A survey of 5,446 healthcare practitioners published last week reveals an alarming lapse in hospital infection control practices associated with the use of syringes, needles, drug vials as well as solutions used to flush intravenous tubings. While the majority of nurses and other healthcare practitioners appear to follow infection control practices consistent with current recommendations made by the government’s Centers for Disease Control and Prevention (CDC) , some survey respondents clearly place patients at risk for transmission of blood-borne diseases, according to a study sponsored by Premier Healthcare Alliance and published in the American Journal of Infection Control.
At issue is reuse of injection equipment on more than one patient. A patient’s blood can sometimes enter drug solutions and syringes during normal treatment processes. For example, when giving an intravenous injection, in order to assure a clear path exists for fluid to enter the vein, it’s standard practice to pull back on the syringe plunger to make sure a small amount of blood is visualized. If the patient happens to be one with a viral disease such as hepatitis B or hepatitis C, the syringe becomes contaminated with the virus. If subsequently used to prepare an injection for another patient, even if a fresh needle is used, the next patient is now placed at risk for also developing the disease.
The survey showed some disturbing results:
---Nearly 1% of respondents admitted to sometimes or always reusing a syringe for more than one patient after only changing the needle.
---6% admitted to sometimes or always using single-use vials for multiple patients. These vials have no preservatives so they can support growth of contaminants in between uses.
---15% reported using the same syringe to re-enter a multiple-dose vial numerous times; of this group, about 7% reported saving these multiple-dose vials for use with other patients. If a contaminated syringe is used, the solution too becomes contaminated.
---9% sometimes or always use a common bag or bottle of IV solution as a source of diluent for drugs for multiple patients or to clear IV tubing. These solutions also have no preservatives and can also become contaminated when used for multiple patients.
Each of these unsafe practices has been associated with disease transmission and is explicitly prohibited in the government recommendations. Clearly, there is a general lack of awareness regarding safe infection control practices as well as numerous misconceptions. For example, one comment frequently made was that the reuse of a single-dose vial depended on the size of the vial, reflecting a misconception that a large volume of medication alone makes it suitable for multiple patients, which is absolutely false. Another misconception is that changing the needle on a used syringe is sufficient protection against disease transmission if there is no visible blood in the syringe. Blood, not always necessarily visible to the eye, can enter the syringe after injection, particularly while the needle is still attached to the syringe.
It’s been more than a decade since we first wrote about the risks associated with these practices. In fact, a hepatitis B outbreak related to the reuse of syringes to access multiple-dose heparin vials was the topic of a feature article during the inaugural year of the ISMP Medication Safety Alert! in 1996. Since then, the topic has been covered by us in dozens of feature articles and other commentaries in our publications. According to the CDC, in the past 10 years there have been more than 50 outbreaks of blood-borne transmission of hepatitis B, hepatitis C, and HIV that required notification of more than 125,000 potentially exposed patients and identification of more than 600 who became infected. Examples are the Texas hospital where 2,114 insulin-dependent diabetic patients were placed at risk when staff used insulin pen devices for multiple diabetic patients after only changing the pen’s needle between patients . Some later tested positive for hepatitis C. Also, large scale outbreaks of infections have occurred in Nevada and Nebraska clinics where syringes were shared. Many outbreaks and sporadic transmissions of hepatitis B and C, for example, go unrecognized because patients who are infected most often do not have symptoms for years.
It goes without saying that the unsafe practices that we are seeing are totally unacceptable. CDC has noted that practices within an organization are highly influenced by its culture or are an expression of its culture. So change needs to start at the top by making organizational leadership, including hospital boards, accountable for safe practices. As a patient, you deserve an explanation from leaders about how they are going about preventing the spread of infections at their facility. You need to know that your health professionals will always use a new needle, syringe and drug vial. Academic settings, licensing bodies, and healthcare providers must also enhance their ongoing surveillance of proper technique and devote resources to ensure staff knowledge and skills associated with even the most basic concepts of infection control and injection safety, such as those in the current CDC guidelines that recommend that syringes and needles be used only once. More information for patients about this topic is available from the CDC here.
For information on ISMP's consumer web site go www.consumermedsafety.org
To check out more Check Up items go to www.philly.com/checkup.