News reports in September 2002 revealed that clusters of patients in Oklahoma, Nebraska, and New York had been diagnosed with Hepatitis C. The common element in all 3 of these outbreaks was that syringes and needles had been reused, including the injection of an expensive or controlled drug into the IV line of more than 1 patient in order to avoid “wasting” medication. Even more troubling were the anecdotal reports that these were not isolated incidents—that the practice was not only permitted, but encouraged, as a cost-saving measure. Infection control specialists saw the reusing of syringes and needles as part of the culture in some areas of practice and had given up trying to change it.
In response to these events, the American Association of Nurse Anesthetists (AANA) convened a task force to develop a series of short-term and long-range strategies to address this serious patient safety issue. The following are some of the strategies suggested for further consideration:
- educating providers and consumers as to the proper use of devices and the consequences of misuse
- issuing of a joint statement by health care organizations condemning the practice and citing best practices
- conducting more research into the practice to determine how prevalent misuse is
- identifying the gap between infection control standards and compliance with standards, i.e., why is misuse happening and what can be done about it
- inspecting the use of syringes and needles as part of the JCAHO and Magnet processes
- publishing a booklet or manual on use and misuse of needles and syringes.
As the initial step, the AANA sent more than 40,000 letters with copies of Infection Control Guidelines to all CRNAs, nurse anesthesia students, and program directors to raise awareness of this issue and urge strict adherence to the guidelines. Letters were also sent to the CEOs of hospitals and ambulatory surgery centers urging them to take an active role in assuring compliance with infection control guidelines. The AANA also developed a series of educational offerings addressing infection control, which continue to be presented.
Survey Reviews Continued Syringe Use
In October 2002, a telephone survey was conducted by Cooper Research to determine the scope of the problem on needle and syringe reuse by health care providers. The survey findings revealed that 1 in 100 of those surveyed reuse the same needle and/or syringe on multiple patients. These findings indicate that millions of patients per year were being exposed to used needles and syringes potentially contaminated with life-threatening disease organisms. The study also indicates that there is a great deal of confusion regarding proper syringe and needle usage among all health care providers.
The AANA sent letters and press releases to the American Hospital Association, American Medical Association, American Society of Anesthesiologists, American Dental Association, American Association of Oral and Maxillofacial Surgeons, American Nurses Association, and Nurse Organizational Alliance to inform them of the issue and to invite them to join in developing an agenda for an upcoming patient safety initiative. Involvement of the Anesthesia Patient Safety Foundation was discussed with foundation leadership. In addition, the AANA initiated a project to solicit input from selected national health care organizations, accrediting agencies, federal government agencies, and medical and nursing professional organizations. The goal of this collaboration was to identify actions to date, identify additional strategies to address the reuse issue, and gauge interest in participation with AANA and other stake holders on future initiatives.
An article entitled “Transmission of Hepatitis B and C Viruses in Outpatient Settings—New York, Oklahoma, and Nebraska, 2000-2002” appeared in the September 26, 2005, issue of Morbidity and Mortality Weekly Report. The article noted the AANA initiative and stated, “CDC is working with professional organizations, advisory groups, and state and local health departments to address these issues.”
JCAHO Plans to Raise Awareness
In late 2003, a project was completed by AANA that surveyed national health care organizations, accrediting agencies, federal government agencies and medical and nursing professional organizations. The majority of organizations responding to the survey indicated that they thought targeted educational initiatives to improve infection control practices related to syringe and needle reuse were needed. Nursing organizations offered to collaborate with the educational initiatives. The following excerpts from the final report reflect some of the findings:
“Most organizations report that they are making the information about needle/syringe reuse available to leaders and members through publications and web sites. Several organizations pointed to their position statements on infection control standards as their position on the issue including the American Hospital Association (AHA). AHA reported that the issue is one of reprocessing and not reuse of devices, noting that a caregiver who takes a syringe/needle, presumably labeled as a single use medical device, and uses it more than once (on a different patient) is engaging in reuse of a single use device. . . unless the syringe/needle is reprocessed. If a caregiver is simply using it again and again. . . it is a clear violation of federal regulations. The American College of Healthcare Executives reported that they would not take a position on the issue but would look to AHA to address the matter. The American Organization of Nurse Executives remarked that they learned of this matter from AANA and had distributed the information to members. The American Society for Healthcare Risk Managers recognized the needle/syringe reuse problem and advised, “Attention needs to be kept on this issue through the JCAHO infection advisory panel, particularly as it relates to clinics and doctors’ offices.”
The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) reported plans to raise the awareness of their surveyors about reuse of “single use” devices on more than one patient, including needles and syringes. JCAHO reported that the “whole issue of single use devices” is a problematic matter. JCAHO reported that they have revamped their infection control standards and 1 standard to be posted in 2005, IC 4-10, will relate to infection control and address the matter of reuse of devices that are deemed disposable by the manufacturer.
Early in 2004, the CDC’s Division of Healthcare Quality Promotion and the Division of Viral Hepatitis were developing proposed initiatives to address the problem of patient-to-patient transmission of blood-borne pathogens in health care settings. In late 2004, a representative from the CDC work group charged with infection control in ambulatory care settings shared with AANA the CDC’s concern that despite their 2002 bulletin regarding reuse of needles and syringes on multiple patients, outbreaks of Hepatitis B and Hepatitis C attributed to syringe reuse continue. While discussing the issue, the representative noted, “The [AANA’s] recommendations seem so intuitive, yet it is so difficult to reach groups who may provide patient care and who are not aware of the risks of reusing injection apparatus and contamination of multi-dose vials. We [CDC] will be addressing this topic again soon and will pass on this information to the working group.”
In April 2005 the CDC sent the AANA a request for the work group to continue with an initial focus on injection safety. The CDC expressed a concern that in spite of publicized outbreaks of Hepatitis B and C, some unsafe injection practices, particularly the injection of residual medication left in a syringe that has already been used on another patient, continue during anesthesia care and are underreported.
Dr. Lester is a Certified Registered Nurse Anesthetist, past President of the American Association of Nurse Anesthetists, and a member of the APSF Board of Directors and Editorial Board.