Tuesday, May 5, 2020

Injection Safety in Outpatient Settings †Free Samples to Students

Question: Discuss about the Injection Safety in Outpatient Settings. Answer: Introduction A safe injection is considered to be one that causes minimum harm or damage to the patient and the health care worker. The skin tissues often get infected by the entry of bacteria through injection into the deeper tissues of the skin. Streptococcus pyogenes, Staphylococcus aureus and coryneform bacteria are the most common microorganisms that are responsible for the incidence of skin infection at sites of medication injection (Stevens et al., 2014). The standard medical practice involves usage of pre-medicated 70% isopropyl alcohol swab to cleanse a skin area prior to injection. This report will critically analyse the necessity of nurses swabbing skin sites before administration of an injection and will comment on its clinical significance. The authors designed a quasi experimental study to assess the necessity of using 70 % alcohol swab for skin preparation before administering injections by clinical and pathological assessments. The effects of 70 % isopropyl alcohol and no preparation before injection, was studied. The two groups included receiving intramuscular (IM), intra-dermal (ID) and subcutaneous (SC) injection after skin preparation with alcohol swabs (221) and those who did not receive skin preparation (186). The skin was swabbed for 30 seconds and allowed to dry before injection. The injection area was assessed after 2-3 days. Pathological assessments were carried out among 51 patients, with and without alcohol swabs and the bacterial colony forming units (CFU/ml) were measured. A statistical analysis showed that skin preparation with alcohol swab destroyed 47% skin bacteria at injection site. Further, no skin preparation failed to show any infection signs. The mean CFU/ml was significantly high (2.473.86) fo r patients without swabbing, compared to those where alcohol swab had been performed. The use of alcohol swabs also involved larger costs. Thus, the study showed that swabbing technique was an inadequate safeguard against infection and failed to show any significant differences in systemic effects and clinical signs. The limitation lies in the fact that the entry of microorganisms by the three ways of injection was not evaluated separately (Khawaja et al., 2013). Insulin is usually injected to the subcutaneous tissue through a clean site on the skin. The study recruited 225 patients with insulin dependent diabetes mellitus and conducted a survey on history of diabetes, preferred injection practices, use of isopropyl alcohol swabs to sanitize skin before injection, and complications that arise from such injections. 10 cases of infection were found among patients who reported use of alcohol swabs very often. Furthermore, patients reporting no use of swabs showed 14 infection cases. Therefore, the results were consistent with the previous findings that alcohol antisepsis before injection fails to reduce incidence of infection at the site. The validity of the findings added to the strength. However, limitations were found in the form of selection bias. Routine users of alcohol swabs might be concerned about infections and are more likely to recall them (ONeill et al., 2013). The need for disinfecting the skin with alcohol swab before injections has long been questioned by the WHO. This study discussed evidences based on current recommendations on pre-injection skin preparation by analysing various articles and arriving at a consensus. The theoretical observations showed that it is impossible to sterilise the living skin by the use of chemical disinfectants. A swab of isopropanol reduces the numbers by 82-91% only. The observations in practice showed that no statistically significant differences were observed in response to formation of abscess at the injection site in the alcohol swab group and no pre-treatment group. Thus, a consensus was formed that skin preparation can be discontinued before subcutaneous injections and would probably not lead to any adverse effects among people with visibly clean skins (Qamar, Gillani Sulaiman, 2012). Critical observation During our clinical placement we were given training on the different measures that need to be adopted for preparing the skin for intramuscular and subcutaneous injections. The clinical placement enhanced innovative thinking capabilities and also provided an insight into the practices that were followed to avoid adverse health outcomes such as infection and abscess formation in patients. During the third week of my placement, a patient Clara (name changed) got admitted to the ward due to extreme loss in weight and appetite. She was 18 years old and had been suffering from type-1 diabetes. She reported symptoms of frequent urination, fatigue, excessive thirst and blurred vision. On admission, I was assigned the task of measuring her blood glucose levels. On assessment, they were found to be extremely high (302 mg/dl). My mentor immediately decided to start insulin therapy in order to control the blood glucose. My clinical knowledge had created the understanding that an alcohol swab was the traditional method of subcutaneous injections (Zhang et al., 2015). However, I was asked to arrange for disposable gloves, antibacterial soap and water for skin preparation. An essential part of learning lies in the fact that nurses should feel motivated to seize such learning opportunities and gather information from the seniors. Therefore, I approached my mentor and inquired the reason for avoiding alcohol swab prior to insulin injection. My mentor said that alcohol swabs have been found to cause cracks and sorenessin people with sensitive skin (Kundrapu et al., 2014). It dries the skin and has not proved effective in preventing skin infections, as evidenced from research articles (Hirsch, Byron Gibney, 2014). Thus, an antibacterial soap and water are used to wash the hands and a cotton wool dipped in water is used to wipe the site before injecting insulin (Kinnunen Mrsny, 2014). I followed my mentor and washed my hands with the antibacterial soap and water vigorously for 15 seconds. I was made to wear gloves after washing for further protection. Furthermore, I learnt that shared alcohol swabs or their inappropriate use often lead to viral contamination such as HCV (Palmateer et al., 2014). Thus, proper care should be taken to ensure that the same swab is not used to disinfect other body parts, as this would increase the risk of bacteria entering the injection site. Some of the recommendations are as follows: It should be made compulsory for healthcare professionals to wash their hands prior injecting a drug (Thompson et al., 2016). Most community healthcare centres should have access to proper sanitation facilities and community members should be encouraged to clean soiled skin of patients before administering any injection (Steinmann et al., 2015). Although alcohol swabs have not shown any significant improvements in preventing infection, care should be taken that sterilised alcohol swabs are used on the skin in cases where water is not available (Lai?Kwon et al., 2014). Alcohol swabs should never be used on sensitive skin if symptoms of dryness and irritation are observed. The skin site should subsequently be cleaned prior to injection. Separate swabs should be used for disinfecting several body parts. The alcohol swabs should never be shared among patients. Conclusion Thus, it can be concluded that cleansing the area with swabs is a traditional practice and is thought to prevent entry of bacteria through the site, into the deeper layers of the tissue. However, research evidences have failed to show their effectiveness in preventing such infection. Moreover, usage of shared swabs has been associated with several forms of contamination, and leads to dryness of the skin. Thus, it is advisable for nurses to use soap and water to cleanse their hands and the skin surface before injecting a drug. Use of alcohol swabs is therefore not a mandatory clinical practice. References Hirsch, L., Byron, K., Gibney, M. (2014). Intramuscular risk at insulin injection sitesmeasurement of the distance from skin to muscle and rationale for shorter-length needles for subcutaneous insulin therapy.Diabetes technology therapeutics,16(12), 867-873. Khawaja, R. A., Sikandar, R., Qureshi, R., Jareno, R. J. M. (2013). Routine skin preparation with 70% isopropyl alcohol swab: is it necessary before an injection? Quasi study.JLUMHS,12(02), 109. Kinnunen, H. M., Mrsny, R. J. (2014). Improving the outcomes of biopharmaceutical delivery via the subcutaneous route by understanding the chemical, physical and physiological properties of the subcutaneous injection site.Journal of Controlled Release,182, 22-32. Kundrapu, S., Sunkesula, V., Jury, I., Deshpande, A., Donskey, C. J. (2014). A randomized trial of soap and water hand wash versus alcohol hand rub for removal of Clostridium difficile spores from hands of patients.Infection control and hospital epidemiology,35(2), 204-206. Lai?Kwon, J., Ly, L., Su, J. C., Nixon, R., Tam, M. M. (2014). Unsuspected allergic contact dermatitis to alcohol swabs following neurosurgery.Australasian Journal of Dermatology,55(4), 296-298. ONeill, J., Grinager, H., Smith, S. D., Sibley, S., Harrison, A. R., Lee, M. S. (2013). Isopropyl alcohol skin antisepsis does not reduce incidence of infection following insulin injection.American journal of infection control,41(8), 755-756. Palmateer, N., Hutchinson, S., McAllister, G., Munro, A., Cameron, S., Goldberg, D., Taylor, A. (2014). Risk of transmission associated with sharing drug injecting paraphernalia: analysis of recent hepatitis C virus (HCV) infection using cross?sectional survey data.Journal of viral hepatitis,21(1), 25-32. Qamar, M., Gillani, S. W., Sulaiman, S. A. S. (2012). The Skin Preparation Knowledge, Attitudes and Practices among the Healthcare Professionals in Compliance with the World Health Organization (WHO) Guidelines.Journal of Clinical Diagnostic Research,6(6) 1041-1046. 6p. Steinmann, J., Becker, B., Bischoff, B., Steinmann, E. (2015). Alcohol hand rub or soap and water for removal of norovirus from handsthe debate continues.Journal of Hospital Infection,91(4), 371-372. Stevens, D. L., Bisno, A. L., Chambers, H. F., Dellinger, E. P., Goldstein, E. J., Gorbach, S. L., ... Wade, J. C. (2014). Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America.Clinical infectious diseases,59(2), e10-e52. Thompson, D., Bowdey, L., Brett, M., Cheek, J. (2016). Using medical student observers of infection prevention, hand hygiene, and injection safety in outpatient settings: A cross-sectional survey.American journal of infection control,44(4), 374-380. Zhang, L. J., Guerrero-Juarez, C. F., Hata, T., Bapat, S. P., Ramos, R., Plikus, M. V., Gallo, R. L. (2015). Dermal adipocytes protect against invasive Staphylococcus aureus skin infection.Science,347(6217), 67-71.

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