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Perilous infection control practices with needles, syringes, and vials suggest stepped-up monitoring is needed

From the December 2, 2010 issue

Problem: A recent online survey of 5,446 healthcare practitioners reveals an alarming lapse in basic infection control practices associated with the use of syringes, needles, multiple-dose vials, single-use vials, and flush solutions.(1) Survey respondents primarily included registered nurses (89.5%) who worked in hospitals. While the majority of nurses and other healthcare practitioners appear to follow infection control practices consistent with current recommendations,(2) some survey respondents clearly place patients at risk for transmission of blood-borne diseases, according to information we received from  the survey sponsor, Premier Healthcare Alliance, while highlighting publication of the survey by Pugliese et al. in the American Journal of Infection Control (www.premierinc.com/injectionpractices).(1)

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% of respondents admitted to sometimes or always using single-dose/single-use vials for multiple patients
  • 15% of respondents 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
  • 9% of respondents sometimes or always use a common bag or bottle of IV solution as a source of flushes and drug diluents for multiple patients.

Each of these unsafe practices has been associated with disease transmission and is explicitly prohibited by the Centers for Disease Control and Prevention (CDC).(2)

Comments provided by respondents involved in these unsafe practices demonstrated 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.

Another misconception is that changing the needle on a used syringe is sufficient protection against disease transmission if aspiration of blood does not occur and there is no visible blood in the syringe. While most respondents called reuse of a syringe “appalling,” some respondents appeared unaware that disease transmission was possible when reusing a syringe when the needle was changed. Pathogenic contaminants not visible to the eye can enter the syringe after injection, particularly while the needle is still attached to the syringe. We’ve published numerous articles about this problem, including an alert in our February 12, 2009, newsletter after a hospital placed 2,114 insulin-dependent diabetic patients at risk for acquiring blood-borne diseases when staff used insulin pen devices for multiple diabetic patients after only changing the pen’s needle between patients. 

Reuse of a syringe to withdraw a medication or solution from a multiple-dose container may not be overt; rather, this unsafe practice is probably engaged in without much thought when multiple doses of the medication (e.g., lidocaine) or solution (e.g., saline) are required during a single procedure. If syringes are deliberately reused after changing the needle, practitioners may erroneously believe that any residual pathogens will be halted by the bacteriostatic or preservative agents in the multiple-dose vials. While common preservatives used in multiple-dose vials may be bacteriostatic, they will not destroy all bacteria, and they do not have antiviral or antifungal activity. Furthermore, even if the preservative effectively stops bacteria from reproducing, there’s about a 2-hour window during which contaminating organisms may remain viable in a multiple-dose vial before the preservative fully exerts its effect.(3)

Comments made by respondents regarding the use of a bag or bottle of IV solution (e.g., saline) as a common source of flushes or drug diluents for multiple patients suggest some awareness regarding the risk of contamination. Nevertheless, other respondents erroneously suggested this practice was safe because they discarded the solution after 24 hours. However, limiting use to 24 hours does not prevent disease transmission if the bag becomes contaminated. Further, use of a contaminated solution for large groups of patients can result in widespread disease transmission.

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.(4) Since then, the topic has been covered in dozens of feature articles, Worth Repeating commentaries, and Safety Briefs 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. The study authors suggest that these outbreaks represent only a portion of the incidence of blood-borne pathogen transmission caused by unsafe injection practices. Many outbreaks and sporadic transmissions of hepatitis B and C, for example, go unrecognized because patients who are infected may be initially asymptomatic or have mild, non-specific symptoms for years.  

Safe Practice Recommendations: Given the lapses in infection control practices and misconceptions regarding unsafe injection practices described via this survey, academic settings, licensing bodies, and healthcare providers must 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. The One & Only CampaignONE needle, ONE syringe, ONLY ONE time—led by the CDC and the Safe Injection Practices Coalition offers free posters, educational brochures for healthcare providers and patients, and a 13-minute video on the topic (www.oneandonlycampaign.org/videos/Default.aspx).  

All staff should understand that any form of syringe and/or needle reuse is dangerous and should be avoided. The current CDC guidelines(2) recommend that syringes and needles be used only once. Single-dose or single-use vials should be used clinically only for one dose for one patient, and then discarded after initial entry into the vial. If multiple-dose vials are used, both the needle and syringe used to access the vial must be sterile, and strict attention must be paid to aseptic technique.

ISMP and CDC also recommend limiting the use of multiple-dose vials of medication to single patients, whenever possible, as an extra barrier of protection against unrecognized syringe reuse or other means of unintended vial contamination. It’s safest to use prefilled syringes or single-dose vials whenever possible to reduce the risk of contamination. Certainly, there are a few settings where it makes sense to use multiple-dose vials: 1) for a single patient; 2) during aseptic pharmacy compounding; and 3) for expensive medications, which should be prepared and dispensed from the pharmacy in unit doses. The relatively inexpensive drugs and solutions that often require multiple entries into the vial (e.g., sodium chloride injection 0.9%, bacteriostatic water, lidocaine) should not be saved for use with other patients. These should be provided in single-use containers that are discarded after first use. Also, do not use bags or bottles of IV solutions as a communal supply for multiple patients unless the bags or bottles are used during aseptic pharmacy compounding, using a fluid dispensing system. 

References
1) Pugliese G, Gosnell C, Bartley JM, Robinson S. Injection practices among clinicians in United States health care settings. Am J Infect Control. 2010;38:789-98). www.premierinc.com/injectionpractices.
2) Centers for Disease Control and Prevention (CDC). Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings 2007. Atlanta (GA): U.S. Department of Health and Human Services, CDC; 2007. www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html.
3) Wilson JP, et al. Updating your multiple-dose vial policy: the background. Hosp Pharm. 1998;33: 427-32.
4) ISMP. Hepatitis B outbreak related to multiple dose heparin vials should serve as a wakeup call. ISMP Medication Safety Alert! 1996;1(14):1.

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