AACN News—April 2009—Practice

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Vol. 26, No. 4, APRIL 2009

Practice Resource Network

Q Recently, there have been outbreaks of hepatitis B virus and hepatitis C virus related to syringe and vial reuse in the United States. In an article by Thompson and colleagues,1 the transmission of these viruses in nonhospital settings occurred because healthcare workers failed to follow basic infection control guidelines. What are the practical considerations for safely administering injections to prevent the transmission of infections to patients?

A Patient safety is the cornerstone of high-quality healthcare. Focusing on patient outcomes plays an influential role in patient safety and practice. An extensive review of the literature and Internet resources reveals a general consensus that safe injection practices should not vary based on the healthcare location (i.e., outpatient settings vs. acute in-patient units). The reuse of needles and syringes, along with the misuse of single-dose medication vials, is occurring in outpatient clinics and ambulatory care centers in the United States.

Examples of unsafe injection practices:

• A nurse obtains a blood sample from an indwelling IV catheter and reuses the same syringe to perform a saline flush. A new syringe is used for each patient; however, solution from a 500-mL bag is used for multiple patients.
• A healthcare worker uses the same syringe to administer medication to more than one patient, even though the needle was changed.
• A physician accesses a multi-dose vial with a syringe that has already been used to administer medication to a patient via a medication port.
• A healthcare worker uses a common bag of IV fluids for more than one patient and leaves an IV administration set in place for dispensing fluids.
• A nurse accesses a “common” bag of IV fluids hanging in the medication room with a syringe that has already been used to flush a patient’s IV tube. Another nurse accesses the “common” bag of IV fluids to draw up solution to flush another patient’s IV tube. Unintentional cross-contamination between the two patients occurs.

Healthcare personnel can prevent transmission of infections to patients by adhering to basic infection control principles and aseptic technique. To ensure healthcare workers comprehend and adhere to the recommended CDC (Centers for Disease Control and Prevention) guidelines, educational training programs should include preventive measures, uniform regulation and viral hepatitis surveillance screening. Nurses who impact adverse outcomes are critical to promoting surveillance, professional oversight and preventive measures. Regulating and accrediting organizations, interdisciplinary guidelines, professional organizations and the public are external drivers that influence the quality and safety of nursing care. The CDC has safety guidelines for administering injections. It plans to kick off an educational campaign beginning with the state of Nevada at the end of April with the slogan, “One Needle, One Syringe, Only One Time.” The “AACN Procedure Manual for Critical Care” (5th ed.) supports discarding used supplies and washing hands to reduce the
transmission of microorganisms.

CDC-recommended preventive measures may include:

• Change behavior of healthcare personnel through educational training programs.
• Use adequate hand hygiene.
• Use aseptic technique and avoid cross-contamination of sterile injec-
tion needles, syringes and vials.
• Do not administer medications from the same syringe to multiple patients, even if the needle on the syringe has been changed.
• Sterile injection equipment (needles, cannulae, syringes and vials) are single-use items.
• Do not administer medications from single-dose vials or ampules to multiple patients or combine leftover contents for later use.
• If multi-dose vials must be used, both the needle and the syringe used for accessing the multi-dose vial must be sterile.
• Do not use intravenous solutions in bags or bottles as a common source of supply for multiple patients.
• Store multi-dose vials away from patient areas and in compliance with manufacturer’s guidelines.

1. Thompson ND, Perz JF, Moorman AC, Holmberg SD. Nonhospital health care-associated hepatitis B and C virus transmission: United States 1998-2008. Annals of Internal Medicine. 2009;150(1):33-39.


American Association of Nurse Anesthetists. Safe Injection Practices Education and Awareness Campaign. http://www.aana.com/News.aspx?ucNavMenu_TSMenuTargetID=62&ucNavMenu
_TSMenuTargetType=4&ucNavMenu_TSMenuID=6&id=18396. Accessed February 6, 2009.

Centers for Disease Control and Prevention. Infection Control Requirements for Dialysis Facilities and Clarification Regarding Guidance on Parenteral Medication Vials.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5732a3.htm. Accessed February 5, 2009.

Centers for Disease Control and Prevention. A Patient Safety Threat - Syringe Reuse. http://www.cdc.gov/ncidod/dhqp/PS_SyringeReuseFS.html. Accessed February 5, 2009.

Centers for Disease Control and Prevention. Safe Injection Practices to Prevent Transmission of Infections to Patients. Accessed January 13, 2009.

Lax Needle Use in Clinics Raises Alarm http://online.wsj.com/article/SB123371129728046131.html. Accessed February 4, 2009.

Manning M. New health study focuses on hepatitis spread. Las Vegas Sun. February 4, 2009. http://www.lasvegassun.com/news/2009/jan/06/new-health-study-focuses-hepatitis-spread/. Accessed February 24, 2009.

Safe Injection Practices Coalition. New study confirms cases of unsafe injection practices. Accessed January 27, 2009.

Tanner L. Campaign warns against reusing plastic syringes. http://news.yahoo.com/s/ap/20090205/ap_on_he_me/med_hepatitis_syringes
;_ylt=Ard_O. Accessed February 11, 2009.

World Health Organization. Guiding Principles to Ensure Injection Device Security. http://www.who.int/medicinedocs/collect/medicinedocs/pdf/s4886e/s4886e.pdf. Accessed February 6, 2009.

World Health Organization. Injection safety. http://www.who.int/mediacentre/factsheets/fs231/en/. Accessed February 6, 2009.

http://www.ismp.org/Newsletters/acutecare/articles/20070419.asp. Published April 19, 2007. Accessed January 19, 2009.

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Beacon Corner

‘Strip and Flip’ – One Unit’s Performance Improvement Project

By Sarah Rosenlund, MHS,RN,CCRN
Nurse Manager, CVICU
Saint Alphonsus Regional Medical Center, Boise, Idaho

Using the PDCA (Plan, Do, Check, Act) format for process improvement, the CVICU at Saint Alphonsus embraced new documentation and assessment guidelines. We implemented an initiative to improve computerized documentation in several areas: restraints, suicide precautions and skin impairment. How we adopted a new plan for initial skin assessment, interventions and documentation is the focus of this article. Restraint and suicide precautions were presented at the same time. The staff adopted the documentation project in a fun and engaging way.

Plan – The identified problem was documentation of initial skin assessments on new patients. If a skin breakdown was noted on admission, the nurses needed to document interventions to promote healing and/or reduce the potential for an increase in the breakdown. Posterior (occipital, ears, coccyx and heels) areas were inconsistently assessed for breakdown in the documentation on new patients. The required skin assessment was not always being thoroughly documented, with interventions of the breakdown being noted. The hospital’s Performance Improvement Team and the Education Department put a plan together to train Super Users on each unit, and they became the change champions for assessment and documentation.

Do – The CVICU has a fun work environment, and our Super User
for this project is a very energetic and positive young nurse. At the staff meeting following the Super User training, she presented the information and expectations. She coined the phrase “Strip and Flip” for the assessment. It became a hit, and the staff would ask if “the patients had been stripped and flipped” on admission. Even some of the patients laughed about the phrase. Posters were also hung in the staff restroom.

Check – Our computerized system allows the documentation of the Braden Scores to be audited. Our CVICU has seen an improvement in the thoroughness of the skin assessments and documentation of interventions from these chart audits. They have moved from an 80 percent compliance rate for documentation of the Braden Score of “less than 23 with interventions” in March to 95 percent compliance in April. Since then the unit has been consistently 95 to 100 percent compliant.

Act – The CVICU nurses embraced the plan and adopted it as the unit standard for admission skin assessment, interventions and documentation. We currently have computerized nursing documentation, but will be changing to a new system. This is an example of nurses embracing change and finding their own way to incorporate it in a healthy work environment, for one another and to improve patient outcomes.

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