Outbreak of Whatever—State X, 2004

Outbreak of Whatever—State X, 2004

Injection Safety Best Practices Evelyn Cook, RN, CIC Outline The Big Picture Outbreak Causes & Best Practices Beyond Outbreaks The One & Only Campaign The Big Picture

4 Practices Have Devastating Consequences Unsafe Injection-Related Outbreaks Since 2001 48 recognized outbreaks Viral hepatitis (n=21) or bacterial infections (n=27) 90% (n=43) occurred in outpatient

settings 10 in pain management clinics 9 in outpatient oncology clinics >150,000 patients potentially exposed *CDC Grand Rounds 11/14/12 & Guh et al, Medical Care 2012 HBV Outbreaks Related to Blood Glucose Monitoring, 2001-2011 23

recognized outbreaks due to the assisted monitoring of blood glucose (AMBG) ~2,000 notifications >170 incident infections Accounted for 92% of all HBV outbreaks in LTC facilities *Thompson et al, Annals Int Med 2009; www.cdc.gov/hepatitis/Outbreaks NC Experience, 2001 2012

Year Setting Type Expos ed (n) 2003 Nursing Home HBV

192 2008 Cardiology Clinic HCV 1200 Incident Infectio ns (n) Lapse

11 AMBG 5 Syringe Reuse Contaminati ng MDV Strengthened . 0206 6/8 patients died, Act to

Protect Adult Care Home Residents 2010 Assistedliving Facility HBV 87 8 AMBG

2010 Skilled Nursing Facility HBV 116 6 Unknown Skilled

Note Outbreak Causes 1. Syringe reuse (direct and indirect) 2. Misuse of single-dose/singleuse vials 3. Failure to use aseptic technique 4. Unsafe diabetes care 1. Syringe Reuse Direct Reuse

Insulin pens, IV tubing, vaccines Indirect Reuse or double dipping Common cause of large hepatitis outbreaks Syringe that had been used to inject medication into a patient and reused to enter a medication vial Contents of the vial are then used for subsequent patients Endoscopy Center, Nevada

(2008) 9 clinic-associated HCV cases 106 possible clinic-associated cases 63,000 potential exposures $1621 million total cost The Nevada Outbreak: Mechanism Two breaches contributed to transmission: Re-entering propofol vials with used syringes Using contents from these single-dose

vials on more than one patient MMWR 2008 57(19);513-517 Dangerous Misperceptions 1. 2. 3. Changing the needle makes a syringe safe for reuse. Syringes can be reused as long as an injection is administered through an

intervening length of IV tubing. If you don't see blood in the IV tubing or syringe, it means that those supplies are safe for reuse. Once they are used, both the needle and syringe are contaminated and must be Best Practices Needles & Syringes Needles and syringes are single use devices A new sterile needle and syringe should be used for each injection Needles and syringes should never be used for more than one patient or reused to draw up additional

medication (even for the same patient) 2. Misuse of single-dose/single-use Vials CDC is aware of at least 19 outbreaks involving SDV use 7 outbreaks involved BBPs 12 involved bacterial infections (majority of patients requiring hospitalization) All outbreaks occurred in outpatient

settings Almost half in pain remediation clinics (n=8) Invasive S. aureus Infections Associated with Pain Injections and Reuse of SDVs Arizona and Delaware, 2012 Clinic Type Pain Clinic (AZ)

Orthopedi c Clinic (DE) Suspected Breaches Outcomes Prepared morning and afternoon contrast solution from SDVs at start of day for multiple patients Failed to wear facemasks during spinal injections 3 MRSA infections among

patients receiving afternoon solution All patients hospitalized, ranging from 4-41 days 1 additional patient found deceased in home; invasive MRSA could not be ruled out SDV accessed over the course of several hours for multiple patients until all contents were withdrawn 7 methicillin-susceptible S. aureus infections All patients required

debridement of infected sites and antimicrobial therapy Average length of hospitalization was 6 days Invasive Staphylococcus aureus Infections Associated with Pain Injections and Reuse of Single-Dose Vials, Arizona and Delaware, 2012; Morbidity & Mortality Weekly Report. 2012;61(27):501-504 Single Dose Vials: CDC Position Statement, 2012 Vials labeled by the manufacturer as single dose or single use should only be used for a single patient. Ongoing outbreaks provide ample evidence that inappropriate use of single-dose/singleuse vials causes patient harm.

Leftover parenteral medications should never be pooled for later administration In times of critical need, contents from unopened SDVs can be repackaged for multiple patients in accordance with www.cdc.gov/injectionsafety/CDCposition-SingleUseVial.html standards in United States Pharmacopeia Best Practice SDVs Single-dose/single-use vials should only be used for a single patient and a single procedure.

3. Failure to Use Aseptic Technique Handling and preparing supplies used for injections in a manner that prevents microbial contamination between the injection materials and the non-sterile environment American Journal of Infection Prevention, 2011 19 Best Practices Aseptic Technique

Manufacturing Out of your hands? Maybe. Maybe not. Storage Medications should be discarded upon expiration or any time there are concerns regarding sterility Preparation Medications should be drawn up in a designated clean medication preparation area Any item that could have come in contact with blood or body fluids should be kept separate

Best Practices Aseptic Technique, continued 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 Single-dose/single-use vials should only be used for a single patient and a single procedure. A new sterile needle and syringe should

4. Unsafe Diabetes Care Use of fingerstick devices or insulin pens on multiple persons Sharing of blood glucose meters without cleaning and disinfection between uses Failure to perform hand hygiene or change gloves between

procedures Patel et al. ICHE 2009; 30:209-14, Thompson et al. JAGS 2010, MMWR 2005; 54:220-3 www.cdc.gov/injectionsafety https:// www.cdc.gov/injectionsafety/blood -glucose-monitoring.html Fingerstick Devices Fingerstick devices, also called lancing devices, are devices that are used to prick the skin and obtain drops of blood for testing. There are two main types of fingerstick devices: those that are designed for reuse on a single person and those that are disposable and for single-use.

Reusable Devices: These devices often resemble a pen and have the means to remove and replace the lancet after each use, allowing the device to be used more than once. Some of these devices have been previously approved and marketed for multi-patient use, and require the lancet and disposable components (platforms or endcaps) to be changed between each patient. However, due to failures to change the disposable components, difficulties with cleaning and disinfection after use, and their link to multiple HBV infection outbreaks, CDC recommends that these devices never be used for more than one person. If these devices are used, it should only be by individual persons using these devices for selfmonitoring of blood glucose. Single-use, auto-disabling fingerstick devices: These are devices that are disposable and prevent reuse through an auto-disabling feature. In settings where assisted monitoring of blood glucose is performed, single-use, auto-disabling fingerstick devices should be used. Blood Glucose

Meters Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared; The device should be cleaned and disinfected after every use, per manufacturers instructions, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. Insulin Pens Insulin Pens containing multiple doses of insulin are meant for single-re3sident use only, and must never

be used for more than one person, even when the needle is changed Insulin pens must be clearly labeled with the residents name or other identifiers to verify that the correct pen is used on the correct resident Facilities should review their policies and procedures and educate their staff regarding safe use of insulin pens State Operations Manual Appendix PP -Guidance to Surveyors for Long Term Care Facilities Unsafe Injections: Causes & Best Practices 1. Syringe reuse (direct and indirect) Never administer medications from the same syringe to multiple patients

Do not reuse a syringe to enter a medication vial or solution Limit the use of MDVs and dedicate them to a single patient whenever possible 2. Misuse of single-dose/single-use vials Do not administer medications from a SDV or IV solution bag to more than one patient Unsafe Injections: Causes 3. Failure to use aseptic technique Use aseptic technique when preparing or administering medications

4. Unsafe diabetes care Use insulin pens and lancing devices for only one patient Dedicate glucometers to a single patient. If they MUST be shared, clean and disinfect after each use Most Outbreaks are Never Detected Asymptomatic infection Long incubation period; difficult to

identify single healthcare exposure Under-reporting of cases Underrecognition of healthcare as risk Barriers to investigation, resource constraints Role of HealthcareAssociated Transmission: Beyond Outbreaks

Among patients 55: Those with acute HBV or HCV are 2.7x more likely to report having had injections in a health care setting Approximately 37% of acute HBV and HCV infections attributable to unsafe injections in health care settings Perz et al, Hepatology 2012.Accepted Article, doi: 10.1002/hep.25688

Growing Reservoir Aging population more frequent interactions with the healthcare system growing reservoir of infected individuals who can serve as a source of transmission to others if safe injection practices and other basic infection control Perz et al, Hepatology 2012.Accepted Article,not doi: 10.1002/hep.25688

precautions are followed 2010 Survey of Provider Practices 5,500 healthcare professionals 1% sometimes or always reuse a syringe on a second patient (direct) 1% sometimes or always reuse a multidose vial after accessing it with a reused syringe (indirect) 6% use single-dose/single use vials for more than one patient Pugliese et al 2010. AJIC. Available at: http://www.cdc.gov/injectionsafety or

http://www.ajicjournal.org/article/PIIS0196655310008539/abstract Why Are We Missing the Mark? Knowledge Gaps Poor training Lax or nonexistent policies and procedures Knowledge not translated into practice Drug shortages Economic/time pressure Malfeasance Drug Diversion

Know and Practice These Simple Rules SAFE INJECTIONS Needles and syringes are single use devices. They should not be used for more than one patient or reused to draw up additional medication. Do not administer medications from a singledose vial or IV bag to multiple patients. Limit the use of multi-dose vials and dedicate them to a single patient whenever

possible. SAFE DIABETES CARE Fingerstick devices should never be used for more than one person. Blood glucose meters should be assigned to an individual person. If shared, it must be cleaned and disinfected per manufacturers instructions

Injection equipment (e.g., insulin pens, needles and syringes) should never be Basic Patient Safety Safe injection practices are basic but they are not optional Dr. Michael Bell, CDC Healthcare should not provide any avenue for transmission of bloodborne pathogens or

microorganisms Entirely preventable through Standard Precautions / safe injection Beyond Good Practice Designate someone to provide ongoing oversight Develop written infection control policies Provide training Conduct quality assurance

assessments Injection Safety is Every Providers Responsibility! One & Only Campaign Goal Ensure patients are protected each and every time they receive a medical injection Increase understanding and implementation of safe injection practices among healthcare providers Empowering patients Campaign Resources

Print Materials Audio & Visual Social Media Toolkits Videos Posters Print Materials www.ONEandONLYcampaign.org

North Carolina Information and State Contact: http://oneandonlycampaign.org/partner/north-carolina 43 Acknowledgments Slides adapted from the following sources:

Perz J, Patel PR, Srinivasan A. A Never Event: Unsafe Injection Practices. www.emergency.cdc.gov/ coca/ppt/UnsafeInjectionPractices032708.ppt Shaefer M. Injection Safety. Presented at APIC North Carolina Fall Education Conference October 5, 2009, Durham, NC. Perz J and Thompson N. Viral hepatitis exposure & public health response. Presented at NACCHO Toolkit Development Workshop January 7, 2009 Las Vegas, NV Perz, CDC Public Health Grand Rounds, 11/14/12 Thank you!

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