1. “Refuse to infuse” Injection Safety for Infection Prevention “Refuse to infuse” Injection Safety for Infection Prevention 2011 Puget Sound APIC Conference Sept 30 and Oct 1, 2011 Lou Hilken, RN, MN, ICP, CIC Providence St. Peter Hospital, Olympia WA

2. Current Scoreboard UW – 31 UW – 31 Seahawks – 13 Seahawks – 13 Olympia High School - 24 Olympia High School - 24 Patient w/o injection related infection – all Patient w/o injection related infection – all Cal 23 Cal 23 Cardinals – 10 Cardinals – 10 Mt. Tahoma – 0 Mt. Tahoma – 0 Pathogens - 0 Pathogens - 0

3. Refuse to infuse, so patients don’t lose

4. Disclosure: several slides were obtained or adapted from: A “Never” Event: Unsafe Injection Practices Joseph Perz DrPH MA, Arjun Srinivasan MD, Priti Patel MD MPH Prevention and Response Branch Division of Healthcare Quality Promotion: Centers for Disease Control and Prevention A “Never” Event: Unsafe Injection Practices Joseph Perz DrPH MA, Arjun Srinivasan MD, Priti Patel MD MPH Prevention and Response Branch Division of Healthcare Quality Promotion: Centers for Disease Control and Prevention Injection Safety Melissa Schaefer, MD Injection Safety Melissa Schaefer, MD Division of Healthcare Quality Promotion Centers for Disease Control and Prevention

5. Learning objectives 1. Describe safe injection, infusion and medication vial practices to minimize cross contamination and infection outbreaks. 2. Discuss situations that led to break in sterile technique and infection related to medication administration. 3. Identify potential practice changes in your Ambulatory Surgery Center (ASC) to further reduce infection risk.

6. Success Strategies Know the game and rules Know the game and rules Learn from past losses Learn from past losses Implement a solid game plan Implement a solid game plan Work with your coaches Work with your coaches

7. Know the game and the rules

8. Injection Safety Measures taken to perform injections in a safe manner for patients and providers. Measures taken to perform injections in a safe manner for patients and providers. Prevent transmission of infectious diseases from: – Patient to patient; Patient to provider; and Provider to patient. Prevent transmission of infectious diseases from: – Patient to patient; Patient to provider; and Provider to patient.http://www.cdc.gov/ncidod/dhqp/injectionSafetyFAQs.html

9. What do your injection practices look like? Multidose vials Multidose vials Single dose vials Single dose vials Pre-drawn meds Pre-drawn meds Needle/syringe management Needle/syringe management Environment Environment

10. CMS Injection Practice Expectations Needles are used for only one patient. Needles are used for only one patient. Syringes are used for only one patient. Syringes are used for only one patient. Medication vial are always entered with a new needle and syringe. Medication vial are always entered with a new needle and syringe. Predrawn meds are labeled with time of draw, initials of person drawing, med, strength, expiration date or time. Predrawn meds are labeled with time of draw, initials of person drawing, med, strength, expiration date or time. Single use med vials are used for only one patient. Single use med vials are used for only one patient.

11. CMS expectations Manufactured prefilled syringes are used for only one patient. Manufactured prefilled syringes are used for only one patient. Bags of IV solutions are used for only one patient. Bags of IV solutions are used for only one patient. Medication administration tubing and connectors are used for only one patient. Medication administration tubing and connectors are used for only one patient. All sharps are disposed of in a puncture-resistant sharps container. All sharps are disposed of in a puncture-resistant sharps container. Sharps containers are replaced when the fill line is reached. Sharps containers are replaced when the fill line is reached.

12. CMS expectations Additional breaches in injection practices, not captured by the previous questions above. Additional breaches in injection practices, not captured by the previous questions above. Multi-dose injectable medications are used for only one patient, if NO then Multi-dose injectable medications are used for only one patient, if NO then Rubber spectum disinfected Rubber spectum disinfected Vial dated and discard appropriately Vial dated and discard appropriately Location of storage and access of med Location of storage and access of med Sharp disposal Sharp disposal Other breaches not covered above Other breaches not covered above

13. www.cms.gov/manuals/downloads /som107_exhibit_351.pdf

14. Gain from Losses…

16. CDC and state and local health departments have investigated an increasing number of outbreaks CDC and state and local health departments have investigated an increasing number of outbreaks Unsafe injection practices Unsafe injection practices Other breaches in very basic infection control Other breaches in very basic infection control Detection is haphazard Detection is haphazard Outbreaks are occurring across the healthcare spectrum Outbreaks are occurring across the healthcare spectrum Ambulatory, home and long-term care settings Ambulatory, home and long-term care settings Infection control programs and oversight Infection control programs and oversight Growing Concern

17. Unsafe Injection related outbreaks > 35 nation wide in past decade > 35 nation wide in past decade ~ 100,00 patients exposed to viral hepatitis ~ 100,00 patients exposed to viral hepatitis More than 500 infected More than 500 infected

18. Bacterial Outbreaks due to Unsafe Injection Practices Pain Clinic – 7 cases – Serratia marcescens Pain Clinic – 7 cases – Serratia marcescens Spinal injections; all patients hospitalized Spinal injections; all patients hospitalized Cohen, AL et al. Clin J Pain 2008; 24(5): 374-380 Primary care clinic – 5 cases – S. aureus Primary care clinic – 5 cases – S. aureus Joint injections; all patient hospitalized Joint injections; all patient hospitalized Kirschke DL et al. CID 2003;36:1369-1373. Kirschke DL et al. CID 2003;36:1369-1373.

19. Storage of multidose vials and preparation of injections in same area that used needles and syringes were dismantled and discarded FACT: injection preparation on surfaces where contaminated substances are handled can lead to the spread of infections Ref: Samandari et al. ICHE 2005; 26: 745-750 Photo: Don Weiss / NYCDOHMH

20. Tallis, GF et al, Journal of Viral Hepatitis, 2003, 10, 234-239 Hepatitis C transmission post arthoscopy Hepatitis C transmission post arthoscopy Same patient, same needle/syringe combo used to draw addition medication Same patient, same needle/syringe combo used to draw addition medication Remainder Propofol and Fentanyl used on next patient Remainder Propofol and Fentanyl used on next patient

21. Oklahoma Pain Remediation Clinic Anesthetist filled single syringe with sedation medication to treat up to 24 sequential patients Anesthetist filled single syringe with sedation medication to treat up to 24 sequential patients Administered through heparin locks Administered through heparin locks Lookback investigation for entire two year time period of clinic operation Lookback investigation for entire two year time period of clinic operation Serologic results for 795/908 (88%) patients Serologic results for 795/908 (88%) patients 71 (9%) clinic-associated HCV infections 71 (9%) clinic-associated HCV infections 31 (4%) clinic-associated HBV infections 31 (4%) clinic-associated HBV infections US $25 million settlement US $25 million settlement Comstock et al. ICHE, 2004, 25:576-583

22. Common Themes Investigations were resource-intensive and disruptive Investigations were resource-intensive and disruptive Notification, testing, and counseling of hundreds of patients Notification, testing, and counseling of hundreds of patients Delayed recognition and missed opportunities Delayed recognition and missed opportunities Prolonged transmission Prolonged transmission Growing reservoirs of infected patients Growing reservoirs of infected patients IC programs lacking or responsibilities unclear IC programs lacking or responsibilities unclear Clinic space rented from a hospital (NE) Clinic space rented from a hospital (NE) Contractors (NYC and OK) Contractors (NYC and OK) Entirely preventable Entirely preventable Standard precautions + aseptic technique Standard precautions + aseptic technique MMWR 2003 52:901-6 / CID 2004; 38:1592–8

23. Practice findings Syringe reuse Syringe reuse Multidose vials in the immediate patient treatment area Multidose vials in the immediate patient treatment area Contamination of vials and IV bags with previously used syringe Contamination of vials and IV bags with previously used syringe Using single-dose medications for more than one patient. Using single-dose medications for more than one patient. Purchase vials containing quantities in excess of those needed for a single patient – Mistaken belief that they can be used in a multi-dose fashion. Purchase vials containing quantities in excess of those needed for a single patient – Mistaken belief that they can be used in a multi-dose fashion. Failure to follow basic infection safety for preparing and administering meds Failure to follow basic infection safety for preparing and administering meds

25. Mistaken beliefs about syringe reuse “But I can prevent of infection transmission by…” “But I can prevent of infection transmission by…” Changing the needle only Changing the needle only Injecting through intervening lengths of IV tubing Injecting through intervening lengths of IV tubing Presence of Check valve Presence of Check valve Maintaining pressure on the plunger to prevent backflow Maintaining pressure on the plunger to prevent backflow

26. ASC Infection Control 68 ASC in 3 states surveyed 68 ASC in 3 states surveyed Hand hygiene, equipment reprocessing, environmental cleaning, handling of blood glucose monitoring equipment and injection safety and medication handling reviewed Hand hygiene, equipment reprocessing, environmental cleaning, handling of blood glucose monitoring equipment and injection safety and medication handling reviewed 28% of ASC had Injection safety lapse 28% of ASC had Injection safety lapse Primary offense - Single dose vials (without preservative) used on multiple patients cases including saline bags Primary offense - Single dose vials (without preservative) used on multiple patients cases including saline bags JAMA, June, 2010-Vol 303, No.22

27. Implement a solid game plan

30. Work with your coaches

32. APIC position paper Unresolved issues Unresolved issues Beyond use date for multidose vials Beyond use date for multidose vials USP 28 days after initial penetration USP 28 days after initial penetration Center for disease control (CDC) supports manufacture’s guidelines Center for disease control (CDC) supports manufacture’s guidelines USP one hour limit for Compounding- Sterile Preparation (CSP) USP one hour limit for Compounding- Sterile Preparation (CSP)

33. Drill #1

34. Drill #2

35. APIC supported strategy for non ISO settings med prep Hand hygiene before: Hand hygiene before: Accessing supplies Accessing supplies Handling vials and IV solutions Handling vials and IV solutions Preparing and administering medications Preparing and administering medications Aseptic Technique Aseptic Technique Clean area and surfaces Clean area and surfaces Discard emergently used meds and solutions Discard emergently used meds and solutions Prevent contact sterile and non sterile Prevent contact sterile and non sterile

36. Drill #3

37. Drill #4

38. Coach’s notes: IV solutions Use Use one IV container and limit infusion supplies to one patient. Limit Limit time between medication/solution prep and administration (unresolved) Disinfect Disinfect IV access ports and vial stoppers “Scrub the hub” Admixtures Admixtures not for immediate use need ISO class 5 setting No No spiking devices for multiple uses or patients.

39. Drill #5

40. Flushing Use single dose containers Use single dose containers Multi-dose vial Multi-dose vial Use only for one patient then discard Use only for one patient then discard Use new unused sterile needle and new, unused sterile syringe each entry Use new unused sterile needle and new, unused sterile syringe each entry

41. Coach’s notes: Syringes Remove sterile needles and/or syringe from package immediately before use Remove sterile needles and/or syringe from package immediately before use Change both the needle and syringe between patients Change both the needle and syringe between patients Use sharp safety devices Use sharp safety devices Discard syringes, needles, and cannulas after use on a patient Discard syringes, needles, and cannulas after use on a patient Dispose at point of use in approved container Dispose at point of use in approved container No syringe to syringe transfer No syringe to syringe transfer No storing or transporting in pockets! No storing or transporting in pockets! Prepare just prior to administration Prepare just prior to administration

42. Drill #6

43. Vials Single use when ever possible Single use when ever possible New syringe and new needle for each access New syringe and new needle for each access Cleanse with antiseptic before access Cleanse with antiseptic before access Discard single dose vials after use Discard single dose vials after use Dedicate multi dose vials to single patient whenever possible Dedicate multi dose vials to single patient whenever possible Keep multi dose vials away from immediate patient care area, and pockets Keep multi dose vials away from immediate patient care area, and pockets

44. Drill #7

45. Carefully review (observe, discuss) infection control practices including injection safety. Carefully review (observe, discuss) infection control practices including injection safety. Injection Safety is a basic expectation and should not be skipped to save time or money. Injection Safety is a basic expectation and should not be skipped to save time or money. Losses teach us: Never administer medications from the same syringe to more than one patient, even if the needle is changed Never administer medications from the same syringe to more than one patient, even if the needle is changed Never enter a vial with a syringe or needle that has been used for a patient if the same medication vial might be used for another patient Never enter a vial with a syringe or needle that has been used for a patient if the same medication vial might be used for another patient Key coaching points

46. Summary Know the game and rules Know the game and rules Learn from past losses Learn from past losses Implement a solid game plan Implement a solid game plan Work with your coaches Work with your coaches

47. Resources CDC Website CDC Website http://www.cdc.gov/injectionsafety/ http://www.cdc.gov/injectionsafety/ http://www.cdc.gov/injectionsafety/ The One and only campaign The One and only campaign www.ONEandONLYcampaign.org www.ONEandONLYcampaign.org www.ONEandONLYcampaign.org Association of Professionals in Infection Control and Epidemiology (APIC) Association of Professionals in Infection Control and Epidemiology (APIC) www.APIC.org www.APIC.org www.APIC.org http://www.apic.org/Content/NavigationMenu/PracticeGuidance/Positi onStatements/AJIC_Safe_Injection0310.pdf http://www.apic.org/Content/NavigationMenu/PracticeGuidance/Positi onStatements/AJIC_Safe_Injection0310.pdf http://www.apic.org/Content/NavigationMenu/PracticeGuidance/Positi onStatements/AJIC_Safe_Injection0310.pdf http://www.apic.org/Content/NavigationMenu/PracticeGuidance/Positi onStatements/AJIC_Safe_Injection0310.pdf

48. Resources Medscape - Medscape - Unsafe Injection Practices: Outbreaks, Incidents, and Root Causes (free CME/CE) http://www.medscape.org/viewarticle/745695 http://www.medscape.org/viewarticle/745695 http://www.medscape.org/viewarticle/745695 GUIDE TO INFECTION PREVENTION FOR OUTPATIENT SETTINGS: Minimum Expectations for Safe Care http://www.cdc.gov/HAI/pdfs/guidelines/standatds-of-ambulatory-care- 7-2011.pdf http://www.cdc.gov/HAI/pdfs/guidelines/standatds-of-ambulatory-care- 7-2011.pdf Infection Control Surveyor Worksheet http://www.cms.gov/manuals/downloads/som107_exhibit_35 1.pdf http://www.cms.gov/manuals/downloads/som107_exhibit_35 1.pdf

49. Refuse to infuse 1995 Seattle Mariners 79 W, 66 L