Hepatitis Outbreaks National Organization for Reform

1Evelyn McKnight, AuD

www.HONOReform.orgwww.OneandOnlyCampaign.orgwww.ANeverEvent.com

A Look at a Never Event and how it is Fostering a National Passion for Patient Safety 1Learners will be able to describe2how 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

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Our Story 333www.ANeverEvent.com4

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What went wrong? 55A Never Event. Arbor Books, 2008.6What Went Wrong?Improper port flush procedure67

7A Never Event. Arbor Books, 2008.8What Went Wrong?Improper port flush procedure

Index case came to clinic in 2000

Complaints from housekeeping, pharmacy, lab, nursing and patientsNo jurisdictionUnsafe practices for at least 16 months

89What Happened to the Victims?6 deaths from HCV not cancer33 antiviral therapy, 28 achieved SVR1 sexually acquired HCV11 died of cancer, including 2 SVRs89 lawsuits, $16M paid from NELFHepatology 2009; 50: 361-368910

Not just once, long ago1010From Gastroenterology article10Not just once, long ago11In 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 2010.1112Outbreaks of bacterial infections associated with unsafe injections, United States, 2001-2011 At least 25 outbreaks identified/reported Majority in outpatient settingsCommon 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;http://shea.confex.com/shea/2010/webprogram/Paper2113.html; 1213

What happens in Vegas13What happens in VegasOutbreak of Hepatitis C at Outpatient Surgical Centers, Southern Nevada Health District,12/09142/2008 - 63,000 patients exposed through syringe reuse at endoscopy center9 definite cases, 106 possibleEstimated cost of outbreak investigation, response and testing is $16-$21M

14happens elsewhere!15

Nebraska 2002New York 2007, 2011Nevada 2008, 2011N Carolina 2008, 2010Texas 2009South Dakota 2009New Jersey 2009Colorado 2009Pennsylvania 2010West Virginia 2010New Mexico 2010Wisconsin 2010, 2011Florida 2010California 2011Minnesota 2011Mississippi 201115Basic lack of infection control16Same 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 patientCommon bag of IV fluid for more than 1 patient, and accessing the bag with a syringe that has already been used to flush a patients catheter

16This will NOT prevent infections!17Changing the needle, but reusing the syringeInjecting through intervening lengths of intravenous tubingAlways maintaining pressure on the plunger to prevent backflow of body fluidsNoting lack of visible contamination or blood

17 Unsafe injection practices result in:18Untold human sufferingDistrust in healthcare systemBloodborne viruses and other infectionsDisciplinary actions against providersMalpractice suits and other legal actions

A medical, financial, emotional and social disaster

1819Medical disaster

Glenn from NEByron&Amber from SD

Michael from OK1920Financial disaster

Melisa from FLJohnny from NC Jill from NE2021Emotional disaster

Karen from NVEmil from NE

Nurse from OK2122Social DisasterThe history of health care in Las Vegas can be divided into two eras: the one before last years 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.

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Its hard to believe this happens in the US23Anesthesiology News, Jan 20122450 NY anesthesiology residents surveyed49% sometimes used same vial for more than one patient25% did not always use a new syringe or needle when drawing from a vial8% had reused syringes on different patientsAnesthesiology News Survey,1/201224Premier Healthcare Alliance Survey255446 respondents (89% RN or MD)0.9% sometimes or always reuse a syringe but change the needle for reuse of a second patient15.1% reuse a syringe to re-enter a multidose vial and then6.5% reuse that vial for use on another patient (1.1% overall)

Am J Infect Control 2010;38:789-9825Infection Control Assessment of ASCs

pilot study in MD, NC & OK 266% reused single use device28% reused single dose vials for multiple patients21% reused fingerstick lancing device32% failed to disinfect glucose meter after each use

JAMA2010;303(22):2273-227926Drug Shortages complicate the issue27Combining single dose vials for reuseMDVs accessed with reused syringes or needles

27Request change of CMS rules re: SDVs28

16 signatories, including 6 MDsLed by Rep Whitfield (KY-R)Backed by ASIPP

American Society Of Interventional Pain Physicians

28Letter to CMS states* BUT what about when they are NOT used?29 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.29AND30Am J Infect Control 2010;38:167-72.Single dose vials lack preservatives to prevent microbial growthRe-entry into vial introduces microbesMicrobial growth begins within 1-4 hours, exponential growth thereafter

Once microbial contamination occurs, theorganism replication can begin within 1 to 4 hourswith exponential growth occurring rapidly afterward.(ref AJIC article, copyright 2010, APIC30But we can do something about it31

31Striving to prevent healthcare transmission of disease due to unsafe injections

Hepatitis Outbreaks National Organization for Reform32

In 2011

15 presentations to 5000 people

BUT

9 outbreak notifications to 6000 people!3334Alliance for Injection SafetyCongressional BriefingGAO report

Programmatic funding

FDA, CMS, HHS & CDC collaborationResponse to SDV controversy

HONOReform is a founding member of the Alliance for Injection Safety (AIS).

Over the next few months, AIS members will hold a Congressional briefing to educate Members of Congress and their staff about unsafe injection practices.

We are also drafting legislation to promote injection safety.

Please contact me if you would like more information about the AIS.

3435Safe Injection Practices CoalitionRaises awareness about safe injection practices

Aims to 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

3536http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf

www.ONEandONLYcampaign.orgBased on Standard Precautions for Safe Injection Practiceshttp://www.cdc.gov/ncidod/dhqp/pdf//Isolation2007.pdf

Please contact me if you would like more information about the AIS.

3637Use aseptic techniqueNever administer meds from same syringe to multiple patientsDo 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

Standard Precautions Highlights3738Provider educationMedscape and Epocrates CMECDC guidelines for injections and outpatient infection controlInjection safety resource centerSafe injection practices training videoProvider toolkit for training

www.ONEandONLYcampaign.org

Please contact me if you would like more information about the AIS.

3839JAMA. 2010; 303:2273-79http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter09_37.pdf

Infection control survey tool for certified/licensed facilities

Please contact me if you would like more information about the AIS.

3940http://www.cdc.gov/HAI/settings/outpatient/outpatient-care-guidelines.html

Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe CareInfection prevention checklist for outpatient settings: Minimum expectations for safe care

Please contact me if you would like more information about the AIS.

4041Needed: A culture of safety

Empowerment to stop colleagues from unsafe practices

Please contact me if you would like more information about the AIS.

4142 Thank you!42

Outbreaks continue to affect many people42From Gastroenterology article42And you can help prevent them!

44Speak up when you see unsafe practices!Visit OneandOnlyCampaign.orgSign up for e-newsletter at www.HONOReform.orgRecommend us for a presentationRecommend A Never Event to othersWrite a review of A Never Event on Amazon

Heres how you can help4445Thank you!Any questions?Evelyn McKnight, AuD

www.HONOReform.orgwww.OneandOnlyCampaign.orgwww.ANeverEvent.com

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