Injection Safety in the OR Kerri A. Thom, MD, MS Assistant Professor of Epidemiology University of Maryland School of Medicine

Nothing to disclose

Key Point Unsafe injection practices have led to many recent outbreaks with larges number of exposed patients and transmission of infectious diseases

Key Points Protect your patient Protect yourself Needles and syringes are always single use Do not use single dose vials for >1 patient All IV bags are single use Limit use of multidose vials Use for single patient when possible Protect your patient Protect yourself

Objectives Define injection safety and identify safe practices in comparison to unsafe practice Recognize harms associated with unsafe injection practices Avoid common mistakes relative to unsafe injection practices

Injection Safety

I’m an average American. I was raised on a Nebraska farm I’m an average American. I was raised on a Nebraska farm. I enjoy traveling, reading, hiking, going to parties with family and friends. I’m married to a family practice physician. We have three sons, all of whom are in medical training. I’m an audiologist with a busy practice. Ten years ago, I was diagnosed with breast cancer. It took all the energy I had to come to our local clinic for treatment. I had no idea that syringes were being reused and saline bags were being used improperly. To my dismay, I was one of the 99 people in Fremont, Nebraska, who was infected with hepatitis C in 2001 while undergoing treatment for cancer. Dr. Evelyn McKnight

What is Injection Safety? Can I use the same syringe to inject and IV medication to more than one patient if I change the needle between patients and I don’t draw back before injecting?

What is Injection Safety? If I use a syringe to infuse medications into an IV port distal to the patients IV catheter site (e.g. several feet away), is it okay to use the same syringe for another patient?

What is Injection Safety? Can I use reuse the same syringe to infuse medication and access the vial during for a single patient who requires additional medication as long as the vial will not be used for another patient?

http://www. oneandonlycampaign http://www.oneandonlycampaign.org/single-dose-multi-dose-vial-infographic

2 cases acute HCV to Nevada HD Labus B, MMWR, May 2008 2 cases acute HCV to Nevada HD Jan 2nd

3rd case of acute HCV reported Labus B, MMWR, May 2008 3rd case of acute HCV reported Jan 2nd Jan 3rd

All 3 recent endoscopy at same clinic w/ 30-90 days Labus B, MMWR, May 2008 Jan 2nd Jan 3rd All 3 recent endoscopy at same clinic w/ 30-90 days

CDC Investigation Initiated Labus B, MMWR, May 2008 CDC Investigation Initiated Jan 2nd Jan 3rd Jan 9th

CDC began notifying patients Labus B, MMWR, May 2008 CDC began notifying patients Jan 2nd Jan 3rd Jan 9th Feb 27th

CDC began notifying patients Labus B, MMWR, May 2008 CDC began notifying patients Jan 2nd Jan 3rd Jan 9th Feb 27th 40,000 patients Going back 4 years Tested for HIV, HBV, HCB

Labus B, MMWR, May 2008 CDC publishes report Jan 2nd Jan 3rd Jan 9th Feb 27th May 16th

Labus B, MMWR, May 2008 CDC publishes report > 40,000 exposed Jan 2nd Jan 3rd Jan 9th Feb 27th May 16th > 40,000 exposed $16-21 million dollars 6 + patients w acute HCV

Indicted, 28 felony charges Labus B, MMWR, May 2008 CDC publishes report Jan 2nd Jan 3rd Jan 9th Feb 27th May 16th 2 CRNAs, 1 MDA Indicted, 28 felony charges > 40,000 exposed $16-21 million dollars 6 + patients w acute HCV

Inappropriate use of MDV Labus B, MMWR, May 2008 CDC publishes report Jan 2nd Jan 3rd Jan 9th Feb 27th May 16th Re-use of syringe Inappropriate use of MDV

http://www.cdc.gov/HAI/settings/outpatient/outbreaks-patient-notifications.html

Keys to Injection Safety - #1 Needles and syringes are always single use

Keys to Injection Safety - #2 Do not use single-dose vials for multiple patients IV bags are all single use

Single vs. Multi-dose Vials http://www.oneandonlycampaign.org/single-dose-multi-dose-vial-infographic

Keys to Injection Safety - #3 Limit use of multi-dose vials Use for single patient whenever possible

Outcomes … Harm to patients Resource intensive investigations Transmission of pathogenic bacteria Transmission of blood-borne viral pathogens Resource intensive investigations Notification of thousands of patients Emotional distress Cost Disciplinary actions to providers Malpractice suits

Protect Yourself! And your colleagues! Properly dispose of sharps Do NOT recap needles Nearly 400,000 sharps injuries per year Injuries decreased 36% from 2001-2006 BUT INCREASING in surgical areas by 6.5%

When do injuries occur?

Outcomes Emotional stressors Loss of time at work Laboratory testing Investigation Cost of treatment Side effects of treatment Risk for infection

Risk of Transmission HIV 0.3% HCV ~ 3% HBV up to 30%

Monitoring Injection Safety CMS pilot of ambulatory surgical centers 68 centers in OK, NC, MD Infection Control worksheet Problems identified Failure to clean equipment between use Re-use of single dose vials for multiple patients Re-use of single-use devices From CDC slide set

What is Injection Safety? Can I use the same syringe to inject and IV medication to more than one patient if I change the needle between patients and I don’t draw back before injecting?

What is Injection Safety? Can I use the same syringe to inject and IV medication to more than one patient if I change the needle between patients and I don’t draw back before injecting? Answer: NO! Syringe and needle may be contaminated Even if positive pressure was applied

What is Injection Safety? If I use a syringe to infuse medications into an IV port distal to the patients IV catheter site (e.g. several feet away), is it okay to use the same syringe for another patient?

What is Injection Safety? If I use a syringe to infuse medications into an IV port distal to the patients IV catheter site (e.g. several feet away), is it okay to use the same syringe for another patient? Answer: NO! Entire system from bag to patient is connected Gravity and distance do not protect

What is Injection Safety? Can I use reuse the same syringe to infuse medication and access the vial during for a single patient who requires additional medication as long as the vial will not be used for another patient?

What is Injection Safety? Can I use reuse the same syringe to infuse medication and access the vial during for a single patient who requires additional medication as long as the vial will not be used for another patient? Answer: NO! Use a new syringe whenever possible Extra-layer of protection

Drug Diversion and Injection Safety Theft of Rx drugs intended for use in a patient If Intravenous – becomes an injection safety issue Can lead to outbreaks

Oh, And… Healthy 26 yo woman presents in active labor Receives spinal anesthesia 15 hrs later bacterial meningitis 2nd Healthy 30 yo woman in active labor Same day Spinal anesthesia Same anesthesiologist 12 hrs later, meningitis Same organism Also found in anesthesiologist Fijter. MMWR, January 2010

Oh, And… No Mask! Healthy 26 yo woman presents in active labor Receives spinal anesthesia 15 hrs later bacterial meningitis 2nd Healthy 30 yo woman in active labor Same day Spinal anesthesia Same anesthesiologist 12 hrs later, meningitis Same organism Also found in anesthesiologist No Mask! Fijter. MMWR, January 2010

Key Points – Injection Safety Needles and syringes are always single use Do not use single dose vials for >1 patient All IV bags are single use Limit use of multidose vials Use for single patient when possible Protect your patient Protect yourself

One and Only Campaign