2Best practices for injection

Publication Details

This chapter assimilates the best practices for delivering injections in health-care and related facilities. It is based on a range of evidence and expands the scope of the WHO publication Best infection control practices for intradermal, subcutaneous, and intramuscular needle injection (7). The chapter outlines recommended practices, skin preparation, preparation and administration of injections, and related health procedures.

Best injection practices described are aimed at protecting patients, health workers and the community.

2.1. General safety practices

This section describes the following practices that are recommended to ensure the safety of injections and related practices:

  • hand hygiene;
  • gloves where appropriate;
  • other single-use personal protective equipment;
  • skin preparation and disinfection.

2.1.1. Hand hygiene

Hand hygiene is a general term that applies to either handwashing, antiseptic handwash, antiseptic hand rub or surgical hand antisepsis (25). It is the best and easiest way to prevent the spread of microorganisms. Hand hygiene should be carried out as indicated below, either with soap and running water (if hands are visibly soiled) or with alcohol rub (if hands appear clean).

Practical guidance on hand hygiene

Perform hand hygiene BEFORE:

  • starting an injection session (i.e. preparing injection material and giving injections);
  • coming into direct contact with patients for health-care related procedures;
  • putting on gloves (first make sure hands are dry).

Perform hand hygiene AFTER:

  • an injection session;
  • any direct contact with patients;
  • removing gloves.

You may need to perform hand hygiene between injections, depending on the setting and whether there was contact with soil, blood or body fluids.

Avoid giving injections if your skin integrity is compromised by local infection or other skin conditions (e.g. weeping dermatitis, skin lesions or cuts), and cover any small cuts.

Indications and precautions for hand hygiene are shown in Table 2.1.

Table 2.1. Indications and precautions for hand hygiene.

Table 2.1

Indications and precautions for hand hygiene.

2.1.2. Gloves

Health workers should wear non-sterile, well-fitting latex or latex-free gloves when coming into contact with blood or blood products (26). Indications for glove use in injection practice are shown in Table 2.2.

Table 2.2. Indications for glove use in injection practice.

Table 2.2

Indications for glove use in injection practice.

2.1.3. Other single-use personal protective equipment

Masks, eye protection and other protective clothing ARE NOT indicated for the injection procedures covered by this document unless exposure to blood splashes is expected.

Practical guidance on single-use personal protective equipment

When using single-use personal protective equipment, dispose of the equipment immediately after use.

2.1.4. Skin preparation and disinfection

Table 2.3 shows the skin preparation protocols for different types of injection.

Table 2.3. Skin preparation for different types of injection.

Table 2.3

Skin preparation for different types of injection.

Practical guidance on skin preparation and disinfection

To disinfect skin, use the following steps (2729):

  1. Apply a 60–70% alcohol-based solution (isopropyl alcohol or ethanol) on a single-use swab or cotton-wool ball. DO NOT use methanol or methyl-alcohol as these are not safe for human use.
  2. Wipe the area from the centre of the injection site working outwards, without going over the same area.
  3. Apply the solution for 30 seconds then allow it to dry completely.

DO NOT pre-soak cotton wool in a container – these become highly contaminated with hand and environmental bacteria.

DO NOT use alcohol skin disinfection for administration of vaccinations.

2.1.5. Summary of best practice

The steps outlined above are summarized in Table 2.4, below.

Table 2.4. Infection prevention and control practices.

Table 2.4

Infection prevention and control practices.

2.2. Injection devices and medications

2.2.1. Injection devices

Health-care settings should ensure that an adequate supply of single-use devices is available, to allow providers to use a new device for each procedure.

Practical guidance on use of injection devices

When using a sterile single-use device (i.e. a syringe and hypodermic needle that is not separated or manipulated unless necessary (7):

  • use a new device for each procedure, including for the reconstitution of a unit of medication or vaccine;
  • inspect the packaging of the device to ensure that the protective barrier has not been breached;
  • discard the device if the package has been punctured, torn or damaged by exposure to moisture, or if the expiry date has passed.

2.2.2. Medication

Types of medication containers and recommendations on their use are given in Table 2.5.

Table 2.5. Recommendations on medication containers.

Table 2.5

Recommendations on medication containers.

Practical guidance on giving medications

  • When giving medication:

    DO NOT use a single loaded syringe to administer medication to several patients (i.e. ensure one needle, one syringe, one patient!);

    DO NOT change the needle in order to reuse the syringe;

    DO NOT use the same mixing syringe to reconstitute several vials;

    DO NOT combine leftover medications for later use.

  • Single-dose vials – Whenever possible, use a single-dose vial for each patient, to reduce cross-contamination between patients.
  • Multidose vials – Only use multidose vials if there is no alternative.

    Open only one vial of a particular medication at a time in each patient-care area.

    If possible, keep one multidose vial for each patient, and store it with the patient's name on the vial in a separate treatment or medication room.

    DO NOT store multidose vials in the open ward, where they could be inadvertently contaminated with spray or spatter.

  • Discard a multidose vial:

    if sterility or content is compromised;

    if the expiry date or time has passed (even if the vial contains antimicrobial preservatives);

    if it has not been properly stored after opening;

    within 24 hours of opening, or after the time recommended by the manufacturer, if the vial does not contain antimicrobial preservatives;

    if found to be undated, improperly stored, inadvertently contaminated or perceived to be contaminated, regardless of expiration date.

  • Pop-open ampoules – Whenever possible, use pop-open ampoules rather than ampoules that require use of a metal file to open. If using an ampoule that requires a metal file to open, protect your fingers with a clean barrier (e.g. a small gauze pad) when opening the ampoule (7).

2.2.3. Preparing injections

Injections should be prepared in a designated clean area where contamination by blood and body fluids is unlikely (1, 7).

Practical guidance on preparing injections

Three steps must be followed when preparing injections.

  1. Keep the injection preparation area free of clutter so all surfaces can be easily cleaned.
  2. Before starting the injection session, and whenever there is contamination with blood or body fluids, clean the preparation surfaces with 70% alcohol (isopropyl alcohol or ethanol) and allow to dry.
  3. Assemble all equipment needed for the injection:

    sterile single-use needles and syringes;

    reconstitution solution such as sterile water or specific diluent;

    alcohol swab or cotton wool;

    sharps container.

Procedure for septum vials

Wipe the access diaphragm (septum) with 70% alcohol (isopropyl alcohol or ethanol) on a swab or cotton-wool ball before piercing the vial, and allow to air dry before inserting a device into the bottle.

  • Use a sterile syringe and needle for each insertion into a multidose vial.
  • Never leave a needle in a multidose vial.
  • Once the loaded syringe and needle has been withdrawn from a multidose vial, administer the injection as soon as possible.
Labelling
  • After reconstitution of a multidose vial, label the final medication container with:

    date and time of preparation;

    type and volume of diluent (if applicable);

    final concentration;

    expiry date and time after reconstitution;

    name and signature of the person reconstituting the drug.

  • For multidose medications that DO NOT require reconstitution, add a label with:

    date and time of first piercing the vial;

    name and signature of the person first piercing the vial.

2.2.4. Administering injections

An aseptic technique should be followed for all injections.

Practical guidance on administering injections

General
  • When administering an injection:

    check the drug chart or prescription for the medication and the corresponding patient's name and dosage;

    perform hand hygiene;

    wipe the top of the vial with 60–70% alcohol (isopropyl alcohol or ethanol) using a swab or cotton-wool ball;

    open the package in front of the patient to reassure them that the syringe and needle have not been used previously;

    using a sterile syringe and needle, withdraw the medication from the ampoule or vial.

Reconstitution
  • If reconstitution using a sterile syringe and needle is necessary, withdraw the reconstitution solution from the ampoule or vial, insert the needle into the rubber septum in the single or multidose vial and inject the necessary amount of reconstitution fluid.
  • Mix the contents of the vial thoroughly until all visible particles have dissolved.
  • After reconstituting the contents of a multidose vial, remove the needle and syringe and discard them immediately as a single unit into a sharps container.
Needleless system
  • If a needleless system is available:

    wipe the rubber septum of the multidose vial with an alcohol swab;

    insert the spike into the multidose vial;

    wipe the port of the needleless system with an alcohol swab;

    remove a sterile syringe from its packaging;

    insert the nozzle of the syringe into the port;

    withdraw the reconstituted drug.

Delay in administration
  • If the dose cannot be administered immediately for any reason, cover the needle with the cap using a one-hand scoop technique.
  • Store the device safely in a dry kidney dish or similar container.
Important points
  • DO NOT allow the needle to touch any contaminated surface.
  • DO NOT reuse a syringe, even if the needle is changed.
  • DO NOT touch the diaphragm after disinfection with the 60–70% alcohol (isopropyl alcohol or ethanol).
  • DO NOT enter several multidose vials with the same needle and syringe.
  • DO NOT re-enter a vial with a needle or syringe used on a patient if that vial will be used to withdraw medication again (whether it is for the same patient or for another patient).
  • DO NOT use bags or bottles of intravenous solution as a common source of supply for multiple patients (except in pharmacies using laminar flow cabinets).

2.3. Prevention of sharps injuries to health workers

Use of best practices can help to prevent sharps injuries to health workers (3133). Further information on this topic can be found in Chapter 4.

Practical guidance on prevention of sharps injuries

To avoid sharps injuries:

  • ensure that the patient is adequately prepared for the procedure;
  • do not bend, break, manipulate or manually remove needles before disposal;
  • avoid recapping needles, but if a needle must be recapped, use a single-handed scoop technique;
  • discard used sharps and glass ampoules immediately after use in the location where they were used, disposing of them into a robust sharps container that is leak and puncture resistant;
  • place the sharps container within arm's reach (preferably in a secured area) to allow for easy disposal of sharps;
  • seal and replace sharps container when the container is three quarters full.

2.4. Waste management

Use of sealed, puncture and leak-proof sharps containers helps to prevent access to used devices (24, 34).

Practical guidance on waste management

To ensure that waste is dealt with safely:

  • transport and store sharps containers in a secure area before final disposal;
  • close, seal and dispose of sharps containers when the containers are three quarters full; assign responsibility in written policy for monitoring the fill level of sharps containers and replacing them when three quarters full;
  • discard waste that is not categorised as sharp or infectious in appropriate colour-coded bags;
  • ensure that infectious waste bags and sharps containers are closed before they are transported for treatment or disposal.