Welcome to safe injection practices. In this module, we will examine the unsafe injection practices that have led to large outbreaks of blood borne pathogens. Then we will examine the recommended best practices for safe injections and blood glucose monitoring. Followed by a review of some of the contributing factors that lead to the misuse of injection equipment. Finally, the one and only campaign, a response to the increasing number of outbreaks related to unsafe injections will be highlighted. The consequences of outbreaks are devastating sometimes resulting in patient illness and deaths. Outbreaks can also result in notifications of many potentially exposed patients, causing considerable psychological impacts. Outbreaks can also result in loss of licenses, legal charges and malpractice suits and criminal charges. Since 2008, the C D C. Has identified 50 outbreaks related to unsafe injection practices during the delivery of injectable medications. These outbreaks have resulted in hundreds of infections. In addition to those infected during this period, there have been over 150,000 patients potentially exposed to infection as a result of poor practices. Since 2008, there have been 15 recognized outbreaks related to the assisted monitoring of blood glucose. Those outbreaks resulted in over 1300 notifications and over 100 incident infections of all viral hepatitis outbreaks in LTC facilities. Those associated with the assisted monitoring of blood glucose accounted for almost 80%. The big four causes that lead to these outbreaks are, syringe reuse either directly or indirectly inappropriate use of single dose or single use vials failure to use aseptic technique. The fourth major cause is unsafe diabetes care. Specifically, the assisted monitoring of blood glucose outbreaks often involve more than one of these breaches. Up next. Watch the reality competition. The technique to learn the dues and don't of safe injections and glue, commoner care. [MUSIC] >> Rejects >> Show me the technique. Contestants from around the country. [MUSIC] One great process this seat on the technique. [MUSIC] >> [APPLAUSE] Welcome everyone. >> I'm Rob Marino and welcome to the technique. After last season's record shattering finale, we're in for a second stellar season on the technique. Where contestants try to prove they've got the best injection safety and glue commodore care skills in their field ,to earn themselves the coveted Mcknight Trophy. >> The Mcknight Trophy honors Evelyn Mcknight whose personal experience motivated her to bring attention to and advocate on behalf of safe injection practices. Dr Mcknight was infected with hepatitis C virus. HCV while battling a recurrence of breast cancer in 2000. In total, 99 residents at the same oncology clinic became infected with HCV when their provider failed to follow safe injection practices for years. This was the largest known health care associated outbreak of HCV in U S History. >> Let's not let that happen again. Judges are we ready for our first contestant? [MUSIC] So tell me Kim what does it mean to you to be appearing on the technique. >> OMG I'm on television. Okay, breathe and breathe okay Rob. It means everything to be on the technique. >> My boyfriend and I drove in from Oklahoma to be here. And I practice my safe injection techniques on in the hallway in the car. Well, if that isn't a dedicated boyfriend, I don't know what is. >> So tell me what's your specialty back in Oklahoma. >> [LAUGH] Well to be honest I've been shadowing my mentors at the nursing home and staying late at night post shift and learning the more unusual techniques. And you know, getting my performance up to speed. >> Well, let's see if Kim's night shifts have been paying off for her and her boyfriend. [MUSIC] >> Let's pick out rising stars in the safe injection category. >> Confidence energy attitude. That is what I am looking for. >> It looks like showmanship is really going to make a difference in today's tryouts Jean. >> What are you looking for in our hopefuls? >> Rob ,What we're really looking for today is safe injection practices. So that's what I'm going to make sure we're going to focus on now. I'm not denying that energy and attitude aren't important. But I'm looking for essential technical practices that can make the difference between life and death. >> Let's take a closer look at the judges criteria for our contestants today. >> CDC, reminds healthcare personnel of the following practices that are critical for residents safety. Now we will be looking for strict adherence to these practices from our contestants today. Never administer medications from the same syringe to more than one resident or to the same resident at another time. Even if the needle is changed or you are injecting through an intervening length of IV Tubing. Needles and syringes are single use items. Do not enter a medication vial bag or bottle with a used syringe or needle. Never use medications packaged as a single dose or single use for more than one resident. This includes ampules bags and bottles of intravenous solutions. Always use strict accepted technique when preparing and administering injections. >> So there it is folks, one needle, one syringe, one time use and only one person. >> So Kim from Oklahoma. What do you have in store for us today? >> Hi Stephan Minerva. >> Today I am going to show you proper usage of a single use vow. >> Let's bring out our residents for Kim. They're beautiful. >> She's carefully reading the order. She sees the single dose vial. He's doing great so far. You can see she's really thinking through the steps before she performs. Here she goes The hand hygiene looks good, spending the appropriate amount of time with the hand sanitizer product rubbing. And now she's put on gloves, she's putting on the gloves. Next, here we go. She's disinfecting the rubber septum with alcohol prior to piercing it. Aseptic technique looks great, preparing the clean needle and syringe. That's appropriate entrance to the vial with the needle Okay, she's administering the injection. Very nice. Looks like the judges agreed too. >> She's smiling, she knows she nailed it. >> And she's disposing of the injection equipment properly. >> What is she doing? >> Wait a minute. She is keeping the syringe and starting up the same single dose files. No, Manasteras. [SOUND] >> Kim. I'm sorry, but some rookie mistakes here. Clearly, you intended on using the same syringe on the next resident. And you were intending on using the medicine from the same vial. >> Yeah, I'm going to have to agree with Stefan on this one. That is unacceptable. One needle, one syringe only one time. You do not have the technique. >> Kim you've got some great techniques down but you still have a lot of work ahead of you. Now, you must remember that after you use them, the syringe and the needle are both contaminated and must be discarded. You always use a new syringe and needle for each resident. >> What a disappointing turn of events for Kim from Oklahoma. But the road to the winner's circle is just beginning. [MUSIC] Fly high and fly. >> Cut. Seeing your auditions are down the hall. [MUSIC] >> Perhaps I spoke too soon. But I've got a great feeling about this next contestant. Jennifer was actually at the auditions last year but tripped and sprained her wrist on the way up to the stage. >> Ever since that fateful moment when I broke my wrist, I knew that proper aseptic technique was going to be the area I really scored well in. Spending the correct amount of time washing and then gloving properly. I have this competition in the bag. [APPLAUSE] My name is Jennifer Abrams and I'm from Spring Lake nursing home in Charleston south Carolina. >> Jennifer, let's see what you've got. >> Hand hygiene looks good, spending the appropriate amount of hand rubbing. Donning the gloves. Her aseptic technique looks good. [SOUND] She's not preparing the syringe and the needle. [SOUND] >> I'm not sure if she's got to get them out of use file. We've set that up it's a tricky trap. [SOUND] >> The judges have thrown her a curve ball, it's a multi dose vial. Let's see how she handed. [SOUND] >> She didn't label it too late. >> Jennifer. She just set that vial down without labeling it. That's going to cost her. Is it enough of an error though to keep her from advancing to round 2? Tell me, Jennifer what type of vile you're using and what should you have done after opening and assessing it the first time. >> Stefan, it's a multi dose vial and I should have used the 28 day beyond use date. I can't believe I forgot to do something so simple. >> To be perfectly honest, you should have noticed that first thing. But you did dispose of the injection equipment properly and the gloves, which shows you're no spring chicken to this in house. >> Stefan, you and your chickens can go back to [INAUDIBLE]. >> Whoa, you're right. She had very good hand hygiene after disposing of the equipment. I say bravo, Jennifer love it. >> But forgetting to label that vial is not something to overlook. I mean, it's important that she labels each multi use vial with a new expiration date. She made an error right off the bat. >> For anyone not familiar with labeling multi use vials, the expiration date is 28 days from the date it was opened in first access. Unless a shorter time is specified by the manufacturer. It's kind of like my self tanning lotion. >> So, what do we think gang is her failure to label the vial properly enough to cost her advancement into round 2? >> I say she passes, a girlfriend nursed herself back to health after a broken wrist and she's brought her a game. Even if there was a slight oversight which she recognized. >> I hear what you're saying but an error is an error. I have to say No. >> True Jean, but I have to go with Minerva on this one. >> My gut says advance. Congratulations Jennifer, you're going on to round 2. [SOUND] >> What do the judges have in store for them next? Find out tomorrow night as we continue with round one of the technique. [SOUND] >> Though it seems unimaginable, health care providers have some knowledge gaps surrounding contamination and have reported syringe reuse. Direct syringe reuse just as it sounds, involves the use of a single syringe for multiple patients. This includes reuse of insulin pins, administering medication through intervening lengths of tubing with the same syringe. Or administering vaccines to multiple patients after changing the needle but reusing the syringe. Direct syringe reuse does happen. But the most common cause for these large hepatitis outbreaks, is indirect reuse or double dipping. This happens when a used contaminated syringe, is used to re enter a vial or bag that is a common source for multiple patients. Previous outbreaks and notification events, have shown that some dangerous misperceptions surrounding safe injections exist. Some providers believe that changing the needle makes a syringe safe for reuse. False, backflow from the injection can contaminate the syringe. Another misperception, is that syringes can be reused if there is a sufficient length of tubing between the patient and the injection site. False, everything from the medication bag to the patient's IV Catheter is a single interconnected unit, distance from the patient, gravity or even infusion pressure. Do not ensure that the syringe will not become contaminated. Lastly, some providers might think that the lack of visible blood means the supplies are safe for re use. Again, this is false. Pathogens like HIV and Hepatitis B and C can be present in sufficient quantities to cause infection without blood being visible. An easy rule to remember is this, once a needle and syringe are used, both are contaminated and must be discarded. A single dose vial lacks antimicrobial preservatives to prevent bacterial growth. It should be discarded after a single use even if there is leftover medication. A multiple dose vial has antimicrobial preservatives to prevent bacterial growth and can be used for more than one patient. Multiple dose vials should be discarded when the beyond use date is reached, when doses are drawn in patient treatment areas and when sterility of the vial is in doubt. Intravenous fluids are for single patient use and should not be used for more than one patient. Just like single dose vials, these fluids lack antimicrobial preservatives to prevent growth of contaminating bacteria. The CDC restated its position on the use of single dose, single use vials in 2012. The CDC stated that vials labeled by the manufacturer as single dose or single use should only be used for a single patient. Ongoing outbreaks, provide ample evidence that inappropriate use of single dose single use vials can cause patient harm. Leftover parental medications, drugs given by injection or infusion should never be pulled or stored for later administration, and in times of shortage medications can be repackaged only if it's done in accordance with established standards. Let's get back to the technique and see how the contestants are doing. >> Three judges. Show me that technique. >> Contestants from around the country. One great price, this seat on the technique. >> Hi folks and welcome back. I'm Rob Marino and this is the technique. Last night we watched Jennifer from Charleston squeaked through the first round after failing to label her multi use vial and Kim from Oklahoma had to turn her car back home after a disastrous attempt to use a single dose vial on to residents. What does tonight's continuation of round one have in store for us? >> Hi, I'm David and I'm from Sunnyside Nursing home and I'm going to win the technique. >> David, loving the confidence today. What does the audience not know about you going into these auditions? Well, Rob, this is my second time competing. I made it at the top two last year, but my grandma got sick and I knew that my perfect techniques were needed more at home than on TV. I love you grandma. >> What a touching story. And is your grandma watching you on the TV this time round? >> Yep, the nursing home that she's in the air, the technique in the main lobby for all the residents to cheer me on. They've seen me personally in action. >> [APPLAUSE] >> And tonight they're ready for me to win. >> Touching story. Now, let's see if David can perform like he promises. >> So, David, you can begin when you're ready. >> His conference. He sees the multi dose vial and labels it at the get go. He knows his 28 day rule. >> Rob, I am loving him already. I agree, hand hygiene is looking great and good amount of time with the hand rubbing. >> Strange. He got another pair. He did. Yeah, I'm rubbing the rubber septum with alcohol for at least 10 seconds prior to drawing up the medication. Now I'm administering the injection, And now I'm disposing of the injection equipment properly. >> And you have no intention of using the multi-use file on another resident. Never, well, way to go, Minerva. Why don't you tell him exactly what to say? >> Yes. I have to say, I wished he had said that on his own. >> But his technique speaks to his knowledge of not sharing multi use vials whenever possible. >> David, can you tell me correct protocol if multi-use vials need to be used on more than one resident? >> Not only can I tell you, I can show you. Let's get the camera on this. The multi-dose vial should always be stored and accessed into clean, dedicated area for medication preparation, and never in the immediate resident treatment area, or a resident room. This is to prevent inadvertent contamination of the vial through direct or indirect contact with potentially contaminated surfaces or equipment that could lead to infections in subsequent residents. Now, if a multi-dose vial enters the immediate resident treatment area, it should be dedicated to the resident only, or discarded after use. In addition, a new sterile needle and syringe should always be used to access the medication and multi-dose vial. Because the reuse of needles or syringes to access multi-dose vial medication can result in contamination of the medicine with microbes that can spread to others when the medicine is used again. >> Well, Jean, satisfied there? >> [APPLAUSE] >> David, I think it's safe to say here on around you. And one last contestant. A late arrival from New York city Amber. >> My name is Amber. And I'm from zebra nursing home in New York city. >> Amber, great. Why don't you begin? >> Mm-hm. >> Right hand hygiene. >> [INAUDIBLE] >> It's definitely up out of the way. It's something familiar about how she did the gloves. Don't you think? >> She reminds me of someone. >> So far so good. >> Well, at least she's hygienic. [SOUND] >> Amber, are you missing something? >> I don't think so. >> Amber, I'm sorry, but you just left the needle in the vial. That's an immediate fail. And not to mention that it's a single use vial, which is another indication of your inability to practice the technique. >> Wait just a second. This looks like a very sloppy performance that we saw earlier in the day. Is that a wig? >> Is this Kim? >> Are you trying to cheat your way onto a spot on the technique? >> I can't even deal with this. Get off our stage immediately. Rob, what happened to screening the contestants first? >> Join us next week as our contestants hone their skills for round 2. Where the technique will turn its focus to glue commoner care. I'm Rob Marino and this is the technique. [SOUND] >> Failure to use aseptic technique when preparing medications, is another major cause of outbreaks relating to unsafe injections. In this context, aseptic technique means handling and preparing supplies used for injections in a manner that prevents microbial contamination between the injection materials and the non sterile environment. Failure to use aseptic technique was due to the following infection control breaches. Lack of hand hygiene, failure to establish a clean medication area and the preparation of medications in areas with visible blood contamination. Use of a common use saline bag and reuse of single dose vials for multiple patients. Now, let's watch the exciting conclusion of the technique. >> Show me that technique. >> Contestants from around the country. [MUSIC] One great price. [MUSIC] This week on the technique. [MUSIC] Hi guys, I'm Rob Marino and welcome back for the second round of the technique. It's been rough for a few contestants but we've got some definite frontrunners and David, Jennifer, and Sarah. Tonight we'll be focusing on safe blood glucose monitoring and insulin administration. [MUSIC] >> All of the contestants that made it through really showed their chops last week. And tonight we are observing their technique in providing safe blood glucose monitoring and insulin administration. And I tell you I can't wait. >> Gene for all the folks at home, can you remind us what the judges will be looking for in this round? >> Sure Rob. The CDC wants all health care providers to know these simple rules for anyone who performs or assists with blood glucose monitoring and insulin administration. There are two types of finger stick devices, those that are designed for reuse on a single person and those that are for single use and disposable. The simple rule is, finger stick devices should never be used for more than one person. Now, these are devices that measure blood glucose levels. Whenever possible, these meters should be assigned to an individual person and not shared. Now, if they are shared, they must be cleaned and disinfected between each use according to the manufacturer's instructions. Insulin can be administered using an insulin pen designed for reuse on a single person. It can also be administered using a needle and syringe after drawing it up from an insulin vial. The simple rule here is, injection equipment like insulin pins, needles, and syringes should never be used for more than one person. Just like with safe injection practices, it is always important that we see these folks perform hand hygiene before putting on gloves and providing care. And again, after removing gloves between residents. It is also important that they maintain the equipment in a clean way, so that blood contamination does not occur. >> Great Gene. Thanks for the recap. Our contestants sure have a difficult test coming up. Our first contestant is Sarah. Before we let her show her technique tonight, let's recap her performance from round one last week that put her through to the second round. [MUSIC] >> Impeccable performance. Absolutely flawless. >> A real challenger for the trophy. >> On the heels of that impeccable performance, it's Sarah. Sarah's starting off strong again, great hand hygiene and glove use. [SOUND] Interesting choice. She picked up the reusable lancing device to pierce the residents finger. [SOUND] Looks like she's finished with the first resident and is moving on to the next one. But wait, she didn't clean the glucose meter and is planning to reuse the lancing device in the next resident, that is not good. >> Rob I've seen enough, stop. Stop. [SOUND] You have just committed to serious errors here. By not disinfecting the glucose meter with an EPA approved disinfectant. And you are about to use the same lancet device on the next resident. You've certainly fallen from the pedestal we put you on. >> I've really had high hopes for you. But clearly you need some practice on your technique. >> I'm sorry, Sarah. You do not have the technique. >> Those are the highs and lows of this competition. You've got to bring your A game every day if you want to make it through the final judgment. >> [APPLAUSE] >> That brings us to our next contestant, Jennifer. You all remember her. She barely made it out of the first round with a split decision from the judges. Let's see if she can change her fortune tonight. Ladies and gentlemen, I give you Jennifer. >> [APPLAUSE] [MUSIC] >> I tell you a good septic technique again. [SOUND] See how smoothly her gloves go on. >> Much better than some of the earlier ones today. >> [SOUND] Awesome. >> [SOUND] Looks like the judges really want to test Jennifer today after her last performance. They've given her an insulin pen. [SOUND] This will require real attention to detail. [SOUND] Really moving through these steps. [SOUND] Did You see two talents at once? That's brilliant. >> [SOUND] Mm-hm. >> [SOUND] She's doing a great job selecting a single use lancet. >> [SOUND] Very nicely done there. >> [SOUND] She's checking the blood sugar. [SOUND] This is so nice to watch when it's done, all right? >> [SOUND] She's properly disposing of the lancet in a puncture proof container I might add. >> [SOUND] Disinfecting the meter. [SOUND] Now she's getting ready to inject the resident. >> [SOUND] Very nice. >> Mm-mh. >> [SOUND] Great job. >> Mm-hm. Great, feel it. >> [SOUND] Okay, here she goes. >> [SOUND] Love. >> [SOUND] Sweet. >> And the resident didn't even move. >> No. [SOUND] When it's done right it's wonderful. >> It's like music. >> [SOUND] This is beautiful. >> Yes, we could have charged admission. >> [LAUGH] >> Very nice. >> [SOUND] Yes. >> [SOUND] Great job. [SOUND] When she recognized the insulin pen and correctly labeled it with the resident's name. >> And she obviously knew that the insulin pen cannot be shared between residents. Beautiful. Absolutely beautiful. [SOUND] Great job. >> So strong. >> [APPLAUSE] >> I have no words, but excellent. >> [APPLAUSE] >> So very strong. Right here. >> I am so happy that you recovered from last week. Can you tell me why you chose to label the insulin pin? >> Sure, I always think be aware. Don't share. Just like with other injection equipment. Insulin pins are meant for use from a single personality and should never be used for more than one person even if the needle is changed. Insulin pin should be clearly labeled with the resident's name or other identifying information to ensure that the correct pin is used on the correct person. >> Jennifer, brilliant performance. You're moving on to final judgment. >> [APPLAUSE] >> Yes. [MUSIC] >> [APPLAUSE] >> Great job, Jennifer. Well, we're down to one final contestant before final judgment. Last week, David demonstrated tremendous skill with his ability to perform safe injections. Can he keep the momentum going? Will he be able to make final judgment? David take it away. >> [APPLAUSE] [SOUND] >> Interesting. David is beginning by cleaning the glucose meter. >> [SOUND] Mm-hm, and now he is washing his hands. >> [SOUND] Great job. [SOUND] And putting on a clean pair of gloves. A solid start. >> [SOUND] Wow, I like the fact that he's using the single use lancet to perform the finger sticks. >> Mm-hm. >> It's good stuff. >> [SOUND] All right, he's done with the first resident. [SOUND] He's disinfecting the glucose meter again. [SOUND] Remove these gloves, and it's performing hand hygiene. >> David, please you can stop right there. Thank you. >> Boy, you look good tonight. >> [LAUGH] >> Minerva. >> [LAUGH] [APPLAUSE] >> I'm in his performance. >> [APPLAUSE] >> David, I really liked the fact that you took the time to disinfect the meter before you started. Can you tell me why you did that? >> I wasn't the last person to use the meter, so I can't be certain that it was clean before now. I cleaned it because the meter may be contaminated with blood, even if it is invisible to the eye and I don't want a resident to get hepatitis or some other germ or. >> Since you seem to have a firm grasp on this. >> Not, firm, so. >> What would be the best practice for facilities regarding glucose meters? >> Well, my facility back home assigns each resident their own meter to use while their residents there. I think that's the best practice since it reduces the chance of a meter being shared. Now, if a facility can assign each resident a meter, it needs to be cleaned between each resident with a compatible EPA approved hospital disinfectant with a TB or HIV, hepatitis speed kill claim with a 1 to 10 diluted bleach solution or according to manufacturer's recommendations. >> Okay, great. I have heard enough. In fact, I need you to stop talking because I'm afraid you're going to take my job. [LAUGH] Let's just say you are on to final judgment, David. >> [APPLAUSE] [MUSIC] >> All right. We're down to our final contestants, Jennifer from Charleston and David from Chapel Hill. It's the battle of north versus south Carolina. It's time for the judges to decide who the Mcknight trophy winner is and who goes home empty handed. Let's tune into the judges deliberation. [SOUND] >> That David is really something special in his expert knowledge and a really great technique. [SOUND] >> Minerva, you bring up some valid points, but I believe your obvious crush is getting in the way of your unbiased judgment. Jennifer. She had really strong performance to that. No. Make that impeccable. So I'm torn here. >> No doubt they both performed well. But honestly, I cannot overlook Jennifer's labeling error last round. Sorry. [MUSIC] >> Rob, I think we're ready to crown the winner here. [MUSIC] >> Jennifer, David, you've both shown that safe injection techniques and proper group commoner care are alive and well in both of your nursing homes and for that, we congratulate your skills and knowledge. But tonight, there can only be one person who truly represents perfection. The one who has the technique. [SOUND] >> Jennifer, >> [APPLAUSE] >> You do not have the technique, David is our winner. [APPLAUSE] >> David congratulations. Is there anything you'd like to say to the audience? >> Grandma, this trophy is for you. [APPLAUSE] >> Well, it looks like grandma's about to be the star of her nursing home these days. While David may get the celebrity treatment from Minerva. [APPLAUSE] >> Tune in next season as we continue to inject our way into your hearts. Just kidding. I don't mean to say that. Thanks for joining us on the technique and have a great night. [MUSIC] >> Another means of spreading blood borne pathogens is through unsafe diabetes care. This underappreciated area of risk has been the mode of transmission for many Hepatitis B outbreaks. The outbreaks have been linked to the infection control breaches shown here, including sharing of blood glucose meters without disinfection and cleaning between uses. Use of fingerstick devices or insulin pens for multiple people. And failure to perform hand hygiene or change gloves between procedures. For safe injections, needles and syringes are single use devices and should not be reused. Do not administer medication from a single-dose vial or IV bag to multiple patients. Limit the use of multi-dose vials and dedicate them to a single patient whenever possible. For safe gluecommenter care, fingerstick devices should never be used for more than one person. Blood glucose meters should be assigned to an individual person or disinfected between uses per manufacturer's recommendations if shared. If they must be shared, clean and disinfect after each use per manufacturer's instructions. If there are no instructions, it cannot be shared. Injection equipment such as insulin pens, syringes or needles should never be used for more than one person. If all health care providers know and practice these three simple rules for safe injections and safe diabetes care, the knowledge gap that contributes to outbreaks will be significantly reduced. If new knowledge is applied to implement safe practices, great strides could be made in preventing devastating outbreaks. We can do this by designating someone to provide ongoing oversight, developing written infection control policies, providing training and conducting quality assurance assessments. And lastly, speak up if you see someone not following safe injection practices, you are not only protecting your residents, you are protecting your colleagues as well. The one and only campaign led by the CDC and the safe injection practices coalition was launched in September of 2009 in response to the increasing number of outbreaks relating to unsafe injections. The free resources that they have developed educate both health care providers and patients. Go to oneandonlycampaign.org for more information.