Infection transmission risks are present in all hospital settings (Siegel, Rhinehart, Jackson, Chiarello, & the Healthcare Infection Control Practices Advisory Committee, 2007, p. 31). A recent online survey of more than 5,000 healthcare practitioners revealed an alarming lapse in basic infection control practices associated with the use of syringes, needles, multi-dose vials, single-use vials, and flush solutions (Paparella, 2011, p. 564). According to the Centers for Disease Control and Prevention (CDC) there has been at least 49 infection outbreaks occurring because of contaminated injectable medical products since 2001 particularly at the time of administration.
Out of the 49 outbreaks occurring, 26 of those took place in the past five years (Jayanthi, 2014). The transmission of bloodborne viruses and other microbial pathogens to patients during routine healthcare procedures continues to occur because of the use of unsafe and improper injection, infusion, and medication vial practices by health care professionals in various clinical settings throughout the United States.
Breaches in safe injection, infusion, and medication vial practices continue to result in unacceptable and devastating events for patients (Dolan et al. , 2010, p. 167). With this in mind it is necessary to understand the causes of and how to effectively prevent infection and injury with safe injection and medication vial practices. In the last decade more than 150,000 patients living in the United States were notified and recommended to get tested for hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus HIV because of the reuse of syringes and misuse of medication vials (“One and Only Campaign | What are They & Why Follow Them? ,” n. d.).
When infectious diseases such as HBV, HCV, HIV, or other bloodborne pathogens are inadvertently transmitted to patients as a result of healthcare personnel violating fundamental infection control guidelines, the quality of life of the patients and their families is greatly affected (Ford, 2013, p. 37).
PREVENTING INFECTION WITH SAFE INJECTION PRACTICES 3 The unsafe practices used by health care personnel in these outbreaks can be categorized as (1) syringe reuse between patients during parenteral medication administration to multiple patients, (2) contamination of medication vials or intravenous (IV) bags after having been accessed with and used syringe and/or needle, (3) failure to follow basic injection safety practices when preparing and administering parenteral medications to multiple patients, and (4) inappropriate care/maintenance of finger stick devices and glucometer equipment between use on multiple patients (Dolan et al. , 2010, p. 167).
According to recommendations by the CDC, single-dose vials are exactly what they sound like: one dose for one use on one patient. In the case of multi-dose vials, one may anticipate them to also mirror their name, but multi-dose vials are generally treated as single-dose vials for a several reasons, raising questions for the rationale of such vials as well as their wastage. A multi-dose vial is just packaged with more than one dose of medication.
The CDC advises multi-dose vials to be dedicated to a single patient whenever possible; however it still does identify the option that a vial may need to be used on multiple patients, which becomes increasingly important as drug deficiencies become visible in the industry (Jayanthi, 2014). Multi-dose vials contain more than one dose of medication because they contain a bacteriostatic agent; there is still a risk that a multi-dose vial may become contaminated. It is also important to note that bacteriostatic agents are not effective against viruses such as HBV, HCV, or HIV.
It is for these reasons that the CDC recommends single-dose vials be used whenever possible and that medications packaged as multi-dose vials be assigned to a single patient whenever possible (Pugliese, Gosnell, Bartley, & Robinson, 2010, p. 793). Whenever possible, single-dose vials use is preferred over multiple-dose vials, especially when medications will be administered to multiple patients.
Based on the CDC’s guidelines and best practices, the PREVENTING INFECTION WITH SAFE INJECTION PRACTICES 4 theory surrounding multi-dose vials on multiple patients does not translate well into reality. The overarching recommendation by the CDC is to stick to one vial – either single or multi-dose – for each patient. If and when healthcare providers are in a situation where they want or need to use multi-dose vials on multiple patients, regulatory guidelines make such a practice difficult to properly execute (Jayanthi, 2014).
Outbreaks associated with unsafe injection practices show that some healthcare personnel are not aware of, do not recognize, or do not adhere to crucial rules of aseptic technique and infection control (Siegel, Rhinehart, Jackson, Chiarello, & the Healthcare Infection Control Practices Advisory Committee, 2007, p. 69). Unfortunately there are a lot of misbeliefs regarding syringe reuse. For example, there is the belief that contamination is limited to the needle portion when a syringe and needle are used together as a unit.
There is also an incorrect belief that the syringe does not become contaminated if the plunger is only “pushed” to inject medications and not “pulled” to aspirate or withdrawal. There is an additional risk of syringe contamination resulting from the negative pressure that occurs if a contaminated needle is removed from the syringe. When a contaminated needle or syringe is used to draw medication from a vial the contamination can then be transferred to the vial (Pugliese, Gosnell, Bartley, & Robinson, 2010, p. 793).
In a study conducted by Paparelle (2011), researchers identified that 15% of those identified used the same syringe to re-enter multi-dose vials numerous times and of this 15% of respondents 7% reused that vial on other patients (Paparella, 2011, p. 564). However, only 1% of respondents in the study admitted to reusing a syringe on more than one patient after changing the needle. Paparelle (2011) also identified that 6% of respondents identified as using single dose vials for multiple patients (Paparella, 2011, p. 564).
The survey by Pugliese (2011) PREVENTING INFECTION WITH SAFE INJECTION PRACTICES 5 revealed comments by the participants (more than 85% were nurses) that clearly demonstrated a general lack of awareness and some misconceptions 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 (Paparella, 2011, p. 564). Safe injection practices are part of Standard Precautions and are aimed at maintaining basic levels of patient safety and provider protections. As defined by the World Health Organization (WHO), 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 (WHO best practices for injections and related procedures toolkit, 2010, p. 1).
The use of safe injection practices is critical to prevent microbial contamination of products administered to patients. The ongoing reports of HBV and HCV transition to patients and ongoing outbreaks of bacterial infections indicate that much more is needed to ensure that the preventative practices are being scrupulously followed in all health care settings (Dolan et al. , 2010, p. 171). Healthcare organizations can demonstrate a commitment to preventing
transmission of infectious agents by incorporating infection control into the objectives of the organization’s patient and occupational safety programs (Siegel, Rhinehart, Jackson, Chiarello, & the Healthcare Infection Control Practices Advisory Committee, 2007, p. 41). Assigning a bedside nurse as an infection control liaison on a patient care unit in other words a “link nurse” is found to be a useful adjunct to improve infection control. The nurses involved receive education and training in basic infection control and have regular communication with the infection control professionals (ICPs), but maintain their primary role as bedside caregiver on their units.
The infection control nurse liaison increases the awareness of infection control (Siegel, Rhinehart, PREVENTING INFECTION WITH SAFE INJECTION PRACTICES 6 Jackson, Chiarello, & the Healthcare Infection Control Practices Advisory Committee, 2007, p. 43). It is recommended that medications packaged as single use vials never be used for more than one patient. Medications packaged as multi-use vials be assigned to a single patient whenever possible. Bags or bottle of intravenous solution not be used as common source of supply for more than one patient. Absolute adherence to proper infection control practices be maintained during the preparation and administration of injected medications (Centers for Disease Control and Prevention, 2013).
Education on injection safety needs to be part of the curriculum that begins in schooling, continues throughout the provider’s career, and is evaluated by annual competencies. Repeated training is a necessary element required to change behaviors (Ford, 2013, p. 40). The One & Only Campaign is a public health campaign, led by the CDC and the Safe Injection Practices Coalition (SIPC), to raise awareness among patients and healthcare providers about safe injection practices. The campaign aims to eradicate outbreaks resulting from unsafe injection practices (Centers for Disease Control and Prevention, n. d. ).
The slogan of the campaign is “One Needle, One Syringe, Only One Time”. The CDC Injection Safety Checklist includes (1) Injections are prepared using aseptic technique in a clean area free from contamination or contact with blood, body fluids or contaminated equipment, (2) Needles and syringes are used for only one patient (this includes manufactured prefilled syringes and cartridge devices such as insulin pens), (3) The rubber septum on a medication vial is disinfected with alcohol prior to piercing, (4)
Medication vials are entered with a new needle and a new syringe, even when obtaining additional doses for the same patient, (5) Single dose (single-use) medication vials, ampules, and bags or bottles of intravenous solution are used for only one patient, (6) Medication administration tubing and connectors are used for only one patient, (7).
PREVENTING INFECTION WITH SAFE INJECTION PRACTICES 7 Multi-dose vials are dated by HCP when they are first opened and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. Note: This is different from the expiration date printed on the vial, (8) Multi-dose vials are dedicated to individual patients whenever possible, and (9) Multi-dose vials to be used for more than one patient are kept in a centralized medication area and do not enter the immediate patient treatment area (Centers for Disease Control and Prevention, n.d. ).
Preventing the spread of bloodborne pathogens is an expectation where ever health care is provided. Noteworthy progress has been made in decreasing the risk of occupational infection with HBV following widespread adoption of safer devices, safe work practices, and vaccinations. This same energy must be applied to reducing unsafe injection practices. It is necessary to adopt a multifaceted approach focusing on surveillance, oversight, enforcement, continuing education, and addressing incorrect beliefs about injection practices.
There is also a need for targeted education initiatives, including curricula in nursing, and other health care professions. The CDC along with a number of organizations provides educational resources, videos, guidelines, and position papers to assist in education and training. Every health care provider has a duty to review infection prevention and control practices as well as work to ensure these policies properly applied. We must create an environment whereby providers are empowered to ensure safe prevention and control practices are followed. Patients must also be educated on safe practices and encouraged to question the practices of any health care provider that may impact their safety.
PREVENTING INFECTION WITH SAFE INJECTION PRACTICES 8 References Centers for Disease Control and Prevention. (2013, August 24). CDC – Information for Providers – Injection Safety. Retrieved December 2, 2014, from http://www. cdc. gov/injectionsafety/providers. html This source provides information and additional resources for healthcare providers regarding safe injection and medication practices. Centers for Disease Control and Prevention. (n. d. ).
One and Only Campaign. Retrieved December 2, 2014, from http://www. oneandonlycampaign. org/The One and Only Campaign site helps education healthcare providers to improve patient safety with safe injection and medication practices. Dolan, S. A. , Felizardo, G. , Barnes, S. , Cox, T. R. , Patrick, M. , Ward, K. S. , & Arias, K. M. (2010). APIC position paper: Safe injection, infusion, and medication vial practices in health care. American Journal of Infection Control, 38(3), 162- 172.
Retrieved from http://www. ajicjournal. org/ The authors of this position paper describe outbreaks involving the transmission of bloodborne pathogens or other microbial pathogens to patients in various types of health care settings due to unsafe injection, infusion, and medication vial practices. Ford, K. (2013). Survey of syringe and needle safety among student registered nurse anesthetists: Are we making any progress. AANA Journal, 81(1), 37-42.
Retrieved from http://www. aana. com/newsandjournal/pages/aanajournalonline. aspx PREVENTING INFECTION WITH SAFE INJECTION PRACTICES 9 The goal of this study was to determine the extent of unsafe injection practices that exist among student anesthesia providers. Jayanthi, A. (2014, July 30). Multi-dose vials: What’s the point?
Retrieved from http://www. beckershospitalreview. com/quality/multi-dose-vials-what-s-the- point. html This source discusses how multi-dose vials boast advantages of reduced costs and less unused medication waste. But regulatory guidelines geared toward infection control can hinder providers from achieving such benefits One and Only Campaign | What are They & Why Follow Them? (n. d. ). Retrieved December 2, 2014, from http://www. oneandonlycampaign. org/content/what-are-they-why-follow-them This site provides information regarding unsafe injection practices.
Unsafe injection practices put patients and healthcare providers at risk of infectious and non-infectious adverse events. Paparella, S. (2011). Safe injection practices: Keeping safety in and the “bugs” out. Journal of Emergency Nursing, 37(6), 564-566. Retrieved from http://www. jenonline. org/ The author of this article describes the alarming lapse in basic infection control practices associated with the use of syringes, needles, multiple-dose vials, single-use vials, and flush solutions.
PREVENTING INFECTION WITH SAFE INJECTION PRACTICES 10 Pugliese, G. , Gosnell, C. , Bartley, J. M., & Robinson, S. (2010). Injection practices among clinicians in United States health care settings. American Journal of Infection Control, 38(10), 789-798. doi:10. 1016/j. ajic. 2010. 09. 003 This study examined the injection practices of health care providers to identify trends and target opportunities for education on safe practices. Siegel, J. D. , Rhinehart, E. , Jackson, M. , Chiarello, L. , & the Healthcare Infection Control Practices Advisory Committee. (2007). 2007 Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Retrieved from.
http://www. cdc. gov/hicpac/pdf/isolation/Isolation2007. pdf This publication offers guidelines for isolation precautions to help reduce and prevent transmission of infectious agents in healthcare settings WHO best practices for injections and related procedures toolkit. (2010). Retrieved from World Health Organization website: http://whqlibdoc. who. int/publications/2010/9789241599252_eng. pdf This tool kits describes how unsafe injection practices can lead to transmission of bloodborne pathogens and preventative measure to avoid transmission of infectious agents in healthcare settings.