Nurses should know better. Syringes, IVs, and vials are never used more than once. It’s basic nursing pratice taught in every nursing school program. But something has gone wrong.
A spate of hepatitis B and C infections traced to unsafe injection practices at ambulatory care centers across the country has prompted the U.S. Centers for Disease Control and Prevention to join a new national education campaign emphasizing safe injection practices to nurses and other healthcare workers.Jackie S. Rowles, RN, president of the American Association of Nurse Anesthetists, which heads up the Safe Injection Practices Coalition, announces the One & Only campaign.
“We now have to make sure we’re watching what we thought was being done safely and correctly and has turned out to have a huge margin of error,” says Jackie S. Rowles, CRNA, MA, MBA, FAAPM, president of the American Association of Nurse Anesthetists, which heads up the Safe Injection Practices Coalition, the official sponsor of the education campaign. “We have to be extra diligent in everything we do — watching how medications are drawn up, prepared, and administered. We have to be willing to step forward and protect the patient, even if we have a fear of retribution.”
Contaminated needles are not the only culprit. More often, re-use of syringes, IV fluid, and medication vials are the means of transmission. The campaign — titled “One & Only” — stresses that infections such as hepatitis C, hepatitis B, and HIV can travel back through needles into syringes. If a contaminated needle or syringe comes in contact with a medication vial or IV fluid bag, that vial or bag becomes contaminated. This appears to be where the short-circuit lies.
“We need everyone to realize the potential that [mistakes] have and not have this laissez-faire attitude that ‘I can cut corners,'” Rowles says. “It’s nursing school 101.”
A study commissioned by the AANA in early 2003 found 1 in 100 nurses surveyed had reused needles or syringes, putting about 1 million people at risk. “The excuses we’ve heard are they were told by their boss to do this to save money, it’s done to save time, or it’s easier,” Rowles says. “I think there are a lot of pressures on providers of all kinds when they’re out in the workplace and sometimes they just make bad judgments.”
A CDC study published in the Jan. 6 issue of the Annals of Internal Medicine revealed 33 outbreaks in nonhospital healthcare settings in the past decade: 12 in outpatient clinics, six in hemodialysis centers, and 15 in long-term care facilities, resulting in 448 people acquiring hepatitis B or C infections. In each setting, the infection was tranferred patient-to-patient through failure of healthcare personnel to adhere to fundamental principles of infection control and aseptic technique, for example, reuse of syringes or lancing devices.
Co-author of the report Nicola D. Thompson, MS, PhD, epidemiologist, Division of Viral Hepatitis, CDC, said all healthcare professionals, from physicians to nurses to technicians were implicated in the incidents. The reasons behind the lax procedures are unclear, however, Thompson says.
“Somewhere along the line there’s been a breakdown, maybe because there’s not been sufficient focus on infection control during medical training,” Thompson says. “People who have been involved in these outbreaks sometimes reported they had been instructed to do things in a certain way to limit costs.”
Although the AANA has been working on this safety issue since 2002, injection-related outbreaks did not receive widespread attention until a slew of infections were traced to two Nevada endoscopy clinics last year.
The Southern Nevada Health District began a hepatitis C exposure registry last year to gather information related to former patients of the Endoscopy Center of Southern Nevada and the Desert Shadow Endoscopy Center. Seven patients who received anesthesia injections in 2007 at the ECSN and one in 2006 from the DSEC have been diagnosed with acute hepatitis C linked to procedures performed at the clinics.
In the same 10-year period studied, comparatively few outbreaks were logged in hospital settings — seven outbreaks resulting in 48 infections, according to the CDC report. Acute care hospitals often have a dedicated infection control officer on staff, Thompson says.
“It seems as though an increase in outbreaks parallels the increase in outpatient settings,” Thompson says. “There’s a need for improved professional oversight and licensing of these facilities.”
The ability of the health or governmental jurisdiction to inspect, license, or certify nonhospital healthcare agencies varies, according to the CDC report. Laws and ability to regulate these healthcare facilities differ in each state. In New York, for example, facilities that offer office-based surgery will be required to obtain accreditation from a nationally recognized accrediting organization, such as the Joint Commission. To facilitate inspection and regulation of these facilities, it would be beneficial if some similar standard-of-care oversight could be achieved throughout the United States, the report stated.
Because of the high incidence of hepatitis transmission at hemodialysis centers, CDC recommendations specific to this setting include the use of additional infection control measures, routine hepatitis B vaccination of patients receiving dialysis, and routine screening to detect new hepatitis B and C infections. Vaccination of diabetic long-term care residents may also be warranted, the report stated. Six of the 97 hepatitis B infections recorded at these facilities resulted in death.
Education is key, Thompson says. “It’s inherently important that people in these settings, including RNs, are familiar with the recommendations,” Thompson says.
Infection control guidelines can be obtained from the AANA via the association’s Web site, www.aana.com, or by calling 847-692-7050, and through the CDC at www.cdc.org or by calling 800-232-4636. A PowerPoint presentation illustrating safe injection practices can be downloaded at http://emergency.cdc.gov/coca/ppt/UnsafeInjectionPractices032708.ppt.