Infection Control: New York State Mandatory Training

Element III: Use of Engineering and work practice controls to reduce the opportunity for patient and healthcare worker exposure to potentially infectious material in all healthcare settings.


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This transmission electron micrograph (TEM) revealed the presence of hepatitis B virions. The large round virions are known as Dane particles. Photo courtesy of CDC/ Dr. Erskine Palmer.

High Risk Exposures

The healthcare setting can be a risky place to work. During the provision of routine healthcare, there exist high risk practices and procedures that are capable of causing healthcare acquired infection with blood borne pathogens.

More than 8 million U.S. healthcare workers in hospitals may be exposed to blood or other body fluids through the following types of contact (NIOSH, 2004):

  • Percutaneous injuries (injuries through the skin) with contaminated sharp instruments such as needles and scalpels (82%)
  • Contact with mucous membranes of the eyes, nose, or mouth (14%)
  • Exposure of broken or abraded skin (3%)
  • Human bites (1%)

The revised New York State syllabus for the Mandatory Infection Control training identifies high risk practices and procedures capable of causing healthcare acquired infection with bloodborne pathogens:

  • Percutaneous exposures
  • Other sharps injuries
  • Mucous membranes and non-intact skin exposures
  • Parenteral exposure.

Percutaneous exposures occur through handling/disassembly/disposal/reprocessing of contaminated needles and other sharp objects. This can occur through manipulating contaminated needles and other sharp objects by hand (e.g., removing scalpel blades from holders, removing needles from syringes, or recapping contaminated needles and other sharp objects using a two-handed technique), or by delaying or improperly disposing (e.g., leaving contaminated needles or sharp objects on counters/workspaces or disposing in non-puncture-resistant receptacles) (NYSDOH, 2008; NIOSH, 2004).

Up to 800,000 percutaneous injuries may occur annually among all U.S. healthcare workers (both hospital-based workers and those in other health care settings). After percutaneous injury with a contaminated sharp instrument, the average risk of infection is 0.3% for HIV and ranges from 6% to 30% for HBV (NIOSH, 2004). On a positive note, the CDC has reported no new cases of occupationally-acquired HIV since 2001 (CDC, 2006).

During the period 1995-2000, there were 10,378 reported percutaneous injuries among hospital workers (NIOSH, 2004). The devices most associated with percutaneous injuries among hospital workers during 1995-2000 were hypodermic needles (29% of injuries), suture needles (17%), winged steel needles (12%), and scalpels (7%). Other hollow-bore needles together accounted for 19% of injuries, glass items for 2%, and other items for 14% (NIOSH, 2004).

During the period 1995-2000 there were 6,212 reported percutaneous injuries involving hollow-bore needles in hospital workers. Drawing blood from a vein (venipuncture) was responsible for 25% of percutaneous injuries involving hollow-bore needles during 1995-2000, and injections were responsible for 22% (NIOSH, 2004).

Recent research on a nationally representative sample utilizing data from the US Bureau of Labor Statistics, identified registered nurses as having the greatest frequency of needlestick injury (Leigh, et al., 2008); while the occupations with greatest risk of needlestick injury included biologic technicians, janitors and cleaners, and maids and housemen.

Other means of sharps injury can occur when performing procedures where there is poor visualization, such as: Blind suturing, non-dominant hand opposing or next to a sharp, or performing procedures where bone spicules or metal fragments are produced.

Mucous membranes and non-intact skin exposures are also a potential method for exposure to bloodborne pathogens. Direct blood or body fluid contact with the eyes, nose, mouth or other mucous membranes occurs through contact with contaminated hands, contact with open skin lesions/dermatitis, or splashes/sprays of blood or body fluids such as might occur during irrigation or suctioning.

Parenteral exposures may occur through injection with infectious material while administering parenteral medications, sharing of blood monitoring devices such as glucometers, hemoglobinometers, lancets, lancet platforms/pens, or through the infusion of contaminated blood products or fluids.

Additional practice to prevent percutaneous exposures include:

  • Avoid unnecessary use of needles and other sharp objects.
  • Use care in the handling and disposing of needles and other sharp objects.
  • Avoid recapping unless absolutely medically necessary.
  • When recapping, use only a one-hand technique or safety device.
  • Pass sharp instruments by use of designated "safe zones".
    • A "safe zone" is an area such as a tray or basin on the sterile field where an instrument is placed before being picked up by a second person. This can prevent "collision" injuries where OR personnel can be tuck by another when passing instruments.
  • Disassemble sharp equipment by use of forceps or other devices.
  • Modify procedures to avoid injury:
    • Use forceps, suture holders or other instruments for suturing.
    • Avoid holding tissue with fingers when suturing or cutting.
    • Avoid leaving exposed sharps of any kind on patient procedure/treatment work surfaces.
  • Appropriately use safety devices whenever available:
    • Always activate safety features. o Never circumvent safety features.

Safe Injection Practices and Procedures

Outbreaks of healthcare-related bloodborne illness have occurred, usually due to unsafe injection practices. Recent news headlines that implicate specific healthcare organizations and specific healthcare providers for unsafe injection practices shocked the thousands of patients who may have had exposure to bloodborne pathogens, but such practices and procedures also shocked the broader healthcare community.

Injection safety or safe injection practices are a set of measures taken to perform injections in an optimally safe manner for patients, healthcare personnel, and others. A safe injection does not harm the recipient, does not expose the provider to any avoidable risks and does not result in waste that is dangerous for the community. Injection safety includes practices intended to prevent transmission of bloodborne pathogens between one patient and another, or between a healthcare worker and a patient, and also to prevent harms such as needlestick injuries.

The investigation of four large outbreaks of HBV and HCV among patients in ambulatory care facilities in the United States identified a need to define and reinforce safe injection practices (CDC, 2008b). The four outbreaks occurred in a private medical practice, a pain clinic, an endoscopy clinic, and a hematology/oncology clinic. The pain clinic was located on Long Island, New York. The primary breaches in infection control practice that contributed to these outbreaks were:

  1. reinsertion of used needles into a multiple-dose vial or solution container (e.g., saline bag) and
  2. use of a single needle/syringe to administer intravenous medication to multiple patients.

In one of these outbreaks, preparation of medications in the same workspace where used needle/syringes were dismantled also may have been a contributing factor. These and other outbreaks of viral hepatitis could have been prevented by adherence to basic principles of aseptic technique for the preparation and administration of parenteral medications. These include the use of a sterile, single-use, disposable needle and syringe for each injection given and prevention of contamination of injection equipment and medication.

The unsafe practices above have resulted in the transmission of bloodborne viruses, including hepatitis B and C viruses to patients; as well as the notification of thousands of patients of possible exposure to bloodborne pathogens and recommendation that they be tested for hepatitis C, hepatitis B virus, and HIV. Additionally, healthcare providers were referred to licensing boards for disciplinary action and multiple malpractice lawsuits were filed on behalf of patients.

Outbreaks related to unsafe injection practices indicate that some healthcare personnel are unaware of, do not understand, or do not adhere to basic principles of infection control and aseptic technique. A survey of US healthcare workers who provide medication through injection found that 1% to 3% reused the same needle and/or syringe on multiple patients. Among the deficiencies identified in recent outbreaks were a lack of oversight of personnel and failure to follow-up on reported breaches in infection control practices in ambulatory settings (CDC, 2008b).

It is important for to remember that pathogens including HCV, HBV, and human immunodeficiency virus (HIV) can be present in sufficient quantities to produce infection in the absence of visible blood. Bacteria and other microbes can be present without clouding or other visible evidence of contamination.

The absence of visible blood or signs of contamination in a used syringe, IV tubing, multi-dose medication vial, or blood glucose monitoring device does NOT mean the item is free from potentially infectious agents.

All used injection supplies and materials are potentially contaminated and should be discarded.

Providers should maintain aseptic technique throughout all aspects of injection preparation and administration, which includes the following:

  • Medications should be drawn up in a designated "clean" medication area that is not adjacent to areas where potentially contaminated items are placed.
  • Use a new sterile syringe and needle to draw up medications while preventing contact between the injection materials and the non-sterile environment.
  • Ensure proper hand hygiene before handling medications.
  • If a medication vial has already been opened, the rubber septum should be disinfected with alcohol prior to piercing it.
  • Never leave a needle or other device (e.g. "spikes") inserted into a medication vial septum or IV bag/bottle for multiple uses. This provides a direct route for microorganisms to enter the vial and contaminate the fluid.
  • Medication vials should be discarded upon expiration or any time there are concerns regarding the sterility of the medication.
  • Never administer medications from the same syringe to more than one patient, even if the needle is changed.
  • Never use the same syringe or needle to administer IV medications to more than one patient, even if the medication is administered into the IV tubing, regardless of the distance from the IV insertion site.
    • All of the infusion components from the infusate to the patient's catheter are a single interconnected unit.
    • All of the components are directly or indirectly exposed to the patient's blood and cannot be used for another patient.
    • Syringes and needles that intersect through any port in the IV system also become contaminated and cannot be used for another patient or used to re-enter a non-patient specific multi-dose vial.
    • Separation from the patient's IV by distance, gravity and/or positive infusion pressure does not ensure that small amounts of blood are not present in these items.
  • Never enter a vial with a syringe or needle that has been used for a patient if the same medication vial might be used for another patient.
  • Dedicate vials of medication to a single patient.
  • Medications packaged as single-use must never be used for more than one patient:
    • Never combine leftover contents for later use;
    • Medications packaged as multi-use should be assigned to a single patient whenever possible;
    • Never use bags or bottles of intravenous solution as a common source of supply for more than one patient.
  • Never use peripheral capillary blood monitoring devices packaged as single-patient use on more than one patient:
  • Restrict use of peripheral capillary blood sampling devices to individual patients.
  • Never reuse lancets. Consider selecting single-use lancets that permanently retract upon puncture.

Safe injection practices as identified in the CDC's Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007 include the following recommendations apply to the use of needles, cannulas that replace needles, and, where applicable intravenous delivery systems (CDC, 2007):

  • Use aseptic technique to avoid contamination of sterile injection equipment.
  • Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed. Needles, cannulae and syringes are sterile, single-use items; they should not be reused for another patient nor to access a medication or solution that might be used for a subsequent patient.
  • Use fluid infusion and administration sets (i.e., intravenous bags, tubing and connectors) for one patient only and dispose appropriately after use. Consider a syringe or needle/cannula contaminated once it has been used to enter or connect to a patient's intravenous infusion bag or administration set.
  • Use single-dose vials for parenteral medications whenever possible.
  • Do not administer medications from single-dose vials or ampules to multiple patients or combine leftover contents for later use.
  • If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must be sterile.
  • Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer's recommendations; discard if sterility is compromised or questionable.
  • Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients.


Each year an estimated 385,000 needlesticks and other sharps-related injuries are sustained by hospital-based healthcare personnel; an average of 1,000 sharps injuries per day (NIOSH, 2008). Healthcare providers who may be exposed to blood or other potentially infected material are at risk, particularly if they are exposed to contaminated needles or other contaminated sharps that may cause injury. In addition to the surveillance needed regarding the potential for injury to healthcare providers, similarly, surveillance is used to identify factors related to the 2 million HAIs per year.

Surveillance is defined as the ongoing, systematic collection, analysis, interpretation, and dissemination of data regarding a health-related event for use in public health action to reduce morbidity and mortality and to improve health (CDC, 2007). Multiple agencies require ongoing evaluation of potential hazards from bloodborne pathogens, including the Occupational Safety and Health Administration (OSHA), the Centers for Disease Control and Prevention (CDC), National Institute for Occupational Safety and Health (NIOSH). In New York State, the Department of Health and each individual healthcare organization or facility has policies that support the safety of patients and healthcare providers, as well as identifying how and to whom HAIs are reported and analyzed.

A comprehensive standardized method for recording and tracking percutaneous injuries and blood and body fluid contact is the Exposure Prevention Information Network (EPINet). The EPINet system consists of a Needlestick and Sharp Object Injury Report and a Blood and Body Fluid Exposure Report, and software programmed in Access®* for entering and analyzing the data from the forms. (A post-exposure follow-up form is also available.) Since its introduction in 1992, more than 1,500 hospitals in the U.S. have acquired EPINet for use; it has also been adopted in other countries, including Canada, Italy, Spain, Japan and U.K (EPINET, 2008). With this system, the following is available:

  • Identify injuries that may be prevented with safer medical devices.
  • Share and compare information and successful prevention measures with other institutions.
  • Evaluate the efficacy of new devices designed to prevent injuries.
  • Target high-risk devices and procedures for intervention.
  • Analyze injury frequencies by attributes like jobs, devices, and procedures.
  • Prepare monthly, quarterly, and annual exposure reports.

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While any sharp device can cause injury and has the potential for disease transmission, some devices have a higher disease transmission risk, such as hollow-bore needles. Other devices have higher injury rates, such as butterfly-type IV catheters and devices with recoil action, blood glucose monitoring devices with lancet platforms/pens. It is important to identify the settings in which exposures occur and the circumstances by which exposure is more likely to occur.

Contiune to Element III, Con't.