Unsafe Injection Practices and Other Sources of Infection in the OR

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Unsafe Injection Practices and Other Sources of
Infection in the OR

• Kelli Ford, RN, BSN, CCRN, SRNA

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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

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Why This Topic?
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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)

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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

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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

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1995 Study

• Assessed reuse of syringes on more than one
  patient by anesthesiologists
• 20 frequently or always reused syringes for more
  than one patient

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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

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2002 Study (cont.)

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

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2010 Inspection by CMS

• Inspection of 68 ambulatory surgical centers
• Most outbreaks occur in outpatient facilities
• None used needles/syringes on multiple pts
• 28 used single-dose vials for multiple pts
• 2.5 used prefilled syringes on multiple pts
• 1.6 used infusion sets on multiple pts

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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

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Risks (cont.)

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

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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

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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

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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

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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

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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

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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

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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

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California, 2003 Pain Clinic

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

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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

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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

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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

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National ResponseSIPC

• 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

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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

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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

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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

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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

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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

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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

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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

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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

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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.

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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.

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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)

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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 patients IV hub is
  considered a single unit

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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

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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.

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Strengths

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

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Weaknesses

• Small response
• Small pool of clinical sites may overestimate
  actual reuse by CRNAs
• School program directors may have influenced
  student responses.

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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

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Problem

• Hospital-acquired infections affect 2 million
  patients annually
• Contribute to 100,000 deaths annually
• US costs 35-45 billion annually
• HAIs 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

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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

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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)

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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

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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

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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

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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 dont change them

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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

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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

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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

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PPE misc

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

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Equipment Contamination

• Stethoscopes used without cleaning
• Glucometers not cleaned between patient use have
  been implicated in multiple outbreaks

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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

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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

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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

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AGH, 2003

• Goal eliminate HAI-catheter related bloodstream
  infections
• Initial rate 5.1/1000 patients 40 ICU
  infections annually gt 1.5 million annually
• Response CCU went 15 months and trauma went 16
  months without infection
• Hospital saved 2.2 million in 2 years

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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

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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

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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

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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

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References

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Questions
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Thank You!