Module D Outbreaks and Safe Injection Practices in Home Health and Hospice Settings Welcome to Module D, Outbreaks and Safe Injection Practices

Outline The big picture Outbreaks and best practices Beyond the outbreaks Resources In this module we will examine closely the some of the unsafe injection practices that have lead to large outbreaks of bloodborne pathogens. Then we will examine the recommended best practices for safe injections and blood glucose monitoring. This will be followed by a review of some of the contributing factors that lead to the misuse of injection equipment.

THE BIG PICTURE The Big Picture

Unsafe Injection Practices Have Devastating Consequences The consequences of these outbreaks are devastating, sometimes resulting in patient illness and deaths. Outbreaks can also result in notifications of many potentially exposed patients, causing considerable psychological impacts including anxiety for patients and their families, even if no actual transmission has occurred. Outbreaks can also result in: Loss of licenses, Legal charges and malpractice suits And criminal charges Additionally, these outbreaks erode confidence in our healthcare system. These “never” events are entirely preventable. Healthcare should never provide any avenue for transmission of bloodborne pathogens or microorganisms.

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 The number of outbreaks has been growing substantially over the past decade. Since 2001, the CDC has identified 48 outbreaks relating to unsafe-injection practices during the delivery of injectable medications. Just over 40% of the outbreaks were viral hepatitis and around 60% were bacterial infections (most of which were bloodstream infections). We are seeing more and more outbreaks in outpatient settings with an over- representation in pain management clinics and oncology clinics. These outbreaks have resulted in hundreds of infections. In addition to those infected during this period, there have been over 150,000 patients potentially exposed to infection as a result of poor practices. These are patients who got letters or phone calls telling them they should be tested for hepatitis, HIV or other infections because of unsafe practices such as syringe reuse. *CDC Grand Rounds 11/14/12 & Guh et al, Medical Care 2012

hepatitis B virus 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 hepatitis B virus outbreaks in long term care facilities Outbreaks of hepatitis B virus infection associated with assisted blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings where residents often require assistance with monitoring blood glucose levels and/or insulin administration. Since 2001, there have been 23 recognized outbreaks related to the assisted monitoring of blood glucose. These outbreaks resulted in about 2,000 notifications and over 170 incident infections. Of all viral hepatitis outbreaks in LTC facilities, those associated with the assisted monitoring of blood glucose accounted for about 90%. Although the majority of these outbreaks have been reported in long-term care settings, the risk of infection is present in any setting where blood glucose monitoring equipment is shared, or those assisting with blood glucose monitoring and/or insulin administration fail to follow basic principles of infection control.  *Thompson et al, Annals Int Med 2009; www.cdc.gov/hepatitis/Outbreaks

NC Experience, 2001 - 2012 ABGM – Assisted Blood Glucose Monitoring Year Setting Type Exposed (n) Incident Infections (n) Lapse Note 2003 Nursing Home hepatitis B virus 192 11 ABGM 2008 Cardiology Clinic hepatitis C virus 1200 5 Syringe Reuse Contaminating MDV Strengthened .0206 2010 Assisted-living Facility 87 8 6/8 patients died, “Act to Protect Adult Care Home Residents” Skilled Nursing Facility 116 6 Unknown 109 Unfortunately, outbreaks related to unsafe injections and glucose monitoring have occurred right here in North Carolina. Since 2001, state and local public health agencies have investigated 5 outbreaks: one hepatitis C outbreak at a cardiology clinic due to syringe re-use, and four outbreaks in long term care facilities due mainly to unsafe diabetes care.   These outbreaks, as unfortunate as they were, did result in strengthening of infection control laws in our state. Following the cardiology clinic investigation, changes were made to NC rule .0206 that included adding injection safety to the list of topics that must be covered in the required infection control course. In response to a 2010 hepatitis B outbreak in North Carolina in which 6 out of 8 infected residents died from complications of hepatitis B, the NC General Assembly passed the “Act to Protect Adult Care Home Residents”. This act requires stronger infection prevention policies, training, inspection, and reporting. ABGM – Assisted Blood Glucose Monitoring

Outbreak Causes & Best Practices We know that these outbreaks are occurring, but what exactly are these lapses in basic infection control that result in outbreaks?

1. Syringe reuse (direct and indirect) Outbreak Causes 1. Syringe reuse (direct and indirect) 2. Misuse of single-dose/single-use vials 3. Failure to use aseptic technique 4. Unsafe diabetes care The ‘big 4’ causes that lead to these outbreaks are: Syringe re-use, either directly or indirectly Inappropriate use of single dose or single use vials Failure to use aseptic technique. Aseptic technique can be defined very broadly and encompasses all of the “big 4,” but in this case, we are referring to contamination of injection equipment from the non-sterile environment. The fourth major cause is unsafe diabetes care, specifically the assisted monitoring of blood glucose. Outbreaks often involve more than one of these breaches.

Syringe Reuse Direct Reuse Indirect Reuse or “double dipping” 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 Though it seems unimaginable, healthcare providers have some knowledge gaps surrounding contamination and have reported syringe re-use. Direct syringe re-use, just as it sounds, involves the use of a single syringe for multiple patients. This includes re-use of insulin pens, administering medication through intervening lengths of tubing with the same syringe, or administering vaccines to multiple patients after changing the needle, but reusing the syringe. As an example of this, in a Colorado pediatric office in 2011, a medical assistant performing vaccinations removed the needle from what she believed was an adult dose and saved the syringe for a second pediatric dose. This also occurred at an obstetrics office in New York in 2008 where the staff put 6 doses of flu vaccine in a syringe, changing only the needle between patients. Direct syringe re-use does happen, but the most common cause for these large hepatitis outbreaks is indirect re-use or “double dipping.” This happens when a used, contaminated syringe is used to reenter a vial or bag that is a common source for multiple patients. As you can imagine, just one entry into a bag with a contaminated syringe can lead to multiple exposures if the medication is used for subsequent patients.

Endoscopy Center, Nevada (2008) 9 clinic-associated hepatitis C virus cases 106 possible clinic-associated cases 63,000 potential exposures $16–21 million total cost This is an unfortunate example of what can happen in this “double dipping” situation. This was a hepatitis C outbreak that occurred in 2008 in an endoscopy center in Nevada. This outbreak resulted in 9 cases and 106 possible cases of hepatitis C. There were 63,000 people potentially exposed and the outbreak resulted in $16 to $21 million dollars in public health costs. http://www.southernnevadahealthdistrict.org/download/outbreaks/final-hepc-investigation-report.pdf

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 In this outbreak, the nurse anesthetists would initially access a single dose vial of propofol with a new needle and syringe. After injecting the patient, they would remove the old needle, replace it with a new one, and re-use the original syringe. They would then access the propofol vial as needed for multiple patients, contaminating the entire vial in the process. This was disastrous for both the patients and the clinic. MMWR 2008 57(19);513-517 13

Dangerous Misperceptions 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 discarded! Previous outbreaks and notification events have shown that some dangerous misperceptions surrounding safe injections exist. As illustrated with the Nevada example, some providers believe that changing the needle makes a syringe safe for re-use. False! Backflow from the injection can contaminate the syringe. Another misperception is that syringes can be re-used if there is a sufficient length of tubing between the patient and the injection site. False! Everything from the medication bag to the patient’s IV catheter is a single interconnected unit. Distance from the patient, gravity, or even infusion pressure do not ensure that the syringe will not become contaminated. Lastly, some providers might think that the lack of visible blood means the supplies are safe for re-use. Again this is False! Pathogens like HIV, and hepatitis B and C can be present in sufficient quantities to cause infection without blood being visible. An easy rule to remember is: once a needle and syringe are used, both are contaminated and must be discarded!

2. Misuse of single-dose/single-use Vials (single dose vial) CDC is aware of at least 19 outbreaks involving single dose vial 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) The misuse of single-dose or single-use vials is a frequent cause of the outbreaks that have occurred. The Nevada endoscopy clinic outbreak is an example of misuse of single-dose or single-use vials, as well as syringe re-use. The CDC is aware of at least 19 outbreaks involving single dose vial misuse, with seven outbreaks involving bloodborne pathogens and twelve outbreaks involving bacterial infections. All of these outbreaks occurred in outpatient settings, with almost half in pain remediation clinics where injections are performed frequently and medications are often packaged in large-volume single-dose vials. The use of IV bags for multiple patients has also been linked to the spread of infection. Transmission can occur due to misuse of multidose vials; however, single-dose vials do not contain preservatives and therefore can become contaminated more easily.

Invasive S. aureus Infections Associated with Pain Injections and Reuse of single dose vial – Arizona and Delaware, 2012 Clinic Type Suspected Breaches Outcomes Pain Clinic (AZ) Prepared ‘morning’ and ‘afternoon’ contrast solution from single dose vials 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 Orthopedic Clinic (DE) single dose vial 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 In the summer of 2012, the CDC reported on two instances of invasive Staphylococcal infections due to the inappropriate use of single dose vials. One clinic drew multiple doses from a single-dose vial to prepare ‘morning’ and ‘afternoon’ solutions at the beginning of the day. All MRSA cases had received the ‘afternoon’ solution. Another clinic accessed a single dose vial multiple times for multiple patients over the course of several hours until the medication was depleted. This practice resulted in 7 Staph infections. Two staff members preparing the medications were colonized with Staphyloccous aureus, one with a strain that was identical to the outbreak strain. All of the infections were serious and most required hospitalization. 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/single-use vials causes patient harm. Leftover parenteral medications should never be pooled for later administration In times of critical need, contents from unopened single dose vials can be repackaged for multiple patients in accordance with standards in United States Pharmacopeia General Chapter ‹797› As a result of outbreaks resulting from single dose vial misuse, the CDC restated its position on the use of single-dose/single-use vials in 2012. The CDC stated that: Vials labeled by the manufacturer as “single dose” or “single use” should only be used for a single patient. Ongoing outbreaks provide ample evidence to support that this misuse results in patient harm. Leftover medications should not be pooled or stored for later administration. And, in times of shortage, medications can be repackaged ONLY if it’s done in accordance with established standards. www.cdc.gov/injectionsafety/CDCposition-SingleUseVial.html

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 Failure to use aseptic technique when preparing medications is another major cause of outbreaks relating to unsafe injections. In this context, aseptic technique means handling and preparing supplies used for injections in a manner that prevents microbial contamination between the injection materials and the non-sterile environment. Failure to use aseptic technique is most often linked to the spread of hepatitis B. Hepatitis B is a hearty virus and has been demonstrated to remain infectious in dried blood on environmental surfaces for at least 7 days. At a New Jersey oncology office in 2009, failure to use aseptic technique resulted in: 29 outbreak-associated cases and an additional 68 possible cases, and 4,600 patients were considered potentially exposed and were notified to be tested. As a result, the practice was closed and the physician’s license was revoked. The outbreak that led to so many people becoming infected with hepatitis B was due to the following infection control breaches: Lack of hand hygiene A clean medication area had not been established and they prepared medications in areas with visible blood contamination. Use of a common-use saline bag, and Re-use of single dose vials for multiple patients American Journal of Infection Prevention, 2011

New Jersey – Oncology Office Single use vials stored and used on subsequent days for multiple patients Single dose vials do not contain a preservative which prevents the growth of bacteria. They should be used when they are opened and any remnants should be discarded. In this picture there are two single-use vials that are dated…this picture was taken days after they were opened.

New Jersey – Oncology Office IV bags with stoppers removed IV bags used as sources of fluid to flush catheters for multiple patients IV bags should not be opened or spiked in advance. United States Pharmacopeia 797 (or USP 797) states that bags should not be spiked for more than 1 hour before use. For regulated facilities undergoing inspections, this is a citable offense. The following is a citation from a recent New Jersey Department of Health inspection: According to USP 797, “Opened or needle-punctured single-dose containers, such as bags, bottles, syringes, and vials of sterile products and Compounding Sterile Preparations shall be used within 1 hour…” IV bags should not be used as a source of fluid for multiple patients. (see NE outbreak, slides 8 & 9)

New Jersey – Oncology Office Blood drawing equipment in area of medication preparation Medication prepared in hood in patient treatment area This is a picture from the New Jersey investigation which revealed quite a few infection control breaches: Uncapped syringes for flushing IVs unwrapped and prefilled in advance, blood drawing equipment in the area of medication preparation, medication prepared in advance, and medication prepared in the hood in the patient treatment area. To reduce possible environmental contamination, medication should not be prepared in areas that are potentially contaminated Syringes should not be unwrapped or filled in advance. Medication may be drawn up 1 hour in advance only. Syringes should not be unwrapped before use to prevent environmental contamination. Medication prepared in advance Uncapped syringes for flushing IVs unwrapped and prefilled in advance

New Jersey – Oncology Office Reused Vacutainer holders in contact with gauze Additionally, environmental surfaces must be kept clean to reduce environmental contamination. Vacutainer holders are single-use devices and should not be reused. OSHA warns against vacutainer re-use due to needle stick risk during removal. Potentially contaminated items should not come in contact with other patient-care items, like gauze. Blood contamination

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 Another means of spreading bloodborne pathogens is through unsafe diabetes care. This underappreciated area of risk has been the mode of transmission for many hepatitis B outbreaks. As mentioned earlier, there have been 23 hepatitis B virus outbreaks associated with the assisted monitoring of blood glucose. These accounted for 92% of all hepatitis B virus outbreaks in long-term care facilities. The outbreaks have been linked to the infection control breaches shown here, including: Sharing of blood glucose meters without disinfection and cleaning between uses, Use of fingerstick devices or insulin pens for multiple people, and Failure to perform hand hygiene or change gloves between procedures. Sharing glucometers without proper disinfection is the most common breach. 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

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 multi-dose vials and dedicate them to a single patient whenever possible 2. Misuse of single-dose/single-use vials Do not administer medications from a single dose vial or IV solution bag to more than one patient Unsafe diabetes care, along with syringe re-use, misuse of single dose vials, and failure to use aseptic technique are areas needing special attention. Regarding syringe re-use: Never administer medications from the same syringe to multiple patients Do not re-use a syringe to enter a medication vial or solution Limit the use of multi-dose vials and dedicate them to a single patient whenever possible Regarding single dose vials: Do not administer medications from a single dose vial or IV solution bag to more than one patient.

Unsafe Injections: Causes and best practices 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 Use aseptic technique when preparing or administering medications. Keep contaminated items and surfaces away from the preparation area. Designate a ‘clean’ medication preparation area that is not adjacent to areas where potentially contaminated items are placed. Perform hand hygiene before handling medications. Insure that the rubber septum is disinfected with alcohol prior to piercing it. And, lastly, with diabetes care – Use insulin pens and lancing devices for only one patient. Dedicate blood glucose meters to a single patient. If they must be shared, clean and disinfect after each use per manufacturer's instructions. If there are no instructions, it cannot be shared.

Beyond Outbreaks We know we have unsafe practices occurring because we have seen the results. What else do we know about why this problem might be increasing beyond what we can observe through these outbreaks?

Most Outbreaks are Never Detected Asymptomatic infection Under-reporting of cases Under-recognition of healthcare as risk Barriers to investigation, resource constraints Long incubation period; difficult to identify single healthcare exposure Unfortunately, the outbreaks described so far are just the tip of the iceberg. Most outbreaks are never detected for a variety of reasons shown here. First of all, hepatitis B and C can be asymptomatic infections. They also have long incubation periods of up to 6 months, which makes it difficult to identify a single healthcare exposure. Moreover, even if an infection is diagnosed, the case might not be reported and healthcare might not be recognized as a risk factor. There are also barriers and resource constraints making investigation of potential healthcare- associated outbreaks difficult. 27

Role of Healthcare-Associated Transmission: Beyond Outbreaks Among patients ≥55: Those with acute hepatitis B virus or hepatitis C virus are 2.7x more likely to report having had injections in a health care setting Approximately 37% of acute hepatitis B virus and hepatitis C virus infections attributable to unsafe injections in health care settings Although most healthcare-associated transmissions and outbreaks are never detected, some recent studies have helped to quantify the risk associated with healthcare. One recent case-control study looked at patients who were 55 years old and over. The results were surprising. Those with acute hepatitis B virus or hepatitis C virus were almost 3 times more likely to report having had injections in a health care setting than those without acute hepatitis. The authors estimated that more than 1/3 of acute hepatitis B virus and hepatitis C virus infections in this age group were attributable to unsafe injections. 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 precautions are not followed” We also know that hepatitis C is the most common chronic bloodborne infection in US with 2 to 3 million people chronically infected. The highest prevalence is among persons born between 1945 and 1964, also known as “baby boomers”. As these baby boomers age and visit their healthcare providers more often, we will have a ”growing reservoir of infected individuals who can serve as a source of transmission to others if safe injection practices and other basic infection control precautions are not followed.” Perz et al, Hepatology 2012.‘Accepted Article’, doi: 10.1002/hep.25688

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 Fortunately, most healthcare professionals do practice safe injection techniques with every injection; however, results from this survey performed in 2010 are alarming and give some indication of why these outbreaks continue to occur. A survey of 5,500 healthcare professionals, mostly nurses, found that: 1% of respondents “sometimes or always” re-use a syringe on a second patient 1% “sometimes or always” re-use a multidose vial after accessing it with a re- used syringe 6% use single-dose vials for more than one patient One percent might not seem like a large proportion, but considering the number of injections a healthcare provider gives on a daily basis, this is an alarming number. Add on top of that the 6% of healthcare professionals that report using single dose vials for more than one patient, and the magnitude of the problem quickly becomes apparent. 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 All of this evidence leaves us with a nagging question: why do outbreaks associated with unsafe injections continue to occur? Some healthcare providers aren’t aware that they are endangering their patients with glucometer sharing, or re-using a syringe. The establishment of policies and procedures to promote infection control will help to reduce knowledge gaps. Knowledge does not necessarily translate into practice. Drug shortages and/or economic and time pressures may lead providers to engage in risky practices they might otherwise avoid. It is important to remember that patient safety should come first. Malfeasance is not something that can be easily addressed through education; however, it is important to mention given recent outbreaks caused by drug diversion. Engineering tamper proof devices might be one way to address this problem, as well as improving procedures around narcotics.

Summary To summarize…

Know and Practice These Simple Rules Safe injections Safe diabetes care 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 single-dose vial or IV bag to multiple patients. Limit the use of multi-dose vials and dedicate them to a single patient whenever possible. 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 manufacturer’s instructions Injection equipment (e.g., insulin pens, needles and syringes) should never be used for more than one person. If all healthcare providers know and practice these 3 simple rules for safe injections and safe diabetes care, the knowledge gap that contributes to outbreaks would be significantly reduced.

Beyond Good Practice Designate someone to provide ongoing oversight Develop written infection control policies Provide training Conduct quality assurance assessments If new knowledge is applied to implement safe practices, great strides could be made in preventing devastating outbreaks. We can do this by: Designating someone to provide ongoing oversight Developing written infection control policies Providing training Conducting quality assurance assessments And lastly, speak up if you see someone not following safe injection practices. You are not only protecting your patients - you are protecting your colleagues, as well.

Injection Safety is Every Provider’s Responsibility. www Injection Safety is Every Provider’s Responsibility! www.oneandonlycampaign.org The One & Only Campaign, led by the CDC and the Safe Injection Practices Coalition, was launched in September of 2009 in response to the increasing number of outbreaks relating to unsafe injections. In an attempt to prevent these unsafe injection practices, the campaign established the goal to ensure that patients are protected each and every time they receive a medical injection. The One & Only Campaign aims to do this by increasing understanding and implementation of safe injection practices among healthcare providers and to empower patients to ask their healthcare providers about their injection practices. The resources that they have developed educate both healthcare providers and patients.

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 Montana, B. Keeping the Infection out of Injection. NJ Department of Health and Senior Services Moore, Zack. Various Slides. NC DHHS. The slides for this module have been adapted from a variety of sources, listed here. You may proceed to the next Module, Principles and Practices of Asepsis.

One and only campaign

Campaign Resources Print Materials Audio & Visual Social Media Toolkits The campaign utilizes many mediums and materials to deliver their messages. In addition to the numerous print materials available on the website, they also have several healthcare provider videos and an injection safety “app.” They use social media, including Facebook and Twitter, to get relevant and engaging materials out to target audience. And, recently, they have developed toolkits to help healthcare providers educate themselves and their staff. All of the materials are free and available either on the campaign website or can be ordered through CDC Info. There are actually quite a few new resources, such as a new video, infographic and bloodborne pathogen training.

Videos The One & Only Campaign has two videos available. The first is a 13 minute educational video that illustrates common injection concerns in a variety of settings. The viewer is presented with three scenarios in three settings where medications are prepared and administered: an operating room, an oncology clinic, and a pain management clinic. The viewer is taken through potential errors that could occur in medication handling or injection preparation or administration. Each scenario ends with a summary of steps that can and should be taken to assure safe care. A fourth segment concludes the video by outlining and correcting myths and misperceptions that healthcare providers may have about safe injection practices. The second was recently released (Nov 2012) and is short (4½ minute), cartoon-based video that focus primarily on the complications that can arise if single-dose vials are not used properly. It follows ‘Joe’ through an injection he received from an orthopedic clinic and the resultant infection. It is a nice introduction to the topic of proper single-dose vial use.

Posters Posters are available, including the three shown here. The campaign has recently released a “One Insulin Pen, Only One Person” poster which focuses on the proper insulin pen use. An insulin pen brochure is also available.

Print Materials I did want to point out a few materials that might be of use to you. This ‘dangerous misperceptions’ flyer is a great tool. It is a useful document that lists the 4 common myths that most frequently have led to outbreaks in the past and it corrects those myths. It is a quick, concise tool that provides a lot of useful information in a short amount of time. Another is the infographic. This is a brief overview of the impacts of unsafe injections in the United States. It includes the burden unsafe injections have had and includes best practices. The last material I wanted to point out is an injection safety checklist. It is a subset of items from the “CDC Infection Prevention Checklist in Outpatient Settings.” It can be used by providers to systematically assess their injection practices, and leaves space to note and correct any deficiencies that are identified. These and other materials are available online.

www.ONEandONLYcampaign.org I encourage you to check out the campaign website and download or order any materials you might find useful in your work. You can use these materials to ensure that healthcare workers in your facility are trained in safe injection practices and to periodically evaluate existing practices to ensure compliance with the establish guidelines. I also wanted to mention that we do send out a weekly digest that includes relevant guidelines, news and other injection-related reports. If you are interested in receiving this or talking more about the campaign, please contact the campaign coordinator at the email or phone listed on the NC One & Only page. North Carolina Information and State Contact: http://oneandonlycampaign.org/partner/north-carolina

Thank you!