Transcript Refuse to infuse – Injection and Medication practices to

“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
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UW – 31
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Cal 23
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Seahawks – 13
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Cardinals – 10
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Mt. Tahoma – 0
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Pathogens - 0
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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:
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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
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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
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Know the game and the rules
Injection Safety
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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?
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Multidose vials
Single dose vials
Pre-drawn meds
Needle/syringe management
Environment
CMS Injection Practice Expectations
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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
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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
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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
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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
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CDC and state and local health departments have
investigated an increasing number of outbreaks
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Unsafe injection practices
Other breaches in very basic infection control
Detection is haphazard
Outbreaks are occurring across the healthcare spectrum
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Ambulatory, home and long-term care settings
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Infection control programs and oversight
Unsafe Injection related outbreaks
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> 35 nation wide in past decade
~ 100,00 patients exposed to viral
hepatitis
More than 500 infected
Bacterial Outbreaks due to Unsafe
Injection Practices
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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
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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
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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
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Investigations were resource-intensive and disruptive
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Notification, testing, and counseling of hundreds of patients
Delayed recognition and missed opportunities
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Prolonged transmission
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Growing reservoirs of infected patients
IC programs lacking or responsibilities unclear
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Clinic space rented from a hospital (NE)
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Contractors (NYC and OK)
Entirely preventable
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Standard precautions + aseptic technique
MMWR 2003 52:901-6 / CID 2004; 38:1592–8
Practice findings
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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
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“But I can prevent of infection
transmission by…”
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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
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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
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Unresolved issues
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Beyond use date for multidose vials
USP <797> 28 days after initial penetration
 Center for disease control (CDC) supports
manufacture’s guidelines
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USP <797> one hour limit for CompoundingSterile Preparation (CSP)
Drill #1
Drill #2
APIC supported strategy for non
ISO settings med prep
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Hand hygiene before:
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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
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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”
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Admixtures not for immediate use need
ISO class 5 setting
No spiking devices for multiple uses or
patients.
Drill #5
Flushing
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Use single dose containers
Multi-dose vial
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Use only for one patient then discard
Use new unused sterile needle and new,
unused sterile syringe each entry
Coach’s notes: Syringes
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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
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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
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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:
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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
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http://www.cdc.gov/injectionsafety/
The One and only campaign
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www.ONEandONLYcampaign.org
Association of Professionals in Infection
Control and Epidemiology (APIC)
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www.APIC.org
http://www.apic.org/Content/NavigationMenu/PracticeGuidance/Positi
onStatements/AJIC_Safe_Injection0310.pdf
Resources
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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
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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