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“Refuse to infuse” Injection Safety for Infection Prevention 2011 Puget Sound APIC Conference Sept 30 and Oct 1, 2011 Lou Hilken, RN, MN, ICP, CIC Providence St. Peter Hospital, Olympia WA Current Scoreboard UW – 31 Cal 23 Seahawks – 13 Cardinals – 10 Mt. Tahoma – 0 Pathogens - 0 Olympia High School - 24 Patient w/o injection related infection – all Refuse to infuse, so patients don’t lose Disclosure: several slides were obtained or adapted from: 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 Injection Safety Melissa Schaefer, MD Division of Healthcare Quality Promotion Centers for Disease Control and Prevention Learning objectives 1. 2. 3. Describe safe injection, infusion and medication vial practices to minimize cross contamination and infection outbreaks. Discuss situations that led to break in sterile technique and infection related to medication administration. Identify potential practice changes in your Ambulatory Surgery Center (ASC) to further reduce infection risk. Success Strategies Know the game and rules Learn from past losses Implement a solid game plan Work with your coaches Know the game and the rules Injection Safety Measures taken to perform injections in a safe manner for patients and providers . Prevent transmission of infectious diseases from: – Patient to patient; Patient to provider; and Provider to patient . http://www.cdc.gov/ncidod/dhqp/injectionSafetyFAQs.html What do your injection practices look like? Multidose vials Single dose vials Pre-drawn meds Needle/syringe management Environment CMS Injection Practice Expectations Needles are used for only one patient. Syringes are used for only one patient. Medication vial are always entered with a new needle and syringe. Predrawn meds are labeled with time of draw, initials of person drawing, med, strength, expiration date or time. Single use med vials are used for only one patient. CMS expectations Manufactured prefilled syringes are used for only one patient. Bags of IV solutions are used for only one patient. Medication administration tubing and connectors are used for only one patient. All sharps are disposed of in a puncture-resistant sharps container. Sharps containers are replaced when the fill line is reached. CMS expectations Additional breaches in injection practices, not captured by the previous questions above. Multi-dose injectable medications are used for only one patient, if NO then Rubber spectum disinfected Vial dated and discard appropriately Location of storage and access of med Sharp disposal Other breaches not covered above www.cms.gov/manuals/downloads /som107_exhibit_351.pdf Gain from Losses… Growing Concern CDC and state and local health departments have investigated an increasing number of outbreaks Unsafe injection practices Other breaches in very 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 Unsafe Injection related outbreaks > 35 nation wide in past decade ~ 100,00 patients exposed to viral hepatitis More than 500 infected Bacterial Outbreaks due to Unsafe Injection Practices Pain Clinic – 7 cases – Serratia marcescens Spinal injections; all patients hospitalized Cohen, AL et al. Clin J Pain 2008; 24(5): 374-380 Primary care clinic – 5 cases – S. aureus Joint injections; all patient hospitalized Kirschke DL et al. CID 2003;36:1369-1373. FACT: injection preparation on surfaces where contaminated substances are handled can lead to the spread of infections Storage of multidose vials and preparation of injections in same area that used needles and syringes were dismantled and discarded Ref: Samandari et al. ICHE 2005; 26: 745-750 Photo: Don Weiss / NYCDOHMH Hepatitis C transmission post arthoscopy Same patient, same needle/syringe combo used to draw addition medication Remainder Propofol and Fentanyl used on next patient Tallis, GF et al, Journal of Viral Hepatitis, 2003, 10, 234-239 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 Common Themes 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 Practice findings Syringe reuse Multidose vials in the immediate patient treatment area Contamination of vials and IV bags with previously used syringe Using single-dose medications for more than one patient. Purchase vials containing quantities in excess of those needed for a single patient – Mistaken belief that they can be used in a multi-dose fashion. Failure to follow basic infection safety for preparing and administering meds Mistaken beliefs about syringe reuse “But I can prevent of infection transmission by…” Changing the needle only Injecting through intervening lengths of IV tubing Presence of Check valve Maintaining pressure on the plunger to prevent backflow ASC Infection Control 68 ASC in 3 states surveyed Hand hygiene, equipment reprocessing, environmental cleaning, handling of blood glucose monitoring equipment and injection safety and medication handling reviewed 28% of ASC had Injection safety lapse Primary offense - Single dose vials (without preservative) used on multiple patients cases including saline bags JAMA, June, 2010-Vol 303, No.22 Implement a solid game plan Work with your coaches APIC position paper Unresolved issues Beyond use date for multidose vials USP <797> 28 days after initial penetration Center for disease control (CDC) supports manufacture’s guidelines USP <797> one hour limit for CompoundingSterile Preparation (CSP) Drill #1 Drill #2 APIC supported strategy for non ISO settings med prep Hand hygiene before: Accessing supplies Handling vials and IV solutions Preparing and administering medications Aseptic Technique Clean area and surfaces Discard emergently used meds and solutions Prevent contact sterile and non sterile Drill #3 Drill #4 Coach’s notes: IV solutions Use one IV container and limit infusion supplies to one patient. Limit time between medication/solution prep and administration (unresolved) Disinfect IV access ports and vial stoppers “Scrub the hub” Admixtures not for immediate use need ISO class 5 setting No spiking devices for multiple uses or patients. Drill #5 Flushing Use single dose containers Multi-dose vial Use only for one patient then discard Use new unused sterile needle and new, unused sterile syringe each entry Coach’s notes: Syringes Remove sterile needles and/or syringe from package immediately before use Change both the needle and syringe between patients Use sharp safety devices Discard syringes, needles, and cannulas after use on a patient Dispose at point of use in approved container No syringe to syringe transfer No storing or transporting in pockets! Prepare just prior to administration Drill #6 Vials Single use when ever possible New syringe and new needle for each access Cleanse with antiseptic before access Discard single dose vials after use Dedicate multi dose vials to single patient whenever possible Keep multi dose vials away from immediate patient care area, and pockets Drill #7 Key coaching points Carefully review (observe, discuss) infection control practices including injection safety. Injection Safety is a basic expectation and should not be skipped to save time or money. Losses teach us: 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 Summary Know the game and rules Learn from past losses Implement a solid game plan Work with your coaches Resources CDC Website http://www.cdc.gov/injectionsafety/ The One and only campaign www.ONEandONLYcampaign.org Association of Professionals in Infection Control and Epidemiology (APIC) www.APIC.org http://www.apic.org/Content/NavigationMenu/PracticeGuidance/Positi onStatements/AJIC_Safe_Injection0310.pdf Resources Medscape - Unsafe Injection Practices: Outbreaks, Incidents, and Root Causes (free CME/CE) http://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-care7-2011.pdf Infection Control Surveyor Worksheet http://www.cms.gov/manuals/downloads/som107_exhibit_35 1.pdf Refuse to infuse 1995 Seattle Mariners 79 W, 66 L