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safe injection practices IAP

  1. 1. Guide Book on Safe Injection Practices Developed in Technical Collaboration with Becton Dickinson, India Indian Academy of Pediatrics
  2. 2. Editorial Board : Advisors: Editors: Dr. A Parthasarathy, Dr. T.U. Sukumaran, Dr. S.S. Kamath, Dr. Anil Mishra First Edition: September, 2004 Second Edition: December 2006 Third (Current) Edition : May 2012 Publication: The Indian Academy of Pediatrics Kailas Darshan, Kennedy Bridge (Nana Chowk) Mumbai 400007 (India) Phone (022) 23887906, 23887922, 23889565 Fax: (022) 23851713 Email: Website: Society Regn.No.BOM 127/1963 GBBSD Public Trust Regn.No. F-1166 (BOM) Technical Collaboration and Educational Grant Support: Becton Dickinson, India National Convenor’s Address: Dr. S. Sachidananda Kamath, National Convenor IAP National Task Force on Safe Injection Practices Welcare Hospital, Vyttila, Cochin 682 019 Ph : 0484-2307897 Email : Published by: IAP National Publication House, Gwalior, MP Designed and Printed by: PrintekWays: 149, DSIDC Complex, Okhla Industrial Area, Phase-I, New Delhi -110020 Dr. Rohit Agrawal, Dr. C.P. Bansal, Dr. Sailesh Gupta, Dr. Pravin J. Mehta IAP Guide Book on Safe Injection Practices
  3. 3. IAP GUIDE BOOK ON SAFE INJECTION PRACTICES Advisors: Dr. Rohit Agrawal Dr. C.P. Bansal Dr. Sailesh Gupta Dr. Pravin J. Mehta Editors: Dr. A Parthasarathy Dr. T.U. Sukumaran Dr. S.S. Kamath Dr. Anil Mishra Editorial Board Technical Collaboration and Educational Grant Support From Becton Dickinson, India Published by: IAP Publication House,Gwalior,MP, India
  4. 4. Dr. ROHIT AGRAWAL MD, DCH President IAP-2012 Consultant Pediatrician Chandrajyoti Children's Hospital, Mumbai Kohinoor Hospital, Mumbai 603/4 Vindyachalneelkanth Valley th 7 Road,Rajawadi,Ghatkopar (East) Mumbai 400077 e-mail, Mobile 9821096353 Dr. T.U. SUKUMARAN President IAP-2011 Professor of Pediatrics PIMS, Thiruvalla, Kerala e-mail; Dr. C.P. BANSAL MD, FIAP, PGDAP, FICMCH Director, Shabd Pratap Hospital, Gwalior 474 012 President Elect- IAP-2013 e-mail; Dr. SAILESH GUPTA MD, FIAP Hon. Secretary General -2012 Ashna Children's Hospital, Uttara Apartments Jan Kalyan Nagar, Malad West, Mumbai-400095 e-mail Mobile 9819042213 Dr. S.SACHIDANANDA KAMATH MD,DCH, FIAP,DHHM,PGDAP Convenor, National Task Force on Safe Injection Practices, Consultant Pediatrician, Welcare Hospital, S A Road, Vyttila, Cochin - 682019 Dr. A. PARTHASARATHY Distinguished Professor of Pediatrics, The Tamil Nadu Dr. MGR University & Retd. Professor of Pediatrics, Madras Medical College & Deputy Superintendent, Institute of Child Health & Hospital for Children, Chennai, TN. Mobile 91 90422 60053, email: Contributors' List Dr. SHIVANANDA Director Professor and HOD Pediatrics Indira Gandhi Institute of Child Health South Hospital Complex, Bangalore - 560023 Mobile: 094484 66562 e-mail; Dr. M.INDRA SHEKHAR RAO. M.D.(Paed.)D.C.H.,NEO(USA)FIAP Senior Pediatric Consultant, Basant Sahney Children's Hospital, Secunderabad, Former Medical Superintendent & HOD Pediatrics, Institute of Child Health, Niloufer Hospital, Hyderabad, A.P. Residence: "Indraprastha", 106, Abhinava Nagar, Padmarao Nagar, Secunderabad, AP - 500 025. e-mail; Dr. RAJU C. SHAH MD, D Ped, FIAP Professor and HOD, Dept of Pediatrics, GCS Medical college, Ahmedabad. National President IAP (2005) Chairman, Injection Safety Task Force, IAP(2004-7) Ankur Institute of Child Health, B/H Ciyu Gold Cinema, Ashram Road, Ahmedabad 380009, Gujarat. Phone: (079) 26583067. e-mail; Dr. BALDEV S. PRAJAPATI M.D.(PED.) GOLD MEDALIST D. PED. FIAP, MNAMS, FICMCH. Professor, GCS Medical College, Hospital & Research Centre, AHMEDABAD. EBM Central IAP (5 Terms) Member& Trainer, Safe Injection Practices(2005- 2007) MEMBER, IAPCOI,2009-2011 Aakanksha Children Hospital, Nava Vadaj Road, AHMEDABAD. PHONES: (079) (H) 27559179, 27559667 (R) 27680256 (M) 09824039376 email: IAP Guide Book on Safe Injection Practices i
  5. 5. Dr. ARUN SHAH MD DCH FIAP FIAMS Associate professor NMCH Brahampura, Muzaffarpur, BIHAR e-mail: Dr. ALOK GUPTA MD Pediatrician & Counselor Jaipur, India. +91 94140 62700 +91 94610 03070 e-mail; Dr. M.A MATHEW MD,DCH London FIAP Professor Of Pediatrics M.O.S.C Medical College Kolenchery 682311 Kerala State Coordinator for SAFE-I Program office : 04843055262 Res:04846494556 Mobile:9447234554 e-mail; Dr. ANIL MISHRA Regional Technical Advisor-Infection Control BECTON DICKINSON, INDIA Boomerang, A - Wing, Unit No- 310, Third Floor, Chandivali Farm Road, Chandivali, Near Powai, Andheri - (E), MUMBAI - 400072 Telephone: 022- 32221318-19. 022- 28582430-32 Mobile: 09669696306 e-mail:, DR. BHASKAR J SONOWAL Technical Advisor- Infection Control and Patient Safety BECTON DICKINSON, INDIA 6th Floor, Signature Tower B, South City 1, Gurgaon, Haryana 122001 India tel: +91-124-3088333 cell: +91-9999501159 fax: +91-124-2383224/5/6 e-mail: Website: Dr. OM PRAKASH KANSAL Advisor-Injection Safety BECTON DICKINSON, INDIA 6th Floor, Signature Tower B, South City 1, Gurgaon, Haryana 122001 India tel: +91-124-3088333 cell: +919910555964 fax: +91-124-2383224/5/6 E-mail: K. RAJESH NAIR Senior ASM – Tender BECTON DICKINSON, INDIA South Regional Office - Kerala e-mail: Mobile:09745603110 Logistics GANESH MEDHE BECTON DICKINSON, INDIA Boomerang,A-Wing,Unit No.310, Chandivali Farm Road,Mumbai, India Pin-400072 Tel- +91-22-33241600 e-mail: Mobile:08291135670 MANOJ CHAUBEY BECTON DICKINSON, INDIA Boomerang,A-Wing, Unit No.310,Chandivali Farm Road,Mumbai, India Pin-400072 Tel- +91-22-33241600 e-mail: Website: ANU KHANNA BECTON DICKINSON, INDIA 6th Floor, Signature Tower B, South City 1, Gurgaon, Haryana 122001 India e-mail: IAP Guide Book on Safe Injection Practicesii
  6. 6. It is indeed a matter of pleasure and pride that IAP in partnership with BD India is making sincere efforts to address the issue of unsafe injections in India, which remains an important public health scourge, even in these times of technology advancements. Out of the injections which are administered in day to day practice of medicine, a significantly high percentage has been found to be unsafe. These unsafe injections will continue to add to the disease burden and loss of life, if the problem is not addressed on urgent basis. I am sure that our efforts will effectively address the issue of unsafe injections, which is a major public health challenge. This guidebook on injection safety will try to address the problem of unsafe injections by serving as a treatise on injection safety. It has been ensured that the key issues which are of relevance to different cadres of medical practitioners are addressed through this book and the basic essential knowledge and skills do not become a hindrance in achieving optimum standards of safety in its entirety. IAP and BD have planned state wise release of this book and will work to address the state specific concerns of injection safety by developing a contextual strategy in partnership with respective state governments. I highly appreciate the efforts of all the experts from IAP and the technical team of BD India, who have worked hard to ensure that the present edition of the guidebook presents all facts and information which are of practical importance to a wide spectrum of medical practitioners, undergraduates, post graduates and nursing cadre as well, in a way that is simple and easy to understand. Dr. Rohit Agrawal National President-IAP, 2012 Foreword IAP Guide Book on Safe Injection Practices iii
  7. 7. rd I am immensely pleased to see that the revised and updated 3 edition of the guide book on safe injection practices, which is a joint academic project of IAP and BD India is available to all of us for use towards improving standards of injection safety. As you all know, Safe Injection Practices has been a focus area of IAP and we continue to move forward in this direction with valuable support from all of you. Injection safety is of paramount importance in Indian context, if we wish to abide by the ethical value of doing no harm to the patients. The concept of Safe Injection Practices in India was conceived in 2004 during the Presidency of Dr. MKC Nair and has become an important part of IAP's action plan. BD also works in different parts of the globe on improving injection safety standards and has been partnering with IAP since the inception of the project on Injection Safety. I am confident that this joint work of IAP and BD will have the desired impact towards reducing unsafe injection practices in India. This guide book will be helpful for the entire spectrum of healthcare staff, i.e. for doctors, nurses, laboratory technicians, other categories of Health care workers and for the registered medical practitioners. The structure, content and language have been kept simplified so as to suit the needs of all categories of healthcare providers in various settings. New chapters on 'Prevention of re-use of syringes 'and' Newer technologies in injection delivery systems' in the present edition will be of immense practical utility to the readers. Chapters on injection techniques, best practices, Healthcare worker safety, Patient safety, waste disposal etc. have been extensively revised. I sincerely thank Dr. SS Kamath for leading this initiative and to all the expert group members from IAP and BD India who have contributed in developing this guide book. I also thank BD India for providing the educational grant for this project. Dr. T. U. Sukumaran National President, 2011, IAP Message IAP Guide Book on Safe Injection Practicesiv
  8. 8. Dear IAP Colleague, Injection Safety has been an area of high focus for the Indian Academy of Pediatrics. The subject has been accorded priority in successive IAP Action plans, every year. Experts in IAP have deliberated on ways to address the issue of unsafe injection practices in India. One of the strategies in the multipronged approach is, to address the knowledge barrier among the healthcare practitioners. As part of this strategy, IAP, in technical collaboration with Becton Dickinson India has developed this guide book on Safe Injection Practices. The objective while planning this book was to provide maximum practical usefulness for healthcare professionals, therefore the structure of the contents is simple and illustrative We are confident that after the book is released and when trainings for the zonal level and district level are rolled out, we will be able to impact the knowledge , skills and practices of healthcare professional and the same would reflect through reduced percentage of unsafe injections in India. It will help us abide by the ethical principle of doing no harm to the patients. We look forward to the stage when we will achieve the highest possible standards of injection safety. I am confident that the joint efforts of IAP and BD will replace the unsafe injections practices in India with safe and ethical practices. Dr Sailesh Gupta, Hon. Secretary General-2012 Message IAP Guide Book on Safe Injection Practices v
  9. 9. Becton Dickinson Company (BD), in pursuance with its mission of Helping All People Live Healthy Lives, besides producing high quality medical technology products, has developed many initiatives across the globe to deliver direct benefits to the patients, healthcare workers and to the people in general. In India, BD's joint work with the Indian Academy of Pediatrics (IAP) to address the issue of Injection safety is one of such initiatives. As a part of this strategy, IAP and BD jointly worked to develop this training module on Injection safety as the first step. Subsequently, this guidebook will be used as the basis of training of the healthcare professional on Injection Safety. A team of highly experienced experts from IAP and technical team members from BD have carried out in-depth discussions to develop this guidebook which provides all necessary information to the practitioners in a very simple but illustrative way. I am confident that this joint effort of IAP and BD, India will work to effectively address the problem of unsafe injections, a critical public health need in India. Manoj Gopalakrishna, Managing Director, BD India Message IAP Guide Book on Safe Injection Practicesvi
  10. 10. It is well known that prevention is always better than cure. Infections still form a major part of under five mortality in a developing country like ours. Vaccines are the most cost effective tools in the hands of pediatricians to prevent morbidity and mortality. As more and more immunizations are being given, one has to bear in mind the rising incidence of diseases transmitted by unsafe injection practices. On one hand we are immunizing to prevent diseases and on the other hand if we do not follow the safe injection practices we will also be instrumental in transmission of diseases. Hence it is very important for all of us to be aware of what are safe injection practices and best injection techniques so that we do not cause any harm while aiming to do good. Injections are a must when we have to give injectable vaccines but are we justified in giving so many injections in the curative section? We need to have rational prescription habits and reduce the unnecessary injections. The lesser the injections we give, lesser will be the risk of transmission due to unsafe practices. One way of making the injections safer in the immunization sector is the use of AD syringes as recommended by WHO. The Indian Academy of Pediatrics has always taken the lead to come out with IAP recommendations in national issues related to child health by conducting workshops which bring out a consensus document. A workshop on safe injection practices was organized in New Delhi in June 2004 by Dr. S.S. Kamath and Dr. Swati Bhave. There was representation of various stakeholders in this meeting, including the Ministry of Health, UNICEF, WHO, IMA, TNAI etc. The Secretary of Health and Family Welfare was kind enough to spend a lot of time to give his comments during the two days. The recommendations brought out have been published in the Indian Pediatrics, as well forwarded to all partners working in the field of child health. One of the recommendations of the workshop was that IAP should form a National Task Force on Safe Injection Practices to propogate the message to the members and in the community. In June 2004 Executive Board meeting, this task force was formed with Dr. Raju C. Shah, the President Elect, as Chairperson, Dr. S.S. Kamath as the Convenor and Dr. Swati Y. Bhave as Scientific Coordinator. It was decided to bring out the IAP Guide Book on Safe Injection Practices and conduct workshops all over the country in the year 2005 with a set of slides and the Guide Book.This is a part of the Presidential Action Plan of 2005. Preface To The First Edition IAP Guide Book on Safe Injection Practices vii
  11. 11. A master trainers' workshop was organized in March 2005 at Cochin.Here a peer review was done of the scientific material and slides which were painstakingly prepared by Dr. Swati Bhawe with a lot of technical inputs and help from Dr. Saurabh Sharma. We are thankful to him and M/s Becton Dickinson India Pvt. Ltd. who have given an educational grant for publication of the guide book and conduction of workshops. All the members of the task force worked hard to give their inputs but special mention must be made of Dr. Parthasarathy, Dr. Indra Shekhar Rao and Dr. Shivananda. We thank Mr Narayanan of Pixel Studio, Cochin for designing and printing under able guidance of Dr. S.S. Kamath. We sincerely hope that this publication will be useful to all pediatricians who care for the wellbeing of children. Dr. S.S. Kamath Dr. Swati Bhave Dr. Raju C. Shah IAP Guide Book on Safe Injection Practicesviii
  12. 12. This guide book on safe injection practices has been developed to strengthen the area of injection safety in India, which remains a major public health concern and is accountable for a significant share of deaths, morbidity and productivity losses. With highly encouraging responses received about the usefulness of the earlier editions, form practicing pediatricians and family physician from all over the country we decided to extensively revise this book and make it of more practical utility for the practitioners. We are immensely pleased to hand over this book to the medical and paramedical community in India. We also urge all medical practitioners to accord highest priority to safe injection practices. This Guidebook is of significant value in helping all categories of Health Care Providers to reduce the risk of spread of blood born infections which are transmitted through unsafe injections including re-use of needles and syringes, needle stick injuries and unsafe disposal of the used injection devices and sharps. The book has made sincere efforts to address the issue of safety in its entirety, i.e. safety of patients, of healthcare providers and of the community at large. The content and structure of this Guide Book is so designed as to present the basic facts related to injection safety in a manner which can be well understood by diverse target groups like nurses, undergraduate medical students, interns, post-graduates, students of laboratory technology, as well as practicing general physicians, specialists and super- specialists, with equal degree of ease. This guide book will also serve as a ready reckoner for all classes of professionals. Special addition in this guidebook is the chapter on Re-use of syringes, which is posing a major risk to the health of people in India. IAP and BD are jointly making efforts to address this problem in India. We hope that orientation of health care providers including Medical practitioners towards the need to put an effective check on the problem of re-use and improving overall standards of injection safety will deliver lasting benefits to the public health in India. It is our fervent hope that this guide book will serve as an important aid to all cadres of health workers in delivering safe injections. Dr. A Parthasarathy Dr. S.S. Kamath Dr. Anil Mishra Preface IAP Guide Book on Safe Injection Practices ix
  13. 13. The current Guide Book on Injection Safety has been jointly developed by IAP and BD India, with the objective of re-orienting the medical practitioners and other health care providers towards this critical aspects of Injection Safety, which is an essential part of day to day medical care. It has been observed that medics and paramedics, keeping their focus on the expected outcome of medical care i.e. cure of the patient and his/her return to normalcy, often overlook needed attention that is required to be paid to the minute details of Injection safety, and this results in serious harm- either to the patient, or to the care giver, and quite often to the community in general. The Content and structure of this Guide Book has been so designed , as to be effective for the larger community of medical practitioners, which includes specialists, general practitioners, Registered Medical Practitioners (Including alternative streams of medicine) , as well for the nursing , paramedical and laboratory staff who frequently deliver injections either for diagnostic or for therapeutic purposes or for both. This Guide Book will be of immense benefit to guide the graduating medical students and nursing students also on issues related to Injection safety, and will help in creating a solid understanding of the issue and also of the behavior and practices required to be adopted for achieving highest levels of injection safety in medical practice, and thereby abiding with the ethical principle of “ doing no harm to the patients”. IAP and BD India , in order to maximize the utility of this Guide Book as an effective training guide on Injection Safety, carried out multiple rounds of discussion on the content and structure of the book. Current knowledge and key gaps amongst the practitioners has been given due consideration in arriving at the final shape. It is expected that this Guide Book will be the most comprehensive and informative practical guide and will serve as 'Desk top reference' on matters of injection safety. The book has given due emphasis on critical areas like, Healthcare worker safety from sharps injury and other exposures, and patient safety from re-use of syringes and needles. It also deals with the safety of the community at large, which faces disastrous effects of improper disposal of bio-medical waste- specifically sharps and used syringes, which are picked up for resale. As stated above, in order to have an understanding of the prevailing knowledge, attitude and practices (KAP) of a small sample of injection providers/medical practitioners on injection safety, a quick assessment was carried out. It was later decided that for ensuring completeness of the information which is being provided on injection safety in this Guide Book, each and every area needs mention, Target Audience, Expected Impact and Methodology IAP Guide Book on Safe Injection Practicesx
  14. 14. IAP Guide Book on Safe Injection Practices xi irrespective of the understanding of medical practitioners around that particular area. This will also make the guidebook suitable for the practitioners who were not a part of the sampling universe, and thus would make it replicable in true sense. In the current scenario in medical practice and day to day medical care, re-use of syringes and needles is a major threat for the patients in reference to spread of blood born pathogens like HCV, HBV and HIV. The same risk is faced by the healthcare workers through Needle Stick Injuries which they sustain in the process of providing care to the patients, and consider it an unavoidable part of their profession. Expert members from IAP and BD strongly felt that these two topics need special emphasis in the book, as they contribute towards spread of blood born pathogens, the investigations and management of which impose a financial burden on the health system, as well as these infections contribute towards productivity losses which again have a financial bearing. As mentioned above, IAP and BD constituted a Technical Expert group, comprising of the members who have worked on specific aspects of the Injection safety, and have taken help of their deep insight into the matter, for developing the structure and content of this guide book. The Individual chapters have also been drafted by the members of this expert team , which were subsequently reviewed by a smaller team of experts. The Technical Expert Group comprised of following experts from IAP and technical team members from BD India: 1. Dr. Rohit Agrawal 2. Dr. T.U. Sukumaran 3. Dr. A. Parthasarathy 4. Dr. Sailesh Gupta 5. Dr. S.S. Kamath 6. Dr. Raju C Shah 7. Dr. C.P. Bansal 8. Dr. Arun Shah 9. Dr. Shivananda 10. Dr. Baldev S Prajapati 11. Dr. M Indra Shekhar Rao
  15. 15. IAP Guide Book on Safe Injection Practicesxii 12. Dr. Alok Gupta 13. Dr. M.A. Mathew 14. Dr. Anil Mishra ( BD India) 15. Dr. Bhaskar J. Sonowal ( BD India) 16. Dr. Om Prakash Kansal (BD India) The Group of Experts got fully apprised to the recent advances and updates on given topics and sub-topics, to ensure that updates on these areas are available for the readers. However, the readers are recommended to continue updating their knowledge on given topics and sub-topics as this is a dynamic field and the advances in technology which can reinforce safety are necessary to be thoroughly understood. Dr. A. Parthasarathy Dr. S.S. Kamath Dr. Anil Mishra
  16. 16. IAP Guide Book on Safe Injection Practices xiii Indian Academy of Pediatrics Table of Contents Chapter - 1.1 Achieving Comprehensive Safety through a Safe Injection Environment 1-5 Chapter - 1.2 Importance of Injections and Injection Safety; Creating The Safe Environment 6-11 Chapter - 1.3 Rational Use of Injections 12-16 Chapter - 2 Best Practices to Ensure Injection Safety 17-25 Chapter - 3.1 Methods of Injection Delivery 26-35 Chapter - 3.2 Phlebotomy 36-47 Chapter - 3.3 IV Cannulation : A Process Oriented Approach 48-65 Chapter - 4.1 Injection Safety- Slicing The Problem of Reuse of Syringes 66-71 Chapter - 4.2 Healthcare Workers Safety 72-88 Chapter - 4.3 Injection Waste Disposal 89-97 Chapter - 5 Newer Technologies available in India to ensure Injection Safety 98-117 Chapter - 6 Surveillance mechanisms to understand Injection Safety 118-122 Chapter - 7 IAP Recommendations on Injection Safety 123-128 Evolution of Syringes-a pictorial journey 131 Resources and Links on Injection Safety 132 Points for Surveillance on Safe Injection Practices 133 IAP Plan of Action on Safe Injection Practices 134 Annexure - I WHO Fact Sheet on Injection Safety 129-130 Annexure - II Annexure - III Annexure - IV Annexure - V Chapter Page No.Title
  17. 17. Injection is one of the most common healthcare interventions globally. WHO estimates that at least 16 billion (1600 crores) injections are delivered annually throughout developing and transitional countries. It is also reported that 90-95% of all injections are in the curative sector for routine care, not for immunization. The INCLEN (International Clinical Epidemiology Network) report of Assessment of Injection Practices in India, 2004 found that approximately 6 billion injections are given in this country every year; however it has also been reported by industries that only 3 billion syringes are actually manufactured. This clearly spells out the huge magnitude of reuse of syringes in India. This definitely needs to be addressed urgently to avoid incidents such as those of Modasa (Gujarat) and Fatehabad (Haryana) where hundreds of people lost their lives due to improper reuse of syringes. Reuse of syringes can easily be prevented by using appropriate devices such as Reuse Prevention (RUP) syringes and following best clinical practices for injection safety. Sharps waste management is another area that should be considered as an important area that needs urgent attention. Healthcare workers, housekeeping staff and the general community are often at risk of infection due to accidental needlesticks when sharps are not appropriately contained. Varied sharps management practices occur throughout India, some of which have been scientifically proven as being potentially harmful to human health. However, due to lack of understanding, awareness and will, several such approaches are still being adopted. Needle burners, often used to blunt the sharp tips of needles, have been shown to cause fumes, aerosol spread of infections, blood and medicine splatter and have been discontinued in developed countries, but their usage in India is still rampant posing a threat to the health of the healthcare workers. Puncture-resistant sharps containers, which have been recommended by the United States CDC (Center for Disease Control and Prevention) are not being universally adopted due to the recurrent costs and inadequate infrastructure at the Combined Waste Treatment Facility (CWTF) to deal with autoclaving and shredding these containers. This lack of adoption helps propagate outdated practices like needle burning. Above all, injection Safety is compromised on several occasions in our healthcare settings, due to the lack of awareness. Injection Safety is not a high focus component of healthcare workers training (doctors, nurses paramedical workers etc) and most of the understanding on injections is by the simple rule of on the job training. Therefore, if a Chapter - 1.1 Achieving Comprehensive Safety through a Safe Injection Environment IAP Guide Book on Safe Injection Practices 1 1.1 Indian Academy of Pediatrics
  18. 18. wrong practice is adopted by the person who is followed by healthcare workers all the healthcare workers learn the same mistakes and thus the effects are multiplied manifold in actual practice. There is therefore a need for a training module that can help address this most common intervention in healthcare – Injection Safety. The concept of Injection safety can be easily understood if we consider the science behind this. It can be thought of as an roadmap where different actions work in tandem, all aligned to create a “Safe Injection Environment”. Figure: The model on Safe Injection Environment (courtesy: Becton Dickinson) Explaining the Safe Injection Environment (SIE): The Safe Injection Environment aims to combat the spread of bloodborne pathogens and avoid clinical complications associated with unsafe injection practices through comprehensive solutions across the continuum of care. Injection safety is not only about a syringe with a needle inserted into a human body to deliver a medication safely. It has several components that go on to make a program in itself, a program that seeks to improve not just the individual practice, but also the environment in which injections are given. The critical step towards ensuring a SIE is to ensure that the devices that are meant to be used for injections are affordable (especially in resource constrained settings), that they Safe Injection Environment Safe Disposal Systems Affordability, Accessibility and Availability A Safe Injection Environment Policy & Compliance Aspiration Enablers: Foundation: IT & Info. Delivery Capability Optimized Workflow Risk Assess. / Surveillance Alternate / New Technologies Optimized Product Array On-going HCW Education & Training Green Solutions / Landfill Diversion IAP Guide Book on Safe Injection Practices2 1.1 Indian Academy of Pediatrics
  19. 19. are accessible (it makes no sense if the affordable injection equipments are not accessible to the provider) and available to the user Box-1: Optimized Product Array The foundation for the SIE happens to be that such devices that are affordable, accessible and available have an optimized product array. For example, while reconstituting medications, a standard injectable needle should not be used because – 1. Using an injectable needle can cause an accidental needlestick injury to the person doing the reconstitution & 2. Such needles do not provide for glass particles to be filtered out, which may then be injected to the recipient. In such situations using a blunt filter needle may be helpful and more clinically appropriate. Another example is that while drawing blood in an emergency situation it is highly possible that due to the rush in patients, there could be inadvertent placement of sharps in places where there may be high chances of accidental needlestick injuries. Moreover in such situations the HIV status of the patients may not be known. To help the healthcare workers in such a situation it is prudent to use safety devices (safety shielded needles) instead of conventional. It is necessary to have an appropriate array of products to build a safer injection environment. Box - 2: Ongoing healthcare workers Education and Training Healthcare workers are a respectable and sometimes limited resource that should be protected while carrying out their healthcare delivery responsibilities. Moreover these healthcare workers should be kept engaged and updated on the ways in which to treat patients as well how to take care of themselves. The high turnover of such healthcare resources, often leads to situations where training and education becomes paramount. Through education and training programs, it can be ensured that Injection Safety can be practiced – through processes that are safe to the patient, safe to the healthcare worker and safe for the community. Box - 3: Safe Disposal Systems Biomedical waste is amongst the most dangerous of any waste that is generated, primarily because of the numerous contaminants that could cause potentially life- threatening illnesses if any person were to inadvertently get exposed to untreated biomedical waste. Sharps waste, generated from needles and cannulae, are amongst the most dangerous of the biomedical waste due to the risk of transmission of blood- borne pathogens. To ensure the safety of the community as well as the environment, it becomes necessary to ensure that the right products and processes are adopted for collection, storage, transportation, disinfection and treatment of such biomedical waste. Injection safety IAP Guide Book on Safe Injection Practices 3 1.1 Indian Academy of Pediatrics
  20. 20. can never be fully achieved if a modern, reliable and scientifically sound system of handling biomedical waste is not available. Box - 4: Green Solutions / Landfill diversions With the growing importance being laid on developing a greener planet and reducing the carbon footprint, some companies have been taking measures to help reduce the environmental impact of healthcare delivery. International companies have invested tremendous R&D resources in developing unique programs that reduce the amount of plastic used to make injection devices, while retaining required performance attributes. Moreover certain programs have been introduced to ensure that sharps disposal containers and all contents therein can be appropriately shredded and recycled, preventing plastic waste from accumulating in landfills. Box - 5: Optimized workflow It is important to ensure that the processes and protocols are available for healthcare workers to optimize their workflow. Rational use of injections and standardization of best practices for injection safety helps to limit clinical variability. When variability is reduced and workflow is optimized, healthcare can be delivered more effectively and efficiently, leading to higher healthcare worker and patient satisfaction. Box - 6: Risk Assessment / Surveillance A critical step towards an SIE, is to ensure that appropriate data is captured in a reliable and consistent manner to monitor progress and improvement. Such data would help the decision makers of the hospital or policy makers in taking the right steps to ensure patient and healthcare workers safety. The data collected should be uniform and complete, so that it is comparable and adequate correction measures in safety can be taken. A uniform software format like EPINet (Exposure Prevention Information Network) developed by the University of Virginia, can help collect information on needlestick injuries and blood and body fluid exposures. Data collected through this system helped change the policy on sharps in the United States. In December 2000, President Bill Clinton signed the historic act that mandates the use of Safety Engineered Devices in US healthcare facilities. This was due in large part to data that demonstrated the high incidence of needlestick injuries, the risks of bloodborne disease transmission and the importance of protecting healthcare workers from such injuries. Box - 7: Alternate / New Technologies Companies are working continuously to develop products that cater to the unmet needs of patients, healthcare workers and the community. Such new technologies are being developed after prudent R&D to ensure that the technology is continuously IAP Guide Book on Safe Injection Practices4 1.1 Indian Academy of Pediatrics
  21. 21. upgraded to meet the challenges of the new healthcare needs. Adopting such proven technology is always a positive step towards ensuring comprehensive injection safety. Box - 8: IT & Information delivery capability IT has revolutionalized the world and has shortened distances. In healthcare, adoption of IT and using IT to enhance patient & healthcare workers benefits is apt to keep pace with the ever-changing medical world. Surveillance processes can get immediate feedback, which can help decision makers to take the right steps on safety. Benchmarking against industry standards and comparing available information helps healthcare organizations know exactly where they stand. Outbreaks can easily be identified and acted upon. Such steps only help healthcare get ready to meet newer challenges. Box - 9: Policy and Compliance For any decision to be taken, it is prudent that the decision maker is armed with data- driven information that can demonstrate the impact of certain healthcare interventions on improving delivery of care. The SIE framework could help influence local, state or even national policies on comprehensive injection safety by demonstrating wins and positive measures that make a large public health impact. Adoption of this framework would definitely help in ensuring Injection Safety across healthcare settings. However, even after a policy is developed to adopt SIE, adherence to the protocols is important so that there is no reversal of the gains made. Continuous monitoring of the activities is important and so is the feedback that is provided. This leads to an environment of continuous improvement. Behaviour change would only happen if habits are concretely formulated. This would help healthcare organizations in reaching the aspired goal of a Safe Injection Environment leading to comprehensive safety across the continuum of care. The current initiative of IAP attempts to address all dimensions of safety as stated above for achieving highest standards of injection safety for the benefit of people, the patients and the healthcare professionals. IAP Guide Book on Safe Injection Practices 5 1.1 Indian Academy of Pediatrics
  22. 22. Injection is the commonest procedure carried out by the health care providers all over the world. Over 22 billion (2200 crore) injections are given in the world, of which16 billion (1600 crore) injections are given every year across the developing countries. Majority of these injections, over 95%, are given for therapeutic purpose. only 3% are used for immunization activity and over 2% are used in laboratory work. Rational use of injection is a highly important subject that is needed to be emphasized, as nearly70% of injection that are being administered are actuary unnecessary. WHY PEOPLE PREFER INJECTIONS? People prefer injections because • They believe injections act fast. • Some Doctors regard injections as the best form of treatment Doctors prescribe injections to satisfy the patients, even though by counseling they can avoid giving these unnecessary injection. Some practitioners do it for commercial gains which is not an ethical practice. WHAT IS A SAFE INJECTION? A safe injection does no harm to the patient, health care giver and to the community. If injections are not delivered in a safe manner, it exposes people to dangerous and deadly infections. Millions are exposed to serious infections due to unsafe injection practices like re use of syringes.Studies in many countries have shown that more often injections are given by dipping the syringes in boiling water in the sterilizer. The study done by INCLEN in INDIA has shown that 66% of injections are unsafe. Reuse of syringes is rampant to the extent o f 40 -60%. Industry trends indicate that 5.8 injections are received by an individual on an average annually. Poor collection and disposal of injection waste practiced in many situations, in private and public sector both, not only expose the health workers but also the community to the hazard of needle stick injuries and thereby to the risk of contracting life threatening infections. Improper disposal of injection waste has other dimension of resale of used syringes and needles and intravenous line tubings. These are rerouted to the health care settings for mere commercial gains. Chapter - 1.2 Importance of Injections and Injection Safety; Creating The Safe Environment IAP Guide Book on Safe Injection Practices6 1.2 Indian Academy of Pediatrics
  23. 23. DISEASES ASSOCIATED WITH UNSAFE INJECTION PRACTICES It is estimated that each year 13 Lac new deaths are attributed to UNSAFE INJECTIONS. and about 2700 million Rupees are spent as medical cost, to treat resulting infections. Unsafe injections are known to transmit blood borne pathogens like bacteria, virus and parasites, particularly, potentially lethal and dangerously morbid diseases like Heptitis B, Hepatitis C, HIV, Malaria and other local and systemic bacterial infections. Nearly 22 million people are infected each year representing 33% of new HBV infections 42% of new HCV infections and 2% of all new HIV infections that are attributable to unsafe injections. WHAT NEEDS TO BE DONE TO CHANGE THIS SCENARIO Safe and appropriate use of infections is the only way and injection safety and basic infection control practices are central to patient safety of saving the man kind from deadly diseases which can be achieved by 3 ways: • Behavioural change of health care providers. • Availability and sustained supply of injection equipments. • Safe and appropriate management of injection waste. Of late it has been observed that in many countries consumers are demanding the safe and quality injection equipments and and are concerned about safe disposable methods. There is an urgent need to ensure availability and sustained supply of safe injections equipments like disposable syringes with safety features to prevent re-use, both at curative and preventive settings to enable the health care workers to use them and to meet the demand of consumers, The supply of disposables and waste disposable should be available as bundle to facilitate the health care givers to practice appropriately. Many countries are adopting the national policy on hospital waste management. Health care providers at all level of care both in private and public settings are oriented in safe injection practices however this is not happening in small care establishments. A comprehensive system of implementation, creation of awareness and training of health workers as per the local need to be developed. WHO through safe injection global network, SIGN, provide technical advice through policy guidelines, decision making, management and advocacy tools to help member countries implement the system of safe injection practices by providing the affordable equipments, capacity building of HCWs and materials to promote rationle use of injections. SIGN also developed specific standard for AD syringes for use in immunization and curative sector. IAP Guide Book on Safe Injection Practices 7 1.2 Indian Academy of Pediatrics
  24. 24. To ensure rational use of injections WHO urges its member countries to develop national drug policy which is essential for appropriate use of drugs and injections. It will also help in removal of unnecessary injectable medicines from essential drug list. WHO developed guiding principles to ensure injection device security by emphasizing the need of sustained supply chain of injection equipments to each health facility in the public health system. Center Of Disease Control and Prevention (CDC, Atlanta) has also emphasized the need of safe injection practices through use of technology, trainings and appropriate policy frameworks. APIC RECOMMENDATIONS The APIC (Association for Professionals in Infection Control and Epidemiology (APIC) full) strongly supports adherence to the following safe injection, infusion and medication vial practices . • Perform hand hygiene (handwashing with soap and water or by application of a 60% or greater alcohol-hand sanitizer rub that is allowed to dry) before accessing supplies, handling vials and IV solutions and preparing or administering medications. • Use aseptic technique in all aspects of parenteral medication administration, medication vial use, injections and glucose monitoring procedures. • Store and prepare medications and supplies in a clean area on a clean surface. • Never store needles and syringes unwrapped because sterility cannot be ensured. • Discard all opened vials, IV solutions and prepared or opened syringes that were involved in an emergency situation. • Avoid contacting sterile drugs and sterile areas of devices and containers with non-sterile objects and/ or secretions and particles shed from personnel. IV SOLUTIONS • Never use IV solution containers (eg, bags, bottles) to obtain flush solutions or for any other purpose for more than 1 patient. • Never use infusion supplies, such as needles, syringes, flush solutions, administration sets, or IV fluids, on more than one patient. • Disinfect IV ports and vial stoppers by wiping with sterile 70% isopropyl alcohol. FLUSHING • Use single-dose containers for flush solutions, when ever possible. IAP Guide Book on Safe Injection Practices8 1.2 Indian Academy of Pediatrics
  25. 25. • If a multi-dose vial must be used, use it for only one patient and then discard it. Each entry into the multi-dose vial (dedicated to that patient) must be made with a new, unused sterile needle and a new, unused sterile syringe. SYRINGES • Remove the sterile needle/cannulas and/or syringe from the package immediately before use. • Never use a syringe for more than one patient even if the needle has been changed between patients. Changing the needle but not the syringe is unacceptable. • Use a new syringe and a new needle for each entry into a vial or IV bag. • Utilize sharps safety devices whenever possible. Discard syringes, needles and cannulas immediately after use. • Dispose off used needles/syringes at the point of use in an approved sharps container. • Do not prepare medication in one syringe to transfer to another syringe. • Never store or transport syringes in clothing or pockets. • Prepare syringes as close to administration as possible. VIALS • Always follow the manufacturer's instructions for storage and use. • Use single-use or single-dose vials whenever possible. • Cleanse the access diaphragm of vials using sterile 70% isopropyl alcohol. • Discard single-dose vials after use. Never use them again for another patient. • Discard any vial that has been placed on a contaminated surface or a used procedure tray or that has been used during an emergency procedure. • Dedicate multi-dose medication vials for a single patient. Access all vials using a new sterile syringe and new needle/cannula adhering to aseptic technique. • Never store or transport vials in clothing or pockets. • Never leave a needle, cannula, or spike device (even if it has a 1-way valve) inserted into a medication vial rubber stopper because it leaves the vial vulnerable to contamination. • Do not use expired drugs. IAP Guide Book on Safe Injection Practices 9 1.2 Indian Academy of Pediatrics
  26. 26. • All vials used during an emergency should be discarded because sterility cannot be guaranteed. BLOOD GLUCOSE MONITORING DEVICES • Assign a glucometer to each individual patient if possible. Clean and disinfect glucometers if they must be shared between multiple patients. • Use single-use lancets that permanently retract after puncture. • Never reuse finger stick devices and lancets. • Thoroughly clean all visible soil or organic material (eg, blood) from the glucometer before disinfection. SOME GENERAL POINTS • Provide the HBV vaccination series to all previously unvaccinated health care personnel whose activities involve contact with blood or body fluids. • Immediately report body fluid exposures and needle-stick/sharps injuries. • Ensure that staff preparing or administering injections or other parenteral medications are competent to perform these tasks aseptically. • Periodically assess compliance with safe injection practices by observing and evaluating all personnel performing these procedures. Phlebotomy, hepatic procedures, dialysis, endoscope settings are the risky areas for Health Care Workers (HCW) and patients. Catastrophic outbreaks have been reported in these settings due to unsafe injections practices and these areas are known for unrecognized transmission CONCLUSION Health care providers everywhere need to spend time along with their colleagues to review injection practices and other issues of care to ensure the safe injection practices are understood and followed to save themselves, patients and community. Safe injection practices are also critical to prevent microbial contamination of products administered to patients. Different reports of HBV and HCV transmission and outbreaks of bacterial infections from different regions indicate that much more is needed to ensure that preventive practices are being scrupulously followed in all health care settings. HCWs and their managers must understand and practice these procedures safely. Administrators of medical facilities must be aware of safe injection practices and ensure that employees have the knowledge, training and equipment to safely implement these procedures. IAP Guide Book on Safe Injection Practices10 1.2 Indian Academy of Pediatrics
  27. 27. Continuing education efforts should be aimed at practicing safe injection practices. It is critical that injectable medications, IV delivery systems and blood glucose monitoring devices are used safely in all health care settings. We have an obligation to reiterate and ensure that safe injection, infusion and medication vial practices are the absolute standard of care throughout various health care settings and across the continuum of care. We must take a lead in promoting adherence to these safe Injection practices by Health care Providers to protect the health and safety of the patients under our care. POINTS TO REMEMBER • Health care providers should prioritize improving their knowledge and skills on injection safety. • Ensuring injection safety as a preventive practice, should be followed in all health care settings. • Administrators of medical facilities should understand safe injection practices and ensure skill building and compliance at the facility level. • Continuing education efforts aimed at improving injection safety standards should be accorded high priority. References: 1. Safe injection practices to prevent transmission of infections to patients CDC2007 guidelines 2. AJIC Injection Practces Among Clinicians of United States Health Care settings 2010 3. WHO SIGN MEETING PROCEEDINGS 2010 4. WHO Injection Safety Guidelines 5. BD Safe Injection Practice Coalition FEB2009 6. CDC PREVENTION OF UNSAFE INJECTION PRACTICES IAP Guide Book on Safe Injection Practices 11 1.2 Indian Academy of Pediatrics
  28. 28. BACKGROUND Medically inappropriate, ineffective and economically inefficient use of pharmaceuticals is commonly observed in health care systems throughout the world, especially in developing countries. However, various forms of inappropriate prescribing often remain unnoticed by those who are involved in health sector decision making or delivery of health services. This problem will usually come to the attention of health decision makers or managers when there is an acute shortage of pharmaceutical budget that requires action for cost-efficiency or there is a resistance to a particular drug. Promoting appropriate use of drugs and Injections in the health care system is needed because of a) Financial reasons with which policy makers and managers are usually most concerned. b) An essential element in achieving quality of health and medical care for patients and the community. Actions or intervention programs to promote the appropriate use of drugs and injections should, therefore, be continuously implemented and systematically incorporated as an integral part of the health care system. Defining Rational Use of Drugs (including injections) People may have different perceptions and meanings regarding rational use of drugs, or more specifically regarding rational prescribing. However, the Conference of Experts on the Rational Use of Drugs, convened by the World Health Organization in Nairobi in 1985, defined rational use as follows: Rational use of drugs requires that patients receive medicines appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time and at the lowest cost to them and their community. Injections are a form of drug administration and choosing this form of administration for the patient needs utmost caution. The requirements for rational use will be fulfilled if the process of prescribing is appropriately followed. This process includes steps in defining a patient's problems (or diagnosis); in defining effective and safe treatments (drugs and non drugs); in selecting Chapter - 1.3 Rational Use of Injections IAP Guide Book on Safe Injection Practices12 1.3 Indian Academy of Pediatrics
  29. 29. appropriate drugs, dosage and duration; in writing a prescription; in giving patients adequate information; and in planning to evaluate treatment responses. The definition implies that rational use of drugs and injections, especially rational prescribing, should meet certain criteria as follows: • Appropriate indication. The decision to prescribe drug(s) is entirely based on medical rationale and the chosen therapy is an effective and safe treatment. • Appropriate molecule. The selection of molecule for a patient is based on efficacy, safety, suitability and cost considerations. • Appropriate patient. No contraindications exist, the likelihood of adverse reactions is minimal and the drug is acceptable to the patient. • Appropriate patient information. Patients are provided with relevant, accurate, important and clear information regarding their conditions and the medication(s) that are prescribed. • Appropriate evaluation. The anticipated and unexpected effects of medications are appropriately monitored and interpreted. Unfortunately, in the real world, prescribing patterns do not always conform to these criteria and can be classified as inappropriate or irrational prescribing. Irrational prescribing may be regarded as "pathological" prescribing when the above-mentioned criteria are not fulfilled. Common patterns of irrational prescribing may, therefore, be manifested in the following forms: • The use of drugs when no drug therapy is indicated, e.g., antibiotics for viral upper respiratory infections. • The use of correct drugs with incorrect administration, dosages and duration, e.g., the use of IV metronidazole when suppositories or oral formulations would be appropriate. • The use of injections due to patient's request or commercial gains. • The use of the wrong drug for a specific condition requiring drug therapy, e.g., tetracycline in childhood diarrhea requiring ORS. • The use of drugs with doubtful or unproven efficacy, e.g., the use of antimotility agents in acute diarrhea. • The use of drugs of uncertain safety status, e.g., use of dipyrone (Baralgan, etc.). • Failure to provide available, safe and effective drugs, e.g., failure to vaccinate against measles or tetanus, or failure to prescribe ORS for acute diarrhea. IAP Guide Book on Safe Injection Practices 13 1.3 Indian Academy of Pediatrics
  30. 30. The use of unnecessarily expensive drugs, e.g. the use of a third generation, broad-spectrum antimicrobial when a first-line, narrow spectrum agent is indicated. Some examples of commonly encountered inappropriate prescribing practices in many health care settings include:- • Overuse of antibiotics and antidiarrheals for nonspecific childhood diarrhea. • Indiscriminate use of injections, e.g., in malaria treatment. • Multiple or over-prescription. • Excessive use of antibiotics for treating minor ARI. • Multivitamins and tonics for malnutrition. • Unnecessary use of expensive antihypertensives. The drug use system is complex and varies from country to country. Drugs may be imported or manufactured locally. The drugs may be used in hospitals or health centers, by private practitioners and often in a pharmacy or drug shop where over the counter preparations are sold. In some countries all drugs are available over the counter. Finally, the public includes a very wide range of people with differing knowledge, beliefs and attitudes about medicines. Consumers may have a very different perspective of what is rational. Factors Underlying Irrational Use of Drugs and Injections Many different factors affect the irrational use of drugs. In addition, different cultures view drugs in different ways and this can affect the way drugs are used. The major forces can be categorized as those deriving from patients, prescribers, the workplace, the supply system including industry influences, regulation, drug information and misinformation and combinations of these factors. Patients - Drug misinformation - Misleading beliefs - Patient demands/expectations Prescribers - Lack of education and training - Inappropriate role models - Lack of objective drug information • IAP Guide Book on Safe Injection Practices14 1.3 Indian Academy of Pediatrics
  31. 31. - Generalization of limited experience - Misleading beliefs about drugs efficacy Workplace - Heavy patient load - Pressure to prescribe - Lack of adequate lab capacity - Insufficient staffing Drug Supply System - Unreliable suppliers - Drug shortages - Expired drugs supplied Drug Regulation - Nonessential drugs available - Informal prescribers - Lack of regulation enforcement Industry - Promotional activities - Misleading claims All of these factors are affected by changes in national and global practices. For example, the frequent use of injections is declining in many African countries because of the fear of AIDS. In some countries, however, the use of injectables remains high due to false assumption of prescribers that injections will improve patient satisfaction and that they are always expected by the patients. Impact of Inappropriate Use of Drugs The impact of this irrational use of drugs can be seen in many ways: • Reduction in the quality of drug therapy leading to increased morbidity and mortality. • Waste of resources leading to reduced availability of other vital drugs and increased costs. • Increased risk of unwanted effects such as adverse drug reactions and the emergence of drug resistance, e.g., malaria or multiple drug resistant tuberculosis. IAP Guide Book on Safe Injection Practices 15 1.3 Indian Academy of Pediatrics
  32. 32. Psychosocial impacts, such as when patients come to believe that there is “a pill for every ill.” This may cause an apparent increased demand for drugs. Hospital Problems Drug use in hospitals has been a neglected area. However in both developed and developing countries, the misuse of antibiotics, particularly for surgical prophylaxis, has been widely reported. More so, the hospitals choose injectable form than oral medications in such scenarios. Hospitals have been able to improve antibiotic use through the use of formularies. Points to Remember • Never use injections due to patient's request or commercial gains. • Appropriate indication. The decision to prescribe injections is entirely based on medical rationale and the chosen therapy is an effective and safe treatment. Analyze patients condition and then only prescribe injections if at all required.Prefer oral medications if patients'scodition permits. • Appropriate molecule. The selection of suitable molecule for a patient is based on the disease condition, drug's efficacy, safety, suitability and cost considerations. • Appropriate patient. No contraindications exist, the likelihood of adverse reactions is minimal and the drug is acceptable to the patient. • Appropriate patient information. Patients are provided with relevant, accurate, important and clear information regarding their conditions and the medication(s) that are prescribed. Discourage them to unnecessarily ask for injections. • Appropriate evaluation. Monitor the patient for anticipated and unexpected effects of medications given through injections. References: Laing RO. Rational drug use: an unsolved problem. Trop Doct. 1990; 20:101–3. Avorn J, Harvey K, Soumerai, SB et al. Information and education as determinants of antibiotic use. Rev Infect Dis. 1987; 9(S3):S286–96. Vance MA, Millington WR. Principles of irrational drug therapy. Int J Health Serv. 1986;16(3):355–61. Quick JD, Foreman P, Ross-Degnan D, et al. Where Does the Tetracycline Go?: Health Center Prescribing and Child Survival in East Java and West Kalimantan, Indonesia. Boston: Management Sciences for Health, October 1988. Ross-Degnan, D, Laing RO, Quick, JD et al. A strategy for promoting improved pharmaceutical use: The International Network for Rational Use of Drugs. Soc Sci and Med. 1992 35 (11) 1329–41. . • IAP Guide Book on Safe Injection Practices16 1.3 Indian Academy of Pediatrics
  33. 33. Background In transitional and developing countries where unnecessary injections are common, the average number of health care injections per person was estimated to be 3.7 per year (this includes all health care injections, including those given to diabetics for administering insulin). Many injections, as well as being unnecessary, are also unsafe. Each year, the reuse of injection equipment may cause 20 million infections with hepatitis B virus (HBV), 2 million infections with hepatitis C virus (HCV) and 250 000 infections with human immunodeficiency virus (HIV) worldwide. These chronic infections lead to a high burden of morbidity and mortality. No evidence-based guidelines are available to guide injection providers through the steps they should follow to prevent injection-associated infections. IAP with the objective of addressing the issue in reference, have worked to develop guidelines and recommendations which are based on the WHO framework. This chapter would throw light on vital aspects of this. Potentially Critical Issues An injection is a procedure that introduces a substance into the body by piercing the skin or a mucosal membrane and thus carries the risk of introducing disease causing agents from outside to inside the body, Therefore some vitally important precautions should always be practiced by the injection providers. The potentially critical issues which carry a risk of causing infections amongst the recipient, the providers and the community in general as well, are listed in the table below Chapter - 2 Best Practices to Ensure Injection Safety IAP Guide Book on Safe Injection Practices 17 2 Indian Academy of Pediatrics
  34. 34. Potential Source of contamination and stages of occurrece Use of sterile injection equipment The most important infection control measures for preventing infection among injection recipients is the use of a sterile syringe and needle for each injection and to reconstitute each unit of medication (for medications that require a diluent). In many countries, the practice of reusing injection equipment in the absence of sterilization is common and such practices have been associated with infections. Use of a new, single-use syringe and needle provides the highest level of safety to the recipient. However, unreliable and insufficient supplies might lead to the equipment being reused. Even though boiling injection equipment for 20 min does not sterilize it, the use of pans to boil single-use injection equipment is common in developing and transitional countries. In many instances these pans are used as containers of tepid water where injection equipment is simply rinsed and soaked between injections Also, it is necessary to use injection equipment that has been inspected for breaches in barrier Potential source of Stage at which contamination Potentially critical issues contamination or exposure or exposure might occur Preventing infection among a injection recipients Injection equipment Sterilization 1. Sterilization of injection equipment Storage 2. Duration and conditions of storage Handling 3. Handling of injection equipment Injected substance Before opening 4. Type of medication 5. Medication and vial check During opening 6. Swabbing of vial stopper/neck 7. Filing and breaking of ampoules and vials After opening 8. Handling of multi-dose vials Skin of the recipient Introduction of the needle 9. Site of injection administration 10. Skin preparation Environment Injection preparation 11. Injection preparation area 12. Aseptic techniques Hands of the provider Injection preparation and administration 13.Hand Hygiene Preventing infection among b injection providers Exposure to the injection recipient’s During injection administration 14. Preparation and/or restraint of patient blood through needle-stick injury Handling of injection equipment 15. Needle recapping after use 16. Needle removal 17. Needle cutting 18. Rising and dissembling sterilizable equipment Collection of contaminated equipment 19. Use of sharps containers 20. Improper disposal of sharps 21. Quality of sharps containers Sharps waste management 22. Removal of containers used to collect sharps Preventing infection b in the community Exposure to the injection recipient’s Sharps waste management 23. Storage of containers used to collect used Sharps Blood through needle-stick injury 24. Terminal disposition of sharps waste a Contamination. b Exposure. IAP Guide Book on Safe Injection Practices18 2 Indian Academy of Pediatrics
  35. 35. integrity and to discard it if it is punctured, torn, or damaged. By inspecting the packaging of individual syringes,we can also have an idea about the completeness of process of sterilization using Ethylene Oxide (ETO), which is carried out by the manufacturers.. In the ribbon packs one should observe for presence of a paper strip with perforations, which allow the ETO to enter and diffuse out. ETO sterilizes the injection equipment and this effect is long lasting. Excess of residual ETO has carcinogenic effects. If the packaging says that the syringe is ETO sterilized and the paper used in not medical grade paper (flow wrap and blister packs) or there is no paper strip with perforations (ribbon packs), then the quality of sterilization is doubtful. Preventing contamination of injection equipment and medication Work environment. It is important to prepare injections in a clean designated area, where the risk of contamination by blood or body fluids is low. HBV persists for up to seven days on surfaces, which can potentially lead to environmental contamination. Environmental contamination is a potential source of HBV infection in settings where chronic haemodialysis is performed. Factors that might facilitate HBV transmission among patients receiving chronic haemodialysis include a high prevalence of HBV infection among patients, an environmental contamination with blood, a high frequency of percutaneous procedures and the presence of patients with high levels of viraemia. These factors might also be found in other health care settings because of following features:- • High HBV endemicity • Limited implementation of standard precautions • Overuse of injections • The presence of people in whom the HBV replicates actively (e.g. children) In Romania, for example, where some of these conditions were present, HBV infection was associated with injections in 1998. However, a review of injection practices in Romania suggested that HBV transmission was probably related to the preparation of injections in environments that were potentially contaminated with blood or body fluids. The preparation of injections in contaminated environments might also lead to bacterial infection. Multi-dose vials. It is important to use single-dose vials rather than multi-dose vials whenever possible. Although preservatives reduce the survival of bacteria, multi-dose vials remain prone to bacterial contamination and the use of multi-dose vials has been reported to be a potential source of infections in number of studies. Needles left in the septum of multi-dose vials might encourage the use of the same syringe to repeatedly draw medications for one patient, a practice that may lead to vial contamination and IAP Guide Book on Safe Injection Practices 19 2 Indian Academy of Pediatrics
  36. 36. infections among subsequent patient,. Thus, if multi-dose vials must be used, it is essential that the person administering the injection pierces the septum with a separate sterile needle and it is important not to leave any needle in place in the stopper. A vial showing a needle in Septum Breaking vials and ampoules. Injuries to injection providers can be another source of infection. While opening glass ampoules, providers may lacerate their hands, which can bleed and may cause infections. Thus, it is important to use pop-open ampoules and vials rather than that need to be opened using a metal file. If a metal file is to be used, the fingers should be protected using a clean barrier (e.g. small gauze pad). Compromised packaging. Cracks and leaks in vials are a potential source of contamination. Although it is not known how effective a visual examination of the vial is in preventing infections, it is important to inspect the vial for and discard medications with visible contamination or breaches of integrity (e.g. cracks or leaks) and to follow product-specific recommendations for use, storage and handling. Aseptic techniques. Medical devices might become contaminated with bacteria if touched. Thus, a needle that has touched any non-sterile surface must be discarded. Provider's hand hygiene and skin integrity. Washing or disinfecting hands is a standard procedure that is carried out before preparing injection material. The need for hand hygiene between each injection will vary depending on the setting and on whether the health care worker has had contact with soil, blood, or body fluids. Injections have been administered in the absence of hand-washing. Skin lesions and skin irritation are associated with bacterial contamination. Thus, it is necessary to avoid giving injections if skin integrity is compromised by local infection or other skin conditions (e.g. weeping dermatitis) and to cover any small cut. This has been described in details in the chapter on injection methods. IAP Guide Book on Safe Injection Practices20 2 Indian Academy of Pediatrics
  37. 37. Swabbing vial tops Cotton balls and gauze stored wet in antiseptics might become contaminated and have contributed to infections among patients, particularly when benz-alkonium chloride was used. Thus, if swabbing with an antiseptic is selected for use, an isopropyl alcohol swab must be used. Cotton balls stored wet in a multi-use container must not be used. Skin preparation of patient before injection. While the benefit of skin preparation is unclear, unsafe skin preparation protocols may be harmful. Thus, if swabbing with an antiseptic is selected for use, an isopropyl alcohol swab must be used. Cotton balls stored wet in a multi-use container must not be used. Prevention of needle-stick injuries to the provider Best infection control practices for preventing infections among injection providers address the prevention of movements of patients, the prevention of unsafe recapping of needles and the collection of contaminated sharps in puncture-proof and liquid-proof containers. Movement of patients. Needle-stick injuries to providers when administering injections are usually attributable to the abrupt movement of patients during the procedure. Thus, it is important that providers anticipate and take measures to prevent sudden patient movement during and after injection. In some instances, physical assistance from other health care workers or family members might help to ensure that the procedure is carried out under appropriate circumstances. Recapping. Avoiding recapping of needles and other hand manipulations of used needles is essential for preventing needle-stick injuries. A high proportion of needle- stick injuries are attributable to recapping. Sharps collection. It is important to collect and properly contain syringes and needles at the point of use in a sharps container that is resistant and leak-proof and that is sealed th before it is full up to 3/4 level. Unsafe sharps waste collection causes between 5% and 28% of needle-stick injuries as per NIOSH. Puncture and liquid-proof containers designed for the collection of contaminated sharps are associated with a lower risk of needle-stick injuries than regular cardboard boxes. The presence of sharps containers close to the point of use reduces the incidence of recapping and of recapping related needle-stick injuries. Interventions that combine the provision of sharps containers and risk communications reduce the total number of needle-stick injuries. IAP Guide Book on Safe Injection Practices 21 2 Indian Academy of Pediatrics
  38. 38. Other practice issues Engineered technologies. Current hypodermic needles and syringes with safety features for preventing needle-stick injuries require a provider-dependent activation step. Their effectiveness is unclear. None are able to protect the provider when giving an injection because the safety feature is only activated after use. Reports on the effectiveness of other, safer needle-bearing devices (e.g. intravenous catheters, phlebotomy needles) to protect health care personnel from needle-sticks are encouraging. Thus, whenever possible, devices designed to prevent needle-stick injury that have been shown to be effective for patients and providers are preferable. Preventing infections in the community Contaminated sharps are a potential source of biohazard to the community at large. To prevent people being exposed to contaminated sharps, it is important to seal sharps containers for transport to a secure area in preparation for disposal. After closing and sealing, sharps containers must not be opened, emptied, reused, or sold. In South Asia, used injection equipment is sought for recycling, mostly for the plasticware industry Such practices might lead to needle-stick injuries among waste pickers and can lead to illegal repackaging of syringes for reuse in hospitals and clinics. Finally, it is important to manage sharps waste in an efficient, safe and environment- friendly way. Contaminated sharps were observed in the immediate surroundings of a high proportion of health care facilities in developing countries. Such unsafe sharps waste management exposes the community to needle-stick injuries. Use of new single use equipment IAP Guide Book on Safe Injection Practices22 2 Indian Academy of Pediatrics
  39. 39. Summary of best infection control practices for intradermal, SC and IM needle injections • Eliminating unnecessary injections is the highest priority in preventing injection- associated infections. • When injections are medically indicated, they should be administered safely. • These best practices are measures that have been determined through scientific evidence or expert consensus most effectively to protect patients, providers and communities. 1. Use sterile injection equipment • Use a sterile syringe and needle for each injection and to reconstitute each unit of medication. • Use a new, single-use syringe and needle. • Inspect packaging for breaches in barrier integrity. • Discard a needle or syringe if the package has been punctured, torn, or damaged. 2. Prevent contamination of injection equipment and medication • Prepare each injection in a clean designated area, where contamination from blood or body fluid is unlikely. • Use single-dose vials rather than multi-dose vials. • If multi-dose vials must be used, always pierce the septum with a separate sterile needle. • Do not leave a needle in place in the stopper of the vial. • Select pop-open ampoules rather than ampoules that need to be opened by using a metal file. If an ampoule that requires a metal file is used, protect fingers with a clean barrier (e.g. small gauze pad) when opening the ampoule. • Inspect for and discard medications with visible contamination or breaches of integrity (e.g. cracks, leaks). • Follow product-specific recommendations for use, storage and handling. • Discard a needle that has touched any non-sterile surfaces. IAP Guide Book on Safe Injection Practices 23 2 Indian Academy of Pediatrics
  40. 40. 3. Prevent needle-stick injuries to the provider • Anticipate and take measures to prevent sudden movement of patient during and after injection. • Do not recap needles and do not manipulate needles manually. • Collect used syringes and needles at the point of use in an enclosed sharps th container that is puncture-proof and leak-proof and that is sealed before it is ¾ full. 4. Prevent access to used needles • Seal sharps containers for transport to a secure area in preparation for disposal. After closing and sealing sharps containers, do not open, empty, reuse, or sell them. • Manage sharps waste in an efficient, safe and environment-friendly way to protect people from accidental exposure to used injection equipment. 5. Other practice issues • Engineered technology. Whenever possible, use devices that have been designed to prevent needle-stick injury and have been shown to be effective for patients and providers. Auto-disable (AD) syringes are increasingly available to prevent the reuse of injection equipment in selected settings, including immunization services. • Hand hygiene and skin integrity of provider. Perform hand hygiene (i.e. wash or disinfect hands) before preparing injection material and giving injections. The need for hand hygiene between each injection will vary depending on the setting and whether there was contact with soil, blood, or body fluids. Avoid giving injections if skin integrity is compromised by local infection or other skin condition (e.g. weeping dermatitis). Cover any small cuts. • Gloves. Single-use gloves may be indicated if excessive bleeding is anticipated. • Swabbing vial tops or ampoules. If swabbing with an antiseptic is selected for use, use a clean, single-use swab and maintain product-specific recommended contact time. Do not use cotton balls stored wet in a multi-use container. • Skin preparation of patient before injection. Wash skin that is visibly soiled or dirty.. If swabbing with an antiseptic is selected for use, use a clean, single-use swab and maintain product-specific recommended contact time. Do not use cotton balls stored wet in a multi-use container. IAP Guide Book on Safe Injection Practices24 2 Indian Academy of Pediatrics
  41. 41. References: Hauri AM, Armstrong GL, Hutin YJF. Contaminated injections in health care settings. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, editors. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneva: World Health Organization; 2003. Best infection control practices for intradermal, subcutaneous,and intramuscular needle injections Yvan Hutin,1 Anja Hauri,2 Linda Chiarello,3 Mary Catlin,4 Barbara Stilwell,2 Tesfamicael Ghebrehiwet,5 Julia Garner,2 & the Members of the Injection Safety Best Practices Development Group Hauri AM, Armstrong GL, Hutin YJF. Contaminated injections in health care settings. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, editors. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneva: World Health Organization; 2003. Dicko M, Oni AQ, Ganivet S, Kone S, Pierre L, Jacquet B. Safety of immunization injections in Africa: not simply a problem of logistics. Bulletin of the World Health Organization 2000;78:163-9. Sopwith W, Hart T, Garner P. Preventing infection from reusable medical equipment: A systematic review.BMC Infectious Diseases 2002;2:4. Available from:URL: Centers for Disease Control. Recommendations for preventing transmission of infections among chronic hemodialysis patients. Morbidity and Mortality Weekly Report 2001;50(RR05):1-43. Hutin YJF, Craciun D, Ion-Neldelcu N, Mast EE, Alter MJ, Margolis HS. Using surveillance data to monitor key aspects of the epidemiology of hepatitis B virus (HBV) infection in Romania. Abstract presented at the annual meeting of the Infectious Diseases Society of America (IDSA). Denver (CO), November 1999.   Dentinger CM, Hutin YJF, Pasat L, Mihilescu I, Mast EE, Margolis HS. Knowledge and practices of nurses regarding injection safety and use of universal precautions, Vilcea district, Romania. Abstract presented at the annual meeting of the Society for Healthcare Epidemiology of America (SHEA). San Francisco (CA), April 1999 (Abstract S 42). Centers for Disease Control. Recommendations for preventing transmission of infections among chronic hemodialysis patients. Morbidity and Mortality Weekly Report 2001;50(RR05):1-43. Simon PA, Chen RT, Elliot JA, Schwartz B. Outbreak of pyogenic abscesses after diphtheria and tetanus toxoids and pertussis vaccination. Pediatric Infectious Disease 1993;12:368-71. Phillips G, Fleming LW, Stewart WK. The potential hazard of using multipledose heparin and insulin vials in continuous ambulatory peritoneal dialysis. Journal of Hospital Infection 1989;14:174-7. Krause G, Whisenhunt S, Trepka M, Katz D, Nainan O, Wiersma S, et al. Patientto- patient transmission of hepatitis C virus associated with use of multidose saline vials in a hospital. Presentation given at the 49th Annual Epidemic Intelligence Service (EIS) Conference. Atlanta (GA), 2000. Simon PA, Chen RT, Elliot JA, Schwartz B. Outbreak of pyogenic abscesses after diphtheria and tetanus toxoids and pertussis vaccination. Pediatric Infectious Disease 1993;12:368-71. Phillips G, Fleming LW, Stewart WK. The potential hazard of using multipledose heparin and insulin vials in continuous ambulatory peritoneal dialysis. Journal of Hospital Infection 1989;14:174-7. Sheth NK, Post GT, Wisniewski TR, Uttech BV. Multidose vials versus singledose vials: a study in sterility and cost- effectiveness. Journal of Clinical Microbiology 1983;17:377-9. Parker MR. The use of protective gloves, the incidence of ampoule injury and the prevalence of hand laceration amongst anaesthetic personnel. Anaesthesia 1995;50:726-9. Bulletin Ross RS, Viazov S, Gross T, Hofmann F, Seipp HM, Roggendorf M. Transmission of hepatitis C virus from a patient to an anesthesiology assistant to five patients. New England Journal of Medicine 2000;343:1851-4. IAP Guide Book on Safe Injection Practices 25 2 Indian Academy of Pediatrics
  42. 42. METHOS OF INJECTION DELIVERY Commandments of Right Injection Delivery: The right vaccine, right drug, to the right child, at the right age, at the right site, in the right dose, in right dose, right interval, by the right procedure at the right age is the best and cheapest investment a health-care system of any country can make for the positive health of its people. To make sure that the entire process of administering an injection is safe, the equipments used, techniques applied and processes involved should be handled in an utmost safe and hygienic manner. It is also known that skin and the environment contain microorganisms which may be commensals, but on the first opportunity can become pathogenic. Unsafe injections can spread pathogens more easily than by inhalation, swallowing or sexual activity, as they introduce them directly into the blood stream. As health care professionals, it is our responsibility to ensure that all healthcare interventions are safe for beneficiaries, the health care workers and the community at large. HAND WASHING Hands are the principal route by which cross-infection occurs. Hand-washing is one of the most important standard precautions for preventing the spread of diseases. Hand decontamination is a simple and effective way in which Health Care Workers or Professionals (HCW/HCP) can prevent the transmission of infection between patients and protect themselves leading to a reduction in patient morbidity & mortality. Hands must be decontaminated before and after every step of care that involves direct contact with patients' skin, their food, invasive devices or dressings. Effective hand decontamination can significantly reduce infection rates leading to a reduction in patient morbidity and mortality. The current spread of antibiotic-resistant organisms can be attributed, at least in part, to a failure of HCW/HCP to perform hand hygiene either as often, or as efficiently as the situation requires. Skin provides an environment that is acidic, arid, limited in nutrients and is constantly shed and renewed. Micro-organisms present on the skin can be classified as “resident” Methods of Injection Delivery Chapter - 3.1 IAP Guide Book on Safe Injection Practices26 3.1 Indian Academy of Pediatrics
  43. 43. or “transient”. Resident microorganisms are commonly termed normal flora. They live deeply seated within the epidermis – in skin crevices, hair follicles and sweat glands and beneath fingernails. Their function is to protect the skin from invasion from more harmful micro-organisms. These organisms do not readily cause infection and are not easily removed. However, they may establish an infection following surgery or invasive procedures. Transient microorganisms are located on the surface of the skin and beneath the superficial cells of the stratum corneum. They are termed transient because direct contact with other people, equipment and other body sites all result in the transfer of these microorganisms to and from the hands. Effective hand washing technique involves three stages; preparation, washing and rinsing & drying. Preparation requires wetting hands under tepid running water before applying liquid soap or an antimicrobial preparation. The hand-wash solution must come in contact with all the surfaces of the hand. The hands must be rubbed together vigorously for a minimum of 10-15 seconds, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers. Hands should be rinsed thoroughly prior to drying with pre-sterilized and clean towels or allowed to air dry. Apply an emollient hand cream regularly to protect skin from the drying effects of regular hand decontamination. Picture demonstrating hand washing techniques IAP Guide Book on Safe Injection Practices 27 3.1 Indian Academy of Pediatrics
  44. 44. Six basic steps SITE SELECTION It varies according to the age of the recipient and the vaccine/drug effect may be enhanced / diminished. All complications of injections viz nerve injury, muscle contractures are also site dependant. The preferred sites for injections in pediatric patients are antero-lateral aspect of thigh and the deltoid region. Vaccines should never be given in the gluteal region, to prevent injury to the sciatic nerve and as gluteal fat retards absorption, thus affecting antibody titers. Antero-lateral Thigh This is the preferred site for IM injection in children. The target muscle is Vastus Lateralis. The injection is given on antero-lateral aspect of thigh, middle third portion between greater trochanter and lateral femoral condyle. The rectus femoris muscle (which is anterior on the thigh) should not be used. Vastus Lateralis Relaxed Area IAP Guide Book on Safe Injection Practices28 3.1 Indian Academy of Pediatrics
  45. 45. Deltoid Muscle This is the alternate site for children above 2-3 years. The injection is given 3-5 cm below the acromian process or midway between acromian process and deltoid insertion. The muscle space is adequate for low volume injections. If not positioned properly there is a potential for injury to axillary and radial nerves and posterior circumflex humeral vessels. Triceps muscle should never be used since radial, brachial and ulnar nerves and profunda brachii artery is under the muscle. POSITIONING This is important to ensure that the pain is minimum and also there is no injury to the provider and the patient. Thigh: Child may be laid supine or be held on adult's (mother's) lap & restrained. Deltoid: Child may be held on adult's lap & restrained or may sit with little restrain, if willing. The part should be completely exposed and the child positioned & restrained such that the target muscle is fully relaxed. IM Injection deltoidDeltoid Muscle Area IM Injection antero-lateral thighPositioning the child for IM injection IAP Guide Book on Safe Injection Practices 29 3.1 Indian Academy of Pediatrics
  46. 46. CLEANSING Cleaning the injection site before giving injection is: • Good Clinical Practice. • Decreases number of microorganisms present in the skin. • Reduce the risk of abscess. If swabs are used to clean the skin they should be used in an inside out semicircular movement, or, top to bottom without returning to the site. In most cases though the recipient may be asked to wash the site prior to injecting. If Alcohol is used for cleaning, it should be allowed to dry before injection is given. Site cleaning DO NOT TOUCH PARTS Preventing contamination of injection equipment is as important as having a clean site. Any part of the syringe that comes in contact with the Injectable drug and human anatomy should NOT be touched. If accidentally any of these parts are touched, the syringe and needle are NOT sterile and needs to be discarded immediately in the appropriate container and new sterile syringe and a sterile needle should be used. The site is cleaned/washed with clean water/soap and water/alcohol wipes and allowed to dry. Routine disinfection of skin is not necessary for Immunization. Wipes impregnated with medicated chemicals may interfere with live vaccines like measles. Avoid pre-wetted cotton swabs (Kept in bottles/bowls) for fear of contamination. Do Not Touch Parts IAP Guide Book on Safe Injection Practices30 3.1 Indian Academy of Pediatrics
  47. 47. SIZE & BORE OF THE NEEDLE Needle length depends upon the site, age of child and muscle mass. Intra-Dermal Injection: BCG: 26/27G x 16mm (2/3 inch) Intra-Muscular Injection: 1) Most infants & children: 23G x 25mm (1 inch) needle. 2) Preterm/small babies (<2m): 26/27G x 16mm (2/3 inch) 3) Very obese children: 23G x 38mm (1½ inch) SC Injection: Measles, MMR etc vaccines: 26G x 16mm (2/3 inch) needle Needle Bore (gauge): Wider the lumen of the needle, less injury will be caused by the 'jet effect' while injecting. 26/27 and 23 G needles are appropriate for most vaccines. TECHNIQUE OF INJECTION ADMINISTRATION 1. WHO Recommended Techniques Intra-dermal Injections 0 Needle inserted at an angle parallel to long axis (at approx.150 ) for about 2 mm, so that entire needle bevel penetrates the skin and the injected solution raises a small bleb. There is no need to aspirate before injecting in immunization. The vaccine should be injected at a moderate rate of around 1ml/10 sec. Intra-muscular Injections 0 Stretch the skin flat and push the needle down at 90 Subcutaneous Injections Pinch up the skin between thumb and forefinger so as to lift the adipose tissue and then 0 push the needle in the pinched up tissue at a 45 .Posterior skin fold of the Triceps muscle in the arm is the ideal site because of the loose skin available for pinching before insertion of the needle, compared to thigh, though other sites are also recommended. Illustration showing techniques of IM, SC and ID Injection Sites on the Body Where a Subcutaneous Injection Can be Given IAP Guide Book on Safe Injection Practices 31 3.1 Indian Academy of Pediatrics
  48. 48. 2. ACIP Recommended Techniques Intra-dermal Injections Intra-dermal injections are generally administered on the volar surface of the forearm, except for human diploid cell rabies vaccine (HDCV) for which reactions are less severe when administered in the deltoid area. With the bevel facing upwards, a 3/8 to 3/4 inch, 26 or 27gauge needle can be inserted into the epidermis at an angle parallel to the long axis of the forearm. The needle should be inserted so the entire bevel penetrates the skin and the injected solution raises a small bleb. Because of the small amounts of antigen used in intra-dermal injections, care must be taken not to inject the vaccine subcutaneously because it can result in a suboptimal immunologic response. Subcutaneous Injections Subcutaneous injections are usually administered into the posterior skin fold of the arm /lateral aspect of thigh of infants and in the deltoid area of older children and adults. A 5/8- to 3/4”, 26/27- gauge needle should be inserted into the tissues below the dermal layer of the skin. Intramuscular Injections • The preferred sites for intramuscular injections are the antero-lateral aspect of the upper thigh and the deltoid muscle of the upper arm. • Generally, gluteal area should not be used routinely for active vaccination of infants, children or adults because of the potential risk of injury to the sciatic nerve. • In addition, injection into the gluteal area has been associated with decreased immunogenicity of certain immunogens like Hepatitis B and Rabies vaccines, presumably because of inadvertent subcutaneous injection or injection into deep fat tissue. • If the gluteal area is used for passive immunization when large volumes are to be injected or multiple doses are necessary (e.g. large doses of immune globulin [IG]), the central region should be avoided; only the upper, outer quadrant should be used and the needle should be directed anteriorly (i.e. not inferiorly or perpendicular to the skin) to minimize the possibility of involvement with the sciatic nerve. • For all intramuscular injections, the needle should be long enough to reach the muscle mass and prevent vaccine from seeping into subcutaneous tissue, but not so long as to endanger underlying neurovascular structures or bone. Vaccinators should be familiar with the structural anatomy of the area into which they are injecting vaccine. IAP Guide Book on Safe Injection Practices32 3.1 Indian Academy of Pediatrics
  49. 49. • An individual decision on needle size and site of injection must be made for each person based on age, the volume of the material to be administered, the size of the muscle and the depth below the muscle surface into which the material is to be injected. Infants (<12 months of age): Among most infants, the antero-lateral aspect of the thigh provides the largest muscle mass and is therefore the recommended site. However, the deltoid can also be used with the thigh; for example, when multiple vaccines must be administered at the same visit. In most cases, a 7/8- to 1inch, 22 to 24 gauge needle is sufficient to penetrate muscle in the thigh of a 4-month-old infant. The free hand should bunch the muscle and the needle should be directed inferiorly along the long axis of the leg at an angle appropriate to reach the muscle while avoiding nearby neurovascular structures and bone. Toddlers and Older Children: The deltoid may be used if the muscle mass is adequate. The needle size 22 to 24 gauges and from 5/8 to 1¼ inches, based on the size of the muscle. As with infants, the antero- lateral thigh may be used, but the needle should be longer—generally ranging from 7/8 to 1¼ inches. Adolescents & Adults: The deltoid is recommended for routine intramuscular vaccination among adolescents & adults, particularly for Hepatitis B vaccine. The suggested needle size is 23G x 1”. They are more prone to fainting attacks and therefore injecting in a supine position will be a better option in susceptible people. Post Injection Precautions: After emptying medication, wait for 10 seconds before withdrawing the syringe. Withdraw the needle with a smooth and steady movement. Apply gentle pressure with a gauze for a few seconds. Do not rub the area for site cleaning and post injection. Do not use alcohol/spirit swab which may cause burning sensation. IM Injection antero-lateral thigh IM Injection in deltoid IAP Guide Book on Safe Injection Practices 33 3.1 Indian Academy of Pediatrics
  50. 50. Multiple Injections Use separate syringe and needle for each injection: If more than one preparation is administered or if vaccine and an immunoglobulin preparation are administered simultaneously, it is preferable to administer each in two different limbs. It is also preferable to avoid administering two intramuscular injections in the same limb, especially if DPT is one of the products administered. However, if more than one injection must be administered in a single limb, the antero-lateral aspect of thigh is usually the preferred site because of the greater muscle mass; the injections should be sufficiently separated (i.e. at least 2.5 cm or 1 inch apart) so that any local reactions are unlikely to overlap & enough dendrite network is available for each vaccine to be carried to the local lymph nodes. POST INJECTION CARE & ANTICIPATORY GUIDANCE The child should be observed for 15 minutes. The parents should be explained to look out for adverse events: immediate and late,Instruct parents regarding management of adverse events. Always keep emergency and resuscitation equipment ready. Management of anaphylaxis is to be done as per standard protocol. EMERGENCY MANAGEMENT 1. Adverse events should be reported immediately to the concerned agencies. 2. Follow the standard procedures of ABC. 3. Shift the patient to emergency room for further appropriate management. POINTS TO REMEMBER 1. Hand-washing before and after procedures including injections and examining patients is a good clinical practice 2. Site selection is important. It is also age dependant. All immunization, except BCG, should be given on the antero-lateral aspect of thigh or Deltoid 3. Different sites and/or limbs, as for as possible, should be used if more than one injection is given at the same visit. 4. If the same site is used under extraordinary conditions the second injection should be given at least one inch apart. 5. Cleaning of injection site reduces the risk of infection 6. Needle size and bore are dependent on the consistency of liquid to be injected (viscous vaccines like DPT and Hepatitis B require longer needles with larger bore IAP Guide Book on Safe Injection Practices34 3.1 Indian Academy of Pediatrics