# Presentation: 644270

## A "Never" Event: Unsafe Injection Practices 

**Joseph Perz DrPH MA**
**Arjun Srinivasan MD **
**Priti Patel MD MPH**** **
**Prevention and Response Branch**
**Division of Healthcare Quality **
**  ****Promotion**
**Centers for Disease Control**
**  ****and Prevention**

## Disclaimer

**	****The findings and conclusions in this presentation are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.**

##      
	Continuing Education Credits DISCLAIMER:In compliance with continuing education requirements, all presenters must disclose any financial or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters as well as any use of unlabeled product(s) or product(s) under investigational use. CDC, our planners, and the presenters for this seminar do not have financial or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters. This presentation does not involve the unlabeled use of a product or product under investigational use. 

**	****Continuing Education Credits DISCLAIMER:****In compliance with continuing education requirements, all presenters must disclose any financial or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters as well as any use of unlabeled product(s) or product(s) under investigational use. ****CDC, our planners, and the presenters for this seminar do not have financial or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters. This presentation does not involve the unlabeled use of a product or product under investigational use.**

## Learning Objectives

**1) Describe safe injection and other basic infection control practices, and be able to recognize and correct unsafe practices**
**2) Understand the need for monitoring healthcare personnel practices in your facility relating to injection safety and basic infection control **
**3) Describe the potential consequences of syringe reuse and other unsafe practices **
**4) Locate related CDC infection control guidance and educational materials  **

## Outline

**Example of a “Never Event”**
**Review of Indirect Transmission**
**Injection Safety**
**Examples of Unsafe Practices**
**Prevention**
**Some FAQs**
**Summary**

## Example of a Never Event Related to Injection Safety and Basic Infection Control

**    ****Macedo de Oliveira et al., Annals of Internal Medicine, 2005, 142:898-902**

## September 2002 – 4 patients recently diagnosed HCV infection reported to Nebraska Health Department
All regularly had cancer chemotherapy at one clinic
Initial investigation identified infection control breach related to catheter flushing, prompting the notification of over 600 patients
99 clinic-acquired HCV infections were identified
All genotype 3a (uncommon in U.S.)
Transmission period: March 2000 – July 2001

- September 2002 – 4 patients recently diagnosed HCV infection reported to Nebraska Health Department
- All regularly had cancer chemotherapy at one clinic
- Initial investigation identified infection control breach related to catheter flushing, prompting the notification of over 600 patients
- 99 clinic-acquired HCV infections were identified
- All genotype 3a (uncommon in U.S.)
- Transmission period: March 2000 – July 2001

**    ****Macedo de Oliveira et al., Annals of Internal Medicine, 2005, 142:898-902**

***Never Event:*****Nebraska Hepatitis C Outbreak**

## Never Event:Nebraska Hepatitis C Outbreak

***Never Event:*****Nebraska Hepatitis C Outbreak**

- Nurse drew blood from indwelling IV catheter, then reused same syringe to perform saline flush
- New syringe was used for each patient
- Solution from 500cc bag used for multiple patients
- Clinic was independently owned and operated
- No active infection control program
- Breaches never reported to state health department
- 2004 – Oncologist’s and RN’s licenses revoked

**    ****Macedo de Oliveira et al., Annals of Internal Medicine, 2005, 142:898-902**

## Growing Concern

**CDC and state and local health departments have investigated an increasing number of outbreaks**
- Unsafe injection practices
- Other breaches in basic infection control
- Detection is haphazard
**Outbreaks are occurring across the healthcare spectrum**
- Ambulatory, home and long-term care settings
- Infection control programs and oversight

## Outbreak of Catheter-Associated Klebsiella oxytoca and Enterobacter cloacae Bloodstream Infections in an Oncology Chemotherapy CenterJohn T. Watson et al. Arch Intern Med. 2005;165:2639-2643History Forgotten is History Relived: Nosocomial Infection Control is Also Essential in the Outpatient SettingDennis G. Maki and Christopher J. Crnich  Arch Intern Med. 2005;165:2565-2567 

## Transmission: Understanding the Basics

## Indirect Contact Transmission

**Transfer of an infectious agent through a contaminated intermediate object or person**
**Hands of healthcare personnel**
**Patient care devices (e.g., glucometers)**
**Instruments (e.g., endoscopes) that are not adequately reprocessed**
**Medications and injection equipment**

- _http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf_

## TRANSMISSION OF PATHOGENS VIA 

**CONTAMINATED EQUIPMENT OR MEDICATIONS**

**CONTAMINATED EQUIPMENT OR MEDICATION**

## Blood Glucose Monitoring and Risks for Bloodborne Pathogen Transmission

**Blood Glucose Monitoring and Risks for Bloodborne Pathogen Transmission**

- Photo courtesy of the Statewide Program for Infection Control and Epidemiology (SPICE) at the University of North Carolina

## Injection Preparation Table, Pakistan

**Injection Preparation Table, Pakistan**

**http://www.who.int/injection_safety/en/**

## What is Injection Safety?

**Injection safety** includes practices intended to _prevent transmission of infectious diseases_ between one patient and another, or between a patient and healthcare provider, and also to prevent harms such as needlestick injuries

*A safe injection does not harm the recipient, does not expose the provider to any avoidable risks and does not result in waste that is dangerous *
*for the community*

## What are some of the incorrect practices that have resulted in transmission of pathogens? 

- Using the same syringe to administer medication to more than one patient, even if the needle was changed
- Using a common bag of saline or other IV fluid for more than one patient, and
- Leaving an IV set in place for dispensing fluid
- Accessing the bag with a syringe that has already been used to flush a patient’s IV or catheter
- Accessing a shared medication vial with a syringe that has already been used to administer medication to a patient

## Unsafe injection practices put patients at risk* and have been associated with a wide variety of procedures

**Administration of anesthetics for outpatient surgical, diagnostic and pain management procedures**
**Administration of other IV medications including chemotherapy, cosmetic procedures and alternative medicine (e.g., chelation therapy; vitamins/steroids)**
**Flushing IV lines or catheters**
**Administration of IM vaccines**
**     ***** infectious and non-infectious adverse events **

## Examples

## Slide 23

## Slide 24

## Transmission of Hepatitis B and C Viruses in Outpatient Settings – MMWR 2003 52:901

- Endoscopy Clinic: New York City, 2001
- 19 HCV infections likely due to contamination of multiple-dose anesthetic vials
- Oncology Clinic: Nebraska, 2002
- Pain Remediation Clinic: Oklahoma, 2002
- Private Medical Practice: New York City, 2001

## Slide 27

## Oklahoma Pain Remediation Clinic

- August 2002 – 6 patients with acute hepatitis C
- All received treatment at a single pain clinic
- Outpatient clinic affiliated with a hospital
- Anesthesia staff were contractors
- One afternoon per week
- Nurse anesthetist was reported for poor practice** **
- First report – not acted upon
- Second report (June 2002) – formal reprimand and change in practice but DOH not notified

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

## Oklahoma Pain Remediation Clinic

**Oklahoma Pain Remediation Clinic**

- Anesthetist filled single syringe with sedation medication to treat up to 24 sequential patients
- Administered through heparin locks
- Lookback investigation for entire two year time period of clinic operation
- Serologic results for 795/908 (88%) patients
- 71 (9%) clinic-associated HCV infections
- 31 (4%) clinic-associated HBV infections
- US $25 million settlement

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

**Oklahoma State Dept. of Health**

## New York City – Private Medical Practice

- 	December 2001:
- 	Two patients aged >75 years developed acute hepatitis B
- Admitted same hospital
- Attended same private medical practice

## New York City – Private Medical Practice

**New York City – Private Medical Practice**

- Notification of >1000 patients; >200 tested
- 38 patients with acute HBV infection
- HBV sequenced from 28 patients was identical
- All staff members negative for HBV markers
- Associated with injection of vitamins and steroids
- 2 or 3 medications together in one syringe

**Samandari et al. ICHE 2005 26(9):745-50**

## Common Themes and Findings

- Investigations were resource-intensive and disruptive
**Notification, testing, and counseling of hundreds of patients**
- Delayed recognition and missed opportunities
**Prolonged transmission**
**Growing reservoirs of infected patients**
- IC programs lacking or responsibilities unclear
**Clinic space rented from a hospital (NE)**
**Contractors (NYC and OK)**
- Entirely preventable
**Standard precautions + ****aseptic technique**

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

## PreventionSafe Injection Practices and Basic Infection Control

## Basic Patient Safety

**Healthcare should not provide any avenue for transmission of bloodborne viruses**
**Basic patient safety / “red flag”**
**Risks of patient-to-patient spread on par with HCW and blood safety efforts**
**Entirely preventable**
**Standard Precautions / ****Aseptic Technique**
- Aseptic techniques for handling parenteral medications, administering injections, and sampling blood

## 2007 Guideline for Isolation PrecautionExecutive Summary

- The **transition of healthcare delivery** from primarily acute care hospitals to other settings (e.g., home care, ambulatory care, free-standing specialty care sites, long-term care)
**Standard Precautions**, first recommended in the 1996 guideline, has led to a reaffirmation of this approach as the **foundation for preventing transmission** of infectious agents in **all healthcare settings**
- Strong evidence base:** Outbreaks of hepatitis B and hepatitis C viruses in ambulatory settings **indicated a need to re-iterate safe injection practice recommendations as part of Standard Precautions

- _http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf_

## Standard Precautions Examples of Safe Injection Practices

- Use aseptic technique to avoid contamination of sterile injection equipment
- Use single-dose vials for parenteral medications whenever possible
- Needles, cannulae and syringes are sterile, single-use items; they should not be reused for another patient nor to access a medication or solution that might be used for a subsequent patient
- Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients

- _http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf_

## What is Aseptic Technique?

**Handling, preparation, and storage of medications and all supplies used for injections and infusions—e.g., syringes, needles, intravenous (IV) tubing—in a manner that prevents microbial contamination**
**Medications should be drawn up in a designated “clean” medication preparation area**
** ****In general, any item that could have come in contact with blood or body fluids should be kept separate**

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

**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

## Safe Handling of Parenteral Medications

**Always use a new sterile syringe and needle to draw up medications**
**Proper hand hygiene should be performed before handling medications**
**Parenteral medications and injection equipment should be accessed in an aseptic manner**

## Maintaining Sterility of Vials

**A new sterile needle and syringe should be used for each injection **
**Medications should be discarded upon expiration or any time there are concerns regarding the sterility of the medication**
**Leftover parenteral medications should **_**never**_** be pooled for later administration**
**A needle should never be left inserted into a medication vial septum for multiple uses**
**This provides a direct route for microorganisms to enter the vial and contaminate the fluid**

## Minimizing the use of shared medications reduces patient risk

**Single-use medications vials (e.g., propofol) should never be used for more than one patient**
**Assign multi-dose vials to a single patient whenever possible**
**Do not use bags or bottles of intravenous solution as a common source of supply for more than one patient**
**Absolute adherence to proper infection control practices must be maintained during the preparation and administration of injected medications**

## Administrative

**Administrative**
- Tailor infection-control measures to individual practice setting
- Clearly designate responsibility for oversight and monitoring
- Periodically review staff practices (e.g., at least annually)
- Establish procedures and responsibilities for reporting and investigating breaches in infection-control policy

**Clinical Infectious Diseases 2004; 38:1592–8     www.cdc.gov/hepatitis**

## Some Frequently Asked Questions

## Q: Is it OK to use the same syringe to give intramuscular (IM) or subcutaneous (SC) injections to more than one patient if I change the needle between patients? 

A: NO. Once they are used, the syringe and needle are both contaminated and must be discarded. Use a new sterile syringe and needle for each patient.

- A: **NO.** Once they are used, the syringe and needle are _both_ contaminated and must be discarded. Use a new sterile syringe and needle for each patient.

## Q: Is it OK to use the same syringe to give an IM or intravenous (IV) injection to more than one patient if I change the needle between patients and I don’t draw back before injecting?

A: NO. A small amount of blood can flow into the needle and syringe even when only positive pressure is applied outward. The syringe and needle are both contaminated and must be discarded.

- A: **NO.** A small amount of blood can flow into the needle and syringe even when only positive pressure is applied outward. The syringe and needle are both contaminated and must be discarded.

## Q: If I used a syringe only to infuse medications into an IV tubing port that is several feet away from the patient’s IV catheter site, is it OK to use the same syringe for another patient? 

A: NO. Everything from the medication bag to the patient’s catheter is a single interconnected unit
	- Separation from the patient’s IV by distance, gravity and/or positive infusion pressure does not ensure that small amounts of blood are not present in these supplies
	- A syringe that intersects through ports in the IV tubing or bags also becomes contaminated and cannot be used for another patient

- A: **NO.** Everything from the medication bag to the patient’s catheter is a single interconnected unit
- 	- Separation from the patient’s IV by distance, gravity and/or positive infusion pressure does not ensure that small amounts of blood are not present in these supplies
- 	- A syringe that intersects through ports in the IV tubing or bags also becomes contaminated and cannot be used for another patient
** **

## Q: Are these recommendations new?

A: NO. These recommendations are part of established guidance. 
	- It is a well established practice to never use the same syringe or needle for more than one patient nor to enter a medication vial with a syringe or needle used for one patient if the same vial might be used for another patient

- A: **NO.** These recommendations are part of established guidance.
- 	- It is a well established practice to never use the same syringe or needle for more than one patient nor to enter a medication vial with a syringe or needle used for one patient if the same vial might be used for another patient
**	**
** **
** **

## Q: How can healthcare providers ensure that injections are performed correctly? 

A: To help ensure that staff understand and adhere to safe injection practices, consider the following:
	- Designate someone to provide ongoing oversight for infection control issues
	- Develop written infection control policies
	- Provide training 
	- Conduct quality assurance assessments

- A: To help ensure that staff understand and adhere to safe injection practices, consider the following:
- 	- Designate someone to provide ongoing oversight for infection control issues
- 	- Develop written infection control policies
- 	- Provide training
- 	- Conduct quality assurance assessments
** **
** **

## Q: Can I reuse a syringe during a procedure for a patient who requires additional medication as long as the vial will not be used for another patient?

A: It is preferable to always use a new sterile syringe to withdraw medications, even if the medication will only be used for one patient. This provides an extra layer of protection for patients and is encouraged 

- A: It is preferable to always use a new sterile syringe to withdraw medications, even if the medication will only be used for one patient. This provides an extra layer of protection for patients and is encouraged
** **

## Q: Why can’t I just visually inspect syringes to determine whether they are contaminated or can be used again?   

A: Pathogens including HCV, HBV, and human immunodeficiency virus (HIV) can be present in sufficient quantities to produce infection in the absence of visible blood
	Similarly, bacteria and other microbes can be present without clouding or other visible evidence of contamination
	Just because you don’t see blood or other material in a used syringe or IV tubing, e.g., does not mean the item is free from potentially infectious agents
	All used injection supplies and materials are potentially contaminated and should be discarded

- A: Pathogens including HCV, HBV, and human immunodeficiency virus (HIV) can be present in sufficient quantities to produce infection in the absence of visible blood
- 	Similarly, bacteria and other microbes can be present without clouding or other visible evidence of contamination
- 	Just because you don’t see blood or other material in a used syringe or IV tubing, e.g., does not mean the item is free from potentially infectious agents
- 	All used injection supplies and materials are potentially contaminated and should be discarded

## SUMMARY

## Improper use of syringes, needles, and medication vials can result in: 

**Transmission of life-threatening infections to patients**
**Notification of patients of possible exposure to bloodborne pathogens and recommendation that they be tested for hepatitis C virus, hepatitis B virus, and human immunodeficiency virus (HIV)**
**Referral of providers to licensing boards for disciplinary action**
**Malpractice suits filed by patients**

## 	
	All healthcare providers are urged to carefully review their infection control practices and the practices of all staff under their supervision
	In particular, providers should:
Never administer medications from the same syringe to more than one patient, even if the needle is changed
Never enter a vial with a syringe or needle that has been used for a patient if the same medication vial might be used for another patient

**	****All healthcare providers are urged to carefully review their infection control practices and the practices of all staff under their supervision**
**	****In particular, providers should:**
- _Never_ administer medications from the same syringe to more than one patient, even if the needle is changed
- _Never_ enter a vial with a syringe or needle that has been used for a patient if the same medication vial might be used for another patient

**Some Key Take-Home Messages**

## Links to CDC Materials

- _http://www.cdc.gov/ncidod/dhqp/injectionsafety.html_

## Thank You

- WWW.CDC.GOV
- DHQP Inquiries
- (inquiries about safe injection practices)
- 1-800-311-3435, option 1
- -or-
- email us at: hip@cdc.gov

## Continuing Education guidelines require that the attendance of all who participate in COCA Conference Calls be properly documented. ALL Continuing Education credits (CME, CNE, CEU and CHES) for COCA Conference Calls are issued online through the CDC Training & Continuing Education Online system http://www2a.cdc.gov/TCEOnline/.  

Those who participate in the COCA Conference Calls and who wish to receive CE credit and will complete the online evaluation by April 26, 2008 will use the course code EC1265. Those who wish to receive CE credit and will complete the online evaluation between April 27, 2008 and March 27, 2009 will use course code WD1265. CE certificates can be printed immediately upon completion of your online evaluation. A cumulative transcript of all CDC/ATSDR CE’s obtained through the CDC Training & Continuing Education Online System will be maintained for each user. 

**Those who participate in the COCA Conference Calls and who wish to receive CE credit and will complete the online evaluation by April 26, 2008 will use the course code EC1265. Those who wish to receive CE credit and will complete the online evaluation between April 27, 2008 and March 27, 2009 will use course code WD1265. CE certificates can be printed immediately upon completion of your online evaluation. A cumulative transcript of all CDC/ATSDR CE’s obtained through the CDC Training & Continuing Education Online System will be maintained for each user. **

## 
CME: CDC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. CDC designates this educational activity for a maximum of 1 Category 1 credit toward the AMA Physician's Recognition Award. Physicians should only claim credit commensurate with the extent of their participation in the activity. 

CNE: This activity for 1.0 contact hours is provided by CDC, which is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center's Commission on Accreditations. 

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CHEC: CDC is a designated provider of continuing education contact hours (CECH) in health education by the National Commission for Health Education Credentialing, Inc. This program is a designated event for the CHES to receive 1 Category I Contact Hour(s) in health education. CDC provider number GA0082.

**CME: CDC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. CDC designates this educational activity for a maximum of 1 Category 1 credit toward the AMA Physician's Recognition Award. Physicians should only claim credit commensurate with the extent of their participation in the activity. **
**CNE: This activity for 1.0 contact hours is provided by CDC, which is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center's Commission on Accreditations. **
**CEU: CDC has been reviewed and approved as an authorized provider by the International Association for Continuing Education and Training (IACET), 8405 Greensboro Drive, Suite 800, McLean, VA 22102. CDC has awarded 0.1 CEU to participants who successfully complete this program. **
**CHEC: CDC is a designated provider of continuing education contact hours (CECH) in health education by the National Commission for Health Education Credentialing, Inc. This program is a designated event for the CHES to receive 1 Category I Contact Hour(s) in health education. CDC provider number GA0082.**