What technique must be used to minimize the risk of infection for parenteral medication administration?

1. Establish and maintain infection control policies and procedures
   • Implement written policies and procedures according to published guidelines.
   • Ensure staff members are familiar with policies and procedures and review regularly.
   • Update written policies and procedures regularly.
2. Properly use and handle needles, cannulae and syringes
   • Whenever possible, use sharps with engineered sharps injury protections (i.e., nonneedle sharp or needle devices with a built-in safety feature or mechanism that effectively reduces the risk of an exposure incident). Do not disable or circumvent the safety feature on devices.
   • Needles, cannulae and syringes are:
     • Sterile, single-use items; any use will result in these items being contaminated.
     • Contaminated once used to enter or connect to any component of a patient's intravenous infusion set.
   • Medication from a syringe must not be administered to multiple patients even if the needle on the syringe is changed.
   • Dispose of all needles and syringes immediately into a leakproof, puncture-resistant, closable container.
   • Develop policies and procedures to prevent sharps injuries among staff and review regularly.
3. Properly handle medications and solutions
   • Designate separate areas for preparation and disposing medications.
   • Minimize use of multidose vials; use single-dose vials for parenteral medications whenever possible.
   • If multidose vials must be used:
     • Always use aseptic technique.
     • A new needle/cannula and a new syringe must be used to access the multidose vial.
     • Do not keep the vials in the immediate patient treatment area.
   • Do not administer medications from single-dose vials or ampules to multiple patients or combine leftover contents for later.
   • Do not use bags or bottles of intravenous solution as a common source of medication or fluid for multiple patients.
   • Use infusion sets (i.e., intravenous bags, tubing and connectors) for one patient only and dispose appropriately after use.
4. Strictly adhere to aseptic technique
   • Ensure all staff members perform proper hand hygiene before and after gloving, between patients, and whenever hands are soiled.
   • Avoid cross contamination with soiled gloves.
   • Provide adequate soap/water, disposable paper towels, and waterless alcohol-based hand rubs throughout the facility.
5. Properly reprocess medical equipment
   • Follow manufacturer's recommendations for proper cleaning, disinfection, and sterilization of all reusable equipment.
   • Designate staff responsible for maintaining proper reprocessing procedures.
   • Ensure designated staff members are properly trained in reprocessing each piece of equipment.
   • Never reprocess equipment designated for single use.
   • Maintain a log of all equipment reprocessing.
6. Fulfill all federal and state requirements for infection control training
   • All healthcare personnel must complete bloodborne pathogen control training regularly.
   • All licensed healthcare professionals in New York State (physicians, physician assistants, special assistants, registered professional nurses, licensed practical nurses, podiatrists, optometrists, dentists, and dental hygienists) are required to receive training on infection control and barrier precautions every four years through a NYS-approved provider.
   • Documentation of appropriate training must be maintained both by the course provider and course participant.

[Please note: The following references and websites have been updated since the original Commissioner letter distributed in 2008]

• APIC position paper: prevention of device-mediated bloodborne infections to health care workers. Am J Infect Control 1998;26:578-80.
• Boyce JM, Pittet D. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002;51(RR16):1-44.
• Centers for Disease Control and Prevention. Immunization of healthcare workers: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR 1997;46(RR-18):1-42.
• Committee on Infectious Diseases and Committee on Practice and Ambulatory Medicine. Infection Control in Physicians' Offices. Pediatrics. Pediatrics 2000;105:1361-1369.
• Department of Labor, Occupational Safety and Health Administration. (29 CFR, Part 1920.1030) Occupational exposure to bloodborne pathogens. Final Rule. Federal Register. December 6, 1991, Volume 56-64004264182.
• Guidelines for infection control in health care personnel. Am J Infect Control 1998;26:289-354.
• Kohn WG, Collins AS, Cleveland JL, Harte JA, Eklund KJ, Malvitz DM. Guidelines for infection control in dental health-care settings--2003. MMWR Recomm Rep 2003;52(RR-17):1-61.
• Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, June 2007.

Bibiliography: Healthcare-Acquired Hepatitis

• Centers for Disease Control and Prevention. Transmission of hepatitis B and C viruses in outpatient settings - New York, Oklahoma, and Nebraska, 2000-2002. MMWR 2003;52(38):901-6.
• Centers for Disease Control and Prevention. Hepatitis C Virus Transmission at an Outpatient Hemodialysis Unit --- New York, 2001—2008. MMWR 2009;58(08):189-194.
• Comstock D, Mallonee S, et al. A large nosocomial outbreak of hepatitis C and hepatitis B among patients receiving pain remediation treatments. Infect Control and Hosp Epidemiol 2004;25:576-583.
• Counard C, Perz J, Linchangco P, et al. Acute hepatitis B outbreaks related to fingerstick blood glucose monitoring in two assisted living facilities. J Am Geriatr Soc 2010; 58:306-311.
• 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. CID. Aug 2010;51:267-273.
• Gutelius B, Perz JF, Parker MM, et al. Multiple clusters of hepatitis virus infections associated with anesthesia for outpatient endoscopy procedures. Gastroenterology 2010;139(1):163-170.
• Maki D, Crnich C. History forgotten is history relived. Arch Int Med 2005;165:2565-2566.
• Moore ZS, Schaefer MK, Hoffmann KK, et al. Transmission of hepatitis C virus during myocardial perfusion imaging at an outpatient clinic. Am J of Cardiol. 2011;108(1):126-132
• Samandari T, Malakmadze N, et al. A large outbreak of hepatitis B virus infections associated with frequent injections at a physician's office. Infect Control and Hosp Epidemiol 2005;26:745-750.
• Thompson ND, Perz JF, Moorman AC, Holmberg SD. Nonhospital health care-associated hepatitis B and C virus transmission: United States, 1998-2008. Ann Intern Med 2009;150:33-9.
• Williams IT, Perz JF, Bell BP. Viral hepatitis transmission in ambulatory settings. Clin Infect Dis 2004; 38:1592-1598.

Websites

The following websites will assist you in developing or updating your infection control policies and procedures.

Association for the Advancement of Medical Instrumentation (AAMI):

Centers for Disease Control and Prevention (CDC):

Occupational Safety and Health Administration (OSHA):

New York State Department of Health:

• Health Care Professionals & Patient Safety

Part three of this four-part series looks at the advantages and disadvantages of parenteral administration

Shepherd M (2011) Administration of drugs 3: parenteral. Nursing Times; 107: 36, early online publication.

• Figures and tables can be seen in the attached print-friendly PDF file of the complete article

• Health professionals must demonstrate their competence before taking responsibility for parenteral administration

• Incorrect technique can cause physical harm and adversely affect drug absorption

• The National Patient Safety Agency has proposed competencies for staff involved in the parenteral administration of drugs

• Intramuscular and subcutaneous administration of drugs can ensure they are released gradually

• Intravenous administration allows drugs to be released instantaneously

Parenteral drug administration means any non-oral means of administration, but is generally interpreted as relating to injecting directly into the body, bypassing the skin and mucous membranes. The common parenteral routes are intramuscular (IM), subcutaneous (SC) and intravenous (IV). Box 1 outlines the advantages and disadvantages of parenteral routes.

Advantages

• Can be used for drugs that are poorly absorbed, inactive or ineffective if given orally
• The IV route provides immediate onset of action
• The intramuscular and subcutaneous routes can be used to achieve slow or delayed onset of action
• Patient concordance problems can be avoided

Disadvantages

• Staff need additional training and assessment
• Can be costly
• Can be painful
• Aseptic technique is required
• May require additional equipment, for example programmable infusion devices

Parenteral administration requires an appropriate injection technique. If performed incorrectly – for example using the wrong size needle or cannula – it can cause damage to nerves, muscle and vasculature and may adversely affect drug absorption.

Intramuscular and subcutaneous

In general, IM and SC injection of drugs establishes a deposit or “depot” that will be released gradually into the systemic circulation. The drug’s formulation will influence the period over which it is released; for example, the formulation of antipsychotic agents such as flupentixol in oil allows them to be administered once a month or every three months.

Intravenous

The IV route carries the greatest risk of any route of drug administration. By administering directly into the systemic circulation, either by direct injection or infusion, the drug is instantaneously distributed to its sites of action. This route of administration can be complex and confusing. It may require dose calculations, dilutions, information to be gathered on administration rates and compatibilities with other IV solutions, as well as the use of programmable infusion devices.

The preparation of IV medicines requires the use of an aseptic technique, often in a ward environment that is unsuited to such work. To minimise the risk of errors, it is imperative that practitioners can demonstrate competence to practise safely, and have access to expert information and advice. Box 2 lists considerations for preparing IV drugs.

Box 2. Considerations for IV administration

• Is the drug suitable for preparation on the ward or should it be prepared in the pharmacy?
• Does the drug require initial dilution? What diluent and volume?
• Does the drug require further dilution? What diluent and volume?
• Is the drug suitable for direct injection or to be infused over time?
• Over what length of time can it be administered?
• Is an infusion device required?
• Is the drug compatible with other drugs or fluids to be administered at the same time?
• Does the drug cause a local reaction?
• Is any monitoring required during or after administration?

The National Patient Safety Agency (2007) has highlighted the risks associated with the preparation and administration of injectable medicines and proposed a set of competencies. These provide a useful basis for the creation of policy and training in this area. 

Martin Shepherd is head of medicines management at Chesterfield Royal Hospital Foundation Trust

National Patient Safety Agency (2007) Promoting Safer Use of Injectable Medicines. London: NPSA.