Examine your practices after large outpatient hepatitis C outbreak

Be on the alert: 1 in 100 providers are reusing needles and syringes

Outpatient managers typically assume that their anesthetists adhere to basic infection control practices, such as using needles and syringes only once. Three hepatitis C outbreaks and a survey in the last two years make the point perfectly clear: Some providers — probably one in 100 — are not following the basics.

The results can be devastating. Dozens of patients can be infected with an infectious disease before the problem is uncovered. Such an outbreak leads to loss of staff privileges, the unwanted attention of accreditation organizations, a public relations nightmare, and financially devastating lawsuits.

"All health care providers must understand that it is entirely unacceptable and extremely dangerous to reuse needles and syringes on multiple patients," says Elliott Greene, MD, associate professor of anesthesiology at the department of anesthesiology at Albany (NY) Medical College.

Cross contaminating between patients indicates "incredible poor judgment and technique," says Larry Hornsby, CRNA, president of Anesthesia Solutions, a physician group practice in Mobile, AL, and vice president of Anesthesia Resources Management, a physician group practice in Birmingham, AL. "It costs pocket change for a needle or syringe," says Hornsby, who is the former president of the American Association of Nurse Anesthetists (AANA) of Park Ridge, IL.

The three most recent outbreaks have been reported in outpatient settings, where staff may feel pressured due to caseloads and cost-saving measures, says Arnold J. Berry, MD, MPH, professor of anesthesiology at Emory University in Atlanta. "But neither of these concerns should prohibit use of appropriate infection control techniques in patient care," Berry emphasizes.

Consider these examples of outbreaks in the outpatient setting:

• An Oklahoma City nurse anesthetist admitted he caused a hepatitis C outbreak after reusing needles and syringes to inject pain medication, according to media reports. The practice, which involved injecting medication through intravenous tubes, infected 80 patients at a hospital pain management clinic.

"By my understanding, this is the biggest outbreak of hepatitis C that has taken place as a result of transmission within a health care facility," said Michael Crutcher, state epidemiologist at the Oklahoma Department of Health. It is unknown how many patients have been exposed to the virus at two surgical facilities where the nurse anesthetist practiced.

Such an outbreak can be caused when a provider uses a syringe to administer medicine to a patient who has hepatitis C, then draws more medicine from the same vial, health officials say. There can be a backflow of blood into the intravenous tube, experts say. Of the 80 patients who tested positive for hepatitis C, the Oklahoma State Health Department has determined there is "strong evidence" that 38 cases are associated with the injections. The nurse anesthetist and the physician who supervised him have lost their hospital privileges. More than 20 of the infected patients have filed lawsuits against those two providers and the hospital.

• At least 81 people treated at a Fremont, NE, cancer clinic have tested positive for hepatitis C in an outbreak discovered in October 2002 that may have been caused by a physician’s reuse of syringes, according to reports.

• In 2001, 19 patients of a Brooklyn, NY, clinic contracted hepatitis C when an anesthesiologist reused needles and a vial of medication. However, at that clinic, inadequate cleaning and disinfection or sterilization of endoscopic equipment also was identified as a possible source of the infection.1

Infectious disease outbreaks are not considered sentinel events by the Joint Commission on Accred-itation of Healthcare Organizations. However, the agency typically requests a response from an accredited facility, reviews the response, and, if it’s accepted, refers the incident to the surveyor handling the facility’s next survey.

The practice of reusing needles and syringes apparently isn’t isolated. A recent survey of providers who give medications through injections reveals that one in 100 reuse the same needle and/or syringe on multiple patients, according to the AANA. (For more information, see the "Resources" section at the end of this article.) The AANA points out that if even a small percentage of providers reuse needles and/or syringes, it potentially exposes millions of patients each year to needles or syringes contaminated with hepatitis, HIV, or other life-threatening infectious diseases.

The telephone survey, which was prompted by the outbreaks, included a random selection of anesthesiologists, other physicians, certified registered nurse anesthetists (CRNAs), other nurses, and oral surgeons. In addition to educating its members, the association is developing a public education campaign to make patients and their families aware of standards for needle and syringe reuse. This campaign could lead to questions from patients and their families regarding your policies and procedures.

Reuse of the same needle and/or syringe on multiple patients is considered unacceptable in the guidelines and practice standards of the AANA, the American Society of Anesthesiologists in Park Ridge, and the Association for Professionals in Infection Control and Epidemiology in Washing-ton, DC. Using the same needle and syringe on multiple patients is considered unacceptable regardless of whether the provider uses needles or a needleless system to administer medications.

"The recent outbreaks of hepatitis C have demonstrated that not all providers are complying," says Arnold J. Berry, MD, MPH, professor of anesthesiology at Emory University in Atlanta. "The cause for any lapses in the recommended infection control practices is not known, but the reuse of needles and syringes in any practice setting could demonstrate a lack of appropriate education on the risks of not following proper infection control protocols."

Consider these suggestions to avoid an infectious disease outbreak at your facility:

• Educate and monitor your staff.

Go over the basic principles, such as a single needle and a single syringe for a single patient, and the potential for contamination with multidose vials, suggests Beth P. Bell, MD, MPH, chief of the epidemiology branch in the Division of Oral Hepatitis at the National Center for Infectious Diseases of the Centers for Disease Control and Prevention.

On an annual basis, provide updated information on bloodborne infectious diseases including hepatitis B and C and HIV, Greene advises.

Many outpatient anesthesia medications are provided in multidose vials, but the doses for individual patients may vary, Bell says. "Any areas within health care that involve multidose vials are places where managers need to pay close attention to infection control practices," she says.

These fundamental principles are not high tech, but they are particularly important in the outpatient setting, Bell adds. "As more and more health care is done in the outpatient setting, [managers] need to make sure the same emphasis on infection control is translated to those settings," she says.

• Update your policies.

Department policy and facility policy manuals need to incorporate pertinent aspects of infection control guidelines and indicate resources where additional information can be obtained, Green says. Look at current recommendations and updates from the national organizations, sources suggest. (See "Resources" at the end of this article.)

• Encourage employees to report lapses.

In many outbreaks of infectious diseases, poor infection control practices have been noticed by others, and in some cases, they have been reported to supervisors, Bell says.

"It’s extremely important for administrators to take reports seriously, investigate, and make sure good infection control practices are being adhered to all the time in these settings," she says. (See information on confidential hotline in "Resources" section at the end of this article.)

These outbreaks are a wake-up call, Hornsby says. "They are an opportunity for every health care professional that comes in contact with contaminates, even beyond needles and syringes, to look at what you’re doing, your practice, and eliminate any possibility that you could cross-contaminate from one patient to another," he says.


1. Muscarella L. Recommendations for preventing hepatitis C virus infection: Analysis of a Brooklyn endoscopy clinic’s outbreak. Infect Control Hosp Epidemiol 2001; 22:669.


For more information on hepatitis C outbreaks, contact:

Arnold J. Berry, MD, MPH, Professor of Anes-thesiology, Emory University, 1364 Clifton Road, Atlanta, GA 30322. Telephone: (404) 778-3937. Fax: (404) 778-5194. E-mail: arnold_berry@emoryhealthcare.org.

Centers for Disease Control and Prevention. General questions: (404) 371-5900. Web: www.cdc.gov/ncidod/diseases/hepatitis/index.htm.

Elliott Greene, MD, Associate Professor of Anesthesiology, Department of Anesthesiology, Albany Medical College, 43 New Scotland Ave., Albany, NY 12208. E-mail: greenee@mail.amc.edu.

• The Recommendations for Infection Control for the Practice of Anesthesiology, prepared by the American Society of Anesthesiologist’s Task Force on Infection Control can be reviewed on-line at www.asahq.org. Click on "Publications and Services" and then "Physician Booklets."

• For more information on the American Associa-tion of Nurse Anesthetists’ study, go to www.aana.com. Under Quick Links, click on "press releases," then "press release archives." Click on the release for Nov. 13, 2002: "Reuse of Needles and Syringes by Healthcare Providers Puts Patients at Risk."

• The Federated Ambulatory Surgery Association (FASA) offers access to an ASC Compliance Hotline. Staff members can report confidentially on sensitive compliance issues, potential legal violations, or general standards of conduct. Within one day of the call, managers receive a written report and can handle the situation internally. For more information, contact FASA at (703) 836-8808. E-mail: fasa@fasa.org.