Safe Injection Practices Speaker Sue Dill Calloway RN, Esq. CPHRM AD, BA, BSN, MSN, JD President Patient Safety and Healthcare Consulting 5447 Fawnbrook Lane Dublin, Ohio 43017 sdill1@columbus.rr.com 614 791-1468 2 3 4 5 6 7 Identify Risks for Transmitting Infections Hospital and ASC in Colorado where surgery tech with Hepatitis C infection steals Fentanyl and replaces it with used syringes of saline infecting 17 patients as of December 11, 2009 and 5,970 patients tested (total 36 for 3 facilities) Kristen Diane Parker in 2010 gets 30 years for drug theft and needle swap scheme Worked at Denver’s Rose Medical Center and Colorado Springs’ Audubon Surgery Center 1 www.krdo.com/Global/link.asp?L=399119 8 9 10 Infection Control The CDC says there are 1.7 million healthcare infection (HAI) in America every year There are 99,000 deaths in American hospitals every year Leadership need to make sure there is adequate staffing and resources to prevent and manage infections Healthcare-Associated Infections (HAIs) are one of the top ten leading causes of death in the US 1 1 www.cdc.gov/ncidod/dhqp/hai.html 11 Infection Control There have been more than 35 outbreaks of viral hepatitis in the past 10 years because of unsafe injection practices This has resulted in the exposure of over 100,000 individuals to HBV and 500 patients to HCV This includes inappropriate care of maintenance of finger stick devices and glucometers Includes syringe reuse, contaminations of vials or IV bags and failure of safe injection practices Source: APIC position paper: Safe injection, infusion, and medication vial practices in health care 12 Infection Control Back to Basics It is important to get back to basics in infection control 1 Education and training is imperative to learn each person’s role in preventing infections What practices and constant reminders do you use to remind staff during patient care encounters? New needle and syringe for every injection Single dose saline syringes 1 http://www.jcrinc.com/infection-prevention-back-to-basics/ 13 What is Injection Safety or Safe Injection Practices? The CDC says it is a set of measures taken to perform injections in an optimally safe manner for patients, healthcare personnel, and others A safe injection does not harm the recipient, does not expose the provider to any avoidable risks and does not result in waste that is dangerous for the community Injection safety includes practices intended to prevent transmission of infectious diseases between one patient and another, or between a patient and healthcare provider, and also to prevent harms such as needle stick injuries 14 CDC Injection Safety Website The CDC has an injection safety website Contains information for providers Injection Safety FAQs Safe Injection Practices to Prevent Transmissions of Infections to Patients Section from Guidelines for the Isolation Precautions to Prevent Transmission and more www.cdc.gov/ncidod/dhqp/injectionsafety.html 15 16 CDC Guidelines CDC has a publication called 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings Has a section on Safe Injection Practices (III.A.1.b. and starts on page 68) Discusses four large outbreaks of HBV and HCV among patients in ambulatory facilities Identified a need to define and reinforce safe injection practices www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf 17 18 19 20 Lumbar Puncture Procedures CDC investigated 8 cases of post-myleography meningitis Streptococcus species from oropharngeal flora None of the physicians wore a mask Droplets of oral flora indicated Lead to CDC recommendations of 2007 Later related to not wearing a mask when anesthesiologists put in epidural lines for pain relief on women in labor 21 CDC Guidelines Recently, five cases where anesthesiologist inserts epidural line in OB patients without wearing a mask January 29, 2010 CDC MMWR at www.cdc.gov/mmwr/preview/mmwrhtml/mm5903a1.htm CDC made recommendation in June 2007 after several reports of meningitis after myelograms Bacterial meningitis in postpartum women and Ohio woman dies May 2009 Streptococcus salivarius meningitis (bacteria that is part of normal mouth flora) 22 Wear Mask When Inserting Epidural/Spinal Hospital in NY –Enhanced hand hygiene –Maintenance of sterile fields –Full gown, gloves, and mask –No visitors when epidural put in CDC has only identified 179 cases of post spinal (including lumbar punctures) world wide from 1952 to 2005 23 24 CDC Guidelines CDC identified four outbreaks in Pain clinic Endoscopy clinic Hematology/oncology clinic Will discuss major findings later 25 CDC Guidelines Primary breaches Reinsertion of used needles into multidose vials Used 500cc bag of saline to irrigate IVs of multiple patients Use of single needle or syringe to administer IV medications to multiple patients Preparing medications in same work space where syringes are dismantled Remember OSHA Bloodborne Pathogen standard (sharps containers at the bedside) 26 27 What to Do? Use only single dose vials and not multidose vials when available This includes the use of saline single dose flushes Single use of a disposal needle and syringe for each injection Prevent contamination of injection equipment and medication 28 What to Do? Wear masks when inserting epidural or spinals Discard used syringe intact in appropriate sharps container Make sure sharps container in each patient room Do not administer medications from single dose vials to multiple patients or combine left over contents for later use 29 What to Do? If multiple-dose vials are used, restrict them to a centralized medication area or for single patient use Never re-enter a vial with a needle or syringe used on one patient if that vial will be used to withdraw medication for another patient Store vials in accordance with manufacturer’s recommendations and discard if sterility is compromised Mark date on multi-dose vial 30 What to Do? Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients Follow the CDC 10 recommendations Maintaining clean, uncluttered, and functionally separate areas for product preparation to minimize the possibility of contamination CMS Hospital CoP requirement, tag 501 TJC 2010 MM.05.01.07 Clean top with Bleach wipe after each use 31 A Scary Study The CDC says a survey of US Healthcare found that 1% to 3% reused the same syringe and/or the same needle on multiple patients This is what lead to the Nevada patients being exposed to HIV, HCV, and HCB 40,000 patients were notified who has anesthesia injections from March 2004 to January 11, 2008 and 115 patients infected with HCV Clinic reused syringes in colonoscopies and other gastrointestinal procedures 32 33 34 Please Ask Me The Ask Me Program and the Nevada Medical Association posts information on their website The Nevada State Health Division has encouraged patients to ask several questions prior to a surgical procedure http://health.nv.gov/docs/030308PressRelease.pdf Can you assure me that I am safe in your facility from the transmission of communicable diseases? 35 Please Ask Me Program How does the staff at this facility conduct sterilization of diagnostic equipment after each patient use? Are single or multiple dose vials used at the facility? Are label instructions followed specifically? Are syringes and needles disposed of after each use? Has your facility ever received a complaint of the spread of an infectious disease to another patient as a result of staff practices? 36 CDC Injections Safety for Providers The CDC also issues Injection Safety for Providers Issued March 2008 at http://www.cdc.gov/ncidod/dhqp/ps_providerInfo.html Notes several investigations leading to transmission of Hepatitis C to patients Thousands of patients notified to be test for HVB, HCV, and HIV Referral of providers to the licensing boards for disciplinary actions Malpractice suits filed by patients 37 38 CDC 10 Recommendations The CDC has a page on Injection Safety that contains the excerps from the Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings Summarizes their 10 recommendations Available at http://www.cdc.gov/ncidod/dhqp/injectionSafetyPr actices.html 39 40 CDC Safe Injection Recommendations Use aseptic technique to avoid contamination of sterile injection equipment. Category 1A Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed. Needles,cannula and syringes are sterile, single-use items; they should not be reused for another patient nor to access a medication or solution that might be used for a subsequent patient.1A 41 CDC Safe Injection Recommendations Use fluid infusion and administration sets (i.e., intravenous bags, tubing and connectors) for one patient only and dispose appropriately after use Consider a syringe, needle, or cannula contaminated once it has been used to enter or connect to a patient's intravenous infusion bag or administration set 1B 42 CDC Safe Injection Recommendations Use single-dose vials for parenteral medications whenever possible 1A Do not administer medications from singledose vials or ampules to multiple patients or combine leftover contents for later use 1A If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must be sterile 1A 43 CDC Safe Injection Recommendations Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer's recommendations; Discard if sterility is compromised or questionable 1A Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients 1B 44 CDC Safe Injection Recommendations Wear a mask when placing a catheter or injecting material into the spinal canal or subdural space Example, during myelograms, lumbar puncture and spinal or epidural anesthesia. 1B Worker safety; Adhere to federal (OSHA) and state requirements for protection of healthcare personnel from exposure to blood borne pathogens 1B 45 CDC has Injection Safety FAQs for Providers CDC has another resources with frequently asked questions What is injection safety? Incorrect practices identified in IV medications for chemotherapy, cosmetic procedures, and alternative medicine therapies Available at http://www.cdc.gov/ncidod/dhqp/injectionSafetyFA Qs.html 46 47 CDC has Injection Safety FAQs for Providers Also puts patients at risk for bacterial and fungal infections beside HIV and Hepatitis Single dose vials do not contain a preservative to prevent bacterial growth so safe practices necessary to prevent bacterial and viral contamination Proper hand hygiene before handling medications Make sure contaminated things are not placed near medication preparation area 48 CDC has Injection Safety FAQs for Providers Single use parenteral medication should be administered to one patient only Pre-filled medication syringes should never be used on more than one patient A needed or other device should never be left inserted into a medication vial septum for multiple uses This provides a direct route for microorganisms to enter the vial and contaminate the fluid 49 CDC has Injection Safety FAQs for Providers Multi-dose Vials The safest thing to do is restrict each medication vial to a single patient, even if it's a multi-dose vial Proper aseptic technique should always be followed If multi-dose medication vials must be used for more than one patient, the vial should only be accessed with a new sterile syringe and needle It is also preferred that these medications not be prepared in the immediate patient care area 50 CDC has Injection Safety FAQs for Providers To help ensure that staff understand and adhere to safe injection practices, we recommend the following: Designate someone to provide ongoing oversight for infection control issues Develop written infection control policies Provide training Conduct performance improvement assessments 51 52 53 54 55 56 57 USP 797 USP published a revision to the USP general Chapter of 797 These standards apply to pharmacy compounded sterile preparation This includes injections, nasal inhalations, suspensions for wound irrigations, eye drops etc. Applies to the pharmacy setting as well as to all persons who prepare medications that are administered And it applies to all healthcare centers 58 USP 797 This chapter includes standards for preparing, labeling, and discarding prepared medications Pharmacies compound sterile preparations under laminar flow hoods with stringent air quality and ventilation to maintain the sterility of the drug (ISO class 5 setting) If prepare outside the pharmacy then environment has particulates and microorganisms increasing the potential for contaminating the vial, IV solution or syringes Need to wash hands before preparing medication outside the pharmacy 59 USP 797 Want to prepare IVs and piggybacks in the pharmacy when at all possible Breathing over the sterile needle and vial stopper can create the potential for microbial contamination USP exempts preparation outside the pharmacy for immediate use 1 hour limit from completing preparation and this includes spiking an IV bag Cost of medication disposal can be daunting if case not started within one hour which is why should consider pharmacy preparing under ISO class 5 environment 60 USP 797 This way the drugs used for surgery are prepared by properly trained, cleansed, and garbed personnel to prolong the usability of the immediate use compounded sterile drugs (CSD) These can be stored for 48 hours Another option is to located a manufacturers injectable product (prepackaged syringe) that is discarded according to manufacturer expiration date APIC supports preparing parenteral medication as close as possible to the time of administration 61 USP 797 APIC Recommendations Make sure only trained staff are preparing medications Need to prepared in a clean dry workspace that is free of clutter and obvious contamination sources like water, sinks Medications should be stored in a manner to limit the risk of tampering Should verify the competency of those preparing medications and monitor compliance with aseptic technique 28 day discard date on multidose vials even though CDC says manufacturers recommendations 62 APIC Recommendations APIC issues recommendations and key talking points for hospitals and healthcare facilities http://apic.informz.net/apic/archives/archive_27223 5.html The infection preventionist at our facility has designed a coordinated infection control program This is protect everyone coming in to our facility Our program implements evidenced based practices from leading authorities including the CDC 63 APIC Recommendations Cleanse the access diaphragm of vials using friction and a sterile 70% isopropyl alcohol, ethyl alcohol, iodophor, or other approved antiseptic swab Allow the diaphragm to dry before inserting any device into the vial Never store or transport vials in clothing or pockets. Discard single-dose vials after use Never use them again for another patient Use multi-dose medication vials for a single patient whenever possible 64 APIC Recommendations Never leave a needle, cannula, or spike device inserted into a medication vial rubber stopper because it leaves the vial vulnerable to contamination even if it has a 1-way valve Use a new syringe and a new needle for each entry into a vial or IV bag Utilize sharps safety devices whenever possible Dispose of used needles/syringes at the point of use in an approved sharps container 65 Blood Glucose Monitoring Devices APIC 66 67 68 APIC Key Talking Points This program includes Rigorous hand hygiene practices Monitoring the cleaning disinfection, and sterilization of equipment and instruments An Exposure Control Plan that serves to minimize bloodborne pathogens such as HIV, Hepatitis B and C by patients and staff As part of this program there are measures to prevent the re-use of items designed to be used only once such as needles and syringes 69 70 A Patient Safety Threat-Syringe Reuse CDC published a fact sheet called “A Patient Safety Threat- Syringe Reuse” It was published for patients who had received a letter stating they could be at risk due to syringe reuse Discusses the dangers of the reuse of syringes Discusses that multidose vial be assigned to a single patient to reduce the risk of disease transmission 71 72 73 Anesthesia Delivery Nevada clinics started with Lidocaine 1 cc and Propofol 9ccs in one syringe Clean needle and syringe initially If patient needed more used clean needle but used old syringe If medication left in the single dose Propofol vial used to sedate the next patient 74 Anesthesia Delivery Propofol is single dose medication and preservative free Bought 20-50cc vials but only used 10-15cc per patient Clinic had not had full inspection by state surveyors in 7 years Identified a number of infection control problems with ASC CMS has new freestanding ASC CMC CfCs May 18, 2009 and revised December 30, 2009 75 Never Event: Unsafe Injection Practices The CDC has a website entitled “ A Never Event: Unsafe Practices” Has a power point presentation and an audio presentation Available at www.cdc.gov/ncidod/dhqp/COCA_Unsafe_I njection_Practices.html 76 77 78 Hematology Oncology Clinic Has an outbreak of HCV among outpatients 3-00 to 7-01 Reported to Nebraska Health Department 99 patients with clinic acquired HCV after having chemotherapy All were genotype 3 a which is uncommon in the US Related to catheter flushing Source: Macedo de Oliveira et al., Annals of Internal Medicine, 2005, 142:898-902 79 Hematology Oncology Clinic Nurse drew blood from the IV catheter Then she reused the same syringe to flush the catheter with saline She did use a new syringe for each patient However, she used solution from same 500cc bag for multiple patients Oncologist and RN license revoked Never use an IV solution bag to flush the solution for more than patient 80 81 82 83 Other Cases Patient in US gets malaria from saline flush Emerging Infectious Diseases, Vol 11, No. 7, July 2005 Oklahoma Pain Clinic where anesthesiologist filled syringe with sedation medication to treat up to 24 patients and injected via hep lock 71 patients with HCV and 31 with HBV 25 million dollar settlement Source: Comstock et al. ICHE, 2004, 25:576-583 84 Other Cases 19 patients get HCV in New York in 2001 from contamination of multi-dose anesthesia vials CDC MMWR September 26, 2003, Vol 52, No 38 NY City private physician office with 38 patients with HBV Associated with injections of vitamins and steroids Gave 2 or 3 in one syringe Source: Samandari et al. ICHE 2005 26 (9);745-50 85 Bacterial Outbreak Due to Unsafe Needle 7 patients get serratia marcescens from spinal injections in a pain clinic Source: Cohen Al et al. Clin J Pain 2008; 24(5):374-380 Several other studies where patients got infection from joint and soft tissue injections Got staph aureus In 2003 and 2009 86 Dialysis Facilities CDC issues MMWR report April 2008 Dialysis units must follow CDC guidelines to receive Medicare payments for outpatient services Recent outbreaks of HCV and other bacterial infections From reentry into single dose medication vials to more than one patient CDC recommends to use single dose vials 87 88 Dialysis Facilities If multi-dose then should be assigned to one person Should be prepared in a clean area separate from potentially contaminated surfaces Medications should be prepared in clean area removed from the patient treatment area because surfaces are subjected to frequent blood contamination 89 Injections Safety and Recent Outbreaks The CDC website has a slide presentation called “Injection Safety & Recent Outbreaks” From APIC North Carolina October 5, 2009 Has 48 slides Available at http://www.cdc.gov/ncidod/dhqp/injectionsafet y.html 90 91 92 93 94 WHO Injection Safety The World Health Organization also has resources on injection safety Recently had 10th annual meeting of the Safe Injection Global Network (SIGN) Has revised injection safety assessment tool 73 pages document http://www.who.int/injection_safety/en/ 95 96 97 WHO Safe Injection Tool 98 99 WHO Also has a 51 pages document Covers the 2008 conference that was held in Moscow Additional information about the Safe Injection Global Network (SIGN) Includes a report of the SIGN 100 101 One and Only Campaign Educational awareness to improve safe practices in healthcare One needle, one syringe, and only one time for each patient To empower patients and re-educate healthcare providers Has free posters Coalition partners include APIC, AANA, CDC. AAAHC, Nebraska Medical Association, Nevada State Department of Health etc. 102 http://oneandonlycampaign.org/ 103 104 105 106 Advancing ASC Quality ASC Quality Collaboration has ASC tool kit for infection prevention Includes one on hand hygiene and safe injection practices Includes a basic and expanded version of the toolkit These are available at http://www.ascquality.org/advancing_asc_quality .cfm 107 108 109 110 111 112 113 The End Questions Sue Dill Calloway RN, Esq. CPHRM AD, BA, BSN, MSN, JD President Patient Safety and Healthcare Consulting 5447 Fawnbrook Lane Dublin, Ohio 43017 614 791-1468 sdill1@columbus.rr.com Avoiding Needlestick Follows 114 Avoiding Needle Stick Injuries Speaker Sue Dill Calloway RN, Esq. CPHRM AD, BA, BSN, MSN, JD President Patient Safety and Education 5447 Fawnbrook Lane Dublin, Ohio 43017 614 579-1481 sdill1@columbus.rr.com 116 OSHA Ten years after the Needlestick Safety and Prevention Act was signed into law Which is part of the OSHA Bloodborne Pathogen Standard (29 CFR 1910.1030) OSHA announces a regulatory review of the law Has this standard had a impact on healthcare worker safety? Recent article says sharps in non-surgical setting has declined by about 32% 1 1 Jagger J, Berguer R, Phillips EK, et al. Increase in sharps injuries in surgical settings versus non-surgical settings after passage of national needlestick legislation. J Amer Col Surg 2010; 210:496-502 117 OSHA Safely engineered devises have resulted in 74% decrease in injuries in phlebotomy However, this is not true in the surgery operating room where adoption of blunt suture needles and other sharps safety measures have lagged Sharps injury has increased from 1993 to 2006 by 6.5% This regulation remains the most frequent cited standard in OSHA inspections of hospitals 118 OSHA Inspectors were most likely to cite for failing to have an adequate exposure control plan or failing to update the plan to reflect changes in technology The standard requires employers to review their exposure control plans annually Hospitals also were cited for failing to provide safety-engineered devices Or failing to document that employees had been offered the hepatitis B vaccine The same types of violations are being seen by ASCs 119 www.osha.gov/SLTC/bloodbornepathogens/index.html 120 Needlestick Safety and Prevention Act The Occupational Exposure to Bloodborne Pathogen Standard was first published in 1991 Passed because of concerns to healthcare workers of things such as HIV, hepatitis B and C who were exposed to blood or other potentially infectious materials saliva, blood, semen, cerebrospinal fluid, amniotic, synovial, pleural, pericardial, peritoneal etc Employer needed an exposure control plan on details on employee protection measures Engineering controls included safer medical devices, such as needleless devices, shielded needle devices and plastic capillary tubes 121 Needlestick Safety and Prevention Act Despite these advances with non-needle devises needlestick and sharps injuries continued OSHA said there were nearly 600,000 percutaneous injuries involving sharps so Congress passed the Needlestick Safety and Prevention Act which became effective April 18, 2001 (passed November 6, 2000) Still requires employers to adopt engineering and work practice controls that would eliminate or minimize employee exposure from hazards associated with bloodborne pathogens 122 Needlestick Safety and Prevention Act Need to pull out your exposure control plan every year Need to do an annual review Need to update to reflect changes in technology that help to eliminate or reduce exposure to bloodborne pathogens Take into consideration new safer devices designed to reduce needlestick injuries Document consideration and use of appropriate safer devices 123 Sample Model Plans from OSHA www.osha.gov/Publications/osha3186.html 124 125 126 Needlestick Safety and Prevention Act List employees involved and describe how input was requested or present minutes of meetings Employers need to get input from employees responsible for direct patient care (non management such as nurses) on evaluation, identification and selection of effective and safer devices Employees selected should include those exposure in different areas like peds, geriatrics, nuclear medicine etc. 127 Needlestick Safety and Prevention Act Engineering controls include things that isolate or remove a hazard from the workplace Such as sharp disposal containers and self-sheathing needles Sharps with engineered sharps injury protection (SESIP) includes nonneedle sharps or needle devices with safety features including Syringes with a sliding sheath that shields the attached needle after use Needles that retract into a syringe after use Shielded or retracting catheters IV delivery systems that use a catheter port with a needle housed in a protective covering 128 Needlestick Safety and Prevention Act Needless systems include IV medication using a port with non needle connections or jet injection system that deliver liquid medicine under the skin or through a muscle Employers must keep a Sharps Injury Log for the recording of percutaneous injuries from contaminated sharps Remember that sharps containers must be easily accessible to employees and located as close as feasible to the immediate area where sharps are used 129 www.cdc.gov/niosh/sharps1.html 130 131 132 133 134 www.osha.gov/SLTC/bloodbornepathogens/index.html 135 Sharps Safety Have a policy and procedure on sharps safety Include safety measures to prevent injury during perioperative care Use double gloving, blunt suture needles for fascial closing and neutral zones, when appropriate, to avoid hand to hand passage of sharps Include references position statements in P&P and where these are located1 1 www.cspsteam.org/sharpssafety/sharpssafety.html / 136 Blunt Tip Suture Needles Surgical personnel are at risk of bloodborne injuries from sharp surgical instruments OSHA has document on the “Use of Blunt-Tip Suture Needles to Decrease Percutaneous Injuries to Surgical Personnel: Safety and Health Information Bulletin” 1 Sharp tip suture needles are the leading source of percutaneous injuries to surgical personnel causing 51 to 77% of these incidents 1 http://www.cdc.gov/niosh/docs/2008-101/ 137 138 Sharp-tip Suture Needles Suture needle injuries can occur when surgical personnel; Load or reposition the needle into the needle holder Pass the needle hand-to-hand between team members Sew toward the surgeon or assistant while the surgeon or assistant holds back other tissue Tie the tissue with the needle still attached Leave the needle on the operative field Place needles in an over-filled sharps container or Place needles in a poorly located sharps container 139 National Associations Blunt Tip Suture American College of Surgeons ACS) recommends in 2005 the universal adoption of blunt-tip suture needles for suturing fascia Also encourages further investigation of their appropriate use in other surgical applications AORN endorsed this ASC statement in support of blunt-tip suture needles where effective and clinically appropriate Other organizations endorse such as ASA, ASPAN, AANA, American Association of Surgical PAs, and the Association of Surgical Technologists 140 141 Blunt Tip Suture Needles Blunt tip suture needles can be used to suture less dense tissue such as muscle and fascia 59% of the suture needle injuries occur when suturing muscle and fascia Multiple studies have reported the effectiveness of blunt tip suture needles in decreasing percutaneous injuries OSHA and NIOSH strongly encourage their use when feasible and appropriate 142 / 143 AORN 2010 Page 697 Perioperative Standards and Recommended Practices 144 ACS www.facs.org/fellows_info/statements/st-52.html 145 146 147 148 www.cdc.gov/sharpssafety/ 149 Free Workbook from the CDC 150 151 International Sharps Injury Prevention Society www.isips.org/ 152 www.jointcommission.org/SentinelEvents/SentinelEventA lert/sea_22.htm 153 http://www.tdict.org/ 154 155 156 www.healthsystem.virginia.edu/internet/epinet// 157 158 159 160 http://nursingworld.org/MainMenuCategories/OccupationalandEnvir onmental/occupationalhealth/SafeNeedles.aspx 161 162 163 www.cdc.gov/niosh/topics/bbp/ndl-law.html 164 www.facs.org/about/committees/cpc/preventingsharpsinjuries.pdf 165 166 167 168 169 170 Resources Jagger J, Bentley M, Tereskerz P. A study of patterns and prevention of blood exposure in OR personnel. AORN J. 1998; 67(5):979-81, 983-4, 986-7 Berguer R, Heller PJ. Preventing sharps injuries in the operating room. J Am Coll Surg. 2004; 199(3):462-7 Makary MA, Al-Attar A, Holzmueller CG, Sexton JB, Syin D, Gilson MM, Sulkowski MS, Pronovost PJ. Needlestick injuries among surgeons in training. N Engl J Med. 2007 Jun 28; 356(26):2693-9 171 Resources Davis MS. Advanced Precautions for Today's OR: The Operating Room Professional's Handbook for the Prevention of Sharps Injuries and Bloodborne Exposures, 1st ed. Atlanta; Sweinbinder; 1999. American College of Surgeons (ACS). Statement on blunt suture needles. Bull Am Coll Surg. 2005 Nov; 90(11):24. Available from http://www.facs.org/fellows_info/statements/st52.html 172 Resources Association of Perioperative Registered Nurses (AORN). AORN Guidance Statement: Sharps Injury Prevention in the Perioperative Setting. In: 2005 Standards, Recommended Practices, and Guidelines. 2005; 199-204. Available from www.aorn.org/about/positions/pdf/SECTI-2esharpssafety.pdf Centers for Disease Control and Prevention (CDC). Evaluation of blunt suture needles in preventing percutaneous injuries among health-care workers during gynecologic surgical procedures-New York City, March 1993-June 1994. MMWR Morb Mortal Wkly Rep. 1997; 46(2):25-9. http://www.cdc.gov/ mmwr/preview/mmwrhtml/00045660.htm 173 Resources CFR (Code of Federal regulations). Title 29 Part 1910, OSHA. Washington, DC: U.S. Government Printing Office, Office of the Federal Register Dauleh MI, Irving AD, Townell NH. Needle prick injury to the surgeon-do we need sharp needles? J R Coll Surg Edinb. 1994; 39(5):310-1. Jagger J, Berguer R, Phillips EK, et al. Increase in sharps injuries in surgical settings versus nonsurgical settings after passage of national needlestick legislation. J Amer Col Surg 2010; 210:496-502 174 Resources Davis MS. Advanced Precautions for Today’s O.R. In: The Operating Room Professional’s Handbook for the Prevention of Sharps Injuries and Bloodborne Pathogen Exposures. Atlanta, GA: Sweinbinder Publications LLC; 2001. Aarnio P, Laine T. Glove perforation rate in vascular surgery—A comparison between single and double gloving. Vasa. 2001;30(2):122-124. Berguer R, Heller PJ. Strategies for preventing sharps injuries in the operating room. Surg Clin North Am. 2005;85(6):1288-305, xiii. 175 Resources Caillot JL, Cote C, Abidi H, Fabry J. Electronic evaluation of the value of double gloving. Br J Surg. 1999;86(11):1387-1390. Dauleh MI, Irving AD, Townell NH. Needle prick injury to the surgeon—Do we need sharp needles? J R Coll Surg Edinb. 1994;39(5):310-311. Eggleston MK Jr, Wax JR, Philput C, et al. Use of surgical pass trays to reduce intraoperative glove perforations. J Matern Fetal Med. 1997;6(4):245247. 176 Resources Evaluation of blunt suture needles in preventing percutaneous injuries among health-care workers during gynecologic surgical procedures—New York City, March 1993–June 1994. MMWR Morb Mortal Wkly Rep. 1997;46(2):25-29. Gerberding JL, Littell C, Tarkington A, et al. Risk of exposure of surgical personnel to patients’ blood during surgery at San Francisco General Hospital. N Engl J Med. 1990;322(25):1788-1793. 177 Resources Hartley JE, Ahmed S, Milkins R, et al. Randomized trial of blunt-tipped versus cutting needles to reduce glove puncture during mass closure of the abdomen. Br J Surg. 1996;83(8):1156-1157 Hollaus PH, Lax F, Janakiev D, et al. Glove perforation rate in open lung surgery. Eur J Cardiothorac Surg. 1999;15(4):461-464. Jagger J, Bentley M, Tereskerz P. A study of patterns and prevention of blood exposures in OR personnel. AORN J. 1998;67(5):979-981, 983-974, 986-977. 178 Resources Jensen SL. Double gloving—Electrical resistance and surgeons’ resistance. Lancet. 2000;355(9203):514-515. Laine T, Aarnio P. How often does glove perforation occur in surgery? Comparison between single gloves and a double-gloving system. Am J Surg. 2001;181(6):564-566. Mingoli A, Sapienza P, Sgarzini G, et al. Influence of blunt needles on surgical glove perforation and safety for the surgeon. Am J Surg. 1996;172(5):512-516; 516-517. 179 Resources Montz FJ, Fowler JM, Farias-Eisner R, Nash TJ. Blunt needles in fascial closure. Surg Gynecol Obstet. 1991;173(2):147-148. Naver LP, Gottrup F. Incidence of glove perforations in gastrointestinal surgery and the protective effect of double gloves: A prospective, randomised controlled study. Eur J Surg. 2000;166(4):293-295. Quebbeman EJ, Telford GL, Hubbard S, et al. Risk of blood contamination and injury to operating room personnel. Ann Surg. 1991;214(5):614-620. 180 Resources Rice JJ, McCabe JP, McManus F. Needle stick injury. Reducing the risk. 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JAMA. 1992;267(21):2899-2904. 181 Resources A recent CDC presentation on Unsafe Injection Practices, along with audio and a transcript of the presentation are available at: www.cdc.gov/ncidod/dhqp/COCA_Unsafe_ Injection_Practices.html Re: infection control and injection practices www.cdc.gov/ncidod/dhqp/ps_providerInfo. html 182 Resources Re: protecting patients from bloodborne pathogens in healthcare settings www.cdc.gov/ncidod/dhqp/bp_patient.html Re: prevention of surgical site infections www.cdc.gov/ncidod/dhqp/gl_surgicalsite.html Re: hand hygiene in healthcare facilities www.cdc.gov/handhygiene/ 183 Resources Re: healthcare facility physical environment and infection control www.cdc.gov/ncidod/dhqp/gl_environinfection. html CDC’s home page for infection control provides links to additional information: www.cdc.gov/ncidod/dhqp/index.html 184 Resources Mast ST, Woolwine JD, Gerberding JL. Efficacy of gloves in reducing blood volumes transferred during simulated needlestick injury. J Infect Dis 1993;168(6):1589-92. Henry K, Campbell S, Collier P, Williams CO. Compliance with universal precautions and needle handling and disposal practices among emergency department staff at two community hospitals. Am J Infect Control 1994;22(3):129-37. 185 Resources Vaughn TE, McCoy KD, Beekmann SE, Woolson RE, Torner JC, Doebbeling BN. Factors promoting consistent adherence to safe needle precautions among hospital workers. Infect Control Hosp Epidemiol 2004;25(7):548-55. Clarke SP, Rockett JL, Sloane DM, Aiken LH. Organizational climate, staffing, and safety equipment as predictors of needlestick injuries and near-misses in hospital nurses. Am J Infect Control 2002;30(4):207-16. 186 Resources CDC Training on Hepatitis www.cdc.gov/hepatitis/Resources/Professionals/TrainingReso urces.htm 187 Resources Danzig LE, Short LJ, Collins K, et al. Bloodstream infections associated with a needleless intravenous infusion system in patients receiving home infusion therapy. JAMA 1995;273(23):1862-4. 188 Resources Patel PR, Larson AK, Castel AD, et al. Hepatitis C virus infections from a contaminated radiopharmaceutical used in myocardial perfusion studies. JAMA 2006;296:2005--11. CDC. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR 1998;47(No. RR-19). Williams IT, Perz JF, Bell BP. Viral hepatitis transmission in ambulatory health care settings. Clin Infect Dis 2004;38:1592--8. 189 Resources Comstock RD, Mallonee S, Fox JL, et al. A large nosocomial outbreak of hepatitis C and hepatitis B among patients receiving pain remediation treatments. Infect Control Hosp Epidemiol 2004;25:576--83. Krause G, Trepka MJ, Whisenhunt RS, et al. Noscomial transmission of hepatitis C virus associated with the use of multidose saline vials. Infect Control Hosp Epidemiol 2003;24:122--7. 190 The End Questions Sue Dill Calloway RN, Esq. CPHRM AD, BA, BSN, MSN, JD Medical Legal consultant 5447 Fawnbrook Lane Dublin, Ohio 43017 614 791-1468 191