Reducing HAI Risk through Safe Injection Practices. Presenter: Sue Barnes, RN, CIC, FAPIC Clinical Consultant

Transcription

1 Reducing HAI Risk through Safe Injection Practices Presenter: Sue Barnes, RN, CIC, FAPIC Clinical Consultant

2 Disclosures Presenter provides consulting services to J&J Ethicon

3 Learning Objectives At the end of the presentation, participants will be able to: 1. List 3 examples of unsafe injection practices which can increase infection risk. 2. Name one pathogen which has been implicated in an outbreak due to unsafe injection practices. 3. Describe how microbial replication occurs in an IV solution once contamination has occurred.

4 Primary Source for Webinar Content Except where otherwise referenced, the primary source for this webinar: PositionPaper.pdf

5 Unsafe Injection Practices: CRBSI Unsafe injection practices increase the risk of transmission of microbial pathogens which can result in CRBSI. The primary sources for most pathogens causing endemic catheterrelated bloodstream infections are the catheter insertion site or the catheter hub. Contamination may result from the patients' own flora or from healthcare workers' hands during insertion or manipulation, or both. o Schmid M. Preventing Intravenous Catheter Associated Infections: An Update. Infection Control Today o Mustafa M. Role of Arterial catheters as a source of Hospital related Bacteremia IOSR Journal Of Pharmacy Volume 4, Issue 11 (November 2014), PP

6 Unsafe Injection Practices: Bloodborne Pathogens Unsafe injection practices increase the risk of transmission of bloodborne viruses including Hepatitis B (HBV) and Hepatitis C (HCV) between patients. Similarly the risk of transmission of HBV and HCV from patient to healthcare worker is also increased. HBV is the cause of up to 50% of hepatocellular carcinomas (HCC). Razavi H et al. Chronic Hepatitis C Virus (HCV) Disease Burden and Cost in the United States. Hepatology Jun; 57(6):

7 The Cost: CRBSI Bloodstream infections resulting from intravascular catheters have become a costly complication of health care, with estimates in the United States ranging from 670 million to 2.68 billion dollars annually This cost includes required therapeutic interventions, i.e. antibiotics, intravenous catheters, bladder catheters, ICU stay And diagnostic interventions required including: scans, blood tests, Xrays CRBSI can range in severity up to and including sepsis and death To reduce costs the Centers for Medicare and Medicare Services (CMS) is no longer paying for the care of hospital associated vascular catheter infections,

8 The Cost: HBV Infection Average annual costs (2004): Chronic hepatitis B infection per case US 761 dollars Compensated cirrhosis, US 227 dollars Decompensated cirrhosis, US 11,459 dollars Liver transplant, US 86,552 dollars Transplant care >12 months following transplant, US 12,560 dollars Hepatocellular carcinoma, US 7,533 dollars. Lee TA et al Cost of chronic hepatitis B infection in the United States. J Clin Gastroenterol Nov Dec;38(10 Suppl 3):S144 7.

9 The Cost: HCV Infection Lifetime cost/case Hepatitis C infection = $64,490 The newer antiviral drugs cure up to 96 percent of people that take them. The cost is approximately $1,000/per pill taken once per day, for 12 to 24 weeks. Razavi H et al. Chronic Hepatitis C Virus (HCV) Disease Burden and Cost in the United States. Hepatology Jun; 57(6):

10 The Cost HCV Outbreak Investigations Outbreak of Hepatitis C at Outpatient Surgical Centers hepc investigation report.pdf

11 Replication of bacteria in IV solution or medication vials Even one bacterium can quickly replicate itself into millions. Under optimal conditions bacteria can double their population every 20 minutes

12 Sources of Infusion Related Infections Contamination from IV fluids and catheters can directly reach the systemic circulation causing CRBSI and/or can travel to organs inducing organ failure. There are two routes for infusion related infections: extra luminal (bacterial invasion from the skin at catheter entry site usually during insertion) and intra luminal (improper handling of infusion system usually occurs > 1 week after placement).

13 Sources of Infusion Related Infections

14 Sources of Infusion Related Infections

15 Unsafe Injection Practices - syringe reuse Although home care agencies routinely train staff on hazards associated with BBP exposures and exposure reporting protocols, difficulties exist in minimizing BBP hazards. Homes are more variable and less controlled than facility based settings Engineering controls include sharps with injury prevention features (SIPFs), however, the previous study found that SIPFs were not frequently used in home care. Markkanen P et al. Understanding sharps injuries in home healthcare: The Safe Home Care qualitative methods study to identify pathways for injury prevention. Published online 2015 Apr 11.

16 Unsafe Injection Practices - contamination of medication vials or intravenous (IV) bags

17 Unsafe Injection Practices - failure to follow basic injection safety practices 1. Preventing Transmission of Infectious Agents in Healthcare Settings (CDC) 2. Safe Injection Practices to Prevent Transmission of Infections to Patients (CDC) 3. Safe Injection, Infusion and Medication Vial Practices in Healthcare (APIC) 4. Multi dose Vials (TJC)

18 Unsafe Injection Practices - inappropriate use and maintenance of POC Testing Devices In the last 10 years alone, there have been at least 15 outbreaks of HBV infection associated with failure to follow basic principles of infection prevention when assisting with blood glucose monitoring. Centers for Disease Control and Prevention. Infection Prevention during Blood Glucose Monitoring and Insulin Administration. Available from glucosemonitoring.html.

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20 Risk by Department Patients receiving anesthesia may develop bacteremia/crbsi, meningitis Hemodialysis patients may be exposed to Hepatitis B, Hepatitis C, and HIV, septicemia and candidemia. Interventional radiology patients may be at risk of meningitis and death. Ophthalmology patients can develop corneal ulcers or endophthalmitis. Orthopedic surgery patients are at risk of post joint injection related infections. Respiratory therapy patients may develop pneumonia and gram negative sepsis. accreditation and patient safety/a measure of safetypreventing infection during medication administration.html

21 Injection Related Outbreaks

22 Injection Related Outbreaks patient notifications.html

23 Case study 1 - HCV infection in Hem-Oncology Clinic In an outbreak in Nebraska 100 hematology/oncology clinic patients contracted HCV This was due to a HCP who routinely used the same syringe to draw blood from patients' central vascular catheters and draw catheter flushing solution from 500 cc saline bags used for multiple patients. As a result, patients HCV contaminated blood on the needle of the syringe was inoculated into the IV bag, which was then used as flushing solution for other patients. Macedo de Oliveira A, White KL, Leschinsky DP, Beecham BD, Vogt TM, Moolenaar RL, et al. An outbreak of hepatitis C virus infections among outpatients at a hematology/oncology clinic. Ann Intern Med 2005;142:

24 Case study 2 - HCV outbreak in endoscopy center in Nevada in 2008 One of the largest HCV outbreaks occurred at an endoscopy center in Nevada in This was found due to reuse of syringes and shared single use medication vials of Propofol between patients. Over 50,000 persons were identified as being potentially exposed and therefore at risk for acquiring hepatitis C. Eight acute hepatitis C cases were determined to be linked directly to care at the clinic. An additional 106 cases were classified as possibly linked. Outbreak of Hepatitis C at Outpatient Surgical Centers. Public Health Investigation Report. December Southern Nevada Health District Outbreak Investigation Team, Las Vegas, Nevada. Available at: hepc investigation report.pdf

25 Case study 3 - Bloodstream infections at a chemotherapy center An investigation of bloodstream infections with Klebsiella oxytoca and Enterobacter cloacae at a chemotherapy center identified 27 patients having one or both of these organisms. All patients had their central venous catheter flushed with either dextrose or isotonic sodium chloride solution at the clinic, which was found to be contaminated and used for multiple patients. Watson JT, Jones RC, Siston AM, Fernandez JR, Martin K, Beck E, et al. Outbreak of catheter associated Klebsiella oxytoca and Enterobacter cloacae bloodstream infections in an oncology chemotherapy center. Arch Intern Med. 2005;165:

26 Case study 4 - Infection transmission and drug diversion Diversion of opioids by a hospital was responsible for a cluster outbreak of Serratia marcescens. Five patients admitted to five different hospital wards within University Hospital in Madison, Wis. developed identical bacteria strains. Four of the five patients recovered, while one died from Serratia sepsis infection. Leah Schuppener, Aurora Pop Vicas, Erin Brooks, Megan Duster, Christopher Cmich, Alana Sterkel, Aaron Webb, Nasia Safdar. Serratia Marcescens Bacteremia: Nosocomial Cluster Following Narcotic Diversion. Web (July 6, 2017). Source: Society for Healthcare Epidemiology of America (SHEA)

27 Promoting Safe Injection Practices Sharps Safety Device Evaluation and Selection Compounding per USP 797 Aseptic Technique Transporting Medications Safely Safe Handling of IV Solutions Safe Flushing Technique Safe Handling of Injectables in the OR Safe Handling of Propofol Safe Neuraxial Techniques Syringe and Needle Safety Safe use of Stopcocks Safe Handling of Medication Vials Safety in POC Glucose Testing

28 Safe Sharps Devices Evaluation and Selection

29 Compounding per USP 797 The United States Pharmacopeia (USP) General Chapter <797> Pharmaceutical Compounding Sterile Preparations provides practice and quality standards for compounded sterile preparations (CSPs). This includes but is not limited to preparing, labeling and storing, and timeframes for discarding CSPs. CSPs include manufactured sterile products and compounded biologics, diagnostics, drugs, nutrients, and radiopharmaceuticals that must be sterile. asked questions/pharmaceutical compounding sterilepreparations

30 Aseptic Technique Aseptic technique relative to injectable medication administration must includes: 1. Perform hand hygiene prior to med administration 2. Disinfect vial access diaphragm or ampule neck 3. Disinfect all IV access ports, needleless connectors prior to administration 4. Use only one needle and one syringe for each patient each time 5. Use a clean needle and syringe each time a vial is accessed 6. Do not use bags or bottles of intravenous fluids as a common source of supply for more than one patient.

31 Transporting Medications Safely Transporting medications in pockets or clothing increases the risk for contamination and errors. One med error resulted in a life threatening event involving Anesthesia provider administering a paralytic agent outside of the OR, from pocket. TJC allows carrying of medications in accordance with institutional policy which includes written medication storage and transport information. o o Hicks RW, Becker SC, Cousins DD. MEDMARX Data Report: A chartbook of medication error findings from the perioperative settings from Rockville, MD: US Center for the Advancement of Patient Safety; 2006.

32 Safe Handling of IV Solutions Key concepts: When preparing infusions outside of an ISO Class 5 environment hand hygiene and sterile gloves with a mask and hair cover are required during preparation. Dispensing spikes for a bag or bottle of sterile fluid cannot be left in place to permit withdrawal for multiple patients. All infusions, fluids, administration sets, and containers are singlepatient use. This includes intravenous tubing, pressure transducers and tubing, and other items that come in contact with the vascular system or other sterile body fluids. Wong MR, Del Rosso P, Heine L, Volpe V, Lee L, Kornbum J, et al. An outbreak of Klebsiella pneumoniae and Enterobacter aerogenes bacteremia after interventional pain management procedures, New York City, Anesth Pain Med 2010;35:496 9.

33 Safe Flushing Technique Key messages A single container of IV solution (e.g., bag, bottle) must never be used to obtain flush solutions for more than one patient. If a multi dose vial must be used, it must be used for only one patient and then discarded. A new, unused sterile needle and new, unused sterile syringe must be used for each entry into the vial. Commercially available or pharmacy prepared prefilled syringes of appropriate IV solution should be used to flush and lock vascular access devices. HH must be performed prior to preparation and administration of IV flush.

34 Safe Handling of Injectables in the OR In the OR place only pre filled flush syringes (e.g., saline, heparin) that are terminally sterilized by the manufacturer after packaging should be delivered onto a sterile field. An Anesthesia cart is not be an appropriate place for drawing from a MDV. Pharmacy bulk packaging (PBP) contrast material used in cath labs and ASCs cannot be used as multidose containers. Injections that require compounding such as those designed to reduce post op bleeding and pain, and/or administered into intra articular space during orthopedic surgical procedures, should be prepared in a pharmacy ISO Class 5 environment instead of in the operating room.

35 Safe Handling of Propofol Precautions specific to Propofol must be taken, due to reports of post op sepsis resulting from extrinsic contamination: 1. Required: Propofol syringes or infusions must be single use, not used for multiple patients 2. Required: Strict aseptic technique must be used during preparation and use of Propofol, including disinfect the rubber stoppers of vials. 3. Not permitted: Batch preparation of Propofol in syringes for use throughout the day 4. Not permitted: preparing Propofol syringes up to 24 hours in advance 5. Not permitted: Using 50 ml and 100 ml single use single patient vials of Propofol as multidose and multi patient vials. 6. Not permitted: Transfer of prepared Propofol syringes between ORs or facilities Recommendations for Infection Control for the Practice of Anesthesiology; review 0417 pp pdf

36 Neuraxial Techniques (e.g. spinal anesthesia) Neuraxial techniques include epidural and spinal administration of anesthetics, analgesics, or steroids; lumbar puncture/spinal tap; epidural blood patch; epidural lysis of adhesions; intrathecal chemotherapy; epidural or spinal injection of contrast agents for imaging; lumbar/ spinal drainage catheters; or spinal cord stimulation trials. Infectious complications include, but are not limited to, epidural, spinal, or subdural abscess; paravertebral, paraspinous, or psoas abscess; meningitis; encephalitis; sepsis; bacteremia; viremia; fungemia; osteomyelitis; or discitis. Aseptic technique including: CHG/Alcohol skin prep with sufficient dry time, sterile gloves, sterile drape, mask, sterile post procedure dressing. Bacterial filters may be considered during extended continuous epidural infusion. Practice Advisory. Anesthesiology 2017; 126:

37 Syringe and Needle Safety Do not prepare medication in one syringe to transfer to another syringe (e.g., HCP draws up solution into a syringe then transfers the solution to a syringe that has the plunger removed or injects it into the bevel of the syringe). Never withdraw medication from a manufacturer prefilled syringe barrel (carpuject style syringe barrel). Never use a syringe for more than one patient even if the needle has been changed Draw up medication into a syringe as close to administration time as feasible. Inject within 1 hour (or as soon as feasible) after drawing up the medication Institute for Safe Medication Practices Safety Alert. ISMP survey reveals user issues with Carpuject prefilled syringes, August 9, 2012.

38 Safe Use of Stopcocks Stopcocks present a potential port of entry for microorganisms into vascular access catheters and IV fluids. According to the CDC, stopcock contamination is common, occurring in 40 50% of cases studied. Studies have reported an association between bacterial contamination of conventional open lumen three way stopcock sets and increased patient mortality, with bacterial contamination from anesthesia provider hands, patients, and the surrounding patient environment shown to contribute to stopcock contamination events. o O Grady NP. Et al. Guidelines for the Prevention of Intravascular Catheter Related Infections. CDC, 2002 Report. o Loftus RW, Koff MD, Burchman CC, Schwartzman JD, Thorum V, Read ME, Wood TA, Beach ML. Transmission of pathogenic bacterial organisms in the anesthesia work area. Anesthesiology 2008;109:

39 Stopcocks Conventional Open- Lumen Stopcock Devices (COLDs) vs. Closed The swabbable stopcock with hub disinfection before injection was associated with a significant reduction in the risk of inadvertent bacterial injection as compared to the conventional open lumen stopcock. Loftus RW, Patel HM, Huysman BC, et al. Prevention of intravenous bacterial injection from health care provider hands: the importance of catheter design and handling. Anesth Analg. 2012;115(5):

40 Safe Handling of Medication Vials Disinfect the rubber septum on all vials prior to each entry, even after initially removing the cap of a new, unused vial. Read the vial label carefully. Vial size does not indicate whether or not a vial is single use or multidose. Store and access multidose vials away from the immediate patient care environment and always use a sterile syringe and needle/cannula each time the vial is accessed. Never use a decapping device to remove the top from a vial (e.g., to pour medications). Label a multidose vial with a beyond use date when first accessing it. The beyond use date after initially entering a multidose vial is 28 days, unless otherwise specified by the manufacturer.

41 Safety in POC Glucose Testing Fingerstick devices should never be used for more than one person Blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer s instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. Insulin pens and other medication cartridges and syringes are for single patient use only and should never be used for more than one person. glucose monitoring.html

42 Oversight and Enforcement Policies should 1) support and ensure that injection safety and infection prevention and control procedures are followed, and 2) mandate corrective action when lapses are identified. Facility must hold HCP accountable for adhering to safe injection, infusion, medication vial, and point of care testing practices. Facility must conduct surveillance to identify infections that may be associated with injection, infusion, medication vial, and point of care testing practices in all healthcare settings. Facility must report infection clusters to the appropriate public health authorities as soon as possible to assist in identification of healthcare associated outbreaks and direct interventions to control and prevent further spread of disease.

43 Innovations in Products Disinfecting port protectors Closed stopcocks CHG plus alcohol for swabbing injection ports

44 Patient Story Evelyn McKnight

45 One and Only Campaign CDC is collaborating with the Safe Injection Practices Coalition (SIPC) to develop and implement an educational campaign to promote safe injection practices by raising awareness among patients and healthcare providers about safe injection practices. For more information visit the One & Only Campaign

46 Additional Resources: Audio and Video Presentations video

47 Additional Resources: Survey Prep ASC Quality Collaboration

48 Additional Resources: Tools Injection Safety ASSESSMENT TOOLS web.pdf t/qmda%20quality%20checklist%201.pdf?la=en %20Practices%20Survey%20(WDHS).doc TEMPLATE POLICIES licy%20and%20procedure%20template.doc TRAINING MATERIALS IMPLEMENTATION AIDS WORKPLACE REMINDERS

49 Additional Resources: ASHP (American Society for Healthcare Pharmacists) Guidelines

50 Additional Resources: ISMP (Institute for Safe Medication Practices)

51 And More atements/2016apicsippositionpaper.pdf topics az/safeinjection practices/safe injection practices/ dit_tool.doc

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