Safe Injection Practices. Dr. B. J. Sonowal Technical Advisor - BD

Transcription

1 Safe Injection Practices Dr. B. J. Sonowal Technical Advisor - BD November 29, 2010

2 Introduction Giving an injection was once the province of doctors. With the advent of penicillin in the 1940s it became an extended role activity of the nurse (Beyea and Nicholl 1995). It is now such a routine nursing activity that nurses can become complacent about it. With increasing demands upon nurses to practice evidence- based care, it is appropriate to reappraise such a fundamental procedure.

3 Magnitude of Injections - India 3 billion syringes sold across Indian markets per year However, 6 billion injections are used in healthcare delivery each year in India ---- indicating a high percentage of unsafe injections across India

4 Unsafe Injections WHO Estimates 39.3% injections administered worldwide are unsafe INCLEN Study in India reported the unsafe Injections as high as 62.9% 31.6% of these injections have potential to cause harm of blood borne infections 53.1% of these injections are due to faulty technique

5 Reasons for Unsafe Injections Injection-associated adverse events are caused by poor injection practices that are a consequence of behavioral and system determinants. 1

6 Rules of Safety 1. Assume all body fluids contain pathogens 2. Assume the skin and the environment contain microorganism 3. Treat all human and body fluids as contaminated by pathogens 4. Unsafe injections can spread pathogens more easily than inhalation, swallowing or sex

7 Can spread pathogens more efficiently than breathing, swallowing, or sex They do so when germs are: transferred from fingers or objects to the needle; present on the skin, picked up by a needle, and carried under the skin; in the medication to be injected; or are inside the syringe barrels or needles that were previously used, inadequately cleaned, or incompletely sterilized

8 What is a Safe injection? An injection is said to be safe, if it : does no harm to the recipient does not expose the health worker to any risk, and does not result in waste that is dangerous for the community.

9 Making Injections Safe for Patient

10 How do we make injections safe for patients? Should not reuse either a syringe or needle in more than one patient Discard a needle that has touched a nonsterile surface Should not attempt to sterilize and reuse disposable syringes Attempting to sterilize injection equipment without prior cleaning Leaving a needle in the vial to withdraw additional doses Reusing the same syringe for reconstituting multiple vials Should not have latex and should be made of virgin plastic Source: Tool for the assessment of injection safety; department of vaccines and biologicals; WHO Geneva 2001

11 Pathogens Transmitted by Percutaneous Injuries* Blastomyces dermatitidis Brucella abortus Colonic adenocarcinoma Corynebacterium diphteriae Creutzfeldt-Jakob Disease Cryptococcus neoformans Dengue virus Ebola/Marburg virus Hepatitis B virus Hepatitis C virus Hepatitis G virus Herpes virus simiae Herpes Simplex virus Herpes Zoster virus Human Immunodeficiency Virus Leptospira icterohaemorrhagiae Mycobacterium marinum Mycobacterium tuberculosis Mycoplasma caviae Neisseria gonhorreae Orientia tsutsugamushi Plasmodium falciparum Rickettsia rickettsii Sarcoma Simian immunodeficiency virus Sporotrichum schenkii Staphylococcus aureus Streptococcus pyogenes Toxoplasma gondii Treponema pallidum Tumors Vaccinia Source: Jane Perry, International Healthcare Worker Safety Center, University of Virginia

12 Hand Washing Scrub hands thoroughly with soap and water for sec Wash under running water Dry in room air or with sterile towel Hand Sterilizers can be used as an option

13 Hand Washing Running Water

14 Touching Sterile Injection Equipment Keep needle and syringe sterile Do NOT touch parts that come in contact with the injectable drug If you accidentally touch any of these parts, the syringe and needle are NOT sterile Discard them immediately in the appropriate container and use a sterile syringe and a sterile needle Do NOT touch Do NOT touch Do NOT touch

15 Injections Site Practices Cleaning the injection site before giving injection is: Good Clinical Practice Decreases number of microorganisms present in the skin May reduce the risk of abscess Rub skin (circular outward motion or Swapping down) with clean cotton wool damped with rubbing alcohol. LET SITE AIR DRY, DO NOT BLOW If alcohol not available, wash with soap and water. Avoid pre-wetted cotton swabs (Kept in bottles/bowls) for fear of contamination

16 Adapted from Craven, R.F. & Hirnle, C.J. (2006) Potential Complications Associated with Intramuscular (IM) Medication Administration

17 Complication Causes Preventive Nursing Measures Pain caused by injection (Patient reports discomfort) Inadvertent tracking of medication or alcohol through SC tissue Medication irritating to IM tissue. Let alcohol skin prep dry before giving injection. Change needle after drawing up medication. Use air lock when giving irritating medication. Use Z-track technique Tensed muscle during injection Encourage client to relax muscles during injection.

18 Complication Damage to SC or IM tissue Hematomas /Bruising Muscle contractions (tissue nodules or indurations /indentation) Sterile abscesses (collection of undissolved medication) Causes IM administration of heparin Injection given into abnormal tissue Injecting of medication into the wrong site (SC instead of IM or vice versa) Preventive Nursing Measures Change to another route as soon as possible. Record sites used for all injections Use the pinch test to determine the needle length before injecting.

19 Complication SC tissue discoloration Causes Injection of drug that is not water soluble. SC deposition of iron supplements Preventive Nursing Measures Be sure that medication is recommended for IM administration. Give iron supplements using Z-track techniques. Muscle contractures (in infant) characterized by difficulty in crawling 4 wks to 1 yr after receiving IM injections Pain in injection site Decrease risk of knee contractures for infants with passive range of - motion exercises and applying warm socks and massage to the thighs.

20 Complication Speed shock or rapid absorption of medication (increased heart and respiratory rate, decreases level of consciousness, cardiovascular collapse) Causes Medication administered directly into a vein or artery Preventive Nursing Measures Aspirate to check for back flow of blood. If blood appears in the barrel, remove syringe and needle and discard. Draw up another dose of medication and administer.

21 Complication Infection of muscle or bone (muscle or bone pain in injection site, skin redness or warmth, localized swelling) Bone injury (pain or bone damage) Causes Organism is introduced into the tissue or bone during injection Bone struck during IM injection Preventive Nursing Measures Follow strict aseptic technique when administering IM injections. Use a shorter needle (1.25 in) when giving injections into the deltoid or ventrogluteal sites. Use visual inspection and palpation to locate injection site.

22 Complication Nerve Injury (shooting pain down the limb causing temporary or permanent paralysis) Causes Nerve struck during injection Medication injected close to nerve Preventive Nursing Measures Use careful visual inspection and palpation to locate injection site. Avoid use of deltoid and dorsogluteal sites whenever possible.

23 Making Injections Safe for Healthcare Worker

24 How do we make injections safe for Healthcare Workers? Recapping contaminated or used needles Placing needles on a surface or carrying them any distance prior to disposal Sharpening blunt or blocked needles for reuse Reaching into a mass of used syringes or needles (for cleaning or sorting waste) Using safety engineered devices that ensures that healthcare worker does not receive a Needle Stick Injury Source: Tool for the assessment of injection safety; department of vaccines and biologicals; WHO Geneva 2001

25 Needlestick & Sharp Object Injuries (US hospitals) Original Purpose of Sharps Device Heparin/Saline Flush, 1.4% Others, 18.3% Injection, IM/SubQ, 23.3% Obtain Body Fluid/Tissue Sample, 2.3% Suturing, 21.2% Cutting (surgery), 8.1% I.V./I.A. Line, 9.6% Blood Sampling, 15.8% Source: U.S. EPINet Network, 2004 Uniform Needlestick and Sharp-Object Injury Report; 48 healthcare facilities

26 Needlestick & Sharp Object Injuries (US hospitals) Type of Device Causing Injury Wire, 1.3% Vacuum Tube Blood Collection Needle, 2.2% I.V. Catheter (Needle), 3.6% Needles, 5.2% Winged Steel Needle, 6.3% Central Line Catheter Introducer Needle, 1.3% Others, 17.7% Disposable Syringe, 35.30% Scapel, 7.4% Suture Needle, 21.0% Source: U.S. EPINet Network, 2004 Uniform Needlestick and Sharp-Object Injury Report; 48 healthcare facilities

27 Needlestick & Sharp Object Injuries (US hospitals) Job Category Others, 12.6% Medical/Nursing Students, 1.4% Technologist (non lab), 5.2% M.D., 23.7% I.V.Team, 5.0% Attendent/ Housekeeper, 11.5% Nurse RN/LPN, 40.6% Source: U.S. EPINet Network, 2004 Uniform Needlestick and Sharp-Object Injury Report; 48 healthcare facilities

28 US Needlestick Safety And Prevention Law Serves to reinforce the Bloodborne Pathogen standard preventing legal challenges to the Novemeber 5, 1999 Federal OSHA Compliance Directive. Federal Bill was signed into law by President Clinton on November 6, 2000 resulting in an April 18, 2001 compliance date.

29 Principles Of The Law

30 Impact of safety needle devices on NSI % % Source: Impact of safety needle devices on occupationally acquired needlestick injuries: a four-year prospective study; Journal of Hospital Infection (2006) -, 1e6

31 Making Injections Safe for Community

32 How do we make injections safe for the community? Leaving used syringes in areas where children can play with them Giving or selling used syringes to vendors who will resell them Leaving used syringes in areas accessible to the public Using technology that ensures that syringes cannot be reused Source: Tool for the assessment of injection safety; department of vaccines and biologicals; WHO Geneva 2001

33 The Problem Injection device reuse of two types: Intentional Downstream Means of Syringe Transmission of Disease Reuse of equipment Unsafe collection Unsafe disposal

34 Market Drivers Proportions of injections given with reused equipment*: Source: World Health Organization (WHO) and Centers for Disease Control (CDC), Waste Images provided by WHO

35 Why Can t it be Zero? 21 million is about the number of people who live in the country of Ghana But it takes only one year for injection devise reuse to cause 21 million new cases of Hepatitis B. 1 2 million is about the number of people who live in the city of Paris But it takes only one year for injection device reuse to cause 2 million new case of Hepatitis C. 1 5% of the population of China is nearly 65 million people 5% of new HIV/AIDS infections are attributed to injection device reuse. The annual global burden for the treatment of these infections is USD$1 billion. 2 Source: 1 A M Hauri, G L Armstrong, Y J F Hutin, The global burden of disease attributable to contaminated injections given in health care settings, International Jounal of STD & Aids 2004; 15: UNAIDS/ WHO. AIDS Epidemic Update: DDecember Geneva, Joint United nations Programme on HIV/AIDS and World Health Organization, 2004.