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Original article

Assessment of the safety of injection practices and injection-related procedures in family health units and centers in Alexandria Taghareed A. Elhoseenya and Juidan K. Mouradb a Department of Health Administration and Behavioural Sciences, High Institute of Public Health and bFamily Medicine Centers, Ministry of Health, Alexandria, Egypt

Correspondence to Taghareed A. Elhoseeny, PhD, Department of Health Administration and Behavioural Sciences, High Institute of Public Health, 165 Al-Horreya Road, Al-Hadara, Alexandria 2156, Egypt Tel: + 20 342 85575/ + 20 114 113 455; fax: + 20 349 07535; e-mail: [email protected]

Received 25 November 2013 Accepted 3 March 2014 Journal of the Egyptian Public Health Association 2014, 89:66–73

Background The Safe Injection Global Network (SIGN) developed an intervention strategy for reducing overuse of injections and promoting the administration of safe injections. Tool C – Revised is designed to assess the safety of the most common procedures that puncture the skin within health services. Objective The aim of the study was to assess injection safety within the primary healthcare facilities in Alexandria using Tool C – Revised. Patients and methods Study setting: A total of 45 family health units and centers in Alexandria were selected by proportional allocation from the eight regions of Alexandria. Data collection: The Tool C – Revised of the WHO was used for observation of the entire facility, injection practices and injection-related procedures, and sterilization practices. Interview of different health providers and immediate supervisor of injections was carried out. Results Indicators that reflect risk included: deficiency of alcohol-based hand rub for cleansing hands (13.3%), compliance with hand wash before preparing a procedure (56.9% before injection practices, 61.3% before phlebotomy, and 67.6% before lancet puncture), and wearing a new pair of gloves before new procedures (48.6% before injection practices, 9.7% for phlebotomy, 11.8% for lancet puncture, and 80% for both intravenous injections and infusions). Enough disposable equipment in all facilities for at least 2 weeks dependent on the statement of the average numbers of procedures per week was shown. Only 38% of the providers had received training regarding injection safety in the last 2 years and 62.5% had completed their three doses of hepatitis B vaccine. Only 42.2% of staffs who handled healthcare waste had access to heavy gloves. Conclusion Indicators related to injection and injection-related practices that reflect risk to patients include deficiency of alcohol-based hand rub tools, nonadherence to hand hygiene before preparing an injection, and inadequate adherence to using a clean barrier when opening a glass ampule and use of gloves. Indicators that may reflect risk to patients and providers include inadequate injection safety training and incomplete hepatitis B vaccination of healthcare providers. Indicators that may reflect risk to providers include nonadherence to safety precautions related to injection practices, such as inadequate access to heavy gloves by staff handling healthcare waste. Keywords: Alexandria, Egypt, injections, safety, Tool C – Revised J Egypt Public Health Assoc 89:66–73 & 2014 Egyptian Public Health Association 0013-2446

Introduction Injections are widely used worldwide. In developing countries, the estimated number of injections per person per year has been estimated to be 3.4, ranging from 1.7 to 11.3, with unsafe injections representing 39% and ranging up to 75% [1]. In Egypt, the use of injections was even more common where the average injection per person per year was estimated to be 4.2 [2]. Injections are 0013-2446 & 2014 Egyptian Public Health Association

not totally safe. According to the WHO, unsafe medical injections led to 340 000 HIV infections, 15 million hepatitis B virus (HBV) infections, one million hepatitis C virus (HCV) infections, three million bacterial infections, and 850 000 injection site abscesses in 2008. The significance of these numbers can be interpreted if we know that these infections accounted for 14% of HIV infections, 25% of HBV infections, 8% of HCV infections, DOI: 10.1097/01.EPX.0000445305.88786.9e

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Assessment of the safety of injection Elhoseeny and Mourad 67

and 7% of infections with bacteremia worldwide. Furthermore, they accounted for 28 million disabilityadjusted life years [3]. A link between injection practices and a high burden of HCV infections was shown when parenteral antischistosomal therapy was proved to have a major role in the spread of HCV throughout Egypt [4]. The WHO defines a safe injection as one that does not harm the recipient, expose the healthcare worker to any avoidable risks, or result in any dangerous waste for the community [5]. This definition has been extended to include phlebotomy, lancet procedure, or intravenous (i.v.) device insertion [6]. When a patient receives an injection, it should be given because the patient needs it (i.e. there is no other clinically appropriate treatment). It should be given by a trained healthcare provider using a sterile needle and syringe that will not or cannot be reused. Immediately after the injection, the syringe must be discarded in a puncture-proof receptacle that will not fall apart if it gets wet. When the safety box is full, it must be kept in a secure, locked location until it can be safely destroyed in an environmentally responsible manner by a health facility worker properly trained in healthcare waste management [5]. The WHO, through the Safe Injection Global Network (SIGN), developed an intervention strategy for reducing overuse of injections and promoting the administration of safe injections. The SIGN strategy is articulated around three basic principles. The first is to promote behavior change by healthcare workers and patients to ensure safe injection practices and to reduce unnecessary injections. The second is to ensure availability of equipment and supplies necessary for injection safety, and the third principle is to manage waste safely and appropriately [7]. The cost-effectiveness of injection safety interventions to reduce the overuse of injections and prevent unsafe injections has previously been evaluated by the WHO, with estimated incremental cost-effectiveness ratios ranging from US $15 to over $77 000 per disabilityadjusted life year gained on average across 10 world regions [3]. The safety of injections, phlebotomies, lancet procedures, and i.v. procedures should be assessed using standardized, representative, simple, and flexible methods that allow for a reliable assessment of the country situation and for comparisons with other countries. Tool C for the assessment of the safety of injections [8] was first implemented in 2000, and has been used for national injection safety assessments since then. The WHO reviewed the lessons learned during field implementation of Tool C and applied those when designing an updated tool (Tool C – Revised). Tool C – Revised is designed to assess the safety of the most common procedures that puncture the skin within health services, including injections of various types, phlebotomy, lancet procedures, and common i.v. procedures such as infusions. The tool proposes a standardized methodology including concepts, study designs, sampling procedures, data collection methods and templates, and a plan for analyzing and reporting country safety assessments [6].

Injection safety assessment surveys using the WHO Tool C – Revised were conducted in the public and private health sectors in Oman, Philippines, Seychelles, and Lao PDR. There were some insufficiencies whose amplitude varied by country. These insufficiencies expose patients, providers, and the community to risk [3]. In addition, this tool was used for baseline assessment of injection safety in Nigeria in 80 public sector healthcare settings and laboratories and found several major risk factors [9]. The Syrian Arab Republic also assessed the injection safety in the country in July 2001 using Tool C – Revised. In the light of recommendation from this assessment, the Ministry of Health of Syria implemented a set of activities under a focused project. A follow-up survey was carried out in 2004, 2 years after initiation of the project using the same assessment tool. This study revealed that injection practices had significantly improved 2 years after the initiation of the project [10]. This tool has been also used in Philippines in 2007, and was successful in diagnosing many deficiencies, which helped to identify problems that still need targeting [11]. In Egypt, assessment of injection safety has been performed in many settings. In Gharbiya Governorate, the safe injection practices were assessed using a standardized checklist (and not Tool C – Revised). There was a lack of infection control policies in all the facilities and a lack of many supplies needed for safe injection. Proper needle manipulation before disposal was observed in only 41% of injections and safe needle disposal in 47.5%, whereas unsafe syringe disposal prevailed. Reuse of used syringes and needles was reported by 13.2% of healthcare workers, and 66.2% had experienced a needlestick injury. Only 11.3% received a full course of hepatitis B vaccination [12]. Better compliance with safety injection practices was recorded in one of the large university hospitals in Egypt where safe injection practices among healthcare workers were assessed. In this study, a checklist based on the WHO definitions but not Tool C – Revised was used [13]. The use of such a tool in our settings will be of great help to assess the current situation of injection and injection-related practices. The use of a standardized tool enables comparison of our situation with that aimed and with that of other developing countries. Therefore, in this study, we used Tool C – Revised to assess injection safety within the primary healthcare facilities in Alexandria.

Patients and methods Study setting

The study was conducted in the family health units and centers in Alexandria. There are 70 family health units and centers distributed in eight districts in Alexandria. Their activities include: family health clinics, laboratory, immunization room, radiography, emergency room, dental clinic, and family planning clinic where injections are provided. We excluded the private sector because of the difficulty to have accurate complete lists of private sector facilities that provide such services.

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Journal of the Egyptian Public Health Association

This was a cross-sectional observational descriptive study.

The pilot test was conducted in five healthcare facilities and their results were included.

Sampling design

Statistical analysis

Using Epi info version 6 (Division of Surveillance and Epidemiology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA), based on a previous study [11], assuming 45% of facilities with no safety injections, precision of 9%, a of 0.05, and population of 70 centers, a minimum sample size required was calculated to be 45 centers. Proportional allocation of 45 centers from the eight regions was performed. The centers were chosen by simple random sampling technique.

The statistical analysis was performed using Excel 2007 (Washington, USA) to calculate proportions. All of the proportions were classified and tabulated according to the standard tables previously developed by the WHO. The results were then represented as proportions of observations and reported practices, which reflect risks of unsafe injection practices, and were categorized into three groups: indicators reflecting risks to patient, indicators reflecting risks to provider, and indicators reflecting risks to community.

Study design

In these 45 facilities, there were 45 vaccination rooms, 45 laboratories, 42 emergency rooms, 42 family planning clinics, and 38 dental clinics. Data collection techniques and tool

The Tool C – Revised of the WHO was used [6]. The revised version includes vaccination and therapeutic injection and other related procedures such as phlebotomy, lancet procedures, i.v. injection, and infusions. Each center was surveyed in 1 day. The assessment survey tool has seven major portions: (1) Structured observation of the entire facility. (2) Structured observation of injection practices including vaccination, intramuscular injections, family planning injections, and dental injections (local anesthetic). (3) Structured observation of other injection-related procedures including phlebotomies, lancet punctures, i.v. injections, and i.v. infusions. (4) Structured observation of sterilization practices – for example, sterilizable dental syringes or if any facility that sterilizes disposable injection equipment. (5) Interview of different healthcare providers. This interview was conducted to collect data about using disposable needles, exposure to needlesticks injury, postexposure counseling and prophylactic medications, training courses about injection safety in the last 2 years, and data about receiving hepatitis B vaccine. Some facilities lacked dentistry and emergency services. (6) Interview of head nurse (immediate supervisor of injection provider) to collect data about availability of the policies and guidelines of injections, the rate of work in every clinic, stock availability of both disposable equipment and puncture-resistant sharp containers, and information about designated staff for handling waste. (7) Structured observation of the disposal injection equipment to collect data about availability according to the rate of work in each department. Pilot study

Before data collection, the tool was pilot-tested to ensure that each data collection item is suitable for the particular circumstances and that the right nomenclature is used.

Administrative consideration

Approval from the Ministry of Health was obtained, and the approval letter was introduced in every facility before collecting data. Ethical considerations

Respondents’ identities were kept confidential to protect their anonymity, and they were ensured that the information they gave would not be used for any purpose other than scientific research.

Results Indicators that may reflect risk to patient

Regarding indicators of structured observation of facilities that may reflect risk to patient (Table 1), the only indicator that showed risk was that only six facilities had alcohol-based hand rub for cleansing hands (13.3%). However, all facilities had no loose disposable injection equipment, no loose disposable phlebotomy equipment, and no loose disposable i.v. equipment outside of packaging anywhere inside the facility. In addition, all facilities had no evidence of attempted sterilization of disposable injection equipment. All facilities had no nonsharps infectious healthcare waste of any type outside of container specific for that and no multidose vials with needles left in the diaphragm.

Table 1. Proportions of structured observations of the facilities that may reflect risk to patient Indicators No loose disposable injection equipment outside of packaging No loose disposable phlebotomy equipment outside of packaging No loose disposable intravenous equipment outside of packaging No evidence of attempted sterilization of disposable injection equipment No nonsharps infectious healthcare waste of any type outside of containers specific for nonsharps infectious waste No multidose vials with needles left in the diaphragm Running water and soap for cleansing hands Alcohol-based hand rub for cleansing hands

N = 45 [n (%)] 45 (100) 45 (100) 45 (100) 45 (100) 45 (100) 45 (100) 45 (100) 6 (13.3)

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Assessment of the safety of injection Elhoseeny and Mourad 69

The total number of injections observation included 45 vaccination practices, 33 intramuscular injections, 34 family planning injections, and 32 dental injections (local anesthetic). Observation of injection practices that may reflect risk to patient (Table 2) showed that, in all facilities, injections were prepared on a clean, dedicated table or tray where contamination of the equipment with blood, body fluids, or dirty swabs is unlikely, and for injections all syringes and needles were taken from a sterile packet or fitted with caps. Only dentists used sterilizable syringes with disposable needles for an observed procedure. Regarding vaccination practices, in all facilities for reconstitutions, a syringe and needle was taken from a sealed packet or fitted with caps, and the diluent used was from the same manufacturer that made the vaccine. In 82.2% of vaccination and 93.9% of therapeutic injections, the provider used a clean barrier to protect fingers when opening a glass ampoule. In all facilities, temperature-sensitive vaccines were kept between 2 and 81C. In only 56.9% of facilities, the provider washed her/his hands with soap and running water before preparing an injection, with all dentists compliant. In 48.6% of facilities, the provider used a new pair of gloves with 100% of the dentists compliant during the period of use. Observation of other injection-related procedures included 31 phlebotomies, 34 lancet punctures, three i.v. injections, and two i.v. infusions (Table 3). Observation of injection-related practices that may reflect risk to patients, showed that, in all facilities surveyed, the procedures were prepared on a clean dedicated area; in addition, before the procedures, all providers prepared the skin at the puncture site using iodine or alcohol 70% and allowed the skin to dry before puncture, and the device used for each procedure was taken from a sterile packet. Similar to injection practices, injection-related practices showed deficiencies. Washing hands with soap and running water before preparing the procedure was distributed as follows: 61.3% before phlebotomy, 67.6% before lancet puncture, and 100% before both i.v. injections and infusions. Only 9.7% of phlebotomists wore a new pair of gloves for phlebotomy, 11.8% for lancet puncture, and 80% wore a new pair of gloves for both intravenous injections and infusions. The table also shows that 6.45% of providers palpated the puncture site after skin preparation with antiseptic. In all facilities surveyed, there was no patient with intravenous system who needed to be accessed either for injection or blood withdrawal. Observation of disposable equipment that may reflect risk to patients (Table 4) showed that, in all facilities, there was enough auto-disable injection equipment, enough disposable injection equipment, enough disposable phlebotomy equipment, enough disposable i.v. catheters, and enough disposable i.v. sets for at least 2 weeks dependent on the statement of the average numbers of procedures per week from interviews. Table 5 shows the indicators that may reflect risk to patient as stated by provider. Healthcare providers interviewed were 212 in number, including 45 nurses working in immunization room, 38 dentists, 45 phlebotomists, 42 nurses working in emergency room, and 42

Table 2. Proportions of structured observation of injection practices that may reflect risk to patients Indicators Injections are prepared on a clean, dedicated table or tray

The provider washes her/his hands before preparing an injection with soap and running water

A sterilizable syringe or needle was used for an observed procedure

Syringes and needles were taken from a sterile packet or fitted with caps

A syringe and needle were taken from a sealed packet or fitted with caps for reconstitutions

The diluent used was from the same manufacturer that made the vaccine for vaccine reconstitutions

Providers cleansed the access diaphragm of multidose vials with antiseptic before inserting a needle into the vial

Providers used a clean barrier to protect fingers when opening a glass ampoule

Temperature-sensitive vaccines were kept between 2 and 81C during the period of use

Providers use a new pair of gloves

Item

n (%)

Vaccination 45 (100) Therapeutic 33 (100) Family 34 (100) planning Dental 32 (100) Total 144 (100) Vaccination 17 (37.8) Therapeutic 19 (57.6) Family 24 (70.6) planning Dental 32 (100) Total 92 (63.9) Vaccination 0 (0) Therapeutic 0 (0) Family 0 (0) planning Dental 32 (100) Total 32 (22.2) Vaccination 45 (100) Therapeutic 33 (100) Family 34 (100) planning Dental 32 (100) Total 144 (100) Vaccination 45 (100) Therapeutic NA Family NA planning Dental NA Total NA Vaccination 45 (100) Therapeutic NA Family NA planning Dental NA Total NA Vaccination 0 (0) Therapeutic NA Family NA planning Dental NA Total NA Vaccination 37 (82.2) Therapeutic 31 (93.9) Tamily NA planning Dental NA Total 68 (47.2) Vaccination 45 (100) Therapeutic NA Family NA planning Dental NA Total 45 (100) Vaccination 0 (0) Therapeutic 12 (36.4) Family 26 (76.5) planning Dental 32 (100) Total 70 (48.6)

NA, not applicable.

nurses working in family planning clinic. The table shows that 98.5% of providers interviewed did not experience any needlestick injury in the last 6 months, and that only 38% of the providers received training regarding injection safety in the last 2 years. Only 66.6% of providers had completed their three doses of hepatitis B vaccine. Indicators that may reflect risk to patient as stated by immediate supervisor of provider are shown in Table 6.

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Table 3. Proportions of structured observation of injectionrelated practices that may reflect risk to patients

Table 5. Indicators that may reflect risk to patients as stated by providers

Indicators

Indicators

Item

The provider washes her/his hands before Phlebotomy preparing an injection with soap and Lancet running water i.v. injections and infusions The procedures are prepared on a clean, Phlebotomy dedicated table or tray where Lancet contamination of equipment with blood, i.v. injections body fluids, or dirty swabs is unlikely and infusions The provider wears a new pair of gloves Phlebotomy before preparing an injection Lancet i.v. injections and infusions Skin at the puncture site is prepared using Phlebotomy iodine or alcohol 70%, which is allowed Lancet to dry before procedures i.v. injections and infusions The provider palpates the puncture site Phlebotomy after skin preparation with an antiseptic Lancet during the procedure i.v. injections and infusions Phlebotomy For each procedure, the device used is taken from a sterile packet or fitted with Lancet cap. i.v. injections and infusions The i.v. system was accessed from an i.v. Phlebotomy port for each procedure performed on Lancet i.v. system i.v. injections and infusions Injection ports are cleaned with iodine or Phlebotomy alcohol before accessing the i.v. system Lancet i.v. injections and infusions

n (%) 19 (61.3) 23 (67.6) 5 (100) 31 (100) 34 (100) 5 (100) 3 (9.7) 4 (11.8) 4 (80) 31 (100) 34 (100) 5 (100) 2 (6.45) NA 0 (0) 31 (100) 34 (100) 5 (100) 0 (0) NA 0 (0) 0 (0) NA 0 (0)

i.v., intravenous; NA, not applicable.

Table 4. Proportions of structured observation of disposable equipment that may reflect risk to patients Indicators There is enough auto-disable injection equipment for at least 2 weeks There is enough disposable and reuse prevention feature (safety syringes) injection equipment for at least 2 weeks There is enough disposable phlebotomy equipment for at least 2 weeks There is enough disposable intravenous catheters for at least 2 weeks There is enough disposable intravenous sets for at least 2 weeks

N = 45 [n (%)]

Facilities exclusively using sterile, single-use needles, and syringes for injections Facilities exclusively using sterile, single-use phlebotomy needles, or sterile, single-use needles, and syringes for phlebotomies Facilities exclusively using sterile, single-use needles, and catheters during performance of intravenous infusions or other procedures accessing intravenous systems Facilities in which there were no stockouts of puncture-resistant sharps containers during the entire last 6 months Facilities in which the provider interviewed did not experience any needlestick injury in the last 6 months Facilities in which the provider interviewed had injection safety training available to them within the last 2 years in a lecture or workshop Facilities in which the provider interviewed had received at least three doses of hepatitis B vaccine

N

n (%)

212 212 (100) 45

45 (100)

5

5 (100)

212 210 (99) 212 209 (98.5) 212

80 (37.7)

198 132 (66.6)

Table 6. Indicators that may reflect risk to patient as stated by immediate supervisor of provider Indicators ‘Injection safety’ policy or guidelines were shown ‘Healthcare waste management’ policy/guidelines were shown No injections administered using sterilizable syringes and needles was reported No stockouts of any standard disposable or safety syringes occurred during the last 6 months No stockouts of puncture-resistant sharps containers in the last 6 months A procedure for placing an emergency order for injection devices exists

N = 45 [n (%)] 45 (100) 45 (100) 45 (100) 43 (95.6) 45 (100) 2 (4.4)

45 (100) 45 (100) 45 (100) 45 (100) 45 (100)

Forty-five head nurses were interviewed. The table shows that 95.6% of facilities did not run out of standard disposable or safety syringes during the last 6 months, whereas 4.4% of facilities placed an emergency order for injection devices. In contrast, 100% of the facilities had injection safety policy/guidelines and healthcare waste management’s policy/guidelines. In addition, in 100% of facilities, the head nurse reported that no injections are administered using sterilizable syringes and needles in their facilities, and there were no stockouts of punctureresistant sharps containers in the last 6 months.

Indicators that may reflect risk to providers

Structured facility observation that may reflect risk to provider shows that all facilities had no nonsharps

infectious healthcare waste of any type outside of containers specific for nonsharps infectious waste, no overflowing or pierced sharps containers of any type in any area of the facility, and no used sharps in an open container in any area of the facility. All facilities surveyed had at least one puncture-resistant and leak-proof sharps container in all areas where vaccinations, therapeutic injections, phlebotomies, and i.v. procedures are performed, and these were also present in stock. On observation of injection practices to detect indicators that may reflect risk to provider, in 100% of facilities there was absence of recapping of needles after administering vaccination and therapeutic injections. It was observed that 100% of providers immediately disposed the used needle/syringe in appropriate sharp containers in both vaccination room and emergency room. Structured observation of injection-related procedures that may reflect risk to provider showed that, in all facilities surveyed, the providers appropriately secured the patient so that the patient could not move during the procedure, and immediately after the procedure the provider disposed sharps and nonsharps infectious waste in their appropriate waste container. Deficient wearing of new pairs of gloves before such procedures has been

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Assessment of the safety of injection Elhoseeny and Mourad 71

mentioned before (Table 2) and is considered as an indicator reflecting risk to providers as well. In 48.4% of all phlebotomy practices, the uncapped needles were not removed from phlebotomy holder/adapters using only hands, and in 41.9% of them the blood was not transferred from a syringe/needle directly into a vacuum tube using a two-handed technique. In the facilities surveyed, there were 90.3% procedures in which no twohanded recapping of any needles after performing phlebotomies occurred, whereas 100% of i.v. procedures occurred with no recapping. Indicators that may reflect risk to provider as stated by healthcare providers and their supervisors are the same as those reflecting risk to patients, including those related to stockouts of puncture-resistant sharps containers in the last 6 months, needlestick or sharps injuries in the last 6 months, and receiving training regarding injection safety in the last 2 years. Other indicators include: 99.5% of providers interviewed reported that sharps injury cases were offered support and counseling, and 93.5% of providers interviewed have had at least one dose of hepatitis B vaccination, whereas only 66.6% have had three or more doses. Interviewing head nurses showed that all facilities had an injection safety and waste disposal policy/guidelines available; there were no stockouts of puncture-resistant sharps containers in the previous 6 months (same indicators as those shown in Table 3). Only 42.2% of staffs who handled healthcare waste had access to heavy gloves. Indicators that may reflect risk to community

Structured observation that may reflect risk to community shows that there was no risk to community regarding waste managements. All facilities were compliant to waste management policies and guidelines. In all facilities surveyed, there were no nonsharps infectious healthcare waste of any type outside of its specific containers and no overflowing or pierced sharps containers of any type in any place of the facility; in addition, there were separate waste containers for infectious nonsharps waste in each injection area, and all sharp containers awaiting final destruction were completely closed, stored in a locked area or otherwise stored safely away from public access. In all facilities, there were no used sharps on the ground immediately outside the health facility and/or around the disposal site. In addition, there were one or more puncture-resistant safety containers in stock. In all facilities, the final disposal for sharps waste generated by the facility was by transport off-site for treatment. The finding that only 38% of the providers interviewed had received training regarding injection safety in the last 2 years in a formal lecture workshop represents risk to community as well.

Discussion The safe and appropriate use of injections is a sound investment in health; thus, injection safety must be assessed. To carry out this survey on injection safety and

safety of injection-related procedures, we used the Tool C – Revised of the WHO. Evaluation of injection practices has been performed previously in Egypt using some parts of the tool or modified tools based on that of the WHO [12,13]. Our study revealed that all facilities had no evidence of attempted sterilization of disposable injection equipment, and syringes and needles were taken from a sterile packet for injection practices with no evidence of reuse. The supervisors of injection practices reported that no stockouts of any standard disposable or safety syringes occurred during the last 6 months in 95.6% of the facilities. Our situation is much better when compared with other developing countries where reuse represents a problem. In Philippines, the frequency of reuse of needles and evidence for attempts to sterilize used needles was less than 16% [11]. In Nigeria, in 2.2% of the injections observed, the needle and syringe were not taken from a sterile package. In addition, 70–80% of supervisors reported having had stockouts of syringes or puncture-resistant sharps containers in the previous 6 months [9]. In Cameron, 44% of health workers at public hospitals reported reuse of injection equipment that could be partly explained by a shortage of syringes through review of injection equipment supply purchase records [14]. In Bangladesh, the providers reused the same syringes and needles up to three times specifically for very poor patients [15]. This finding acknowledges the efforts of the Egyptian ministry to combat reuse of injection equipment through appropriate provision of disposable syringes and improved awareness of the healthcare staff about the danger of reuse. Still the presence of procedure for placing an emergency order for injection devices was deficient (two facilities only). Structured observation of healthcare facilities and injection and injection-related practices revealed good performance except that 6.45% of phlebotomists palpated the puncture site after skin preparation with an antiseptic, but this did not occur during intravenous injections or infusions. An important break to safety was noncompliance to hand hygiene or the use of gloves by the staff. They were compliant only before dental injections and phlebotomy procedures. All facilities had soap and running water but alcohol-based hand rub for cleansing hands was found in only 13.3% of facilities. Alcohol-based hand rub is the gold standard proposed by the WHO hand hygiene guidelines [16]. Availability of alcohol-based hand rub represents a practical solution for this danger supported by continuous supervision and monitoring of staff compliance. These findings indicate that our situation is better compared with other developing countries that used the same instrument, such as Philippines, where only between one-half and two-thirds of health facilities surveyed were documented to have at least one acceptable puncture-resistant container in designated areas. Sinks with water and soap were only available in 70% of government health facilities and alcohol-based hand rub was available in 40.0% [11]. In Nigeria, facilities for hand washing were not readily available to the providers. Loose used sharps waste were

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found in 78.7% of facilities observed, and over 30% of facilities did not have enough standard disposable injection equipment to last at least 2 weeks [9]. Overflowing sharps container and loose injection materials scattered around the open areas were observed frequently. Only 16.2% of the facilities were found with safe final waste disposal methods in Bangladesh [15]. However, our results reflect only one governorate, which cannot be generalized to the whole country, especially Alexandria, which is the second most urbanized city after the capital. In Egypt, another governorate reported reuse of used syringes and needles by 13.2% of the healthcare workers. Proper needle manipulation before disposal was observed in only 41% of injections, safe needle disposal in 47.5%, and safe syringe disposal in 0% [12]. Regarding the supply of disposable equipment, our results showed that there were always enough autodisable syringes for vaccination practices. The auto-disable syringes could virtually eliminate the risk of unsafe injection practices; once used, the syringe cannot be reloaded to provide another injection [17]. There were also enough disposable syringes, phlebotomy equipment, disposable i.v. catheters, and i.v. sets for at least 2 weeks. In Philippines, many facilities could not maintain enough supply of disposable injection and injection-related equipment for at least 2 weeks [15]. In Syrian Arab Republic, there was no shortage of disposable injection equipment in 90% of facilities by 2001, with improvement in 2004 to 96% [10]. According to providers’ statements, only 38% of healthcare providers received injection safety training in the last 2 years. Only 66.6% of them received all three doses of hepatitis B vaccine. The healthcare providers interviewed revealed that 98.5% of them did not experience any needlestick injury in the last 6 months. Transmission of blood-borne pathogens such as HBV, HCV, and HIV is a serious consequence of accidental needlestick injury, and from handling sharp medical equipment. Healthcare workers are recommended to be immunized against HBV to prevent acquiring the infection [18]. In Philippines, incomplete protection for hepatitis B through vaccination of healthcare providers was recorded. Only 61.2% admitted to have had received three or more doses of hepatitis B vaccine, and 77.5% received at least one dose of the vaccine. About 50% of the providers interviewed had needlestick injury in the last 6 months [11]. Needlestick injuries were common in Bangladesh; only 23% of injection providers and 4.2% of the waste handlers from all study sites were fully immunized against HBV [15]. Still, there was a risk to the healthcare workers who handled the waste in the present study in Alexandria, because they did not protect themselves properly as only 42.2% of them had access to heavy gloves and the rest wore only latex gloves. This is comparable with Philippines, where only 38.7% of the staffs handling healthcare waste had access to heavy gloves [11]. The WHO recommends healthcare personnel and waste workers to take their safety measures and protective equipment during handling with infectious medical waste [19].

Keeping the previous results in consideration, we can get the following impression about injection safety in our settings; the overall state is fair enough for patient safety. However, there was still risk concerning healthcare providers themselves because of either lack of supply of latex gloves or because of certain behaviors that need to be corrected. This could be achieved by continuous training and continuous supervision to follow both the injection safety and infection control guidelines. In developing countries, there is an urgent need for organizational commitment to the occupational safety of healthcare workers along with the provision of training in injection safety and universal precautions, adequate supplies of personal protective equipment, and hepatitis B vaccination [20].

Strengths and limitations of the study

The present study used the Tool C – Revised of the WHO to assess the safety of injection practices and injectionrelated procedures. However, the study was conducted in only 45 centers, as data collection was carried out by only one person, but in either Philippines or Syria it was a group study that covered the whole country. These results cannot be generalized, as the study did not cover Ministry of Health hospitals or other sectors such as the Health Insurance Organization or university hospitals. It is recommended to conduct this survey in different healthcare sectors through a group study to be able to compare between the results, especially the Health Insurance Organization that has its family health units as well.

Acknowledgements Conflicts of interest There are no conflicts of interest.

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Assessment of the safety of injection practices and injection-related procedures in family health units and centers in Alexandria.

The Safe Injection Global Network (SIGN) developed an intervention strategy for reducing overuse of injections and promoting the administration of saf...
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