Injection Safety and Needle-stick Injury Management

Standard Precautions

Injection Safety and
Needle-stick Injury Management

Unsafe Injection Practices

WHO Estimated That 16 Billion Healthcare Injections Are Administered Globally Each Year. Unsafe Injection Practices Are

  • Incorrect handling of sharps
  • Reusing syringes and needles
  • Inappropriate administration of single or multi-dose vials,
  • Using non-sterile equipment from unsealed or damaged packaging,
  • Not properly disinfecting the skin or the intra-venous line hubs

These Unsafe Injection Practices Put Patients And Healthcare Workers (Hcws) At Increased Risk Of Acquiring Blood-Borne Pathogens And Other Infections.

Overuse of injections and unsafe injection practices worldwide in 2000 (WHO)

Unsafe injection practices, annually

21 million hepatitis B infections (30% of new cases)

2 million hepatitis c infections (41% of new cases)

260 000 HIV/AIDS infections (9 % of new cases)

3 Million Accidental needle-stick injuries (2003) leading to

  • 5.5% of new HIV cases
  • 39% of new HCV cases
  • 37% of all new HBV cases in HCWs

Equipment

The most common reason for an unsafe injection is the re-use of injection equipment. Re-use can mean:

• The same syringe and/or needle are used for more than one patient.

• The same syringe and/or needle are used to withdraw medication multiple times from a medication container (e.g., vial, IV bags, pen injector cartridges).

• The same syringe is used with a new needle. Re-use directly (via contaminated injection equipment) or indirectly (via contaminated medication vials) expose patients to infections.

Unsafe Injection Practices and Disease Transmission

A new needle and syringe are used to draw medication.

  • when the needle is used on a HCV-infected patient, backflow from the injection contaminates the syringe. Changing the needle does not prevent contamination of the syringe.
  • When re-used to obtain medication, the contaminated syringe can contaminate the medication vial.
  • If the contaminated vial is used for other patients, they can become infected with HCV. (Although this example uses HCV, these same principles apply to other blood borne pathogens)

Preparing and storing medication

Unsafe injection practices can also result from incorrectly administering medications. During medication preparation, there are multiple steps that can be prone to error or cause contamination of the vial or syringe. Such examples include

  • A medication tray or cart/trolley having more than one injection for different patients
  • If the injections are not prepared with good sterile technique (for example they can become contaminated from a dirty environment, like the medication tray)
  • A health care worker may pick up the wrong syringe or medication vial for a patient if it is mislabelled or not labelled at all
  • Cotton balls used for disinfecting should not be pre-soaked; nor should pre-soaked cotton balls or swabs be stored in containers

Single-dose vials

Single-dose vials are meant to be used for a single procedure or injection for one patient only. Unlike multi-dose vials, single-dose vials do not contain antimicrobial preservatives. Re-use of single-dose vials puts subsequent patients at risk of infections.

Intravenous (IV) bags

Unsafe use of IV bags can lead to blood borne pathogen transmission - for example, when a common bag of saline or any other IV fluid is used for more than one patient or the same bag is accessed with a syringe that was used earlier to flush another patient’s IV line or catheter.

Unnecessary Injections

Many HCWs and patients favour injections over other ways to administer or receive medication. Reducing the number of unnecessary injections can reduce the number of unsafe injections. In addition, unnecessary antibiotic injections can increase antimicrobial resistance.

Risk of Harm Due to Re-used Syringe

It is important to remember that the risk of transmission
increases due to unsafe injection

Length of time virus can survive outside the body

Disease Length of time a virus can survive outside the body Risk of transmission from re-used syringe
Hepatitis B 1 Week 31%
Hepatitis C 3 Weeks ( on environmental surface at room temperature ) 3%
HIV 3 Days ( In dried blood at room temperature ) 0.3%

Safe Injection

“Safe injection” as one which does not harm the recipient, does not expose the provider to any avoidable risk and does not result in waste that is dangerous for the community-WHO.

IPC Multimodal Strategy to Injection Safety

To reduce infections associated with unsafe injections, (IPC) programmes should place high priority on elimination of unnecessary injections.

Build It

Procuring safety-engineered injection devices in your healthcare facility.

Teach It

Educating Hcws On Safe Injection Practices As Part Of A Broader IPC Programme, Appropriate Sharps Disposal, And Waste Management

Check it

Monitoring staff adherence with best injection safety practices and availability of equipment (safety-engineered injection devices and safety boxes) at the point of care and providing feedback.

Sell it

Using reminders and other communication supports to help inform and reinforce proper injection safety practices

Live It

Having those in charge of district health management and health centres ensure that budgets are dedicated for adequate injection equipment.

Safety – engineered injection device

Traditional single use syringe

Advantages

  • Provide sterile injections when used properly
  • Widely available
  • Low cost

DisAdvantages

  • Can be repeatedly re-used
  • Risk of needle stick injuries remains
  • Sharps waste remains

AD (Auto Disposable) syringes for immunization

Advantages

  • Widely available
  • No user intervention required if disabling mechanism activated before injection given

DisAdvantages

  • Can be re-used if safety feature is deliberately avoided on ADs with safety mechanism activated after completion of injection
  • Sharps waste remains
  • No SIP feature

RUP syringes for therapeutic injections

Advantages

  • Full range of sizes including special sizes
  • Re-use can be prevented when activation of re-use prevention mechanism activated upon completion of dose
  • Widely available

DisAdvantages

  • Can be re-used if the safety feature is deliberately avoided on syringes with an RUP feature Type 2 which requires elective activation upon completion of intended dose
  • Sharps waste remains
  • No SIP feature

SIP – Plastic Needle Shield to be added to a syringe

Advantages

  • Full range of sizes Plastic needle shield is added to protect the needle
  • Sharp is contained
  • The needle is manually retracted inside the barrel after the completion of injection by pulling the plunger backwards
  • The needle is automatically retracted inside the barrel after pushing a button on the plunger

DisAdvantages

  • Activation of the safety mechanism is dependent on user action and compliance
  • Not all models provide similar protection in all clinical applications

Best Practices to Prevent Needle-Stick Injury

Seven Steps of Safe Injection Practices

Clean workspace

Hand Hygiene

Sterile safety-engineered syringe

Sterile vial of medication and diluents

Skin cleaning and antisepsis

Appropriate collection of sharps

Appropriate waste management

  • Always Check the patient’s file or prescription to confirm the identity of the patient and the correct dose to be injected.
  • Prepare each injection in a clean, hygienic area where there is low risk of blood and body fluid contamination, or of any splashing
  • It is important to keep the medication preparation area clean and removing clutter from all surfaces so that they may be adequately disinfected prior to gathering the necessary injection equipment. Always:
  • Clean your hands with an alcohol-based hand rub or soap and water before preparing medication and touching the patient. Follow WHO’s “5 Moments for Hand Hygiene”.
  • When preparing a medication vial, wipe the rubber septum (or stopper) with Cotton swab or ball soaked with 60-70% alcohol. Do not touch, fan, or wipe off the disinfectant; allow the septum to air dry. Pierce the septum of the vial with a new and sterile syringe and needle. Insert air into the vial before drawing up the medication.
  • Do not leave a needle in the septum of a vial as this can lead to contamination.
  • Medication in the form of powder must be reconstituted. Reconstitution is the process of adding a liquid to a dry ingredient before administering it. The following aseptic technique must be followed when reconstituting medication.
  • Always use a sterile syringe and needle to withdraw the reconstitution solution (liquid) from an ampoule or vial.
  • Once the solution is withdrawn, inject the necessary amount of fluid into the single or multi-dose vial by inserting the needle into the rubber septum.
  • Mix the contents of the vial thoroughly until all visible particles have dissolved.
  • Disinfect the patient’s skin before injection, using a 60-70% alcohol-soaked swab. Work from the centre of the area outwards. Avoid wiping the same area with the same swab. Wait 30 seconds for the area to air dry.
  • Pre soaked cotton balls that have been stored in containers should not be used for disinfection. This could cause contamination. Methanol (or methyl alcohol) is not suitable for use on humans and should not be used as a skin disinfectant.
  • Collect the used syringe and needle immediately after the injection, and dispose of them without any additional manipulation into the sharps container.
  • Immediately place syringes and un-capped needles into a sharps container
  • Never recap a needle.
  • Do not bend, break, manipulate, or manually remove the needle or syringe.
  • A sharps container must be within arm’s reach of where sharps are used (at the point of care).
  • When a sharps container is about three quarters filled, it must be sealed and stored in a secure place before final disposal.
  • Opening a sharps container prior to its final disposal can lead to potential needle-stick injury and/or infection
  • In cases when proper sharps containers are difficult to procure, you may provide low-cost alternatives.
  • Improvised sharps containers may be made from throw-away items, such as metal containers, plastic bottles, or durable cardboard boxes.
  • Label your improvised sharps container as “sharps waste”.
  • Once it is full, make sure you can completely close and tightly seal this container to prevent it from being opened before final disposal.

Causes of Needle-stick Injury and what to do

Needle-Stick Injury (exposure) Management

Hepatitis -B Post-Exposure Prophylaxis (PEP)

  • PEP is not necessary for those vaccinated against HBV. If an injured health worker has not been vaccinated
  • the worker must receive an initial vaccination dose immediately after exposure.
  • All scheduled doses of the vaccination series should be completed even if the source of exposure is hepatitis b negative.
  • the most effective pep regimen (between 85% and 95%) for hbv is a combination of hepatitis b immunoglobulins (hbig) and the vaccine series.
  • the most effective pep regimen (between 85% and 95%) for hbv is a combination of hepatitis b immunoglobulins (hbig) and the vaccine series.
  • If the health worker received the vaccine after the injury, test for antibody formation against the vaccine one to two months after vaccination. If HBIG was given in combination with the vaccine, you cannot determine if antibodies formed in response to the vaccine within this period.

Hepatitis -C Post-exposure

While the risk of exposure to HCV is low, the consequences of infection are high. There is no recommended PEP for HCV-positive blood, and there are no immunoglobulins, antiviral agents or vaccines against HCV.

Note on new HCV treatment: The treatment of HCV with new drugs can cure most persons with HCV in 12 weeks. WHO is currently updating its treatment guidelines to include direct-acting antiviral (DAA) drugs and simplified laboratory monitoring. The role of pegylated interferon (PEG-INF) and ribavirin is very limited at present, but prices of these DAAs have dropped dramatically in resource-limited countries due to the introduction of generic versions of these medicines.

  • Perform baseline testing for antibodies, as well as Alanine Aminotransferase (ALT) blood testing.
  • At 4 to 6 months after exposure, retest the exposed person for antibodies and ALT.
  • For early diagnosis, test RNA 4 to 6 weeks after exposure.
  • If HCV antibodies repeatedly return positive enzyme immunoassay (EIA) results, supplemental tests may be needed.
  • If infection is identified, the exposed person must be referred to a specialist for treatment.

HIV Post exposure

The type of exposure and HIV status of the source patient will determine whether PEP should be provided to the exposed person.

PEP is recommended if the exposure meets all the following criteria

  • Exposure to the HIV virus occurred within 72 hours
  • The exposed individual is HIV negative.
  • the source of the exposure is either HIV positive, or their status is unknown.
  • The source of the exposure is blood, body tissue, visibly blood-stained fluid, cerebrospinal fluid (CSF), or synovial, peritoneal, pericardial, or amniotic fluid and
  • the puncture is deep, from a hollow-bore needle, or from other sharps visibly contaminated with any of the above-mentioned fluids.

If the HIV status of the source is positive, a two-drug regimen is recommended for any percutaneous injury or severe blood splash; the source patient treatment history and resistance pattern, if available, should be considered to decide the PEP regimen. PEP for HIV should be taken for 28 days.

No PEP for HIV is recommended if any of the following criteria apply

  • More than 72 hours have passed
  • The exposed individual is HIV positive.
  • The source of the body fluid is an HIV-negative individual who is not high risk for infection.
  • The skin of the exposed individual is intact (not broken or punctured).

PEP Counselling and follow-up

Explain to the exposed individual about how HIV is transmitted (via blood and sexually) and provide counselling about proper use of contraception (such as condoms) during any sexual act. The exposed person should avoid organ and sperm donation until testing negative.For lactating mothers, suggest alternatives to breastfeeding.

Follow-up visits are crucial to ensure adherence to PEP, prevent or treat any side effects, and identify possible seroconversion.

Drug reactions must be monitored within 72 hours of initiating PEP treatment.

HIV testing is recommended at baseline, 6 weeks and 6 months after exposure.

If the exposed person seroconverts, refer for treatment.

Delay In Injection

Re-cap the needle using the one-handed ‘scoop’ technique

Do not use your other hand to re-cap the needle; it is safer to place the needle cap on a flat surface and scoop the needle inside the needle cap. This protects your other hand from an accidental needle-stick injury. Once the needle is inside, you may use your other hand to secure the cap in place. This image depicts this technique.

Label and store the syringe according to the manufacturer’s recommendations.

If the needle comes into contact with a non-sterile surface, immediately discard the syringe.