The following article was originally published in Preventing Infection in Ambulatory Care, the quarterly e-publication from the Association for Professionals in Infection Control and Epidemiology (APIC). To learn more about receiving this resource and joining APIC, visit www.apic.org/ambulatorynewsletter. To learn more about APIC, visit www.apic.org.
Preventing infection during medication administration requires knowledge, forethought and careful attention to protocol. Medication administration is subject to human factors. This, in turn, can negatively impact process reliability leading to adverse outcomes including infection.
Especially in the categories of intravenous and inhaled medication, associated infection can result in serious morbidity. One of the most common causes of infection related to medication administration is the contaminated multi-dose vial. Outbreaks related to multi-dose vials have been reported for more than 20 years, but have not yet been fully eliminated from healthcare. One study reports a total of 64 outbreaks of infection associated with multi-dose vials between 1991 and 2007.
Departments administering intravenous and/or inhaled medications are the most frequent source of reported serious medication-related infections. Patients receiving anesthesia may develop bacteremia or surgical site infections. Hemodialysis patients may be exposed to Hepatitis B, Hepatitis C, and HIV, while those on inpatient/outpatient nursing units may be exposed to Hepatitis B, Hepatitis C, septicemia and candidemia. The chief threats in interventional radiology units are meningitis and death. Ophthalmology patients can develop corneal ulcers or endophthalmitis. Orthopedic units carry risks of post-operative and post joint injection-related infections, while patients receiving respiratory therapy may develop B. cepacia pneumonia and gram-negative sepsis.
In each of these areas and throughout the continuum of care, the most important action that can help to prevent infection related to medication administration is good hand hygiene, by both provider and patient. Additional interventions crossing all departments and medication types include preparing medications in a clean area — not adjacent to any location where potentially contaminated items are placed — and using aseptic technique for injectable medication preparation and administration.
Aseptic technique relative to injectable medication administration must include such actions as using only one needle and one syringe for each patient each time, using a clean needle and syringe each time a vial is accessed, and not using bags or bottles of intravenous fluids as a common source of supply for more than one patient.
The risk of infection transmission posed by multi-dose vials has been clearly demonstrated, and should inform a practice of one vial for one patient whenever possible. Infection transmission risk is reduced when single or multi-dose vials are designated to a single patient. In the event that multi-dose vials are used for more than one patient, there must be strict attention to preventing contamination. This would include such actions as examining the vial for particulate matter, discoloration or turbidity, discarding the vial if sterility is questioned, vigorously cleaning the rubber septum of the vial with 70% alcohol swab prior to each draw, using a new needle and new syringe for every entry into the vial, and dating the vial to reflect the day it was opened and the day of expiration (28 days from the day of opening).
For single-dose vials opened in room air, the contents must be utilized within one hour (USP Chapter 797 Standard). Additionally, single-use medications should never be used for more than one patient.
A unique medication that has been associated with a number of reported incidents of infection transmission is propofol. This medication is administered intravenously by anesthesia or in intensive care for sedation purposes. Since it is a lipid emulsion, it can support the growth of microorganisms, so special care must be taken in order to prevent contamination — including disinfection of vials and ampoules with isopropyl alcohol prior to accessing, and discarding within the prescribed timeframe. This timeframe is within six hours if administered in a syringe, and within 12 hours of bag spike for IV infusion. In addition, for infusions, the IV line must be flushed every six hours, and at the end of the infusion, to remove residual propofol. Propofol in a syringe or IV bag must be labeled with the following information (Joint Commission Standard): medication name, strength, and amount (if not apparent from the container), expiration time and date prepared.
Finally, in order to prevent employee blood borne pathogen exposure (Hepatitis B, Hepatitis C and HIV) during injectable medication administration, it is important to take sharp safety precautions. These precautions include activating any safety device on needles, disposing of needles and syringes in a sharps container close to point of use, changing the sharps container as soon as it becomes three-quarters full, and ensuring that all healthcare workers with potential blood borne pathogen exposure receive the Hepatitis B vaccine.
In order to reduce the risk of infection transmission related to inhaled medication, hand hygiene is critical before preparing medications and before administering the medication. And to ensure that infections are not transmitted via medication or equipment, the use of single-dose drug preparations and single-patient devices (e.g. nebulizers, inhalers) is recommended. And if MDI (multi-dose inhalers) are used — even placebo MDI for patient teaching — these should be considered single patient use (both canister and plastic mouth piece). Patient infection transmission related to contaminated water has also been reported, so the use of sterile water or saline as needed is recommended. To learn more about infection prevention in medicine administration, visit www.cdc.gov/mmwr/preview/mmwrhtml/rr5005a1.htm or www.asahq.org/publicationsAndServices/infectioncontrol.pdf.
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