1. Safe Injection Practices
Barbara J Connell MS,MT(ASCP)SH
VP Clinical Services
Medline Industries, Inc.

2. Disclosures Employee of Medline Industries, Inc.
Opinions expressed are my own and not necessarily representative of Medline Industries, Inc.

3. Objectives
Define safe injection and other basic infection control practices, and be able to recognize and correct unsafe practices
Describe the potential consequences of unsafe injection practices
Understand the basic mechanisms of infectious agent transmission via unsafe injection practices
Highlight best practices when performing point of care testing to reduce the risk of transmitting bloodborne pathogens
Understand the need for monitoring healthcare personnel practices in your facility relating to injection safety and basic infection control

4. What is Injection Safety
Measures taken to perform injections in a safe manner for patient and providers
Prevent transmission of infectious diseases from:
Patient to Patient
Patient to Provider
Provider to patient
„Minimum infection prevention practices that apply to all patient care, regardless of the suspected or confirmed infection status of the patient, in any setting where healthcare is delivered.
2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings:

5. What is Injection Safety
Prevents harms
Does not harm the recipient
Does not expose the provider to any avoidable risk
Does not result in waste that is dangerous for the community
Part of the “standard precautions” that should be used on all patients/residents, in all settings, all the time.
„Minimum infection prevention practices that apply to all patient care, regardless of the suspected or confirmed infection status of the patient, in any setting where healthcare is delivered.
2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings:

6. Has a section on Safe Injection Practices (III. A. 1. b
Has a section on Safe Injection Practices (III.A.1.b.and starts on page 68)

7. 2007 Guideline for Isolation Precaution
The transition of healthcare delivery from primarily acute care hospitals to other settings (e.g., home care, ambulatory care, free- standing specialty care sites, long-term care)
Standard Precautions, first recommended in the 1996 guideline, has led to a reaffirmation of this approach as the foundation for preventing transmission of infectious agents in all healthcare settings
Strong evidence base: Outbreaks of hepatitis B and hepatitis C viruses in ambulatory settings indicated a need to re-iterate safe injection practice recommendations as part of Standard Precautions

8. More than 50 outbreaks of viral and bacterial infections occurred in the United States during because of these unsafe medical practices. These outbreaks resulted in the transmission of hepatitis B virus (HBV), hepatitis C virus (HCV), and bacterial pathogens to more than 700 patients.1-4

10. Nebraska Clinic - 99 patients in oncology/hematology clinic acquired HCV after having chemotherapy. All were genotype 3 a which is uncommon in the US. Related to catheter flushing
Nurse drew blood from the IV catheter. Then she reused the same syringe to flush the catheter with saline. She did use a new syringe for each patient, However, she used solution from same 500cc bag for multiple patients. Oncologist and RN license revoked. Never use an IV solution bag to flush the solution for more than patient
Source: Macedo de Oliveira et al., Annals of
Internal Medicine, 2005, 142:
Oklahoma Pain Clinic where anesthesiologist filled syringe with sedation medication to treat up to 24 patients and injected via hep lock. 71 patients with HCV and 31 with HBV - 25 million dollar settlement
Source: Comstock et al. ICHE, 2004, 25:

11. May 21, 2015

12. April 2016
One hundred sixty-three injection safety observations were performed that revealed medication vial rubber septums were disinfected with alcohol 78.4% (95% confidence interval [CI], 71.1%-84.7%) of the time before piercing.
Three hundred thirty hand hygiene observations revealed 33.9% (95% CI, 28.8%-39.1%) use of alcohol-based handrub, 29.1% (95% CI,24.2%-34.0%) use of soap and water, and 37.0% (95% CI, 31.8%-42.4%) use of no hand hygiene.

13. Unsafe Injection Practice Outbreaks
Associated with a wide variety of procedures
Administration of anesthetics for outpatient surgical, diagnostic and pain management procedures
Administration of other IV medications including chemotherapy, cosmetic procedures and alternative medicine (e.g., chelation therapy; vitamins/steroids)
Flushing IV lines or catheters
Administration of IM vaccines

14. Unsafe Injection Practice Outbreaks
Syringe reuse between patients during parenteral medication administration to multiple patients.
Contamination of medication vials or intravenous (IV) bags
Failure to follow basic injection safety practices when preparing and administering parenteral medications to multiple patients.
Inappropriate use and maintenance of finger stick devices and glucometer
The unsafe practices used by healthcare personnel in these outbreaks can be categorized as:
syringe reuse between patients during parenteral medication administration to multiple patients,
(2) contamination of medication vials or intravenous (IV) bags after having been accessed with a used syringe and/or needle, (3) failure to follow basic injection safety practices when preparing and administering parenteral medications to multiple patients
(4) inappropriate use and maintenance of finger stick devices and glucometer
equipment used on multiple patients.
APIC Position paper 2016
Using the same syringe to administer medication to more than one patient, even if the needle was changed
Using a common bag of saline or other IV fluid for more than one patient, and
Leaving an IV set in place for dispensing fluid
Accessing the bag with a syringe that has already been used to flush a patient’s IV or catheter
Accessing a shared medication vial with a syringe that has already been used to administer medication to a patient

16. How have providers justified syringe reuse?
Mistaken belief that the following prevent infection transmission risks
Changing the needle
Injecting through intervening lengths of intravenous tubing
Presence of a check valve
Always maintaining pressure on the plunger to prevent backflow of body fluids

17. What Can Happen When You Do Not Follow Safe Injection Practices?
Transmission of disease to patients
Patients at risk for bacterial, fungal, viral, and parasitic infections
>50 outbreaks in the U.S. since 2001
56% bacterial infections
44% viral hepatitis (hepatitis B, hepatitis C)
Notification of thousands of patients who have been exposed; recommendations to test
Referral of providers to licensing boards for disciplinary action
Unsafe injection practices put patients at risk for bacterial, fungal, viral, and parasitic infections.
Since 2001, at least 50 outbreaks involving unsafe injection practices were reported to CDC
90% (n=45) occurred in outpatient settings
56% bacterial, 44% viral hepatitis
Many hundreds of infected patients
Over 150,000 patients notified and tested
In the last decade, more than 150,000 patients in the United States were advised to get tested for hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV due to the reuse of syringes and misuse of medication vials.

18. Malpractice lawsuits filed by the patient
COSTLY TO PATIENTS, PROVIDERS, and HEALTH DEPARTMENTS

19. Transmission: Understanding the Basics

20. Indirect Contact Transmission
Transfer of an infectious agent through a contaminated intermediate object or person
Hands of healthcare personnel
Patient care devices (e.g., glucometers)
Instruments (e.g., endoscopes) that are not adequately reprocessed
Medications and injection equipment

21. Bloodborne Pathogens
Unsafe injection practices expose healthcare workers, patients or residents to viruses in the blood that can cause illness.
Hepatitis B virus (HBV)
Risk of transmission from needlestick: 6-31%
Hepatitis C virus (HCV)
Risk of transmission from needlestick: 1.8%
Human immunodeficiency virus (HIV)
Risk of transmission from needlestick: 0.3%

22. CONTAMINATED EQUIPMENT OR MEDICATION
Transmission Basics
SOURCE
Infectious person,
e.g. chronic, acute
CASE Susceptible,
non-immune person
CONTAMINATED EQUIPMENT OR MEDICATION

23. Transmission

24. Prevention: Safe Injection Practices

25. Basic Patient Safety
Healthcare should not provide any avenue for transmission of bloodborne viruses
Basic patient safety / “red flag”
Risks of patient-to-patient spread on par with HCW and blood safety efforts
Entirely preventable
Standard Precautions / Aseptic Technique
Aseptic techniques for handling parenteral medications, administering injections, and sampling blood

26. What is Aseptic Technique?
Handling, preparation, and storage of medications and all supplies used for injections and infusions—e.g., syringes, needles, intravenous (IV) tubing—in a manner that prevents microbial contamination
Medications/Injections should be prepared in a clean area free from contamination or contact with blood, body fluids, or contaminated equipment
In general, any item that could have come in contact with blood or body fluids should be kept separate
Aseptic technique is a set of specific practices and procedures performed under carefully controlled conditions with the goal of minimizing contamination by pathogens. The application of aseptic technique will vary by setting (for example, the practices will be more stringent in a surgical setting than in other settings).
Aseptic technique includes:
Hand hygiene
Use of gloves and other personal protective equipment
Creation of a sterile field
Opening and introducing packages and fluids in a way that avoids contamination
Constant avoidance of contact with nonsterile items

27. FACT: injection preparation on surfaces where contaminated substances are handled can lead to the spread of infections
Storage of multidose vials and preparation of injections in same area that used needles and syringes were dismantled and discarded
Absolute adherence to proper infection control practices must be maintained during the preparation and administration of injected medications
Ref: Samandari et al. ICHE 2005; 26:
Photo: Don Weiss / NYCDOHMH
Ref: Samandari et al. ICHE 2005; 26: Photo: Don Weiss / NYCDOHMH

28. Medication Preparation
Make sure only trained staff are preparing medications
Need to prepared in a clean dry workspace that is free of clutter and obvious contamination sources like water, sinks
Medications should be stored in a manner to limit the risk of tampering
Should verify the competency of those preparing medications and monitor compliance with aseptic technique
28 day discard date on multi-dose vials even though CDC says manufacturers recommendations

29. Safe Injection Practices: Multiple-Dose Vials
Use single dose vials (e.g., propofol) whenever possible.
Use right-sized vials and prefilled syringes.
If multiple-dose (“multi-dose”) vials must be used:
Designate to a single person whenever possible.
Both the needle and syringe used to access the vial must be sterile.
IV.H.4. Use single-dose vials for parenteral medications whenever possible. Category IA
IV.H.6. If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must be sterile. Category IA IV.H.7. Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer's recommendations; discard if sterility is compromised or questionable. Category IA
- Multi-dose vials to be used for more than one patient should be kept in a centralized medication area and should not enter the immediate patient treatment area (e.g,. operating room, patient room/cubicle).

30. Safe Injection Practices: Multiple-Dose Vials
Do not keep multi-dose vials in the immediate patient/resident treatment area (e.g., patient’s room).
Store them in accordance with the manufacturer’s recommendations.
Discard vial if sterility is compromised or questionable.
IV.H.4. Use single-dose vials for parenteral medications whenever possible. Category IA
IV.H.6. If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must be sterile. Category IA IV.H.7. Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer's recommendations; discard if sterility is compromised or questionable. Category IA
- Multi-dose vials to be used for more than one patient should be kept in a centralized medication area and should not enter the immediate patient treatment area (e.g,. operating room, patient room/cubicle).

31. Safe Injection Practices: Multiple-Dose Vials
Do not use bags or bottles of intravenous solution as a common source of supply for more than one patient
Use fluid infusion and administration sets (i.e., IV bags, tubing, and connectors) for one person only and dispose appropriately after use.
Leftover parenteral medications should never be pooled for later administration
IV.H.4. Use single-dose vials for parenteral medications whenever possible. Category IA
IV.H.6. If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must be sterile. Category IA IV.H.7. Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer's recommendations; discard if sterility is compromised or questionable. Category IA
- Multi-dose vials to be used for more than one patient should be kept in a centralized medication area and should not enter the immediate patient treatment area (e.g,. operating room, patient room/cubicle).

32. Maintaining Sterility of Vials
A new sterile needle and syringe should be used for each injection
After a syringe or needle has been used to enter or connect to a person’s IV, it is contaminated and should not be used on another person or to enter a medication vial.
A needle should never be left inserted into a medication vial septum for multiple uses
Medications should be discarded upon expiration or any time there are concerns regarding the sterility of the medication
Never store or transport vials in clothing or pockets
This provides a direct route for microorganisms to enter the vial and contaminate the fluid

33. Safe Injection Practices
Proper hand hygiene should be performed before handling medications
Always use a new sterile syringe and needle to draw up medications
Use blunt needle to withdraw meds
Wear a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space.
Parenteral medications and injection equipment should be accessed in an aseptic manner
5 cases Bacterial meningitis in postpartum women and Ohio woman dies May Streptococcus salivarius meningitis (bacteria that is part of normal mouth flora)

34. SAFE INJECTION PRACTICES
Injections:
Disinfect (scrub) all vial tops, IV hubs/ports with alcohol for 10 secs and allow to dry before accessing.
Use 1 sterile needle, 1 sterile syringe for each injection and each entry into a vial.
Infusions:
Begin administration within 1 hour of spiked IV bag (USP 797)
Best if irrigation solutions are discarded between patients
Use fluid infusion and administration sets (i.e., IV bags, tubing, and connectors) for one person only and dispose appropriately after use.

35. SAFE MEDICATION VIAL PRACTICES
Medications:
Discard prepared syringes at end of case; do not save for next patient!
Administer all eye & ear drops/ointments using a “no touch” technique; if tip of container touches patient, dispose!
Obtain topicals in smallest UOM; remove w/sterile applicator each time (no double-dip)
Pre-drawn syringes must include labeling: time, person’s initials, med name, dose, expiration date

36. Before the Procedure
Carefully read the label of the medication vial.
Visually inspect the vial to ensure there is no visible contamination.
Is it single-dose?
If it has already been accessed (e.g., punctured by a needle), throw it away.
Is it multi-dose?
If so, double-check the expiration date and the beyond-use date if it was previously opened.
Discard if either of those dates has passed.
When in doubt, throw it out.

37. During the Procedure Use aseptic technique.
Clean your hands immediately before handling any medication.
Disinfect the medication vial by wiping the rubber septum with alcohol and allow to dry.
Use a NEW needle and syringe for every injection.
Use a new needle and syringe even when obtaining additional doses for the same person.
Do not leave the needle in the medication vial septum if using the vial for multiple uses.
Medication vials should be entered with a new needle and a new syringe, even when obtaining additional doses for the same patient.
A needle or other device should never be left inserted into a medication vial septum for multiple uses.

38. Draw Up the Medication
Draw up medications in a designated clean medication area that is not next to areas where potentially contaminated items are placed (like used needles, blood collection tubes, or other soiled equipment or materials).
Any item that could have come in contact with blood or body fluids should not be in the medication prep area.
If a multi-dose vial is used, it should not be kept or accessed in the immediate patient/resident treatment area.
This prevents accidental contamination of the vial.
If a multi-dose vial enters the immediate patient/resident area, it should be dedicated to that person only and discarded immediately after use.
Where should I draw up medications?
Medications should be drawn up in a designated clean medication area that is not adjacent to areas where
potentially contaminated items are placed. Examples of contaminated items that should not be placed in or
near the medication preparation area include: used equipment such as syringes, needles, IV tubing, blood
collection tubes, needle holders (e.g., Vacutainer® holder), or other soiled equipment or materials that have
been used in a procedure. In general, any item that could have come in contact with blood or body fluids
should not be in the medication preparation area.
Can multi-dose vials be used for more than one patient? How?
Multi-dose vials should be dedicated to a single patient whenever possible. If multi-dose vials must be used for more than one patient, they should not be kept or accessed in the immediate patient treatment area. This is to prevent inadvertent contamination of the vial through direct or indirect contact with potentially contaminated surfaces or equipment that could then lead to infections in subsequent patients. If a multi-dose vial enters the immediate patient treatment area, it should be dedicated to that patient only and discarded after use.

39. After the Procedure
Appropriately discard all used needles, syringes, and SDVs after the procedure is over.
Store used MDVs appropriately.
Discard MDVs when:
The beyond-use date has been reached
Manufacturer’s date
Open vial date
Doses are drawn in a patient treatment area
Any time vial sterility is in question

40. Blood Glucose Monitoring & Insulin PEns

41. Point of Care (POC) Device: Unsafe Practices
Using Finger stick devices for more than one person
Using Blood Glucose meters or other POC devices for more than one person without cleaning and disinfecting between uses per the manufacturer’s instructions.
Using insulin pens or multi-dose insulin vials for more than one person.
Failing to change gloves and perform hand hygiene between finger stick procedures

42. POC : Safe Practices Preparing to perform the procedure
Do Not put supplies down on the bedside table or bed.
Use a “clean field”, such as a paper towel on a medication cart to contain the equipment
Change the “clean field” between patients even if there is not visible blood
Have all supplies easily accessible (sharps container, bandages etc…)
The facility should think through the process of where to perform BGM and administer insulin. Make sure that a culture of safety for protection of healthcare workers is established to prevent spills, sticks, etc. before instituting this procedure. A lot depends on where they do this procedure.
The “clean field” needs to be changed between residents even if there is not visible blood. Outbreak observation where the facility used the same paper towel for each resident's BGM equipment before and after use and each resident placed his/her hand on this paper towel.)
Staff should observe the site of finger puncture for bleeding before letting the resident walk away. Band-Aids are hard to place over fingers, and light pressure with a gauze pad may be necessary. Lots of these residents may be on aspirin therapy or other blood thinner products so they may “bleed” easily thus drips of blood could occur. It is easy to want to push through and get a line of residents done and plans need to include observation time for this step.

43. POC: Safe Practices Perform Hand Hygiene Gloves
Before putting on gloves
Immediately after glove removal
Between patients
Gloves
While performing finger stick or insulin injection
Between patient/resident contacts
After touching finger stick wounds or potentially contaminated objects/equipment
Before touching clean surfaces
Discard gloves in appropriate container

44. POC: Safe Practices
Finger stick devices are not used on more than one person
This includes both the lancet and the lancet holding device
Select single-use devices that permanently retract upon puncture
Insulin pens and other medication cartridges and syringes are for single-use only and should never be used for more than one person

45. POC: Safe Practices
Dedicate blood glucose meters to a single patient if possible
If shared, the device should be cleaned and disinfected after every use, per manufacturer’s instructions
Blood can be transferred back to the glucometer when handled to obtain reading
If manufacturer does not provide instructions for cleaning and disinfection, then the device should not be used for more than 1 patient
Educate staff on blood glucose monitoring and safe injection practices
If glucometer not cleaned and disinfected after use, blood and virus particles remaining can be transferred to next person via care provider’s hands

46. CMS IC Surveyor Worksheet

47. CMS IC Surveyor Worksheet

48. CMS IC Surveyor Worksheet

49. CMS IC Surveyor Worksheet

50. Summary Have a dedicated person responsible for infection prevention
Include Safe Injection Practices in your risk assessment and Infection Prevention program
Assure that existing policies reflect latest recommendations and guidelines
Monitor what practices are occurring in your facility
Are they consistent with your policy
Consequence for not following policy

51. Summary
Education and training is imperative to learn each person’s role in preventing infections
Train staff based on policy, NOT what other staff have been doing

52. Resources

53. Resources

54. Resources

55. Resources

56. Resources
- Safe Injection Practices - How to Do It Right

57. Thank you!