Dangerous needle/syringe injection practices by healthcare workers ? such as the reuse of syringes to withdraw medication from a container that was used for other patients ? have resulted in 130,000 patients being notified they were at risk of infection with viruses or bacteria over the last decade, according to a report from the Centers for Disease Control and Prevention.
Additionally, "a survey of healthcare providers who prepared and/or administered parenteral medications (revealed that) nearly 1% have reused a syringe directly from one patient to another. Such dangerous practice may stem from the misconception that changing only the needle is sufficient to prevent disease transmission," the study said.
These events, the authors found, "may represent a small fraction of a larger problem." The article is published in last week's journal Medical Care.
Alice Guh, MD, medical officer in the CDC's Division of Healthcare Quality Promotion, says CDC and state health officials the agency worked with to gather the data, don't have a good idea how extensive unsafe injection practices are, nor how many patients were infected because of them. There is no formal system for tracking patient notification events, although CDC has kept records for those it helped to investigate.
That's because it's unclear how many of these unsafe practices have been noticed or reported. When they are, the process of notifying patients does not always find them. If the patients are found, not all seek testing and if they do seek testing, they may choose not to get back to the notifying health provider whether they were infected.
"I honestly don't know," says Guh, principal author of the report. "There is a part of me that wonders if this is the tip of the iceberg."
Healthcare workers "are not waking up and saying, you know, I'm going to go and intentionally, deliberately re-inject a syringe," Guh says. "A lot of it comes down to providers or clinicians doing what they observed others doing or what they had been taught. We find that people say, 'Well, this is how I was taught to do it,' and so they continue doing it that way."
Guh's study looked at events that resulted in communicating to groups of patients about the possibility they were infected with a bloodborne pathogen stemming from an unsafe injection practice between 2001 and 2011.
The researchers said they identified 35 patient notification events in at least 17 states and the District of Columbia. And nearly three in four occurred since 2007, including all four of the events involving more than 5,000 patients.
The number of patients involved in each ranged from as few as 25 who were injected with an influenza vaccine with a syringe that had been reused between patients in New York, to 8,690 ambulatory surgical center and hospital patients in Colorado and New York who received fentanyl from a provider who had reused syringes, to 63,000 patients of ambulatory surgical centers (single purpose endoscopy clinics), who received propofol through syringes that contaminated medication vials in Las Vegas, NV.
Nearly two-thirds of the events involved identified hepatitis B or hepatitis C transmission. "The primary breach implicated was accessing shared injectable medications with reused syringes (at least 16 notification events)," their report said. "However, overt reuse of syringes or insulin pens from one patient to another was also identified (at least 12 notification events), including the reuse of prefilled syringes to administer influenza vaccine or botulinum toxin."
The substances in the syringes ranged from saline flush and vitamin C and B12 to lidocaine, insulin and unspecified anesthesia medications.
Guhn says that officials for the CDC and various state health agencies that investigated the incidents "were surprised at the magnitude of patients who were potentially exposed," however she quickly added that it was not a surprise in terms of knowing that unsafe injection practices have occurred, and still occur today."
Several national campaigns, such as the CDC's "One and Only," are under way to educate healthcare providers about safe practices. And last July, the CDC launched an Ambulatory Care Safety campaign and Healthcare Provider Toolkit.
The CDC investigation also highlighted the special vulnerability of ambulatory care settings, which do not have the same level of infection control infrastructure or licensing requirements as hospitals, Guh says. CDC is trying to work with the Centers for Medicare & Medicaid Services to tighten the link between CMS certification of ambulatory care centers eligible for federal reimbursement, and certain infection control quality criteria.
"Working with CMS, we're also trying to think of ways to provide financial incentives and disincentives to facilities to ensure that appropriate infection control practices are implemented. We're trying to be creative, for example working with partners like malpractice insurers, to engage them in the dialogue." That could lead to requirements that healthcare organizations provide assurance or documentation that their workers are taking necessary infection control courses, she says.
"There's a lack of resources in many of these settings compared to acute care settings," Guh says.
She emphasizes that she does not think the number of patients who will be notified that they were potentially infected will go down in the short term, in fact, she thinks it will increase because of increased awareness.
Better education of healthcare providers not to reuse syringes will result in better detection of those who are unaware of appropriate practices.
"People are going to be more in tune to what they're observing and will be more likely to pick up when there is a potential lapse," Guh says. "And that tends to increase detection of potential outbreaks and associated notification of them."