Safe Injection Practices

Injection Devices and Medications

Injection devices

Health-care settings should ensure that an adequate supply of single-use injection devices is available, to allow providers to use a new device for each procedure. The health institutes should not fall into a situation, where while the stock of syringes and needles is available, however the providers in wards and OPD areas cannot access this, due to some managerial issues like store keeper not available or the morning duty nurse did not leave enough stock for the evening and night use for IPD patients. In addition of adequate supply of syringes and needles it is also important to ensure availability of hub cutters and waste segregation bags.

• The needle,
• The barrel,
• The plunger.

The needle goes in the patient's muscle; the barrel holds the medicine and has markings on it like a ruler. The markings are in milliliters (mL). The plunger is used to get medicine into and out of the syringe.

The catheter should be small in diameter as possible so it takes a less space in the vain. This reduces the risk of phlebitis as it reduces the mechanical and chemical irritation to the vein wall.

• 26-24 gauge for infants and children.
• 24- 22 gauge for children and elderly patients.
• 24- 20 gauge for medical patients and post -operative surgical patients.
• 18 gauge for surgical patients and for rapid blood administration.
• 16 gauge for trauma patients and those requiring large volume of fluid rapidly

Practical guidance on use of injection devices

When using a sterile single-use device (i.e. a syringe and hypodermic needle that is not separated or manipulated unless necessary)

• Use a new device for each procedure, including for the reconstitution of a unit of medication or vaccine
• Inspect the packaging of the device to ensure that the protective barrier has not been breached;
• Discard the device if the package has been punctured, tom or damaged by exposure to moisture, or if the expiry date has passed.

Practical guidance on giving medications

When giving medication

• DO NOT use a single loaded syringe to administer medication to several patients
• DO NOT change the needle in order to reuse the syringe;
• DO NOT use the same mixing syringe to reconstitute several vials;
• DO NOT combine leftover medications for later use.

Single dose vials - Whenever possible, use a single-dose vial for each patient

Multi dose vials - Only use multi dose vials if there is no alternative

• Open only one vial of a particular medication at a time in each patient-care area.
• If possible, keep one multi dose vial for each patient, and store it with the patients name on the vial in a separate treatment or medication room.
• Always clear the rubber cap before loading injections
• DO NOT store multi dose vials in the open ward, where they could be inadvertently contaminated with spray or spatter.
• DO NOT leave needles in a multi dose vial after use.

Discard multi dose vial

• If sterility or content is compromised;
• If the expiry date or time has passed (even if the vial contains antimicrobial preservatives);
• If it has not been properly stored after opening;
• Within 24 hours of opening, or after the time recommended by the manufacturer, if the vial does not contain antimicrobial preservatives;
• If found to be undated, improperly stored, inadvertently contaminated or perceived to be contaminated, regardless of expiration date.

Pop-open ampoules - Whenever possible, use pop-open ampoules rather than ampoules that require use of a metal file to open. If using an ampoule that requires a metal file to open, do not use hard objects to open the ampoules. Doing so may spill the content of vials reducing the prescribed dose.

Preparing Injections

Injections should be prepared in a designated clean area where contamination by blood and body fluids is unlikely.

1. Keep the injection preparation area free of clutter so all surfaces can be easily cleaned.
2. Before starting the injection session and whenever there is contamination with blood or body fluids, clean the preparation surfaces with 70% alcohol (isopropyl alcohol or ethanol) and allow to air dry.
3. Assemble all equipment needed for the injection:

• Sterile single-use needles and syringes;
• Reconstitution solution such as Sterne water or specific diluent;
• Alcohol swab or cotton wool
• Hub Cutter/Sharps container.

Practical Guidance in Administering Injections

• Check the drug chart or prescription for the medication and the corresponding patient's name and dosage
• Check for expiry dates and labels and match with prescription
• Re-confirm the route of administration in the label and prescription
• Perform hand wash using soap and running water before and after an injection session.
• Use hand sanitizers in between injections in a busy OPD
• If IV injections or diagnostic purposes it is advisable to use gloves for self-protection as you are directly in contact with blood
• If using a vial, wipe the top of the vial with 60-70% alcohol (isopropyl alcohol or ethanol) using a swab or cotton-wool ball
• Always clean the injection site using a alcohol swabs except for vaccinations
• Do not use alcohol swab for vaccines as alcohol could kill live attenuated vaccines. In case if using alcohol swabs wait for 30 seconds after cleaning the site and giving injections
• Check the packet of syringes and needle and please do not use if the packet is punctured or damaged.
• Open the injection package in front of the patient to reassure them that the syringe and needle have not been used previously.
• Using a sterile syringe and needle, withdraw the medication from the ampoule or vial.
• If reconstitution using a sterile syringe and needle is necessary, withdraw the reconstitution solution from the ampoule or vial, insert the needle into the rubber septum in the single or multi dose vial and inject the necessary amount of reconstitution fluid/diluent.Mix the contents of the vial thoroughly until all visible particles have dissolved.
• After reconstituting the contents of a multi dose vial, remove the needle and syringe and discard them immediately as per recommendations.

Ensuring That Injections are Performed Correctly

• Designate someone to provide ongoing oversight for infection control issues; if the hospital has Infection Control Nurses, then this becomes their responsibility.
• Develop and display message boards at the site of injections
• Ensure the availability of colour coded bags for segregation of bio medical wastes
• Provide training to Prescribers, Providers, Administrators and Bio Medical Waste handlers
• Designate workers, time and equipment’s for safe disposal of wastes including terminal disposal
• Include Safe Injection Practice issues in already planned quality assurance assessments.
• State Health departments could review Safe Injection Practice issues at all levels in their regular program reviews.

Hand Hygiene Is Basic Ingredient of Safe Injection Practice

• Hands are the principal route by which cross infections occurs and therefore handwashing is the one of the most important standard precautions for preventing the spread of the disease.
• Effective hand washing technique involves three stages: Preparation, washing, and rinsing and drying. Always use a running water source for hand washing

Newer Technologies for Safer injections

Technology helps the health care professionals immensely in their endeavor to achieve the desired standards of health care. Technology has evolved significantly in the last decade or so to make injection and related processes much safer for patients, health care workers and the community. It is worth knowing and practicing the technological solutions, as and when they are available in your settings.

Auto disable/Re Use Prevention syringes : These syringes imbibe the basic mechanism of getting locked after their single intended use. There are two types of mechanisms:

• Active Mechanism: In this, the plunger is to be pushed actively by the user for locking the syringe.
• Passive Mechanism: Here the plunger locks automatically after it is bottomed out after pushing the intended medicine.

Advantages of Auto disable/Re Use Prevention syringes

1. AD and RUP syringes are locked after injection; this syringe is thus not available for repacking, thereby ensuring use of fresh syringe each time.
2. AD/RUP syringes ensure proper disposal of syringes since it is being locked after injection & breakable plunger. In other words, the syringe cannot be put to any further clinical use.
3. These prevent both intentional & downstream reuse.

Prefilled Injection Devices: These are the syringes having prefilled medication in the exact dose which is required to be given to a patient. After administration, the syringe gets locked. Thus, a sterile dose is delivered safely without posing risk to the provider as well. In a study carried out in Indian settings, the prefilled syringes have shown to reduce the time taken for injection procedure to almost half.

Safety Syringes: The needle in these syringes is locked through a luer lock mechanism i.e. the needle gets strongly attached to the tip of the syringe, thus, accidental spillage of medication or the needle is avoided.

Vacuum Based Technology for Drawing Blood: Instead of normal syringes, this is a better, safe and sterile technology for drawing the blood from the patients. The blood is collected directly into small tubes as per need for a particular investigation through a small plastic chamber.

Safety Needles and Cannulas: These needles have a plastic sheath which is used for covering the needle immediately after use. Similarly, in the cannulas, the plastic sheath covers the stellate automatically after the cannula is inserted into vein and stellate is removed. Additionally, there are blunt needles available for reconstitution of the powder form of vaccines and medications. The tip of such needle is blunt thus reducing possibility of accidental prick to the health care workers while undertaking the procedure.

Role of Surveillance in Injection Safety

Surveillance is data collection for action. The data is used as a basis for planning, implementing and evaluating the event or disease prevention and control activities. In the context of Safe Injections, the following minimal information is required.

• Unsafe injections pose a major risk to the patients, of contracting unwanted infections during the process of care or investigations.
• These infections can result into productivity losses frequently, and are also lethal at times.
• Unsafe injection practices result into harm to the injection providers also. One of such most common incidents is needle stick injury (NSD.
• Unsafe disposal of injection waste results in spread of infection in the general population

Source: National Centre for Disease Control (NCDC)