Safe Injection Guidelines for Needle and Syringe Use Standard 10 of the American Association of Nurse Anesthesiology (AANA) Standards for Nurse Anesthesia Practice states that Certified Registered Nurse Anesthetists (CRNAs) “verify and adhere to infection control policies and procedures as established within the practice setting to minimize the risk of infection to patients, the CRNA, and other healthcare providers.”1 Further, the AANA Code of Ethics for the Certified Registered Nurse Anesthetist states that the CRNA “has a personal responsibility to understand, uphold, and adhere”2 to the ethical standards contained therein. Specifically, Code of Ethics for the Certified Registered Nurse Anesthetist affirms that the CRNA provides positive role modeling by upholding and promoting quality patient care outcomes and the professional standards of practice.2 The AANA Infection Prevention and Control Guidelines for Anesthesia Care promotes and fosters patient and healthcare provider safety through evidence-based infection prevention and control practices.3 Despite attempts to educate healthcare providers regarding the public hazards of syringe and needle reuse and other unsafe injection practices, transmission of bloodborne pathogens continues to occur in the United States.4-9 During 2008 to 2019, there were 66 outbreaks of Hepatitis B or C viruses within a variety of inpatient and outpatient health care settings.8 These outbreaks placed over 125,000 patients at risk for contracting bloodborne infections.8 Successful prevention of the transmission of infectious agents involves adherence to evidence-based practices by the anesthesia professional and the entire healthcare team. This is accomplished when facility leadership, clinicians, and other facility personnel collaborate to foster the culture of robust infection risk identification to continuously improve systems of prevention of harm.1,3,10 Adherence to infection control practices during routine anesthesia care is a priority that may become challenging when providing emergent, lifesustaining care. During emergencies, the anesthesia provider focuses on the patient’s hemodynamic and ventilatory status to prevent immediate patient harm and collaborates with the healthcare team to address any related infection risk.1-3,10,11 Strategies for infection control and prevention, include establishing policies and procedures on safe injection practices; educational programs on infection control measures for all perianesthesia personnel; proper cleaning of anesthesia equipment and environmental surfaces; stocking procedure areas with adequate materials for infection control; preparing equipment in accordance with infection control requirements; observing strict aseptic technique with any sterile procedure; and ongoing monitoring of local and nationally reported infection control data for continued quality improvement efforts.3,10 These guidelines address aspects of anesthesia care which involve the use of needles and syringes when administering injectable medications. The following statements reflect current safe practices for needle and syringe use by CRNAs: •
Never administer medications from the same syringe to multiple patients, even if the needle is changed.11-14 1 of 5 American Association of Nurse Anesthesiology | O'Hare International Center 10275 West Higgins Road, Suite 500 | Rosemont, IL 60018 Professional Practice Division l 847-655-8870 l practice@aana.com
•
Never reuse a needle,9,11,15-18 or needleless access device even on the same patient. Once a needle or access device has been used, it is considered contaminated and must be discarded in an appropriately identified sharps container.19 Access devices are single- use devices.9,12
•
Never refill a syringe once it has been used, even for the same patient. Syringes are single-use devices.3,9,16,17,20 Once the plunger of a syringe has been completely depressed in order to expel the syringe contents (i.e., intravenous medication), the internal barrel of the syringe is considered contaminated and must be discarded in an appropriate fashion. A syringe must only be used once to draw up medication, and must not be used again even to draw up the same medication from the same vial for the same patient.20-23 In recognizing the needs of anesthesia care workflow, one syringe may contain medication to be administered over a period of time in incremental doses. The syringe tip should be protected with a sterile cap at all times when not being actively used to administer an incremental dose of medication.12 For medication administration, the sterile cap should be removed and the injection port should be cleansed with 70% alcohol prior to injection of medication.12,24 Following medication injection, the sterile cap should be reattached, being careful not to contaminate the syringe tip.12 CRNAs should weigh the risks of possible syringe contamination (e.g., from anesthesia workspace contamination25-30) that may occur when repeatedly connecting and disconnecting a medication-filled syringe from an intravenous infusion set or other administration systems.
•
Never use an infusion or intravenous administration tubing set for more than one patient.12 Infusion and intravenous sets are single-patient use items and must be used according to applicable policies and guidelines. These devices are to be used on one patient only and must never be used between patients.
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Never reuse a syringe or needle to withdraw medication from a multidose vial (MDV).9,31-33 A new sterile syringe and needle or access device are required each time an MDV is accessed.9,16,32-34
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Avoid use of MDV for more than one patient. Practitioners should avoid using MDVs if at all possible.16,32,33,35 If MDV must be used, the practitioner should consider using that MDV on only one patient.13,17,36,37 Although MDVs contain a preservative, they still may become contaminated with infectious agents due to unsafe practices that are not evident.
•
Do not access an MDV in the immediate patient treatment area unless the MDV is dedicated to a single patient and discarded immediately thereafter.12,33,38
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Never reenter a single-dose medication vial, ampoule or intravenous infusion bag.13,31,38,39 It is not appropriate to prepare multiple intravenous flush syringes for single or multiple patients from the same single-dose intravenous solution bag or bottle (e.g., normal saline).9,17,40 It is not appropriate to prepare multiple fentanyl, midazolam, or propofol syringes for the same or multiple patients from the same 2 of 5 American Association of Nurse Anesthesiology | O'Hare International Center 10275 West Higgins Road, Suite 500 | Rosemont, IL 60018 Professional Practice Division l 847-655-8870 l practice@aana.com
single-dose medication vial, ampoule, or solution. Do not store a single-dose medication vial for future use. Do not reenter a single-dose medication vial, even for the same patient. •
When accessing medication vials, complete hand hygiene, don clean gloves, use a new sterile needle, and cleanse the access diaphragm with 70% alcohol prior to needle insertion.24,41
The AANA supports and goes beyond the Centers for Disease Control and Prevention One and Only Campaign: One Needle, One Syringe, Only One Time to provide guidance on safe injection and medication vial management unique to the anesthesia setting.42 CRNAs have an ethical obligation to deliver anesthesia care that minimizes risk of infection for their patients and themselves. Intentional integration of these evidence-based guidelines for safe injection and medication management optimizes patient safety and outcomes, as well as minimizes healthcare costs through preventative infection control measures.43 References 1. Standards for Nurse Anesthesia Practice. Park Ridge, IL: American Association of Nurse Anesthesiology; 2019. 2. Code of Ethics for the Certified Registered Nurse Anesthetist. Park Ridge, IL: American Association of Nurse Anesthesiology; 2018. 3. Infection Prevention and Control Guidelines for Anesthesia Care. Park Ridge, IL: American Association of Nurse Anesthesiology; 2015. 4. Wilson WO. Infection control issue: understanding and addressing the prevalence of unsafe injection practices in healthcare. AANA J. 2008;76(4):251-253. 5. Pugliese G, Gosnell C, Bartley JM, Robinson S. Injection practices among clinicians in United States health care settings. Am J Infect Control. 2010;38(10):789-798. 6. Alhumaid S, Al Mutair A, Al Alawi Z, et al. Knowledge of infection prevention and control among healthcare workers and factors influencing compliance: a systematic review. Antimicrob Resist Infect Control. 2021;10(1):86. 7. AlJohani A, Karuppiah K, Al Mutairi A, Al Mutair A. Narrative Review of Infection Control Knowledge and Attitude among Healthcare Workers. J Epidemiol Glob Health. 2021;11(1):20-25. 8. Centers for Disease Control and Prevention. Healthcare-Associated Hepatitis B and C Outbreaks (≥ 2 cases) Reported to the CDC 2008-2019. https://www.cdc.gov/hepatitis/outbreaks/healthcarehepoutbreaktable.htm. Published 2020. Accessed May 5, 2022. 9. Centers for Disease Control and Prevention. Protect Patients Against Preventable Harm from Improper Use of Single–Dose/Single–Use Vials. https://www.cdc.gov/injectionsafety/cdcposition-singleusevial.html. Published 2012. Accessed May 5, 2022. 10. Griffis CA, Reede L, O'Rourke M, Hledin V. Infection Control and Patient Safety: What Is Desirable and What Is Possible During Anesthesia? AANA J. 2017;Online Content(2):13-16. 11. Van Vlymen JM, Magnus J, Jaeger M, et al. Hepatitis C Contamination of Medication Vials Accessed with Sterile Needles and Syringes. Anesthesiology. 2019;131(2):305-314. 3 of 5 American Association of Nurse Anesthesiology | O'Hare International Center 10275 West Higgins Road, Suite 500 | Rosemont, IL 60018 Professional Practice Division l 847-655-8870 l practice@aana.com
12. Siegel JD, Rhinehart E, Jackson M, Chiarello L, Health Care Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings. Am J Infect Control. 2007;35(10 Suppl 2):S65-164. 13. Fischer GE, Schaefer MK, Labus BJ, et al. Hepatitis C virus infections from unsafe injection practices at an endoscopy clinic in Las Vegas, Nevada, 2007-2008. Clin Infect Dis. 2010;51(3):267-273. 14. Rathore MH, Jackson MA, Committee On Infectious Diseases. Infection Prevention and Control in Pediatric Ambulatory Settings. Pediatrics. 2017;140(5). 15. King CA, Ogg M. Safe injection practices for administration of propofol. AORN J. 2012;95(3):365-372. 16. Moore ZS, Schaefer MK, Hoffmann KK, et al. Transmission of hepatitis C virus during myocardial perfusion imaging in an outpatient clinic. Am J Cardiol. 2011;108(1):126-132. 17. Dolan SA, Arias KM, Felizardo G, et al. APIC position paper: Safe injection, infusion, and medication vial practices in health care. Am J Infect Control. 2016;44(7):750-757. 18. Muscarella LF. Infection control and its application to the administration of intravenous medications during gastrointestinal endoscopy. Am J Infect Control. 2004;32(5):282-286. 19. Denault D, Gardner H. OSHA Bloodborne Pathogen Standards. In: StatPearls. Treasure Island (FL)2022. 20. Perz JF, Thompson ND, Schaefer MK, Patel PR. US outbreak investigations highlight the need for safe injection practices and basic infection control. Clin Liver Dis. 2010;14(1):137-151; x. 21. Perceval A. Consequence of syringe-plunger contamination. Med J Aust. 1980;1(10):487-489. 22. Huey WY, Newton DW, Augustine SC, Vejraska BD, Mitrano FP. Microbial contamination potential of sterile disposable plastic syringes. Am J Hosp Pharm. 1985;42(1):102-105. 23. Olivier LC, Kendoff D, Wolfhard U, Nast-Kolb D, Nazif Yazici M, Esche H. Modified syringe design prevents plunger-related contamination--results of contamination and flow-rate tests. J Hosp Infect. 2003;53(2):140-143. 24. WHO Best Practices for Injections and Related Procedures Toolkit. Geneva: World Health Organization; 2010 Mar 2, Best Practices for Injection. Available from: https://www.ncbi.nlm.nih.gov/books/NBK138495/. 25. Baillie JK, Sultan P, Graveling E, Forrest C, Lafong C. Contamination of anaesthetic machines with pathogenic organisms. Anaesthesia. 2007;62(12):1257-1261. 26. Jeske HC, Tiefenthaler W, Hohlrieder M, Hinterberger G, Benzer A. Bacterial contamination of anaesthetists' hands by personal mobile phone and fixed phone use in the operating theatre. Anaesthesia. 2007;62(9):904-906. 27. Loftus RW, Koff MD, Burchman CC, et al. Transmission of pathogenic bacterial organisms in the anesthesia work area. Anesthesiology. 2008;109(3):399-407. 28. Loftus RW, Muffly MK, Brown JR, et al. Hand contamination of anesthesia providers is an important risk factor for intraoperative bacterial transmission. Anesth Analg. 2011;112(1):98-105. 29. Kawakami Y, Tagami T. Pumping infusions with a syringe may cause contamination of the fluid in the syringe. Sci Rep. 2021;11(1):15421. 30. Munoz-Price LS, Bowdle A, Johnston BL, et al. Infection prevention in the operating 4 of 5 American Association of Nurse Anesthesiology | O'Hare International Center 10275 West Higgins Road, Suite 500 | Rosemont, IL 60018 Professional Practice Division l 847-655-8870 l practice@aana.com
room anesthesia work area. Infect Control Hosp Epidemiol. 2019;40(1):1-17. 31. Branch-Elliman W, Weiss D, Balter S, Bornschlegel K, Phillips M. Hepatitis C transmission due to contamination of multidose medication vials: summary of an outbreak and a call to action. Am J Infect Control. 2013;41(1):92-94. 32. Folkema A, Wang HL, Wright K, et al. An outbreak of hepatitis C virus attributed to the use of multi-dose vials at a colonoscopy clinic, Waterloo Region, Ontario. Can Commun Dis Rep. 2021;47(4):224-231. 33. Miller DC, Smith C. The Safe Use of Multidose and Single-Dose Vials. Pain Med. 2019;20(5):1047-1048. 34. Arrington ME, Gabbert KC, Mazgaj PW, Wolf MT. Multidose vial contamination in anesthesia. AANA J. 1990;58(6):462-466. 35. Rehan HS, Chopra D, Sah RK, Chawla T, Agarwal A, Sharma GK. Injection practices of healthcare professionals in a Tertiary Care Hospital. J Infect Public Health. 2012;5(2):177-181. 36. Perez F, Deshpande A, Kundrapu S, Hujer AM, Bonomo RA, Donskey CJ. Pseudooutbreak of Klebsiella oxytoca spontaneous bacterial peritonitis attributed to contamination of multidose vials of culture medium supplement. Infect Control Hosp Epidemiol. 2014;35(2):139-143. 37. Bhatia M, Mishra B, Loomba PS, Dogra V. A pilot study for evaluation of knowledge and common practises of nursing staff regarding use of multidose injection vials and their microbial contamination rate in a super-specialty hospital. J Educ Health Promot. 2018;7:120. 38. Silberzweig JE, Khorsandi AS, Dixon RG, Gross K, Nikolic B. Society of Interventional Radiology position statement on injection safety: improper use of single-dose/single-use vials. J Vasc Interv Radiol. 2013;24(1):111-112. 39. Centers for Disease Control and Prevention. Infection control requirements for dialysis facilities and clarification regarding guidance on parenteral medication vials. MMWR Morb Mortal Wkly Rep. 2008;57(32):875-876. 40. Greeley RD, Semple S, Thompson ND, et al. Hepatitis B outbreak associated with a hematology-oncology office practice in New Jersey, 2009. Am J Infect Control. 2011;39(8):663-670. 41. The Joint Commission. Preventing infection from the misuse of vials. Sentinel Event Alert. 2014(52):1-6. 42. Centers for Disease Control and Prevention. One & Only Campaign. https://www.cdc.gov/injectionsafety/one-and-only.html. Published 2019. Accessed May 13, 2022. 43. Ford K. Survey of syringe and needle safety among student registered nurse anesthetists: are we making any progress? AANA J. 2013;81(1):37-42. In January 2009, the AANA Board of Directors adopted Position Statement 2.13, Safe Practices for Needle and Syringe Use. This position statement was reaffirmed by the AANA Board of Directors in November 2012. In April 2014, the AANA Board of Directors archived this position statement and adopted the Safe Injection Guidelines for Needle and Syringe Use. Updated by the AANA Board of Directors August 2022. © Copyright 2022
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