Script for Podcast on Injection Safety MB: Hi, I m Mary Beth Wenger, of the New York One & Only Campaign. New York is a partner state in the national One & Only Campaign which is a public health campaign led by the Centers for Disease Control and Prevention or CDC and the Safe Injection Practices Coalition. This initiative is aimed at ensuring that safe injections are given in healthcare each and every time. Today we are speaking with Dr. Guthrie Birkhead, Deputy Commissioner, Office of Public Health, New York State Department of Health. One needle, one syringe, only one time is the slogan of the One & Only Campaign and to many that seems patently obvious. But the CDC has documented numerous cases of transmission of both viral and bacterial infection due to unsafe injection practices. Today we want to dispel some of the common and persistent misperceptions among healthcare providers regarding what makes an injection safe. Thanks for joining us, Dr. Birkhead. Dr. Birkhead: Glad to be here, Mary Beth. MB: While most providers know they should not reuse needles and syringes from patient to patient, there are certain areas that persistently seem to trip up some healthcare professionals. For example, there is this mistaken belief among some that simply changing the needle makes a syringe safe to reuse. Now, we know that is not the case. Dr. B: Mary Beth, there are a couple of problems with this scenario. First of all, the providers open themselves up for needle stick injuries if used needles are removed from syringes, so that is NOT recommended. Secondly, when you use a syringe to inject medication into a patient or into an IV line attached to the patient, microscopic pathogens can be contained in backflow into the syringe, even if there are no visible signs of blood, even if positive pressure is applied to
the syringe and even if there is an intervening length of tubing between the patient and the syringe. Simply changing the needle does not make a syringe safe for reuse. Used syringes and needles should be discarded. MB: What about batching or drawing up multiple doses of medication into syringes before dispensing? Dr. B: This practice is also not recommended, and in fact it is strongly discouraged by both the CDC and New York State Department of Health. For example, CDC recommends that influenza vaccine be drawn up into a syringe at the time of administration. However, we understand that might not be always feasible at a busy clinic. In that case, if a number of influenza vaccine doses are pre-drawn the number should not exceed ten (10) doses. Also, the person drawing up the flu shot should be the person administering the vaccine. There are issues about how long drawn up syringes may sit before being administered, so the manufacturers instructions need to be followed for storage of syringes. And I want to emphasize that these recommendations are for clinical practice. Recommendations for pharmacies and hospital settings are a bit different as these are not settings where patients are being treated. In a hospital pharmacy situation, drawing up multiple doses, for example, influenza vaccine, may be done safely, strictly following US Pharmacopeia Chapter 797 rules. MB: One other area where we see wide misunderstanding is titration, where medication is drawn up into a syringe and then administered to one patient in incremental doses. In fact, we got a call from an orthopedic outpatient center with a question about best practice: should they draw up the entire single-dose vial into a syringe, disconnecting the syringe from the tubing after each dose, or draw up each dose with a new needle and syringe to re-enter the tubing? Dr. B: This might also come up in instances where for example, an anesthetic like lidocaine is needed for numbing an area of skin. We have to stress that the safest
practice is to use needles and syringes only once. That prevents harm to the healthcare worker who won t get a needle stick injury and it reduces risk of contamination to the medication in the vial itself. If a medication comes in a single dose vial, it is acceptable to draw up the entire contents of the vial into a syringe to be used on one patient in incremental doses. This must occur in a single procedure with strict adherence to aseptic technique. That syringe must be closely attended the provider can t walk away and come back some time later and the syringe must be discarded at the end of the procedure. There have been instances where a syringe is inadvertently not discarded and ends up being used on another patient. MB: Would it be good practice to insert IV tubing into an IV bag and run then IV fluid through the tubing the night before an endoscopy procedure? Dr. B: No, in general, bags and bottles of IV fluids should be accessed as close as possible to the time they will be used. With limited data on actual contamination in real practice and linking contamination with patient infection, recommending a definitive time frame is not feasible at this time. MB: When using multi-dose vials to draw up flu vaccine, is it necessary to change the needle between drawing vaccine and injecting? Dr. B: In general, it is not necessary to change needles after drawing up a medication and before administration. However, it is important to always follow medication manufacturer instructions for handling and administration of medications. If there is a question that the needle should be changed for a particular medication, it is advisable to check with the pharmacist or the medication manufacturer.
MB: Do multi-dose vials contain preservatives, and wouldn t this help prevent transmission of infections? Dr. B: In general, multi-dose vials tend to contain preservatives where single-dose vials do not. However, you should consult the product manufacturer s literature to determine the contents of any specific medication vial. And, even if a multidose vial contains preservatives, that preservative is intended only to prevent the growth of bacteria if the vial is used over a period of time; the preservative has no effect on viruses nor does it protect against immediate bacterial contamination when a healthcare provider fails to follow safe injection practices. MB: Dr. Birkhead, could you walk us through the ways a glucometer might transmit infectious disease? Dr. B: Sure, and indeed we have seen transmission by glucometer of hepatitis B virus, a bloodborne infection. This is a hardy virus that can live on surfaces for some time. A glucometer that is not properly cleaned and disinfected between each and every patient, could be contaminated with small amounts of blood not visible to the naked eye. One study looked at glucometers in a medication room that were tested for microscopic amounts of contaminants. Many of them turned out to be contaminated. There is a possibility that if the glucometer is not thoroughly cleaned and disinfected according to manufacturer s instructions, trace amounts of blood could get on a provider s gloves or on a patient s skin where the needle stick occurs, and cause transmission. The bottom line is that glucometers should not be shared between patients. They should be used for only one patient and that patient s name put on it. If they must be shared and the package insert says that is permitted, the manufacturer s recommendations for cleaning and disinfection must always be followed. If the manufacturer does not provide these instructions, the device must not be shared.
MB: There is still a misperception that performing fingersticks with a shared lancet pen is acceptable, but that s not the case. A provider might say, Well, I change the lancets each time. But that doesn t protect against transmission of disease, is that right? Dr. B: Yes, the New York State Department of Health did an investigation between 2007 and 2008 looking into shared lancet pens and hepatitis B virus transmission was identified. This has been an issue in some acute and long-term care facilities. What may be adding to the confusion is the fact that in the past, FDA cleared some fingerstick devices for use on multiple patients. That practice has now been determined to be unsafe. The FDA, CDC and New York State Department of Health now all recommend that all fingerstick devices (including lancet pens and lancets) not be shared. MB: We have been talking with Dr. Guthrie Birkhead, Deputy Commissioner of the Office of Public Health, New York State Department of Health, about injection safety and the One & Only Campaign. For more information, please visit online at www.oneandonlycampaign.org or the New York State Department of Health injection safety webpage at www.health.ny.gov Thank you for listening!