Injections are used inappropriately just as antimicrobials and other drugs are. In addition to the usual hazards associated with inappropriate medicine use (poor patient outcome, wastage of resources and unnecessary adverse effects), inappropriate injections are also associated with the extra risk of disease transmission due to non-sterile equipment and technique. Hepatitis B and C and HIV are commonly transmitted by injection. Furthermore, injections are more expensive than many oral medicines. Thus, it is very important for the DTC to pay particular attention to whether injections are used appropriately and whether injection practices are safe.
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BOX 8.2 CHECKLIST TO ASSESS THE RELIABILITY OF A MICROBIOLOGY LABORATORY
1 Laboratory facility
• What percentage of the day are the following services available:
- regular running water (necessary for cleaning equipment)?
- electricity (necessary for running incubators, fridges and freezers)?
- gas (including bottled)?
• Is there a back-up power source? If yes, what systems are protected?
- refrigerators? ventilation/air conditioning? computers? incubators? other?
• What ventilation is provided?
- windows?
- electrically-powered ventilation system (exhaust, not fans) or air conditioning?
• Is the laboratory clean?
• Does the laboratory appear to be well organized?
• Are the activities - (1) washing/sterilizing equipment, (2) specimen processing and (3) waste disposal -done in clearly separate locations?
• What is the workload of the staff?
• Is there a 24-hour service? If not, what are the hours of service?
• What proportion of the time is a trained microbiologist supervising the laboratory?
• Has training been conducted for laboratory staff in the past year?
• Are safety procedures in place and are they implemented?
- is waste disposal adequate?
- are documented standard operating procedures and safety manual available?
- are protective clothing and equipment for staff, for example latex and other gloves, lab coats, safety visors and glasses available?
2 Equipment
Is all the appropriate equipment present?
Capital equipment
• Refrigerators (+4 C) and freezers (-20 ° C)
• Optical microscope with oil immersion objective
• Scale or balance
• Candle jars or an anaerobe jar
• Bunsen burner or electric heater or alcohol lamp to sterilize loops and needles
• pH meter and pH paper
• Staining facilities - sink and slide rack
• Manual pipettes and pipette washers (if pipettes not disposable)
• Water distillation system (or distilled water)
• Centrifuge (hand or electrically powered)
• Autoclave - manually controlled and electrically controlled
• Hot air oven
• Electrically-powered water-bath
• Warm air incubator (for culture) with temperature monitor
• CO2 incubator and CO2 tanks
Recurrent equipment
• Slides, cover slips
• Loop/needle handles, 0.01 and 0.001 ml calibrated loops
• Petri dishes - disposable or glass
• Test-tubes and test-tube racks
• Adequate glassware for media preparation (flasks, graduated cylinders, etc.)
• Wash bottles
Is all the equipment functioning and is this routinely monitored and recorded?
• Microscope calibration
• Checking the temperatures of refrigerators, freezers and incubators
• Calibration of pipettes, handling devices, autoclave function, balances
• Is there an emergency generator to maintain the power supply?
3 Reagents for bacterial culture, isolation, identification and sensitivity (discs) testing
• Where are reagents procured? a commercial supplier? another lab? prepared in-house?
• Are the reagents stored and labelled appropriately?
• Do the reagents have expiry dates? What percentage are expired?
• What type of water is used for preparation of media and reagents?
- deionized? distilled? distilled and deionized? tap water?
4 Specimen collection
• Are all specimens labelled with the patient’s name, location, a unique identifier and the time of collection?
• Are all specimens accompanied by a form stating the patient details and tests required?
• Are there protocols for specific specimen collection? If yes:
- Are they available to all staff (for example in wards and in outpatients)?
- Are they followed and is this documented?
- Are adequate sterile collection procedures and transport media used?
• Are specimen transport and storage times and temperatures satisfactory? These times will vary, e.g:
|
Specimen type |
Transport |
Storage |
midstream urine in sterile container |
<2 hours RTa |
<24 hours 4 °C |
sputum expectorate in sterile container |
<2 hours RT |
<24 hours 4 °C |
urethral/genital/cervical specimen in transport swab |
<2 hours RT |
<24 hours RT |
abscess pus in transport swab |
<2 hours RT |
<24 hours RT |
faeces in sterile container |
<1 hour RT |
<24 hours 4 °C |
blood culture in culture vials |
<1 hour RT |
<24 hours RT |
cerebrospinal fluid in sterile container |
<15 min RT |
<24 hours RT |
conjunctival specimen in transport media |
<15 min RT |
<24 hours RT |
|
a RT, room temperature
5 Processing specimens in the laboratory
• Are there manuals for test procedures, internal quality control, safety and safe waste disposal? Have they been updated in the last 5 years?
• Are samples of culture media regularly checked for sterility? What percentage are found not to be sterile?
• Are known bacterial strains regularly grown on samples of culture media to ensure the quality of the culture media? What percentage of samples do not grow the expected strain?
• Are known bacterial strains with known susceptibility patterns regularly grown and checked against samples of antibiotic discs in order to ensure the quality of the discs? What % of samples do not show the expected susceptibility pattern?
• Are isolation rates of bacteria monitored, analysed and appropriate action taken?
- Changes in isolation rates may be due to a problem in processing the specimens
- Certain bacteria are difficult to grow and may be very dependent upon processing, for example quality of transport media (Vibrio cholerae), incubation temperature (Haemophilus influenzae), shorter specimen transport time than usual (<15 min for Neisseria meningitidis)
- Lower isolation rates as compared to previously, or to other similar hospitals, may be due to laboratory processing problems, not lower rates of infection
- Higher isolation rates with different bacteria as compared to previously or to similar hospitals may be due contaminants or overgrowth of bacteria due to laboratory processing problems, not higher rates of infection
• Are specimens sent to other institutions for processing?
• Is there timely reporting of individual specimen results to staff and patients?
• Is there periodic reporting of sensitivity test results to clinical staff and the DTC or an antimicrobial subcommittee of the DTC?
Adapted from Murray et al. (1995) and WHO (2001).
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Inappropriate use of injections is a very important kind of drug misuse. Often injections are used when oral drugs could be used. In many countries, both prescribers and patients believe that injections are ‘stronger’ and work faster than oral drugs. Prescribers often complain that they prescribe injections unnecessarily because of patient demand, whereas patients often say that it is the prescribers who wish to give injections. Uncertainty about the diagnosis and likely patient outcome probably contributes to overuse of injections. Strategies to promote more rational, safe use of injections are similar in the main to those used for promoting rational use of drugs in general, and antimicrobials, including infection control, in particular. Box 8.3 describes an intervention strategy used in Indonesia to reduce the overuse of injections.
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BOX 8.3 IMPROVING THE USE OF INJECTIONS IN INDONESIA
A study carried out by the Ministry of Health in Indonesia in 1988 found various types of inappropriate drug use including overuse of injections. Focus group discussions found that prescribers often gave injections because they felt that patients demanded them, but that patients in fact preferred oral medications. It was hypothesized that an interactional group discussion focusing on the discrepancies between prescribers’ and consumers’ perspectives might result in a reduced use of injections. In 1992 a randomized control trial of a group process intervention to reduce injection use was conducted in one district, involving 24 health centres, 12 receiving the intervention and 12 acting as controls. The group process involved a facilitated 2-hour discussion between health workers and the community concerning the use of injections. In the group discussion, health workers’ beliefs that patients demanded injections and patients’ beliefs that they did not demand injections, were shared. This intervention resulted in a significant reduction in injection use (p < 0.025) and the number of items prescribed per patient (p < 0.025) over 6 months. This improvement was sustained over the next 2 years.
|
Group |
Control |
Facilitated discussion |
Number of drug items per prescription |
3.97 → 3.88 (-2.3%) |
4.03 → 3.67 (-8.9%) |
% prescriptions with injections |
75.6 → 67.1 (-8.5%) |
69.5 → 42.3 (-27.2%) |
Source: Hadiyono et al. (1996) |
In addition to general strategies to promote more rational use of medicines, the safe and appropriate use of injections requires the safe disposal of used syringes and needles. Strategies particularly concerned with injection overuse include:
1. An injection subcommittee of the DTC, with the following tasks:
• Monitor injection use and its appropriateness - this may involve using the WHO/ INRUD indicators (WHO 1993), monitoring monthly syringe or needle use, or a more specific injection utilization review.
• Ensure the availability of appropriate equipment in sufficient quantity. Preferably, disposable syringes and needles should be used if there is sufficient money. If re-sterilizable syringes and needles are used, the DTC must ensure that adequate sterilizing equipment is available (steam sterilizer) and that documented monitoring and supervision is undertaken to ensure safe injection practices. Attention should be given to matching the quantities ordered of syringes and needles with injectable drugs. For example, the number of disposable syringes and needles ordered should match the total number of injection doses ordered; the number of sterilizable syringes and needles should be sufficient for one syringe and needle per patient per day (or other interval between re-sterilization).
• Ensure adequate disposal facilities; this includes sharps boxes in clinical areas and access of the health facility to a waste disposal pit or incinerator.
• Educate prescribers with regard to safe, appropriate injections
- prescribe oral drugs whenever possible
- use one syringe and needle per patient, taken either new from a sterile unbroken package or directly from a sterile area
- without recapping, place syringes and needles in a safety box immediately after use
- manage waste safely and appropriately.
• Educate patients with regard to safe, appropriate injections, for example
- take oral drugs, and not injections, wherever possible
- accept injections only from trained personnel
- accept an injection only if the needle and syringe are taken from a new sealed package or (if reusable) from a clean sterile container.
2. An infection control committee with the following tasks:
• Monitor the safety of injection use with regard to:
- sterilization of equipment
- sterile technique in administration
- safe disposal of equipment.
• Train and regularly supervise staff in sterilizing equipment, using a sterile technique for administration and safe disposal.
• Recognize and investigate outbreaks of adverse reactions associated with injection delivery, and take appropriate corrective action.
In large hospitals there can be a separate DTC, injection subcommittee and infection control committee, as may also be the case for antibiotics (see section 8.1). However, in many smaller hospitals, there may only be sufficient personnel for a DTC and infection control committee, or only a DTC. Such small hospitals should liaise with bigger hospitals and professional groups on issues of infection control. It does not matter exactly which committee undertakes these functions, but it is the DTC’s responsibility to ensure that the activities are undertaken. Box 8.4 shows a checklist used by supervisors in assessing injection safety in Uganda.
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BOX 8.4 CHECKLIST FOR ASSESSMENT OF SAFE INJECTIONS IN UGANDA
Before administration
• Are reusable syringes and needles flushed with water after use and before sterilization?
• Is steam sterilization done at the correct temperature (121 C) for 15 minutes?
• Is equipment boiled for 20 minutes after the last contaminated piece of equipment is put into the boiling water?
• Are only sterile solutions injected?
• Are hands washed with soap?
• Are the rubber tops of ampoules/vials disinfected?
During administration
• Can anything not in an aseptic condition contaminate the injection fluid?
• Does the person injecting touch the needle with his/her finger?
• Does the needle come into contact with any other non aseptic surface?
• Are several patients injected with the same needle?
• Are several patients treated with the same syringe?
After administration
• Are disposable syringes and needles placed into a final disposal container?
• Are disposables recapped before disposal?
• Are disposable syringes and needles disposed of and not reused?
• Are patients observed for about 30 minutes after injection?
• Are sterilizable syringes and needles flushed with water after use?
Source: WHO (1994b)
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