Unsafe Injection Practices and Other Sources of Infection in the OR

Kelli Ford, RN, BSN, CCRN, SRNA

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

Why This Topic?

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)

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

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

1995 Study

Assessed reuse of syringes on more than one patient by anesthesiologists

20% frequently or always reused syringes for more than one patient

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

2002 Study (cont.)

45% MDAs & 26% CRNAs would allow anyone to reuse a needle or syringe on themselves or a member of their family

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

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

Risks (cont.)

Fines Loss of or discipline against license Increased malpractice premiums Loss of income Decreased production

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

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

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

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

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

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

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

California, 2003: Pain Clinic

52 patients at risk, 35 screened 4 patients infected with HCV Contamination of multidose lidocaine vials

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

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

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

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

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

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

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

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

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 surveymonkey.com

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

Results

325 students responded– 23 1st 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

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

Do you ever administer medications from the same syringe to multiple patients?

Yes4%

No96%

Yes

No

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.

Do you ever reuse a needle on the same patient?

Yes18%

No82%

Yes

No

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.

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)

Do you ever refill a syringe once it has been used, even for the same patient?

Yes82%

No18%

Yes

No

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

Do you ever use infusion or IV administration sets on more than one patient?

Yes1%

No99%

Yes

No

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

Do you ever reuse a syringe/needle to withdraw medication from a multidose medication vial?

Yes22%

No78%

Yes

No

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.

Do you ever reenter a single-use medication vial to prepare medications for multiple patients, even if the

needle/syringe is clean?

Yes49%

No51%

Yes

No

Strengths

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

Weaknesses

Small response Small pool of clinical sites may overestimate

actual reuse by CRNAs School program directors may have influenced

student responses.

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

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

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

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%)

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

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

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

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

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

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

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

PPE misc

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

Equipment Contamination

Stethoscopes used without cleaning Glucometers not cleaned between patient use

have been implicated in multiple outbreaks

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

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

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

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

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

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%

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

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

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.

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

Questions

Thank You!