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

2. Nothing to disclose

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

4. 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

5. 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

6. Injection Safety

7. 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

8. 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?

9. 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?

10. 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?

11. http://www. oneandonlycampaign

12. 2 cases acute HCV to Nevada HD
Labus B, MMWR, May 2008
2 cases acute HCV to Nevada HD
Jan 2nd

13. 3rd case of acute HCV reported
Labus B, MMWR, May 2008
3rd case of acute HCV reported
Jan 2nd
Jan 3rd

14. 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/ days

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

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

17. 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

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

19. 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

20. 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

21. 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

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

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

26. Single vs. Multi-dose Vials

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

28. 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

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

30. When do injuries occur?

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

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

33. 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

34. 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?

35. 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

36. 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?

37. 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

38. 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?

39. 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

40. 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

42. 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

43. 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

44. 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

46. One and Only Campaign