Introduction

Worldwide, billions of injections are performed each year, making them the most common healthcare procedure performed.1 A safe injection is one that does not harm the recipient, does not expose the healthcare worker to avoidable risk and does not result in waste that is a danger to the community.2 Safe injection practices require strict adherence to the principles of infection control and aseptic technique. Unfortunately, the literature is replete with examples of disease outbreaks connected to unsafe injections via the misuse or reuse of syringes, needles and medications.3-6 In 2010, an estimated 1.7 million people worldwide were infected with hepatitis B virus because of unsafe injection practices.7 Although many of these outbreaks are the result of unsafe injections by persons using intravenous drugs, an alarming number are the direct result of injections administered by healthcare professionals.3-7 In developing countries, unsafe injection practices are widespread, with a lack of education and inadequate medical supplies identified as major barriers to the use of safe injections.8 But even in developed countries, where resources are plentiful, unsafe injections occur. Between 1998 and 2014, more than 50 outbreaks of viral and bacterial infections occurred in the United States due to unsafe injection practices.9 Several outbreaks were directly linked to unsafe injections administered by anesthesia providers.10-12

Multiple outbreaks of disease related to unsafe injection practices were recorded across the United States in 2008 and 2009. In one incident, a medical center in Colorado notified thousands of patients that they may have been exposed to the hepatitis C virus (HCV) during surgery. Syringes of fentanyl were removed from the anesthesia workstation by a surgical technician with HCV infection who then refilled the syringes with saline, causing anesthesia providers to unknowingly inject patients with the contaminated syringes. At least 26 patients were infected with HCV, and multiple anesthesiologists were named in lawsuits for failure to properly secure narcotic medications.10 In a second outbreak, eight cases of severe methicillin-susceptible Staphylococcus aureus infection were identified among 110 patients who received epidural injections at an outpatient pain clinic in West Virginia. The clinic was staffed with certified registered nurse anesthetists and physician anesthesiologists. An infection control assessment of the facility revealed non-adherence to safe injection practices.11 A third outbreak involved transmission of bacterial meningitis during spinal anesthesia for cesarean sections at two unrelated hospitals in New York and Ohio. Seven women were affected and one death was reported. As in earlier outbreaks, an assessment of the hospitals revealed a failure to adhere to institutional infection control policies and safe injection practices by anesthesia providers.12 Lastly, reuse of syringes and single-use propofol (anesthetic medication) vials between patients by anesthesia providers in a Nevada endoscopy clinic in 2008 led to eight patients becoming infected with HCV.13

The United States is not alone in experiencing these disease outbreaks. A 2015 publication examining HCV transmission related to injectable anesthetic opioids revealed outbreaks in Spain, Australia and Israel.14 The diversion of opioids and other narcotics represents a type of unsafe injection that is distinctly different from a lack of adherence to the principles of infection control. Narcotic diversion is often a matter of intentional syringe misuse, whereas lack of adherence to the principles of infection control is usually inadvertent. The two separate issues intersect at the point of patient care, with anesthesia providers having been implicated in outbreaks due to intentional and unintentional syringe misuse.

In response to these and other outbreaks, the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) published updated infection control guidelines and launched awareness campaigns with information specific to safe injection practices.15,16 Professional anesthesia organizations in the United States followed suit, releasing clinical guidelines tailored to the needs of anesthesia providers. Although some variation exists between the published guidelines, the following standards are universal:

i. Hand hygiene should be performed before and after direct patient care.

ii. Aseptic technique should be used to avoid contamination of injection equipment.

iii. Injection equipment should be used for one patient only.

iv. Single-dose vials should be used where possible, and medication from single-dose vials should not be administered to multiple patients.

v. Multidose vials should be stored according to the manufacturer's recommendations, accessed with sterile equipment outside of the immediate patient care area and discarded if sterility is in question.17,18

Strict adherence to these guidelines may not always be possible during the administration of anesthesia.19 Guidelines recommend preparation of medications outside of the patient care area, but the work space used by anesthesia providers for medication preparation is in the operating room, an active patient care area. Anesthesia providers must rapidly prepare and administer a large variety of injectable medications before and during routine surgical cases. This places anesthesia providers in a unique and precarious position wherein the demand for rapid preparation and administration of a medication may compete with the demand for adherence to safe injection practices.20

Despite the push from professional anesthesia organizations to publicize information about safe injection practices, anesthesia providers continue to perform unsafe injections. Three recent cases parallel the above-cited incidents that prompted the WHO and CDC to launch their 2010 public awareness campaigns. In 2016, a medical center in Colorado notified thousands of patients that they may have been exposed to human immunodeficiency virus due to diversion of unsecured syringes of fentanyl by a surgical technician.21 In 2015, at least six patients from a pain clinic in Michigan were infected with HCV due to unsafe injection practices leading to contamination of medication vials.22 And in 2014, a case report from Slovenia detailed how failure to adhere to infection control standards led to a case of meningitis after epidural placement for pain control during labor.23 Unsafe injection practices remain a global threat to public health, and further action must be taken to reduce this threat.

A wide variety of literature exists on the subject of safe injection practice. Numerous case reports and editorials have been published, but few prospective studies or reviews exist. A preliminary search in October 2017 in the JBI Database of Systematic Reviews and Implementation Reports, CINAHL Complete, Cochrane Library, MEDLINE and Access Medicine revealed no existing scoping or systematic reviews on the subject of safe injection practices in anesthesia. In addition to numerous articles detailing outbreaks related to unsafe injections, one review has been published examining safe injection practices in relation to the use of single-dose medication vials.24 At least five self-report surveys have been conducted to examine injection practices in the clinical setting.25-29 Clinical practice guidelines have been published by several professional anesthesia organizations.17,18,30-32 One study has examined the cost of unsafe injections to the U.S. healthcare system.33 To date, no reviews have sought to specifically address the barriers to the use of safe injection practices in anesthesia.

The objective of this review therefore is to identify and map literature related to safe injection practices among anesthesia providers in developed nations. The mapped literature will be used to identify barriers to safe injection practices; identify interventions that have been used to reduce the prevalence of unsafe injection practices; and determine if there is sufficient literature available on which specific questions can be posed, through a future systematic review, to address and reduce the prevalence of unsafe injections in modern anesthesia practice.

Review question

What types of evidence exist to address and inform anesthesia providers regarding safe injection practices in developed nations?

Inclusion criteria

Population

The population for this review will be anesthesia providers. Anesthesia providers include nurse anesthetists, anesthesiologists and anesthesiology assistants.

Concept

This scoping review will consider any research article or policy document, including unpublished reports, that provides information related to:

* Iatrogenic infections caused by unsafe injection practices

* Prevalence of unsafe injection practices among anesthesia providers

* Barriers to the use of safe injection practices

* Cost of unsafe injections to healthcare systems

* Interventions that have been carried out to reduce the risk of unsafe injections

Context

This review will be restricted to anesthesia providers in countries with very high human development as defined using the United Nations Human Development Index (HDI).34 The HDI is a statistical measure that incorporates economic development and productivity with education and health. This restriction is intended to control for differences in the prevalence and underlying causes of unsafe injections caused by disparate levels of education and financial resources. Inpatient/hospital and outpatient/clinic anesthesia care settings will be included.

Types of studies

All quantitative research designs pertaining to the scoping review objectives will be considered. Few controlled trials are anticipated due to the ethical considerations associated with safe injection practices. Qualitative research, economic evidence, research and policy documents and clinical practice guidelines will also be considered for inclusion. Studies published in English after 2000 will be included. This date range restriction was imposed to ensure the included publications are consistent with current safe injection standards.

Methods

Search strategy

The search strategy will aim to find published and unpublished literature. Based on the Joanna Briggs Institute (JBI) methodology for scoping reviews, a three-step search strategy will be utilized for this review.35

An initial limited search of Ovid MEDLINE and CINAHL has been undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A full secondary search will be performed across all included databases using the keywords and index terms identified from the initial limited search. A full search strategy for MEDLINE is included in Appendix I. To help identify any additional studies, a tertiary literature search will be performed by examining the reference lists of all literature meeting the inclusion criteria of this review.

The databases to be searched include: Ovid MEDLINE, CINAHL and Google Scholar.

The search for unpublished literature will include:

* Websites for anesthesia organizations

* Agency for Healthcare Research and Quality

* Centers for Disease Control and Prevention Stacks

* National Institutes of Health research portfolio online reporting tools

* OpenGrey (gray literature database from Europe)

* Networked Digital Library of These and Dissertations (U.S. thesis/dissertation database)

* Internet search engine (Google.com).

Study selection

Following the search, all identified citations will be collated and uploaded into RefWorks (ProQuest, LLC, Ann Arbor, USA) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Studies that may meet the inclusion criteria will be retrieved in full and their details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; Joanna Briggs Institute, Adelaide, Australia). The full text of selected studies will be retrieved and assessed in detail against the inclusion criteria. Full-text studies that do not meet the inclusion criteria will be excluded, and reasons for exclusion will be provided in an appendix in the final scoping review report. The results of the search will be reported in full in the final report and presented in a PRISMA flow diagram.36 Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.

Data extraction

Data will be extracted from papers by two independent reviewers using a standardized data extraction tool for published and unpublished literature. Separate tools will be utilized for charting the results from published and unpublished data (Appendix II and III). These data extraction tools are modified versions of those developed by JBI.35 The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review questions and specific objectives. A third reviewer will be utilized to resolve differences of opinion regarding data extraction. If necessary, the reviewers will seek further information from the authors of primary studies or reviews. Additional data points may be included during the duration of the scoping review if the review team deems the new information pertinent to the review. In response to the addition of data, the review team will include a detailed description in the scoping review.

Data presentation

The results of this scoping review will be presented as a map of the data extracted from the included literature in a tabular form and in a narrative descriptive summary that aligns with the objectives of the review. Policy documents, including clinical guidelines for safe injection, will be presented in a table mapped to date of development, country of origin, source and key elements. Research studies will be mapped in a tabular form, including setting, study design, population, and key findings/recommendations. Figures will be used to detail and map the findings related to prevalence rates for unsafe injection and barriers to the use of safe injection. However, the determination of actual incidence or prevalence rates will not be addressed in this scoping review. To further encapsulate the findings of this review, any identified interventions used to decrease unsafe injections, and their related costs, will be outlined with additional figures, diagrams or tables.

Acknowledgments

This scoping review has been developed as part of the requirements toward completion of a doctoral degree in nurse anesthesia for JLA and DBR.

Appendix I: Search strategy for MEDLINE

Search date: May 30, 2018

Appendix II: Data extraction tool for published/peer-reviewed literature

Appendix III: Data extraction tool for unpublished literature

References