AFPA_Safe_Injection_Presentation__PDF.pdf

Safe Injection Practice

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1. FAMILY PRACTICE PEARLS SAFE INJECTION PRACTICE DR. KAMLESH LALA M.B.B.S.; D.PED, FCGP FAMILY PHYSICIAN NARANPURA AND SHAHIBAG KAMLESHLALA@HOTMAIL.COM
2. HISTORY  Invention of syringes date back to 1848.  It opened a new channel for blood borne diseases  The first recorded outbreak (Later on identified as Hepatitis B) occurred in 1883 following smallpox vaccination.  In 1943, Bigger and MacCalum showed that non sterile injections transmitted a pathogen that caused jaundice..  Disposable syringes came in 1950.
3. MAGNITUDE OF INJECTION PRACTICE • Most common percutaneous health care procedure • India contributes to ~30% of the 16 billion injections administered worldwide per year. • Average number of health care injection per person was estimated to be 3.7 per year • More than 95% injections are given for therapeutic purposes • 5% are given for preventive services including immunization and family planning. • Majority of them are unnecessary (90%) and unsafe (50%) • 63% of injections in India are estimated to be unsafe and nearly 27% of these are due to re-use.
4. Source: WHO South-East Asia Journal of Public Health 2012;1(2):189-200.
5. IS GIVING AN INJECTION NECESSARY ?? According to WHO use injections only when necessary – oral medicines are effective in most cases. Indications for therapeutic injections are 1. Severe and life threatening illness 2. Inability to swallow 3. Profuse vomiting 4. Non availability of effective oral agent 5. Significantly altered absorption pattern 6. The issue of onset of action is clinically relevant only in life threatening illness
6. WHEN INJECTIONS ARE MEDICALLY INDICATED : THEY SHOULD BE SAFE According to WHO definition: Safe injection 1. Does not harm the recipient 2. Does not expose the provider to any avoidable risk 3. Does not result in waste that is dangerous for the community
7. WHAT MAKES INJECTION UNSAFE • Unnecessary use of injection • Needle stick injuries • Unsafe sharp waste management • Re-use of needle and syringe • Recycling of used equipment
8. In India, this problem is complex and multifactorial due to • The lack of awareness, • Social commitment • Lack of availability of sufficient resources in health care settings. • This problem is quite intense in the rural areas.
9. THE FIRST SAFE INJECTION INITIATIVE BEGAN ALMOST MORE THAN 100 YEARS AGO.
10. RISKS: • Unsafe injections place recipients and provider at risk of disease, disability and death. • Can cause injuries and toxicities when wrong injection site, drug, diluent or dose is used. • The risk of transmission of infection after injury with contaminated sharps is: 1. 1:3 workers for HBV 2. 1:30 for HCV 3. 1:300 for HIV • HBV persists for up to seven days on surfaces.
11. RISKS: Apart from HBV, HCV and HIV transmission, other complications are: 1. Transmission of other viral, bacterial, fungal or parasitic infections 2. Vaso vagal shock 3. Drug toxicities including Anaphylaxis 4. Injection abscess and infections 5. Nerve injury
12. MAGNITUDE It is important to note that symptoms of HBV and HCV sometimes do not appear and risks are unappreciated until ten or more years after infection, so many more patients may have been infected but are not yet aware of their condition. For example, an assessment of injection practices in India found that nearly one third of all injections carried a potential risk of transmitting a blood borne pathogen.
16. WHAT IS INJECTION SAFETY? Injection safety includes practices intended to prevent transmission of infectious diseases • Between one patient and another • Between a patient and health care provider • Prevent harms such as needle stick injuries
17. SAFE INJECTION PRACTICES INVOLVE • Ensure universal precautions irrespective of infectivity of patient and assuming all body fluids infectious. • Use of sterile single-use needles and syringes for each procedure. • Prevention of any form of contamination to the medication or vaccine to be injected. • Prevention of sharps injuries and • Appropriate waste disposal to prevent reuse of needles and syringes.
18. CHARACTERISTICS OF UNSAFE INJECTIONS (63% of all injections are unsafe – All India) CAUSE Percentage Wrong Habits of Injection Givers 54% Questionable Sterility 24% Reuse 22%
19. PRACTICES THAT CAN HARM RECIPIENTS (SELECTION OF EQUIPMENT) • Involves issues like sterilization, storage and handling • Reusing syringe or needle for giving injection, for reconstitution of medication, or withdrawal from a multidose vial • Improper selection of length and bore of needle • Changing the needle but reusing the syringe.
20. PRACTICES THAT CAN HARM RECIPIENTS (STERILIZATION ISSUES) • Sterilization without supervision or monitoring with time, steam and temperature indicators. • Attempting to sterilize and reuse syringe. • Attempting to sterilize injection equipment without prior cleaning. • Boiling injection equipment in an open pan. (Still done by dentists) • Using only disinfectant on contaminated equipment to prepare them for reuse.
21. PRACTICES THAT CAN HARM RECIPIENTS (MEDICATION PREPARATION ISSUES) • May be • Before Opening • During Opening • After Opening
22. PRACTICES THAT CAN HARM RECIPIENTS (MEDICATION PREPARATION ISSUES) Before Opening • Unsafe environment • Error in selection of type of medication • Not checking medication vial label and expiry date • Wiping the stopper with antiseptics (Use only spirit and allow it to dry) • Medication should be drawn up in a designated clean area. • Do not reconstitute it till the person to be immunized is ready
23. PRACTICES THAT CAN HARM RECIPIENTS (MEDICATION PREPARATION ISSUES) During Opening • Use of Incorrect diluent. (Diluents are vaccine specific) • Use of incorrect quantity of diluent. • Carelessly breaking the ampoule so as to injure oneself. • Mixing two partially opened vials of same vaccine. • Loading syringe with multiple doses and injecting multiple persons. • Mixing more than one medications in the same syringe. • WHEN IN DOUBT, THROW IT OUT
24. PRACTICES THAT CAN HARM RECIPIENTS (MEDICATION PREPARATION ISSUES) After Opening • Keeping freeze dried vaccines more than six hours after reconstitution. • Leaving a needle in the vial to withdraw additional doses. • Handling of Multidose vial (use new needle every time even if it has not been used) • Opened vial submerged in water.
25. PRACTICES THAT CAN HARM RECIPIENTS (MEDICATION PREPARATION ISSUES) • Not following product specific recommendations for use, storage and handling, especially vaccines. • Single dose vial used for multiple patients. • Multidose vial when punctured, should be discarded within 28 days. • Always consider IV tubing, syringe and other components as a single inter connected unit. • Even if no blood is seen in IV tubing or syringe, they are always considered as contaminated.
26. INTRAMUSCULAR INJECTIONS There are 24 potentially critical steps in giving an injection have been formulated by steering group of WHO and has drawn an evidence based guidelines to make injection safer
27. INTRAMUSCULAR INJECTIONS 1. Environment (clean designated area) 2. Preparation of Injection Equipment, Needle size, Air bubble, Wiping the needle 2. Position 3. Proper hand washing and Site preparation (cleansing) 4. Technique 5. Measures to alleviate discomfort and pain 6. Procedure: Insertion of needle, aspiration, pushing the medication 7. Withdrawal of syringe 8. Multiple injections 9. Post injection (Applying pressure to bleeding site with cotton or finger)
29. PRACTICES THAT CAN HARM RECIPIENTS (PATIENT) • Giving vaccines in buttocks. • Giving injection to infants in gluteal region • Touching needle with finger while injecting (Use as a support) • Dividing the dose of same vaccine.
30. PRACTICES THAT CAN HARM RECIPIENTS (SOMETHING UNUSUAL) I have seen the ward boy in one so called multi specialty hospital injecting the patient and taking sutures. 1. Mixing tetanus toxoid and diclofenac in the same syringe. 2. Tetanus toxoid was not stored in refrigerator. 3. Giving that injection in gluteal region. (Vaccines are never ever to be given in gluteal region). 4. Took a previously used skin stapler lying in the open tray and took sutures. Just see how many issues have been compromised???
31. PRACTICES THAT CAN HARM HCW OUR MAIN AIM IS TO PREVENT SHARP INJURIES Magnitude of Sharp Injury (Needle Stick Injury-NSI): Considering it on an individual basis, according to WHO, it ranges from 0.93 to 4.68 injuries per person per year in developing countries as against only 0.18 to 0.74 in developed countries. Majority of sharp injuries occur between completing the procedure and disposing of the device.
32. NEEDLE STICK INJURIES According to a study by the trauma center of AIIMS, Delhi Doctors were found to have the highest exposure to needle stick injuries (36.2%), followed by nurses (14.6%) and hospital waste disposal staff (7.6%)
33. PRACTICES THAT CAN HARM HCW OUR MAIN AIM IS TO PREVENT SHARP INJURIES • Skin integrity is compromised by local infection or weeping dermatitis. (cover any small cut with water proof adhesives or wear gloves) • Moving around with a filled or used syringe in the hand. • Accidental injury while giving injection (Beware of unusual and abrupt movement by a child or patient)
34. PRACTICES THAT CAN HARM HCW OUR MAIN AIM IS TO PREVENT SHARP INJURIES • Trying to recap, bend or manually remove the needle from the syringe after use. • Reaching into a mass of used equipment (For cleaning or sorting waste) • Sharp container is kept at a distance from place of procedure. • Quality and standard of sharps container.
35. NEEDLE STICK INJURY • Do not accept it as apart of job. • Imparting knowledge is not enough. • There is a need to change the behavior of both service provider and patients. • The risks can be drastically reduced by 84-100% through IEC, safer working place and using newer technology. • Minimum handling of injection equipment is key to preventing sharp injuries. • Use of Needle cutter and burner has been made mandatory by law.
36. NEEDLE STICK INJURY DO’S AND DON’S AFTER NSI
37. PRACTICES THAT CAN HARM THE COMMUNITY (OTHER PROBLEMS BEYOND CONTROL) • Discarding and dumping used injections in public places by drug users. • Home injections for diabetes, cancer, AIDS, osteoporosis etc. • SMBG by diabetics • Children, home health care providers, sanitation workers, rag pickers are at a risk of sharp injury. • Giving or selling used syringes to vendors who will resale them.
38. PRACTICES THAT CAN HARM THE COMMUNITY (OTHER PROBLEMS BEYOND CONTROL)
40. DO’S AND DON’TS SAFE DISPOSAL OF NEEDLES AND OTHER SHARPS USED AT HOME, AT WORK, OR WHILE TRAVELING Do • Immediately place used needles and other sharps in a sharps disposal container to reduce the risk of needle-sticks, cuts, or punctures from loose sharps. • Keep all needles and other sharps and sharps disposal containers out of reach of children and pets • Be prepared — carry a portable sharps disposal container for travel.
41. DO’S AND DON’TS SAFE DISPOSAL OF NEEDLES AND OTHER SHARPS USED AT HOME, AT WORK, OR WHILE TRAVELING DON’T throw loose needles and other sharps into the trash. DON’T flush needles and other sharps down the toilet. DON’T put needles and other sharps in your recycling bin -- they are not recyclable. DON’T try to remove, bend, break, or recap needles used by another person.
43. SHARPS CONTAINERS All sharps disposal containers should be: • made of a heavy-duty plastic • able to close with a tight-fitting, puncture-proof lid, without sharps being able to come out • upright and stable during use • leak-resistant • properly labeled.
44. Priced at Rs. 2000/= Priced at only Rs. 60/= only small, portable, bedside, economic
45. Be assure to manage home sharps waste in an efficient, safe and environmental friendly way.
46. WHAT TO DO IF NO SAFETY BOX IS AVAILABLE If safety boxes are not available, • Strong cardboard boxes, metal cans or thick plastic containers may be used. • Collect needles and syringes and transport them to a site where they can be properly treated (buried, incinerated or autoclaved and shredded). • Containers should be sealed when they are three-quarters full. • They should not be reused once filled. • Emptying sharps containers for reuse increases the risk of accidental needle-stick injuries and infections.
52. REUSE OF SYRINGES May be Downstream Re-use or Intentional Re-use Downstream Reuse – After not properly discarding the syringes by the injection giver, someone else takes it for reuse. • Improper Disposal • Picked up by rag pickers • Sold to scrap dealers • Cleaned, Disinfected(?), Repacked • Resale in the market
53. REUSE OF SYRINGES Intentional Re-use Injection giver intentionally brings about reuse of the syringe • Lack of knowledge, education and awareness. • Ignorance and misconception • Altruism- disinterested and selfless concern for the well being of others • Lack of resources and corruption • Monitory gain "Most healthcare workers who do reuse syringes are really decent people, but the system forces them to."
54. PREVENTING RE-USE To prevent Re-use of syringes, imparting knowledge is not enough. There is a need to change the behavior of both service providers and their patients. In February 2015, the WHO issued a policy that urged all nations to switch to the use of "smart" single-use syringes by 2020. These are syringes that are specifically engineered to prevent their re-use. The transition could potentially help save millions of lives.
55. PREVENTING RE-USE In India needle cutting and/or burning is made compulsory by law. It can be manual or electrical and available for anything between Rs. 200 to 2000.
56. WHO RECOMMENDED INJECTION TECHNOLOGY Newer technologies help professionals immensely in their endeavor towards safe injection practice. It prevents both downstream and intentional reuse. 1. Auto Disable AD syringe 2. Re use prevention RUP syringe 3. Prefilled injection devices. 4. Safety syringes with retractable needles 5. Vacuum based technology for blood collection
57. WHO RECOMMENDED INJECTION TECHNOLOGY Auto-disable syringes: Auto-disable (AD) syringes automatically become disabled after one use. After the plunger is depressed past the point of safety, it cannot be pulled backwards for reuse. These are in use across the globe post a joint endorsement by WHO, UNICEF and UNFPA.
58. WHO RECOMMENDED INJECTION TECHNOLOGY Re-use preventive syringes (RUP): RUP is mechanically similar to the AD syringe. RUP syringes are disposable syringes with self-locking mechanisms that allow only one use.
59. WHO RECOMMENDED INJECTION TECHNOLOGY SYRINGE WITH RETRACTABLE NEEDLE The needle automatically retracts into the syringe and plunger rod, allowing safe and compact disposal.
60. WHO RECOMMENDED INJECTION TECHNOLOGY SIP + RUP retractable syringes: Once the plunger is fully pressed, the plunger mechanism locks into the needle unit. When the plunger is pulled back, the needle also gets pulled back into the syringe barrel, enclosing the used needle. The needle shield protects others from accidental needle sticks and prevents reuse of the syringe.