Lax Needle Use in Clinics Raises Alarm

* THE INFORMED PATIENT
* FEBRUARY 4, 2009

Lax Needle Use in Clinics Raises Alarm
Recent Hepatitis Outbreaks From Reuse of Syringes Spur Efforts to Improve Practices

By LAURA LANDRO - WALL STREET JOURNAL

Getting an injection can hurt, but in the wrong hands it can be a life-threatening experience.

Unsafe injection practices are one of the leading causes of infections in doctors' offices, outpatient clinics and long-term-care facilities, according to the Centers for Disease Control and Prevention. Although most health-care workers are aware of the dangers of reusing needles, other injection guidelines aren't always followed, including disposing of syringes after each use. Contaminated shots can lead to transmission of such diseases as hepatitis and HIV, along with other viral and bacterial infections.
[Needle] APIC

The CDC has long had safety guidelines for administering injections. But outbreaks of hepatitis in recent years have pointed to lax practices at many clinics nationwide. The CDC and private medical groups next week plan to kick off an educational campaign with the slogan, "One Needle, One Syringe, Only One Time." Last year, for instance, six patients contracted hepatitis C after staff reused syringes and medication vials at two Las Vegas endoscopy clinics. As a result, health officials urged some 60,000 patients to get tested for hepatitis and HIV. Lawmakers in Nevada and other states are working on policies to more closely regulate such clinics.

"It isn't that health-care professionals have malicious intent or a desire to shortchange the patient, but they just aren't thinking all the steps through and understanding how they are putting the patient at risk," says Evelyn McKnight, who contracted hepatitis C from a reused contaminated syringe a few years ago while being treated at a private oncology clinic in Nebraska. With funds from the settlement of a malpractice suit, Ms. McKnight, 54 years old, started the nonprofit educational group Hepatitis Outbreaks National Organization for Reform (HONOReform.org). She also co-authored a book about her experience, "A Never Event."

Diseases like HIV and hepatitis can be transmitted if an infected person is given a shot and either the syringe or needle is then reused. Even microscopic backflow into the syringe from the infected person can contaminate it. A health-care worker may replace the needle, thinking that eliminates risk, and then reuse the syringe. Disease also can be passed on if an unclean needle or syringe is used to draw additional medication from a multiple-dose vial, thus contaminating the vial and putting subsequent patients at risk.

"It's really important that we empower patients to ask questions like, 'Is this a new needle and syringe for me? What about this medication vial? Has it been used before and will it be used after me?'" Ms. McKnight says.

Medical experts are mainly concerned about unsafe injection practices at non-hospital facilities, where a growing number of patients receive care. These include pain clinics, surgery centers, radiology clinics, infusion centers and dialysis centers, among others. These facilities are not as tightly regulated as hospitals. Their infection-control standards may be lax, and inexperienced staffers may be allowed to administer injections. The CDC says it is working with regulators and medical societies to emphasize safe-injection practices as part of the accreditation process of non-hospital facilities.
Safer Shots

Unsafe injection practices can transmit infections. Here's how to protect yourself:

* Check that both the needle and syringe are being used for the first time.
* Request a single-dose vial of medicine to avoid possible contamination.
* Consider using clinics affiliated with major hospitals, which are likely to better train workers.

Discuss

* Have you ever been worried about getting an infection at a hospital or clinic, but been afraid to ask if the staff is washing their hands and following other infection prevention practices before treating you? Join the discussion at Journal Community.

Hospitals' biggest infection-control problems center on fast-spreading bacterial infections such as MRSA, a drug-resistant staph infection that can travel on unwashed hands or on hospital surfaces. Although hospitals aren't free of risk from injections, they generally train staffers in safe-injection guidelines. Most have hospital pharmacists prepare injectable medications under aseptic conditions.

For patients, it pays to consider sticking with surgical centers and clinics that are affiliated with major hospitals, which are likely to better train workers and take responsibility for infection control. "You want to make sure that wherever you go for treatment, there are strict protocols for safe injections, and that the staff is following those protocols," says Marcia Patrick, infection-control director for the MultiCare Health System in Tacoma, Wash., and a board member of the Association for Professionals in Infection Control.

The American Association of Nurse Anesthetists raised concerns about injection safety in 2002 after a survey found that one in every 100 health-care workers who give injections reuse the same syringe or needle on multiple patients. Jackie Rowles, the group's president, says it sent letters to thousands of members to warn of the dangers of transmitting disease. Now it is participating in the One & Only educational campaign to reinforce that message. "Best practices that we should know from basic nursing aren't being followed, and there have been some devastating outcomes as a result," says Ms. Rowles, a nurse anesthetist in Indianapolis.

In 2003, there was a series of hepatitis outbreaks linked to outpatient clinics, dialysis centers and long-term-care facilities in various states. The CDC blamed unsafe injection practices and urged health-care providers to educate staff to follow strict guidelines.

But until recently, these outbreaks were seen as "isolated and unusual incidents," says Joseph Perz, a CDC injection-safety expert. That view changed as more outbreaks occurred in the past two years, including the Nevada incidents. "This problem is now squarely in the mainstream, and we have to make sure the basic safe practices are understood by everyone working in health care," Dr. Perz says.

In a study published last month in the Annals of Internal Medicine, the CDC reviewed hepatitis outbreaks in the 10 years ended in June. The study, which Dr. Perz co-authored, found 33 outbreaks in 15 states. These incidents led to more than 60,000 patients being urged to get tested for viral hepatitis, of which 450 people were found to be infected.

In the planned educational campaign, to be tested in Nevada before being launched nationwide, the CDC is working with the Safe Injection Practices Coalition, which brings together professional medical societies, equipment suppliers, patient advocacy groups and others. The aim is to get more health-care workers to follow basic safety guidelines and to let consumers know how they can protect themselves. (To see the guidelines, search for "injection safety" on the cdc.gov Web site.)

Gina Pugliese, vice president of the Safety Institute at hospital purchasing cooperative Premier Inc., says infections can be transmitted in various ways. She says nurses may inject a sterile needle into a patient's IV tubing to flush it with saline solution and then reuse it for another patient, figuring it only came in contact with sterile solution. In fact, the solution could be contaminated with microscopic amounts of disease. "The bottom line is there is no reason to ever reuse a syringe and a needle on multiple patients," Ms. Pugliese says.

* Email: informedpatient@wsj.com.

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