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Unsafe Injection Practices and Other Sources of Infection in the OR Kelli Ford, RN, BSN, CCRN, SRNA.

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Presentation on theme: "Unsafe Injection Practices and Other Sources of Infection in the OR Kelli Ford, RN, BSN, CCRN, SRNA."— Presentation transcript:

1 Unsafe Injection Practices and Other Sources of Infection in the OR Kelli Ford, RN, BSN, CCRN, SRNA

2 Objectives Discuss incidence of unsafe injection practices among anesthesia providers Discuss risks of unsafe injection practices Discuss AANA position statement 2.13 Discuss other sources of infection in the OR

3 Why This Topic?

4 History Common to use same syringe for multiple patients, only changing needle Common to use same IV bag/tubing for all patients in the same day. (ie succinylcholine infusion)

5 History Evidence regarding blood-borne pathogen transmission developed over time. Infection control standards and guidelines developed, adopted, and disseminated. Despite having knowledge, clinicians continue with unacceptable practices

6 Prior Research Few studies in the US and abroad Many abroad in underdeveloped countries Focused on unnecessary injections, availability/cost of disposable equipment, and availability of proper sharps containers Hepatitis/AIDS more prevalent there Few focused on anesthesia & none addressed all 6 AANA position statements

7 1995 Study Assessed reuse of syringes on more than one patient by anesthesiologists 20% frequently or always reused syringes for more than one patient

8 2002 Study Assessed MDAs, CRNAs, nurses, physicians, and oral surgeons. 3% MDAs/1% CRNAs reused syringes/needles on multiple patients 42% MDAs/18% CRNAs reused overall, primarily on the same patient 8% of all respondents reused IV tubing

9 2002 Study (cont.) 45% MDAs & 26% CRNAs would allow anyone to reuse a needle or syringe on themselves or a member of their family

10 2010 Inspection by CMS Inspection of 68 ambulatory surgical centers Most outbreaks occur in outpatient facilities None used needles/syringes on multiple pt’s 28% used single-dose vials for multiple pt’s 2.5% used prefilled syringes on multiple pt’s 1.6% used infusion sets on multiple pt’s

11 Risks of Unsafe Injection Practices Transmission of infection Cost to notify and test patients Cost to treat patients Emotional toll on patients/families Legal fees

12 Risks (cont.) Fines Loss of or discipline against license Increased malpractice premiums Loss of income Decreased production

13 Risks to Facility DOH fines: $500/day per occurrence (and up) CMS/Insurance Fraud: ie Mixing one bag of neosynephrine and billing to all patients that receive the medication Possible DEA violations with improper documentation of wastage when saving narcotic for the next patient

14 Mechanisms of Transmission Reuse of syringes/needles between patients Refilling an empty syringe Multiple use of single-dose vials Improper use of multi-dose vials Reuse of infusion sets between patients

15 Outbreaks Since 1999 Over 30 outbreaks of viral hepatitis and other healthcare-associated infections More than 125,000 Americans notified of their potential exposure 448 people infected with HBV or HCV

16 Outbreaks (cont) Cost of treating HIV infected individual from diagnosis to death: $80,902-371,600 Average annual cost: $20,114 Lifetime cost to treat HBV infected individual: $39,654-70,678 Estimates do not include treating diseases acquired as a result of having the disease

17 Supply Costs Blunt tip needle: $.03 3cc syringe: $.04 5cc syringe: $.07 10cc syringe: $.07 20cc syringe: $0.22 60cc syringe: $0.32 Extension tubing: $0.97

18 New York, 2001: Physician Office 2192 patients at risk, 1315 screened 19 patients developed HCV infection Syringe reuse Contamination of multidose vials used for anesthesia

19 Oklahoma, 2002: Outpatient Pain Clinic 908 patients at risk, 795 screened 31 patients infected with HBV 71 infected with HCV Same syringes/needles used for all patients each day CRNA license revoked and fine issued Prompted AANA survey of practice

20 California, 2003: Pain Clinic 52 patients at risk, 35 screened 4 patients infected with HCV Contamination of multidose lidocaine vials

21 Nevada, 2008: Endoscopy Clinic 40,000 patients notified of potential exposure Notification cost: $16 million - $21 million 6 infected with HCV Reuse of syringes to draw up propofol 2 CRNAs/1 MDA indicted on 28 felony charges

22 Nevada Update MDA surrendered license, suffered strokes & filed for bankruptcy Declared incompetent to stand trial Currently at a forensic mental hospital 2 CRNAs to stand trial this March

23 Nevada Update Investigation of affiliated centers prompted: 9 total cases found/106 possibly linked 5 CRNAs surrendered licenses One physician license suspended $500,000 fine to clinic $500 million fine to Teva and Baxter-in appeal Jan 2010: Settlement with 18 people

24 National Response:SIPC The Safe Injection Practices Coalition Founded in 2008 Launched “One and Only Campaign” with CDC Newly released video for healthcare providers Goal is one needle and one syringe one time for every injection


26 National Response: AANA Contracted with independent firm in 2002 to conduct telephone survey Sent mailings to members, students, school program directors, and hospital administrators after the Oklahoma incident

27 AANA (cont) Position statement number 2.13 Safe Practices for Needle and Syringe Use, adopted 1/09 Contains 6 statements reflecting current safe practices for needle and syringe use by CRNAs

28 Methods All 110 educational programs recognized by the Council on Accreditation of Nurse Anesthesia Educational Programs were contacted using the contact information provided in the December 2010 AANA Journal

29 Methods (cont) Request made to permit SRNAs with at least 3 months clinical experience to participate in anonymous survey Survey consisted of 8 yes/no questions derived from AANA position statement and student experiences with CRNAs

30 Methods (cont) 37 program directors responded and agreed to allow their students to participate in the survey Email sent to program directors with a note to the students and a link to the anonymous survey administered through

31 Methods (cont) Program directors instructed to forward the email to their students and asked to not direct their responses. IRB exemption obtained Informed consent implied by completion

32 Results 325 students responded – 23 1 st year, 123 juniors, 177 seniors & 2 not identifying their year in the program 81% witnessed a CRNA violate at least one of the 6 safe practice standards 58% asked/instructed by their CRNA to violate at least one of the 6 standards

33 Statement One Never administer medications from the same syringe to multiple patients, even if the needle is changed. – This can cause the direct transmission of blood/body fluid between patients. – Y-port defense is not defensible


35 Statement Two Never reuse a needle, even on the same patient. – Needles are single-use devices that are considered contaminated once used and must be discarded in an appropriately identified sharps container. A new needle must be used if additional meds needed.


37 Statement Three Never refill a syringe once it has been used, even for the same patient. – Syringes are single-use devices. Once the plunger is depressed, the internal barrel is contaminated and should not be used to draw up additional medication.

38 Statement Three (cont.) CRNAs should weigh the risk of possible syringe contamination that can occur when repeatedly connecting and disconnecting a medication-filled syringe from an IV infusion set. (ie: anesthesia workspace contamination)


40 Statement Four Never use infusion or intravenous administration sets on more than one patient. – These are single-use items and can directly transmit blood/body fluids between patients. – Entire unit from IV bag to patient’s IV hub is considered a single unit


42 Statement Five Never reuse a syringe or needle to withdraw medication from a multidose vial. – Unsafe practices can cause contamination with infectious agents – Vials contain a preservative, but it is not effective against viruses. – Avoid use if possible or consider single-patient use. – Should clean rubber hub with alcohol



45 Statement Six Never reenter a single-use medication vial, ampoule or solution. – Solutions do not contain a preservative and can become contaminated. – This includes IV solution bags (NSS) and medication vials.


47 Strengths First-hand account information obtained Peer-reviewed Entire population used

48 Weaknesses Small response Small pool of clinical sites may overestimate actual reuse by CRNAs School program directors may have influenced student responses.

49 Other sources of infection in OR Lack of hand washing Improper care of IV access devices Anesthesia workspace contamination Improper use of PPE Equipment contamination Drug-abusing healthcare workers

50 Problem Hospital-acquired infections affect 2 million patients annually Contribute to 100,000 deaths annually US costs $35-45 billion annually HAI’s can result in up to $27,000 in unnecessary medical costs per patient CMS will not reimburse these costs Hospital stay 3-4x longer in those with HAI

51 Lack of Hand washing Single best way to prevent transmission of infection Should be done before and after any patient contact and in between procedures on the same patient Antiseptic hand cleansers acceptable as long as hands are not visibly soiled

52 Hand washing (cont) 93-97% of anesthesiologists wash hands after exposure to high risk patients/body fluids 58% wash after exposure to low risk Overall adherence to hand hygiene lowest among anesthesiologists (28%)

53 Hand washing (cont) Study of CRNAs by SRNA showed 18% compliance, few studies in literature Anesthesia workspace contaminated within four minutes, regardless of case, length, ASA Strongly suggests contamination by hands of anesthesia provider

54 Improper Care of IV Access Scrubbing the hub is the single best way to prevent catheter infections Wear gloves & use aseptic technique with insertion of peripheral sites Do not use same needle for multiple punctures Gown,glove, mask, cap, & sterile drape standard for central line insertions

55 Workspace Contamination Laryngoscope handle with used blade Dials on vaporizers/APL Rebreathing bag on breathing system Used syringes on “clean” areas Masks/oral airways on “clean” areas

56 Workspace Contamination (cont) Minimal cleaning during/between cases 60.5% anesthesiologists (or technicians) rarely or never disinfect anesthesia work surfaces Many use towels/disposable cloths on work surfaces yet don’t change them

57 Workspace Contamination (cont) Metallic ions in anesthesia machines have a significant lethal effect on bacteria Contaminated environment has been implicated in multiple outbreaks of infection HBV can survive in dry blood for 7 days HCV can survive in dry blood 16hrs-4 days

58 Improper Use of PPE Always follow universal precautions Wear goggles/eye shields for any spatter risk: intubation, extubation, suction, high risk cases Do not start IVs, intubate, place oral airways, etc. without proper equipment Needle precautions An infected provider can infect a patient

59 Improper Use of PPE (cont) Hepatitis B Virus – Risk of infection 23-62% after needle stick injury – Mucosal exposure risk much less Hepatitis C Virus – Risk of infection 1.6% after needle stick injury HIV – Risk of infection 0.3% after needle stick injury – Risk of infection 0.09% after mucosal exposure

60 PPE misc Tuberculosis RSV Influenza Herpes/Herpetic Whitlow CMV Rubella/Rubeola Viruses in Smoke Plumes

61 Equipment Contamination Stethoscopes used without cleaning Glucometers not cleaned between patient use have been implicated in multiple outbreaks

62 Future Implications Educational needs persist Education needs to start during school Students are adopting aberrancies into their own practice With voluntary information, people may not access it if they feel they do not need to change behaviors

63 Future Implications (cont) Education should continue throughout career – Hold self accountable – Hold co-workers accountable – Infection control oversight – In-services and competencies Repeated training is a necessary element required to change behaviors

64 Future Implications, cont. Management and administration need to set high standards of care and enforce Create a culture of transparency and learning Allow mistakes/poor processes to be discussed without fear of repercussion Federal and state institutions help set standards and see they are met

65 AGH, 2003 Goal: eliminate HAI-catheter related bloodstream infections Initial rate 5.1/1000 patients = 40 ICU infections annually = > $1.5 million annually Response: CCU went 15 months and trauma went 16 months without infection Hospital saved $2.2 million in 2 years

66 AGH, cont Change started with CFO Worked with board and infection prevention(IP) team to develop strategies Set expectations that IP measures will be applied by all healthcare workers 100% of the time IP weaved into job descriptions and performance evaluations

67 AGH (cont) Instituted training for all residents, new hires, sub specialists, and nursing staff Saw additional 44% decrease in CR-BSI over two years Decreased incidence of CR-BSI by 97%

68 Final Thoughts All outbreaks reviewed were caused by breaches of basic infection control guidelines Interventions to prevent are pennies on the dollar compared to the cost to tx HAIs – We are not a third-world country CRNAs guided by ethical principle of beneficence & nonmaleficence

69 Final Thoughts Anesthesia providers need to examine and change their practice where needed Consistently follow AANA standards Substandard practice can affect thousands Devastating to patients/families impacted Damages trust in healthcare institutions Can affect your license and ability to practice

70 References 1. Wilson W. Infection Control Issue: Understanding and Addressing the Prevalence of Unsafe Injection Practices in Healthcare. AANA J. 2008; 76(4): 251-253. 2. One Needle, One Syringe, Only ONE Time Healthcare Coalition Launches New Training Video. AANA News Bulletin. July 2010: 17. 3. Thompson ND, Perz JF, Moorman AC, Holmberg SD. Nonhospital Health Care-Associated Hepatitis B and C Virus Transmission: United States, 1998-2008. Ann Intern Med. 2009; 150(1): 33-40. 4. Comstock RD, Mallonee S, Fox JL, et al. A Large Nosocomial Outbreak of Hepatitis C and Hepatitis B Among Patients Receiving Pain Remediation Treatments. Infect Control Hosp Epidemiol. 2004; 25(7): 576-583. 5. Perz JF, Thompson ND, Schaefer MK, Patel PR. US Outbreak Investigations Highlight the Need for Safe Injection Practices and Basic Infection Control. Clin Liver Dis. 2010; 14(1): 137-151. 6. Lee JM, Botteman MF, Xanthakos N, Nicklasson L. Needlestick Injuries in the United States: Epidemiologic, Economic, and Quality of Life Issues. AAOHN J. 2005; 53(3): 117-133. 7. Roberts RR, Kampe LM, Hammerman M, et al. The Cost of Care for Patients with HIV from the Provider Economic Perspective. AIDS Patient Care STD’s. 2006; 20(12): 876-886. 8. Position Statement Number 2.13 Safe Practices for Needle and Syringe Use. AANA. 2009. 9. Tait AR, Tuttle DB. Preventing Perioperative Transmission of Infection: A Survey of Anesthesiology Practice. Anesth Analg. 1995; 80: 764-769. 10. Schaefer MK, Jhung M, Dahl M, et al. Infection Control Assessment of Ambulatory Surgical Centers. JAMA. 2010; 303(22): 2273- 2279. 11. Yan Y, Guangping Z, Chen Y, Zhang A, Guan Y, Ao H. Study on the Injection Practices of Health Facilities in Jingzhou District, Hubei, China. Indian J Med Sci. 2006; 60(10): 407-416. 12. Or RCH, Hsieh TK, Lan KM, Kang FC, Chen YH, So EC. Profile of Anesthetic Infection Control in Taiwan: A Questionnaire Report. J Clin Anesth. 2009; 21: 13-18.

71 References, cont. 13. Ryan AJ, Webster CS, Merry AF, Grieves DJ. A National Survey of Infection Control Practice by New Zealand Anaesthetists. Anaesth Intensive Care. 2006; 34(1): 68-74. 14. Daly AD, Nxumalo MP, Biellik RJ. An Assessment of Safe Injection Practices in Health Facilities in Swaziland. SAMJ. 2004; 94(3): 194-197. 15. Ismail NA, Ftouh AM, El-Shoubary WH, Mahaba H. Safe Injection Practice Among Health-Care Workers in Gharbiya Governorate, Egypt. East Mediterr Health J. 2007; 13(4): 893-906. 16. Logez S, Soyolgerel G, Fields R, Luby S, Hutin Y, Baatar U. Rapid Assessment of Injection Practices in Mongolia. AJIC. 2004; 33(1): 31-37. 17. Dentinger C, Pasat L, Popa M, Hutin Y, Mast E. Injection Practices in Romania: Progress and Challenges. Infect Control Hosp Epidemiol. 2004; 25(1): 30-35. 18. Halkes MJ, Snow D. Re-use of Equipment Between Patients Receiving Total Intravenous Anaesthesia: A Postal Survey of Current Practice. Anaesthesia. 2003; 58: 582-587. 19. Germain JM, Carbonne A, Thiers V, et al. Patient-to-Patient Transmission of Hepatitis C Virus Through the Use of Multidose Vials During General Anesthesia. Infect Control Hosp Epidemiol. 2005; 26(9): 789-792. 20. Williams IT, Perz JF, Bell BP. Viral Hepatitis Transmission in Ambulatory Health Care Settings. Clin Infect Dis. 2004; 38(11): 1592-1598. 21. Wayre K, Granato J. Target: Zero Hospital-Acquired Infections. Healthc Financ Manage. 2009; 63(1): 86-91. 22. Pittet, D., Simon, A., Hugonnet, S., MD, Pessoa-Silva, C.L., Sauvan, V., & Perneger, T.V (2004). Hand Hygiene among Physicians: Performance, Beliefs, and Perceptions. Annals of Internal Medicine, 141, 1-8. 23.. Loftus, R.W., Koff M.D., Burchman C.C., Schwartzman, J.D.,Thorum, V., Read, M.E., Wood T.A., & Beach, M.L. (2008). Transmission of Pathogenic Bacterial Organisms

72 Questions

73 Thank You!

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