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SAFE INJECTION PRACTICES

Remember to Ask Your Doctor About Safe Injection Practices

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INTRODUCTION:

In recent media coverage and legal proceedings, inappropriate uses of single-dose vial (SDV) and multi-dose vial (MDV) injectable medications have been widely reported. This well-documented aberrant behavior has been present in both inpatient and outpatient settings, with pain management and orthopaedic clinics bearing a high percentage of reported cases. Susceptible pain management procedures may include injecting medications in sterile spaces including the spine, peripheral joints, tendons and tunnels (1).

A single-dose medication vial that is typically preservative-free should not be used for more than one injection. The “One & Only Campaign” by the CDC and Safe Injection Practices Coalition states, “one needle, one syringe, only one time” (2). The mishandling of injectable medical products is a multifaceted problem. Inappropriate use and handling of needles, syringes and medications have been reported in CDC and Health Department led outbreak investigations since 1999. Cases have included the same syringe being used for more than one patient, a used syringe penetrating a medication vial, and the contaminated vial subsequently used for another patient (3). Moreover, vials are being left in potentially contaminated areas, there is an improper or lack of standard operating procedures, and multiple health personnel have been reported utilizing MDVs.

Based on a 2014 report, there have been at least 49 outbreaks reported by the CDC due to “improper use of injectable medicines” since 2001. The outbreaks, which involve transmission of Hepatitis (B,C) and bacterial infections (e.g. Staphylococcus), have caused more than 150,000 patients to be tested due to increased risks for secondary infections (1). Patients acquiring such infections have been hospitalized anywhere from 3 to 41 days (4). The potential associated cost of secondary infections may include, but is not limited to, the cost related to emergency department admission, in-patient hospital stay, possible surgery, post-hospitalization rehabilitation and residual disability.

According to a 2012 CDC statement, “Medications come in very large vials, but they’re often only approved for use in one person. Healthcare providers see that as waste. There’s a desire to use what you’ve paid for. And they don’t understand that they’re putting their patients at risk” (2). This need for healthcare providers to use what has been paid for, or be properly reimbursed for what is used, is jeopardizing the health and safety of patients.

A 2014 survey of 5,446 healthcare practitioners revealed that 6% (326) admitted to “sometimes or always” using SDVs for multiple patients. In the same survey, 15% (816) reported using the same syringe to re-enter a MDV “numerous times” for the same patient (3).

Unfortunately, these incorrect injection habits appear to be forming early on in the careers of healthcare practitioners. In 2013, a survey was done on 325 student registered nurse anesthetists with at least 3 months of clinical experience. According to the survey results, 4% (14) administered medications from the same syringe to multiple patients, 18% (59) reused needles on the same patient, and 82% (266) reported re-filling used syringes. Moreover, 22% (71) re-used a syringe or needle to withdraw medication from a MDV, and 49% (160) re-entered a SDV to prepare doses for multiple patients (5).

SOLUTION

In an effort to mitigate this issue, the CDC and Centers for Medicare and Medicaid Services (CMS) have outlined and recommended “safe injection practices to prevent transmission of infections to patients” (6,7,8). However, a standard protocol in and of itself is not enough to tackle this widespread public health problem. At AHS we consult on safe and effective delivery of healthcare.

The use of pre-packaged, single-use, disposable FDA compliant injection kits can be a potential vehicle to complement CDC and CMS injection protocols and actively reduce the risk of secondary infections. Spinal epidural and peripheral nerve block kits are already being manufactured and available for use (9). Pre-packaged FDA compliant injection kits reduce the potential for human error and environmental contamination. Single-use disposable kits also eliminate the possibility of vial, syringe and needle re-use for more than one patient. These pre-packaged single-use kits are capable of standardizing injection procedures and re-enforcing CDC and CMS injection protocols; therefore, improving patient health and safety by reducing the risk for secondary infections. Furthermore, pre-packaged kits can save in setup time during clinic hours and standardization of the process can save in training time. This solution must be accompanied by continued efforts to educate the medical community in safe injection practices. In particular, it is crucial that “a single-dose be utilized in a single patient” (11). These products facilitate the process of a change in human behavior in order to improve patient safety by reducing secondary infection.

“To resolve the issue of single-dose vials in reference to infection outbreaks, the administration and Congress should impose regulations on manufacturers to produce single-dose vials which are cost-effective rather than artificially inflate prices where a 50 mL vial of contrast medium is less expensive than a 10 mL vial.” A 2012 Pain Physician Review concluded, “To continue to utilize CDC guidelines that a single dose be utilized in a single patient, it is crucial that the Administration and Congress work with manufacturers and produce cost-effective single-dose vials, which do not increase health care costs and curb access to health care (12).”

The "One & Only Campaign" is a public health campaign, led by the Centers for Disease Control and Prevention (CDC) and the Safe Injection Practices Coalition (SIPC), to raise awareness among patients and healthcare providers about safe injection practices. The campaign aims to eradicate outbreaks resulting from unsafe injection practices:

Avicenna Health Solutions (AHS) is a medical consulting organization. Dr. Emad, the Founder and Medical Director of AHS is a board certified specialist in Physical Medicine and Rehabilitation (PMR), as well as, Pain Medicine (PM) with a wealth of experience in administering injections. He has been a PMR and interventional PM specialist for 16 years and has performed roughly 30,000 injections. Among the teaching, consulting and telemedicine services that Dr. Emad provides, is reinforcement of safe injection practices and protocols. Dr. Emad also lectures on the topic of Safe Injection Practices, with the aim of educating the medical community on the proper use of syringes, needles, vials and aseptic techniques as it relates to orthopedic and pain management office injection procedures to reduce the risk of secondary infections. The CDC guidelines are highlighted for the medical providers and their support staff.

We at Avicenna Health Solutions educate the medical providers, as well as, the "consumers". We believe that consumer education is very important and effective in dealing with secondary infections related to orthopedic and pain management injection procedures. Patients are encouraged to demand a higher standard of care from their doctors as our patient slogan states: "Remember to ask your doctor about safe injection practices".

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Joint Commission Issues Alert on Unsafe Injection Practices. Medscape. June 17, 2014.
Preventing Infection From the Misuse of Vials. Sentinel Event Alert. A complimentary publication of The Joint Commission. Issue 52, June 16, 2014.
Safety by Design: Capturing Ideas and Innovations to Make Injections Safer. Injection Safety. Centers for Disease Control and Prevention. May 2010.
Staph Infections Tied to Misuse of Drug Vials. NPR. July 12, 2012.
Ford K. Survey of Syringe and Needle Safety Among Student Registered Nurse Anesthetists: Are We Making Any Progress? AANA J. 2013 Feb;81(1):37-42.
Safe Injection Practices to Prevent Transmission of Infections to Patients. Injection Safety. Centers for Disease Control and Prevention. April 1, 2011.
Safe Injection Practices in Ambulatory Surgical Centers (ASCs). Department of Health & Human Services. Centers for Medicare & Medicaid Services. May 16, 2008.
Safe Use of Single Dose/Single Use Medications to Prevent Healthcare-associated Infections. Department of Health & Human Services. Centers for Medicare & Medicaid Services. June 15, 2012.
Combined Spinal Epidural Trays (Kits). B Braun. 2015.
Enovachem http://enovachem.us.com/
Manchikanti L, Falco FJ, Benyamin RM, Caraway DL, Helm Li S, Wargo BW, Hansen H, Parr AT, Singh V, Hirsch JA. Assessment of Injection Control Practices for Interventional Techniques: A Best Evidence Synthesis of Safe Injection Practices and Use of Single-Dose Medication Vials. Pain Physician. 2012 Sep-Oct;15(5):E573-614.
http://www.painphysicianjournal.com/2012/september/2012;15;E573-E614.pdf