Awareness growing about IV catheter-associated infections due to inappropriate use of disposables

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PROBLEM: Recycling of disposable medical equipment, even though labeling allows just a single use, has become popular as a way to cut costs. However, injuries have been reported after improper sterilization or wearing out of equipment. According to wire service reports this week, FDA is now aware of numerous reports of infection, chemical injury or mechanical failures. Obviously, if an item intended for single use is to be reused at all, patient safety must first be assured through implementation of appropriate controls. FDA, CDC and HCFA (Health Care Financing Administration) are huddling this week over the need for governmental action before hospitals decide to sterilize and reuse cardiac catheters, hemodialysis filters, arthroscopic b lades and other single use equipment.

Of greater danger to patients and relatively common, though NEVER sanctioned, is the use of a single disposable syringe for flushing IV catheters in sequential patients. This very practice is occurring, perhaps more commonly than imagined. A recent outbreak of Plasmodium falciparum malaria reported this week by a Saudi Arabian hospital serves as an example of what goes wrong (Abulrahi HA, Bohlega EA, Fontaine RE et al. Plasmodium falciparum malaria transmitted in hospital through heparin locks. Lancet 1997;349:23-5.) An investigation carried out post-incident, which included use of anonymous questionnaires, indicated that 10% of the nurses treating infected patients used a single disposable syringe for more than one heparin lock, and 50 % of the nurses filled syringes with enough drug for three to ten patients' locks!

Hospital standards are comparatively high in Saudi Arabia, and many practitioners are from other countries, including the US. There is no reason to believe that misuse of disposable syringes is an isolated problem or one restricted to Saudi Arabia. Several articles have documented the same problem in the US and elsewhere, including the outbreaks of hepatitis B (which is easier to transmit than malaria) in several western US hospitals reported last year by CDC (Morbidity and Mortality Weekly Report 1996;45:285-9).

Clearly, reuse of disposables is extremely dangerous. Yet many hospitals are unintentionally fostering the practice when, to save money, they withdraw prefilled unit dose syringes, replace them with multiple dose vials and plastic disposable syringes, and assume that all personnel understand and use proper technique.

SAFE PRACTICE RECOMMENDATION: Due to lack of knowledge of possible consequences, some practitioners may take short cuts or use poor technique to prepare syringes and flush IV catheters when caring for multiple patients. Where multiple dose vials of flush solution are used, managers must be assured that all personnel (including physicians, nurses and technicians who must access IV lines) know proper techniques to prepare syringes and flush IV catheters and understand the extreme danger presented when procedures designed for safety fall short. In addition, health care personnel should be monitored to assure that they understand necessary infection control measures. Managers must also monitor supplies used in known infected patients to assure that they are isolated for use only in that patient. Only rigid adherence to such procedures can assure patient safety. If these measures are not undertaken, or controls cannot be assured, only commercially available prefilled syringes should be used. Because of the extreme difficulty in making such assurances, we favor routine use of prefilled syringes in most situations. [A, D (Infectious Disease), N, P, Q]