strategy for APIC supported strategy for non ISO settings med prepnon ISO settings med prep

Hand hygiene before:Hand hygiene before: Accessing suppliesAccessing supplies Handling vials and IV solutionsHandling vials and IV solutions Preparing and administering medicationsPreparing and administering medications

Aseptic TechniqueAseptic Technique Clean area and surfacesClean area and surfaces Discard emergently used meds and Discard emergently used meds and

solutionssolutions Prevent contact sterile and non sterile Prevent contact sterile and non sterile

Drill #3Drill #3

Drill #4Drill #4

Coach’s notes: IV solutionsCoach’s notes: IV solutions

Use one IV container and limit infusion Use one IV container and limit infusion supplies to one patient.supplies to one patient.

Limit time between medication/solution prep Limit time between medication/solution prep and administration (unresolved)and administration (unresolved)

Disinfect IV access ports and vial stoppersDisinfect IV access ports and vial stoppers““Scrub the hub”Scrub the hub”

Admixtures not for immediate use need ISO Admixtures not for immediate use need ISO class 5 settingclass 5 setting

No spiking devices for multiple uses or No spiking devices for multiple uses or patients.patients.

Drill #5Drill #5

FlushingFlushing

Use single dose containersUse single dose containers Multi-dose vialMulti-dose vial

Use only for one patient then discardUse only for one patient then discard Use new unused sterile needle and new, Use new unused sterile needle and new,

unused sterile syringe each entryunused sterile syringe each entry

Coach’s notes: SyringesCoach’s notes: Syringes

Remove sterile needles and/or syringe from Remove sterile needles and/or syringe from package immediately before usepackage immediately before use

Change both the needle and syringe between Change both the needle and syringe between patientspatients

Use sharp safety devicesUse sharp safety devices Discard syringes, needles, and cannulas after Discard syringes, needles, and cannulas after

use on a patientuse on a patient Dispose at point of use in approved containerDispose at point of use in approved container No syringe to syringe transferNo syringe to syringe transfer No storing or transporting in pockets!No storing or transporting in pockets! Prepare just prior to administrationPrepare just prior to administration

Drill #6Drill #6

VialsVials

Single use when ever possibleSingle use when ever possible New syringe and new needle for each New syringe and new needle for each

accessaccess Cleanse with antiseptic before accessCleanse with antiseptic before access Discard single dose vials after useDiscard single dose vials after use Dedicate multi dose vials to single patient Dedicate multi dose vials to single patient

whenever possiblewhenever possible Keep multi dose vials away from immediate Keep multi dose vials away from immediate

patient care area, and pocketspatient care area, and pockets

Drill #7Drill #7

Carefully review (observe, discuss) infection Carefully review (observe, discuss) infection control practices including injection safety.control practices including injection safety.

Injection Safety is a basic expectation and Injection Safety is a basic expectation and should not be skipped to save time or money.should not be skipped to save time or money.

Losses teach us:Losses teach us: NeverNever administer medications from the same administer medications from the same

syringe to more than one patient, even if the syringe to more than one patient, even if the needle is changedneedle is changed

NeverNever enter a vial with a syringe or needle that enter a vial with a syringe or needle that has been used for a patient if the same has been used for a patient if the same medication vial might be used for another medication vial might be used for another patientpatient

Key coaching pointsKey coaching points

SummarySummary

Know the game and rules Know the game and rules Learn from past lossesLearn from past losses Implement a solid game Implement a solid game

planplan Work with your coaches Work with your coaches

ResourcesResources

CDC WebsiteCDC Website http://www.cdc.gov/injectionsafety/http://www.cdc.gov/injectionsafety/

The One and only campaignThe One and only campaign www.ONEandONLYcampaign.orgwww.ONEandONLYcampaign.org

Association of Professionals in Infection Association of Professionals in Infection Control and Epidemiology (APIC)Control and Epidemiology (APIC)

www.APIC.orgwww.APIC.org http://www.apic.org/Content/NavigationMenu/PracticeGuidance/http://www.apic.org/Content/NavigationMenu/PracticeGuidance/

PositionStatements/AJIC_Safe_Injection0310.pdfPositionStatements/AJIC_Safe_Injection0310.pdf

ResourcesResources

Medscape - Medscape - Unsafe Injection Practices: Outbreaks, Incidents, and Root Causes (free CME/CE) http://www.medscape.org/viewarticle/745695http://www.medscape.org/viewarticle/745695

GUIDE TO INFECTION PREVENTION FOR OUTPATIENT SETTINGS: Minimum Expectations for Safe Care

http://www.cdc.gov/HAI/pdfs/guidelines/standatds-of-ambulatory-care-7-2011.pdf

Infection Control Surveyor Worksheet http://www.cms.gov/manuals/downloads/som107_exhibit_351.pdf

Refuse to infuseRefuse to infuse1995 Seattle Mariners 79 W, 66 L1995 Seattle Mariners 79 W, 66 L