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Evelyn McKnight, AuD HONOReform OneandOnlyCampaign ANeverEvent

A Look at a “ Never Event” and how it is Fostering a National Pa ssion for Patient S afety. Evelyn McKnight, AuD www.HONOReform.org www.OneandOnlyCampaign.org www.ANeverEvent.com. Learners will be able to describe….

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Evelyn McKnight, AuD HONOReform OneandOnlyCampaign ANeverEvent

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  1. A Look at a “Never Event” and how it is Fostering a National Passion for Patient Safety • Evelyn McKnight, AuD • www.HONOReform.org • www.OneandOnlyCampaign.org • www.ANeverEvent.com

  2. Learners will be able to describe… • how reuse of syringes and multi-dose vials can lead to patient to patient transmission of bloodborne pathogens • how a large scale healthcare associated hepatitis outbreak affects how the public accesses healthcare • two patient outcomes of the Nebraska Hepatitis C outbreak

  3. Our Story 3

  4. www.ANeverEvent.com

  5. What went wrong? 5

  6. What Went Wrong? • Improper port flush procedure A Never Event. Arbor Books, 2008.

  7. What Went Wrong? • Improper port flush procedure • Index case came to clinic in 2000 • Complaints from housekeeping, pharmacy, lab, nursing and patients • “No jurisdiction” • Unsafe practices for at least 16 months A Never Event. Arbor Books, 2008.

  8. What Happened to the Victims? • 6 deaths from HCV not cancer • 33 antiviral therapy, 28 achieved SVR • 1 sexually acquired HCV • 11 died of cancer, including 2 SVR’s • 89 lawsuits, $16M paid from NELF Hepatology 2009; 50: 361-368

  9. Not just once, long ago 10

  10. Not just once, long ago • In past 11 years, 620 patients were infected in 52 outbreaks • Majority of outbreaks (42 out of 51) occurred in non-hospital settings Thompson NT et al. Abstract #396. A review of hepatitis B and C virus infection outbreaks in healthcare settings, 1998-2008. Fifth Decennial Conference on Healthcare-Associated Infections 2010.

  11. Outbreaks of bacterial infections associated with unsafe injections, United States, 2001-2011 • At least 25 outbreaks identified/reported • Majority in outpatient settings • Common breaches: • Repetitive use of single-dose vials/saline bags, multi-dose vials entered multiple times with non-sterile syringes/needles, pooling leftover contents of vials. • Poor hand hygiene, aseptic technique, and improper storage and labeling of medications. htttp://shea.confex.com/shea/2010/webprogram/Paper2113.html;

  12. What happens in Vegas…

  13. What happens in Vegas… • 2/2008 - 63,000patients exposed through syringe reuse at endoscopy center • 9 definite cases, 106 possible • Estimated cost of outbreak investigation, response and testing is $16-$21M Outbreak of Hepatitis C at Outpatient Surgical Centers, Southern Nevada Health District,12/09

  14. …happens elsewhere! • Nebraska 2002 • New York 2007, 2011 • Nevada 2008, 2011 • N Carolina 2008, 2010 • Texas 2009 • South Dakota 2009 • New Jersey 2009 • Colorado 2009 • Pennsylvania 2010 • West Virginia 2010 • New Mexico 2010 • Wisconsin 2010,2011 • Florida 2010 • California 2011 • Minnesota 2011 • Mississippi 2011

  15. Basic lack of infection control • Same syringe to administer medication to more than 1 patient, even if the needle was changed. • Same vial for more than 1 patient and accessing the vial with a syringe that has already been used to administer medication to a patient • Common bag of IV fluid for more than 1 patient, and accessing the bag with a syringe that has already been used to flush a patient’s catheter

  16. This will NOT prevent infections! • Changing the needle, but reusing the syringe • Injecting through intervening lengths of intravenous tubing • Always maintaining pressure on the plunger to prevent backflow of body fluids • Noting lack of visible contamination or blood

  17. Unsafe injection practices result in: • Untold human suffering • Distrust in healthcare system • Bloodborne viruses and other infections • Disciplinary actions against providers • Malpractice suits and other legal actions • A medical, financial, emotional • and social disaster

  18. Medical disaster Glenn from NE Byron&Amber from SD Michael from OK

  19. Financial disaster Melisa from FL Johnny from NC Jill from NE

  20. Emotional disaster Emil from NE Karen from NV Nurse from OK

  21. Social Disaster • The history of health care in Las Vegas can be divided into two eras: the one before last year’s hepatitis C outbreak and the one after it. -Las Vegas Sun, 3/1/2009 • UNLV School of Public Health survey after outbreak showed 57% of respondents were less likely to get a colonoscopy in Las Vegas.

  22. It’s hard to believe this happens in the US

  23. Anesthesiology News Survey,1/2012 • 50 NY anesthesiology residents surveyed • 49% sometimes used same vial for more than one patient • 25% did not always use a new syringe or needle when drawing from a vial • 8% had reused syringes on different patients Anesthesiology News, Jan 2012

  24. Premier Healthcare Alliance Survey • 5446 respondents (89% RN or MD) • 0.9% “sometimes or always” reuse a syringe but change the needle for reuse of a second patient • 15.1% reuse a syringe to re-enter a multidose vial and then • 6.5% reuse that vial for use on another patient (1.1% overall) Am J Infect Control 2010;38:789-98

  25. InfectionControl Assessment of ASCspilot study in MD, NC & OK • 6% reused single use device • 28% reused single dose vials for multiple patients • 21% reused fingerstick lancing device • 32% failed to disinfect glucose meter after each use JAMA 2010;303(22):2273-2279

  26. Drug Shortages complicate the issue • Combining single dose vials for reuse • MDV’s accessed with reused syringes or needles

  27. Request change of CMS rules re: SDVs • 16 signatories, including 6 MD’s • Led by Rep Whitfield (KY-R) • Backed by ASIPP

  28. Letter to CMS states… “There is no evidence that transmission of blood borne pathogens during health care procedures continue to occur because of the use of single dose vials in multiple patients when* appropriate sterile procedures are used.” * BUT what about when they are NOT used?

  29. AND… • Single dose vials lack preservatives to prevent microbial growth • Re-entry into vial introduces microbes • Microbial growth begins within 1-4 hours, exponential growth thereafter Am J Infect Control 2010;38:167-72.

  30. But we can do something about it

  31. Hepatitis Outbreaks National Organization for Reform

  32. In 2011 15 presentations to 5000 people BUT 9 outbreak notifications to 6000 people!

  33. Alliance for Injection Safety • Congressional Briefing • GAO report • Programmatic funding • FDA, CMS, HHS & CDC collaboration • Response to SDV controversy

  34. Safe Injection Practices Coalition • Raises awareness about safe injection practices • Aimsto eradicate outbreaks resulting from unsafe injection practices AAAHC, AANA, APIC, BD, CDC, CDCF, Covidien, Hospira, HONOReform, NACCHO, NE Med Soc, NV Med Assn, Premier, MEDRAD, FDA; State Partners: NV, NJ,NY, NC

  35. www.ONEandONLYcampaign.org Based on Standard Precautions for Safe Injection Practices http://www.cdc.gov/ncidod/dhqp/pdf//Isolation2007.pdf http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf

  36. Standard Precautions Highlights • Use aseptic technique • Never administer meds from same syringe to multiple patients • Do not reuse a syringe to enter a vial • Do not administer meds from single-dose vials to multiple patients • Limit the use of multi-dose vials and dedicate them to a single patient

  37. www.ONEandONLYcampaign.org Provider education • Medscape and Epocrates CME • CDC guidelines for injections and outpatient infection control • Injection safety resource center • Safe injection practices training video • Provider toolkit for training

  38. Infection control survey tool for certified/licensed facilities JAMA. 2010; 303:2273-79 http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter09_37.pdf

  39. Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care Infection prevention checklist for outpatient settings: Minimum expectations for safe care http://www.cdc.gov/HAI/settings/outpatient/outpatient-care-guidelines.html

  40. Needed: A culture of safety Empowerment to stop colleagues from unsafe practices

  41. Outbreaks continue to affect many people Thank you! 42

  42. And you can help prevent them!

  43. Here’s how you can help • Speak up when you see unsafe practices! • Visit OneandOnlyCampaign.org • Sign up for e-newsletter at www.HONOReform.org • Recommend us for a presentation • Recommend A Never Event to others • Write a review of A Never Event on Amazon

  44. Thank you! Any questions? • Evelyn McKnight, AuD • www.HONOReform.org • www.OneandOnlyCampaign.org • www.ANeverEvent.com

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