Safe Injection Practices

Roza Tammer, MPH, CIC

HAI Reporting Epidemiologist

Alyssa McClean, MPH

Public Health Educator
Objectives

• Describe how unsafe injection practices contribute to healthcare-

associated infections (HAI)
• Identify four common misconceptions related to injection safety
• Explain three current evidence-based recommendations for safe
medication handling practices
• List infection prevention resources that can be used to promote
injection safety
• Understand steps a facility can take to prevent unsafe injection
practices
• Become familiar with the CDC’s One & Only Campaign and how
Oregon is involved
• Identify three ways to get involved in injection safety work

2
What are safe injection practices?

• A safe injection “does not harm the recipient,

does not expose the health worker to any risk,
and does not result in waste that puts the
community at risk” (World Health
Organization)

• Examples of breaches in injection practice

include
– Reinsertion of used needles into multi-dose vial
(MDV) or solution container (e.g., saline bag)
– Use of a single needle/syringe to administer
intravenous (IV) medication to multiple patients
– Preparing medications in a workspace where
used needles/syringes were dismantled
Why worry about injection practices?

• Clinicians self-report unsafe injection practices

– Survey of 690 US nurses and physicians
• 12% of physicians and 3% of nurses indicate syringe reuse on multiple
patients occurs in their workplace
– During outbreak investigations, “Providers reported that they believed
that changing the needles on the device was sufficient to prevent the
transmission of infection”

• Outbreaks confirm this does occur

– 1998-2008: 33 hepatitis B (HBV) and hepatitis C (HCV) outbreaks in US
healthcare settings resulting in 448 infected patients
Why worry about injection practices?
Patient impact

• Poor injection practice can lead to development of bloodstream

infections (BSI)
– Breaches in hand hygiene, skin prep, aseptic technique

• Morbidity and mortality of BSI

– Poor outcomes for individual patients are common
– Nearly 36,000 deaths in the US in 2008

• Major impact on general population

– About 600,000 cases per year
– Ranked as 11th leading cause of death in the US in 2008
Patient impact

• Bloodborne viral pathogens

– Human immunodeficiency virus (HIV)
– Hepatitis B virus (HBV)
– Hepatitis C virus (HCV)

• Other pathogens
– Bacterial (Staphylococcus aureus – methicillin resistant and
susceptible, Streptococcus spp.)
– Fungal (Exserohilum rostratum & Aspergillus fumigatus)
– Parasitic (Plasmodium falciparum)
– Other viral pathogens
Patient impact
What kind of care is implicated?

Endoscopy

Specimen Point-of-
collection care testing

Pain
management
Microinjection

Insulin Chelation Botox

administration
Fingerstick
Anesthesia
What kind of care is implicated?

Endoscopy

Specimen Point-of-
collection care testing

Pain
management
Microinjection

Insulin Chelation Botox

administration
Fingerstick
Anesthesia
What practices might lead to infection?

• Poor medication handling

– Management and storage
– Preparation
– Compounding
– Administration
• Poor hand hygiene
• Inappropriate equipment re-use and disposal
• Drug diversion
Practice requirements

• CDC’s Guideline for Isolation Precautions: Preventing Transmission

of Infectious Agents in Healthcare Settings (2007) – III.A.1.b, IV.H
(1-8)
– [Link]

• OHA’s OAR 333-019-0061, effective 1/1/18 requires all licensed

healthcare providers to adhere to standard precautions defined in
the CDC guideline
– [Link]
239050
Perceptions about injection practices

Changing the needle

makes a syringe
safe for reuse.
Perceptions about injection practices

Once used, both needle and

syringe are contaminated
and must be discarded. A
new sterile needle and new
sterile syringe must be used
for each injection and each
entry into a medication vial.
Perceptions about injection practices

If you don’t see blood

in the IV tubing or
syringe, it means
those supplies are
safe for reuse.
Perceptions about injection practices

Pathogens are invisible

to the naked eye, but
can easily infect patients
even when present in
microscopic quantities.
Do not reuse syringes,
needles, or IV tubing.
Perceptions about injection practices

It’s okay to use

leftover medication
from used single-dose
or single-use vials for
more than one patient.
Perceptions about injection practices

Single-dose or single-
It’s vials
use okayshould
to use not
leftover
be used medication
for more than
from
one used
patientsingle-dose
regardless
or
of single-use
how much vials for
medicine
more than one patient.
is remaining.
Perceptions about injection practices

Syringes can be
reused as long as an
injection is
administered through
IV tubing.
Perceptions about injection practices

Syringes and needles should

never be reused. IV tubing,
syringes, and other components
represent a single,
interconnected unit. Distance
from patient, gravity, and
infusion pressure don’t ensure
that small amounts of blood
won't contaminate the syringe
once it has been connected to
the unit.
Medication handling

• Perform hand hygiene before handling medication

• Use new, sterile equipment for each patient, injection, and
draw/access
• Examine integrity of cap on vial, and disinfect rubber septum with
alcohol prior to piercing
• Draw up medications in designated clean areas separate from
contaminated items and patients
• Disinfect multi-dose vials used on multiple patients
Medication handling

• Draw up medication just prior to administration

• Label pre-drawn medications
– Time of draw
– Initials of person drawing up the medication
– Name of the medication
– Strength of the medication
– Expiration date if not printed by manufacturer
• Do not carry medication syringes in clothing/pockets

23
Multi-dose versus single-dose vials
Multi-dose versus single-dose vials
Spiking/priming IV bags in advance

United States Pharmacopeia (USP) Convention

• One hour time limit from preparation (spiking bag) until beginning
administration if not prepared in an International Organization for
Standardization (ISO) 5 environment
– Precludes microbial growth if contaminated
– Organism replication can occur within 1-4 hours

• Longer timeframe if primed by pharmacy in ISO 5 environment

26
Expiration date vs. beyond-use date

• Manufacturer expiration date

– Date after which an unopened MDV should not be used
• Beyond-use date
– Date after which an opened MDV should not be used

• Joint Commission requires a 28-day expiration date for MDVs

from date of opening/puncture, unless manufacturer specifies
otherwise
• Beyond-use date should never exceed manufacturer expiration
date

27
Sterile compounding

• Medication compounding
– Combining, mixing, or altering ingredients of a drug to create
personalized medication

• USP 797 requires sterile compounding of medications administered

via injection, IV infusion, intraocular (eye), or intrathecal (spine)
– Requirements for personnel, training, facilities, environmental
monitoring, storage/testing of finished preparations
Sterile compounding

• 2012: Start of 20-state outbreak investigation

• Contaminated preservative-free steroids compounded by the New
England Compounding Center (NECC) directly injected into spine
and joints
• Fungal meningitis and peripheral joint infections
– Case count 753
– Deaths 64
• Laboratory-confirmed organisms from NECC product samples
included Paenibacillus, Bacillus, Lysinibacillus, Kocuria, Penicillum,
Cladosporium, Aspergillus, and Brevibacillus spp.
Insulin administration

• Assign insulin pens to individuals; never use for more than one
person
• MDVs of insulin should be dedicated to an individual whenever
possible
– Enter medication vials with new equipment each time
– Store and prepare vial away from patients and potentially contaminated
equipment
• Dispose of used sharps in an approved sharps container
Fingerstick devices

• Fingerstick devices should never be used for more than one

person
• Select single-use lancets that permanently retract after puncture
• Dispose of used lancets at point of use in approved sharps
container
Blood glucose meters

• Whenever possible, blood glucose meters should be assigned

to an individual and not shared
– If meters must be shared, device should be cleaned and
disinfected after every use per manufacturer’s instructions to
prevent contamination with blood and infectious agents
– If manufacturer does not provide instructions for
cleaning/disinfection, then it may not be shared
Drug diversion

• Removal or use of medications intended for patients

• Mechanisms of diversion
– False documentation
– Scavenging of wasted medication
– Theft by tampering
• Harms to patients
– Failure to receive prescribed medications
– Exposure to substandard care from an impaired HCW
– Exposure to potentially life-threatening infections
Drug diversion prevention & response

• Develop a comprehensive approach to, and clear action plan for, suspected
drug diversion
• Prevention
– Offer non-punitive programs for staff affected by substance issues
– Limit access to controlled substances
– Improve processes for medication preparation and use, including use of locked
storage
– Enhance accountability and oversight
– Minimize mobile medication boxes
• Response
– Ensure no ongoing risk to patients while investigation occurs
– Assessment of harm to patients
– Communication with partners including public health, other facilities, and
exposed patients
– Prompt reporting to enforcement/regulatory agencies
What can facilities do to promote
injection safety?
• Designate staff member to oversee injection safety
• Develop written policies
• Provide competency-based training/education (at hire and ongoing)
• Conduct quality assurance assessments and quality improvement
projects
• Think outside the box
• Communicate about possible issues early and often
• Constant vigilance!
CDC’s One & Only Campaign

Raise awareness and

prevent outbreaks
Free online and print resources via
CDC-INFO
 Special project background

Learning and
Hepatitis C case in
campaign promotion Pilot survey
prolotherapy clinic
opportunity

40
Survey goals

Learn what
Provide
people are
resources
doing

Identify Promote
“champions” toolkit
Toolkit goals

Promote One and Only

Campaign membership
Share resources on
injections and needle use
Encompass diverse practice
settings and care types
Join the One & Only Campaign
Who can be a member?
• Professional and nonprofit organizations
• Healthcare systems
• Provider groups
• Private companies
What do members do?
• Raise awareness
• Share materials
• Receive updates
• Be recognized

To join, email injectionsafety@[Link]

Read the injection safety issue of
CD Summary
• 2-page newsletter followed by short quiz for free CMEs
• Audience: licensed health care providers, public health and health
care agencies, media representatives, medical laboratories,
hospitals, those interested in epidemiology and public health
Follow us on Facebook
[Link]
Resources & references

• World Health Organization: [Link]

• Centers for Disease Control and Prevention
– One and Only Campaign: [Link]
– Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) – III.A.1.b, IV.H (1-
8): [Link]
– Info on Demand: [Link]
– Injection safety website: [Link]
• Oregon Health Authority
– Oregon’s One and Only Campaign partner state web page: [Link]
– CD Summary:
[Link]
2017/[Link]
– Injection safety website:
[Link]
[Link]
• Oregon Patient Safety Commission
– Infection Prevention & Control Toolkit (Safe Injection Practices 5.00-5.02): [Link]
resources/oregon-ambulatory-surgery-center-infection-prevention-control-toolkit/436
– Video: Preventing Infection During Blood Glucose Monitoring and Insulin Administration:
[Link]
• United States Pharmacopeia General Chapter 797:
[Link]
Resources & references

• Severe bloodstream infections: A population-based assessment

– [Link]
• Overall burden of bloodstream infection and nosocomial bloodstream infection in
North America and Europe
– [Link]
• Outbreaks of Infections Associated with Drug Diversion by US Health Care Personnel
– [Link]
• One needle, one syringe, only one time? A survey of physician and nurse knowledge,
attitudes, and practices around injection safety
– [Link]
• US Outbreak Investigations Highlight the Need for Safe Injection Practices and Basic
Infection Control
– [Link]
• Nonhospital Health Care-Associated Hepatitis B and C Virus Transmission: United
States, 1998-2008
– [Link]
c-virus-transmission-united?volume=150&issue=1&page=33
Questions & discussion

Roza Tammer, MPH, CIC

(971) 673-1074
[Link]@[Link]

Alyssa McClean, MPH

(971) 673-0968
[Link]@[Link]