Course Work on Skin Preparation with Alcohol Before Injections

Introduction Injections are among the most common health care procedures throughout the world but there is a general reluctance among some people to accept the injection without cleaning the location with alcohol swab. According to World Health Organization, there is a no need to routinely apply alcohol swab for the skin preparation before subcutaneous, intra-dermal and intramuscular injection. For the purpose of this survey, the term injection refers to intramuscular, intra-dermal and subcutaneous injections: it does not include intravenous or intra-articular injections. In medical health care, an injection is the introduction of a drug, vaccine, contraceptive or other therapeutic agent into the body by using a needle and a syringe. Injections are among the most common health care procedures throughout the world and are regularly used as nursing procedures with an estimated 16 billion administered on an annual basis in the developing and transitional countries (1-3). The skin is the largest organ of the body, covering its entire surface and it serves as a protective shield against heat, light, injury and infection. The other functions of the skin include the regulation of body temperature, and the storage of water and fat. The skin also acts as a sensory organ and prevents water loss and the entrance of any bacteria into the body. A normal human skin is occupied by large numbers of organisms which live harmlessly as commensals on it’s surface (4). Alcohol swab is saturated with 70% isopropyl and is believed to be the oldest topical antiseptic used for preoperative skin preparations and also as a surgical scrub and was in use during the 19th century. However, there is a very little evidence to support the requirement for disinfection of the skin prior to any intra-dermal, subcutaneous and intramuscular injections. Many studies have reported that the routine skin preparation by using the alcohol swab before intra-dermal, intramuscular and subcutaneous injection is quite unnecessary (5-11). Yoshika Kazuaki and his colleagues compared some distillate water cotton with that of the alcohol swab for the skin preparation before a vaccination, and he was surprised when he found no infection in both groups.   But interestingly, there are side effects of using alcohol swab by those who frequently use it (12). But the general practitioners, community practitioners and health visitors associations who assessed the incidence of injection related infections as indicated by the abscess in the injection location concluded that one abscess occurs per 1 2 million injections (13). One particular research shows that among the drug users who use the injections, the skin cleaning before the injection may be associated with a lower risk of bacterial infections (14). But according to the recommendations of World Health Organization (WHO), the swabbing of the clean skin before giving an injection is really unnecessary. WHO also suggests that it is important to wash the skin which is visibly dirty or soiled. But if swabbing with an antiseptic is the preferred mode for use, it is imperative to use a clean, single-use swab and also maintain the product-specific recommended contact time. It is not wise to use cotton balls which are stored as wet in a multi-use container. The recommendations for the alcohol swab however is to wipe the swab for 30 seconds over the location intended for the injection and also to allow the drying for a further 30 seconds so as to ensure that the bacterias are rendered inactive, otherwise there may be some increased pain when the needle is injected into the skin (15-16). Currently, according to the policy guidelines at the King Khalid University Hospital, the use of alcohol swabs for the preparation of skin before injection is very necessary. A survey was conducted to assess the theoretical knowledge and attitude of the heath care providers and the visiting patients towards the use of alcohol swabs and to have some awareness and a step towards WHO guidelines. A cross sectional research was conducted among the highly educated health care workers and their patients at King Khalid University Hospital, King Saud University Riyadh, Saudi Arabia during November 2008 to February 2009.   In this research, a ratified random sampling technique was used to present to both male and female physicians, nurses and patients and a pre-tested, pre-designed well-structured questionnaire, and containing open-ended and close-ended questions written in English with Arabic translation, was given to the participants during the working hours between 8:00 am 4:00 pm. The c overing letter of the questionnaire outlined the title and the reason for the study and the identity of the researcher. The participants were educated about the importance of the study and were also encouraged to participate willingly. The questionnaire was divided into various sections about the current general knowledge, attitude and practices of skin preparation by using 70% isopropyl alcohol swab before the subcutaneous, intra-dermal and the intramuscular injections. Various steps were taken to increase the content validity of the questionnaire and at first, a comprehensive review of the relevant literature was carried out. Secondly, a pilot survey of some 28 participants was conducted and on this basis a few questions were changed, added or deleted. Lastly, but not least, all the participants were informed on the requirement of anonymity and of not identifying the information was included in the questionnaire. Out of two hundred participants, one hundred and sixty three anonymo usly completed the questionnaires which were then returned to the investigator. The statistical analysis data was entered into the spreadsheet and processed on Statistical Package for Social Sciences-16 (SPSS-16). The demographic data and answers of questionnaire were analyzed in a descriptive fashion and the results were expressed as counts and percentages. Results Out of two hundred distributed questionnaires, 163 successfully completed questionnaires were returned, which amounted to 85.5 per cent. Among the one hundred and sixty three participants, thirty nine were physicians, sixty three nurses and sixty one were patients (Figure 1). Fifteen physicians were from the Primary Care Clinics, thirteen from the Medicine and Allied, four from Pediatrics, five from surgery and two from the Obstetric and Gynecology departments. Nineteen nurses participated from primary care clinics, ten from the accident and emergency department, eleven from medicine and allied, nine from paediatrics, two from general surgery and twelve from obstetrics and gynecology departments. 69 per cent of the physicians were board certified and 94 per cent were registered nurse (RN or BSN). Most of the attendants who were surveyed were out patients who had visited to get vaccinated for the vaccination or who had accompanied the patient. The majority of the participating health care providers were Non-Saudis, 94 per cent were expatriates, whereas the majority of patients 92 per cent were Saudis. Out of the 94 per cent or163 respondents were males and 69 or 42.33 per cent were females and the mean age of physicians, the nurses and attendants were 41, 33 and 39, years respectively (Table 1). Variable Physicians (n = 39) Nurses (n = 63) Patients (n = 61) Male, Female 28, 11 11, 52 55, 6 Mean age in years (range) 41 (27 58) 33 (23 59) 39 (18 78) Mean years qualified (range) 15 (2 31) 11 (4 38) Mean years practicing in *KKUH (range) 8 (1 22) 7 (1 19) Saudi Expatriates 6, 33 3, 60 56, 5 *KKUH = King Khalid University Hospital TABLE 1: Basic characteristics of survey participants Respondents current knowledge Most of the participants derived their knowledge from various sources and more than three quarters of the respondents indicated that the mass media and the health care providers had contributed much about their knowledge about cleansing locations of injection before the subcutaneous, the intra-dermal and the intra-muscular injections. The other sources of knowledge were indicated to be magazines, medical books, medical journals and family and friends (Table 2). Source of knowledge Physicians N=39 Nurses N=63 Patients N=61 Total N=163 (%) Mass media 30 55 50 135 (83) Magazines 12 14 33 59 (36) Health personnel 35 58 45 138 (85) Medical books 28 46 0 74 (45) Medical journals 36 15 0 51 (31) Family and friends 11 32 22 65 (40) TABLE 2: Survey participants source of knowledge (multiple sources were allowed) The respondents knowledge about swabbing before injection and any injection related infections was poor and more than three quarters of all three participating groups wrongly answered and said Routine skin preparation with alcohol swab before intra-dermal, subcutaneous and intramuscular injection will prevent infections. Almost all the health care providers and approximately half of the patients knew correctly that the swabbing before subcutaneous, intra-dermal and intramuscular injection will not minimize the pain before or after an injection. 15.38 per cent of the physicians and nurses 15.87 per cent had a wrong belief and mentioned that the , alcohol swab will minimize bleeding after injection, whereas the majority of them correctly replied to this question. Approximately half of the patients replied correctly to this question but unfortunately, only half of the physicians, two thirds of nurses and two thirds of patients answered correctly that, if swabbing is selected for use, wipe the swab for 30 seconds over the location of injection and allow drying for a further 30 seconds before the injecting the needle. But only 22 per cent of the participants answered correctly that the alcohol swab may affect the contents of injected medication and may affect the mode of action. Attitude of respondents Nearly all the participants agreed that the routine use of the alcohol swab is time consuming and increases the cost of health budgets. But despite this view, more than two thirds of the participants will refuse to be injected and will not allow anybody to inject them without the skin preparation by the alcohol swab before an injection. The main reason for refusal was the belief that, alcohol swab will prevent an infection of bacteria. Furthermore, 95 per cent of participants stated that, I or my family had never had an injection without wiping the location of injection with alcohol swab (Table 3). Question (Survey statement) Response Physician n=39 (%) Nurses n=63 (%) Patients n=61(%) Total n=163 (%) Swabbing before injection will minimize the risk of infection Yes No 31 (79.5) 8 (20.5) 57 (90.5) 6 (9.5) 55 (90.2) 6 (9.8) 143(88) 20(12) Swabbing before injection will minimize pain during injection Yes No 1 (2.6) 38 (97.4) 2 (3.2) 61 (96.8) 33 (54.1) 28 (45.9) 36(22) 127(78) Swabbing before injection will minimize pain after injection Yes No Dont know 3 (7.7) 36 (92.3) 3 (4.8) 58 (92.0) 2 (3.2) 25 (41.0) 34 (55.7) 2 (3.3) 31 (19) 128 (78) 4 (3) Swabbing before injection will minimize the risk of bleeding after injection Yes No Dont know 6 (15.4) 33 (84.6) 10 (15.9) 53 (84.1) 33 (54.1) 25 (41.0) 3 (4.9) 49 (30) 111 (68) 3 (2) The correct time to give an injection after swabbing is: A. let the alcohol evaporate (30 sec) B. while skin wet with alcohol A B A B 21 (53.8) 14 (35.9) 4 (10.3) 41 (65.1) 8 (12.7) 14 (22.2) 38 (62.3) 12 (19.7) 11 (18.0) 100 (61) 34 (21) 29 (18) Swab by itself can affect the medication constituents (so affect the action of the drug) Yes No Dont know 5 (12.8) 31 (79.5) 3 (7.7) 19 (30.2) 42 (66.7) 2 (3.1) 11 (18.0) 48 (78.7) 2 (3.3) 35 (22) 121 (74) 7 (5) Will you agree to receive an injection without cleaning the site Yes No 8 (20.5) 31 (79.5) 17 (27.0) 46 (73.0) 8 (13.1) 53 (86.9) 33 (20) 130 (80) Had ever you or your family member received injection without swabbing Yes No 0 (0.0) 39 (100) 2 (3.2) 61 (96.8) 0 (0.0) 61 (100) 2(1) 161(99) Not swabbing is time saving and economical Yes No 38 (97.4) 1 (2.6) 60 (95.2) 3 (4.8) 61 (100) 0 (0.0) 159(98) 4(2) TABLE 3: Participants response related their Knowledge, Attitude and Practice of alcohol swab wiping before injection Conclusion Currently due to the local policy, skin preparation with alcohol swab is in practice at King Khalid University Hospital, Riyadh and the nursing staffs are supposed to routinely clean the skin at the location of injection before giving the subcutaneous, the intra-dermal and the intramuscular injections. This survey was conducted so as to focus on specific education and training programs for the health care providers and and also create awareness programs for the patients in respect to implementing WHO practice guidelines for safe injections. The success in reducing the rate of the unnecessary skin preparation by using the alcohol swab before the subcutaneous, the intra-dermal and the intramuscular injections as per the WHO guidelines can only occur if we know the current theoretical knowledge, attitude and practice of the health care providers and the patients. This will help to mold the training and awareness programs for the health care personnel and the patients. The results of this study clearly show that the WHO guidelines should only be implemented after providing sufficient knowledge and by changing the behavior of the health care providers by providing them with additional training and also ensure that the patients by awareness programs are implemented. In this study, the overall knowledge of the health care providers is poor as regards the routine preparation of the skin before the injection. According to the findings of this survey, the important disadvantage of not using the alcohol swab before the injection i s the increased risk of infections. This notion is not in agreement with those reported earlier, both from the developing and the developed countries4-7, 9-10. At the same time, the poor knowledge most likely leads to a flawed attitude and some misconceptions towards the use of the routine alcohol swab. According to World Health Organization (WHO) the best infection control practices, and eliminating the unnecessary injections is the highest priority in preventing injection-associated infections. When the injections are medically proposed, they should be administered safely so as to protect the patients, the providers and the communities. Furthermore, WHO is against the routine skin preparation before the intra-dermal, the subcutaneous and the intramuscular injections (15). Due to the economical downturn worldwide, and particularly in the third world countries, there should be a review of the controversial health-related procedures which might save the cost and time without compromising health. The World Health Organization guidelines on various procedures to prevent the injection related infections are easily available, time-saving, economical and convenient and do not compromise the health (15). The author suggests implementation of following WHO guidelines on different issues related to injections and prevention of infection. This should include the use of sterile injection equipment. This will go a long way because there will be no need to have the needles to be sterilized by boiling them in hot water so as to re-use them on another patient. There should be internationally recognized ways and means on how to prevent the contamination of injection equipment and medication. The needles should always be sterilized and wrapped in air tight papers so as to ensure that they remain clean until after the wrapper has been opened when there is the need to inject someone. At the same time, the person who is injecting a patient should always use sterile gloves which should be disposed immediately after they have been used on a patient and should never be used on another patient so as to prevent the passing of bacteria diseases such as those found on the skin of some patients. There is also the need on how to prevent needle-stick injuries to the provider. This can only be made possible if and when the agencies concerned lays down rules that will govern the use of needle-stick. It is possible to do so if the agencies banned people who are not trained to inject people never to do so. It should be recommended that only nurses and other health professionals should be allowed to handle the needle-sticks. At the same time, there is the need on how to prevent access to used needles. If   the agencies banned the usage of the used needles, it would be possible for the used ones to be disposed immediately after they have been used. Fortunately, many countries have now started using needles that are sterilized and wrapped in air tight cases and they are now not very costly as they used to be before. Even more so, it would be important for the health care providers to strive to educate the people they treat on the need to ask if the needle has been used by someone else so as to prevent some blood related diseases such as the dreaded HIV. The other practice issue guidelines to prevent injection infection are related to engineered technology where it is possible to make needles that will be rendered useless when they have been used on a patient. There is also the importance and necessity of hand hygiene and skin integrity of provider. The health care giver should always wash their hands before and after injecting the patient and should always use a glove which must be disposed immediately after use. They should also strive to tell the patient they are attending to if they have a skin disease so that the patient can immediately get treated. There should be laid down guidelines related to the use of gloves during injection. The gloves should not be used once they have been used to inject a patient and should instead be disposed off immediately. The patient should also insist to have the health care provider use gloves that have not been used. There should also be laid down guidelines on how to swab vial tops or ampoules. The health care provider should always strive to remember to swap the vial tops or ampoules by using alcohol based sterilizers so as to ensure that no germs are transferred to the patient while preparing the dosage with which to inject the patient. There is the need for skin preparation of patient before injection, by using the alcohol swab because the patient might have some skin disease which is not visible. The health care provider should also strive to advise the patient on the need to be clean every time they go for their injection and at the same time tell them whenever they see a skin disease which the patient might not be aware of. Although the findings reported here may be influenced by the inevitable limitations of the study design and the available data, it is believed that the results provide a valuable insight into the health care provider and the patients knowledge and attitudes towards the routine preparation of the skin by using the alcohol swab before injection in Saudi Arabia. But one major limitation with this study is that it took place in one hospital of Riyadh city only. However, the questionnaire was anonymous, which should have encouraged the accurate and honest self-disclosure. References Didier Pittet, SirLiam Donaldson. Clean care is safer care: the first global challenge of the WHO World Alliance for Patient Safety. American journal of infection control 2005; 33(8): 476-479 Pittet D. Clean hands reduce the burden of disease. Lancet 2005; 366: 185-187 Didier Pittet, Benedetta Allegranzi, Juli Storr, Liam Donaldson. Clean care is safer care: the Global Patient Safety Challenge 2005-2006. 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