Course Access
True enough Michael…although all sorts of tiny vessels lie within the
subcutaneous and muscle tissue…who’s to say we are not injecting directly
into some of these when we gve an IM/SC?
As you say, better to err on the side of caution since the consequences are
so catastrophic…as your cost-benefit analysis bears out 🙂
Best regards, Claire
*Professor Claire Rickard RN PhD*
c.rickard@griffith.edu.au | +61 7 3735 6460 | Skype: clairexm1 | Twitter:
IVAD_Research | Intravascular Access Device Research Group | NHMRC Centre
of Research Excellence in Nursing | Centre for Health Practice
Innovation | Griffith
Health Institute | Griffith University
Visiting Scholar: Royal Brisbane & Women’s Hospital | Princess Alexandra
Hospital | The Prince Charles Hospital
P.S. Research frequently takes me off campus. Please contact Jenny Chan,
School Secretary 3735 5406 or *j.chan@griffith.edu.au*
with any urgent enquiries.
On 25 March 2013 12:17, Michael Wishart wrote:
> Hi Claire****
>
> ** **
>
> I, too, agree with Matthias, but I do not think your comparison with IV
> access is correct. Giving a sub-cut or IM injection has a much lesser risk
> of infective complications than any direct access to the blood stream (such
> as IV access or phlebotomy, for example). In my own practice I currently
> still use alcohol swabs prior to IM vaccination as it is quick, cheap and
> not worth the potential infective risk (which is yet to be well quantified
> as pointed out by Matthias).****
>
> ** **
>
> If patients are self-injecting (either sub-cut or IM), then the risk from
> auto-inoculation with their own flora may be even lower (viz
> self-catheterisation guidelines), so I would have no issues with teaching
> patients not to swab their own skin prior to a simple injection (as long as
> they were not directly injecting into a vein or device, though). The
> evidence supporting this is also pretty scant, though.****
>
> ** **
>
> Cheers****
>
> Michael****
>
> ** **
>
> *Michael Wishart*****
>
> *CNC Infection Control*****
>
> *Holy Spirit Northside Private Hospital*****
>
> 627 Rode Road, Chermside, Qld 4032 ****
>
> *t:* (07) 3326 3068 | *f:* (07) 3607 2226 ****
>
> *e:** *Michael.Wishart@hsn.org.au****
>
> *w:*www.holyspiritnorthside.org.au****
>
> Please consider the environment before printing this email****
>
> ** **
>
> ** **
>
> *From:* ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] *On
> Behalf Of *Claire Rickard
> *Sent:* Monday, 25 March 2013 11:42 AM
> *To:* AICALIST@AICALIST.ORG.AU
> *Subject:* Re: RE; Alcohol swab before injections****
>
> ** **
>
> I completely agree with you Matthias.****
>
> ****
>
> With injections into IV ports we are now encouraged to “scrub the hub” for
> 30 seconds with either isopropyl alchol or alcoholic chlrohexidine etc!***
> *
>
> ****
>
> Yet for the skin, which is nice and warm and moist – capable of supporting
> much higher microbe counts than a dry cool rubber bung, we use
> nothing…bizarre!!!
> ****
>
>
> Best regards, Claire
>
> *Professor Claire Rickard RN PhD*
>
> c.rickard@griffith.edu.au | +61 7 3735 6460 | Skype: clairexm1 | Twitter:
> IVAD_Research | Intravascular Access Device Research Group | NHMRC Centre
> of Research Excellence in Nursing | Centre for Health Practice Innovation |
> Griffith Health Institute | Griffith University****
>
> ****
>
> Visiting Scholar: Royal Brisbane & Women’s Hospital | Princess Alexandra
> Hospital | The Prince Charles Hospital
>
> P.S. Research frequently takes me off campus. Please contact Jenny Chan,
> School Secretary 3735 5406 or j.chan@griffith.edu.au with any urgent
> enquiries.****
>
> ** **
>
> On 25 March 2013 11:29, Matthias Maiwald (KKH) matthias.maiwald@kkh.com.sg> wrote:****
>
> Dear Franciska, ****
>
> ****
>
> Not sure about clexane and insulin (s.c. injections), but I have looked in
> some detail into the current Australian recommendations concerning
> vaccinations. Most vaccinations are i.m. injections, which are biologically
> quite different from s.c. injections and also from venipuncture. The
> official recommendation by the Australian Immunisation Handbook is not to
> swab (so if you follow that, you are following official recommendations),
> and only to swab if the injection area is visibly dirty, but the problem is
> that these recommendation are severely misguided and intellectually flawed.
> ****
>
> ****
>
> (1) Much of it is based on a short 2001 article in the MJA, examining a
> few hundred s.c. injections and venipunctures, and concluding that swabbing
> for ANY type of injection is not necessary, including i.m. injections.
> There are two fatal flaws with this assumption. (a) The article did not
> examine even a single i.m. injection and made conclusions pertaining to
> these (which is inconsistent with the principles of evidence-based
> medicine, which the article purported to adhere to), and (b) the natural
> infection rate after i.m. injections is very low, estimated to be in the
> range of 1:5000 to 1:10000 or less (which is reassuring), but if you study
> a smaller population than is needed to capture the natural incidence of an
> event, then you cannot make conclusions that the intervention has no effect
> on the occurrence of the event. ****
>
> ****
>
> (2) The recommendation to swab only if visibly soiled is not justified
> either, because microorganisms are invisible, and implementing this as a
> cutoff between swabbing and non-swabbing is arbitrary without a scientific
> base or evidence base. Imagine you sit in front of a patient with a darker
> skin colour and want to give an injection. When would you be confident that
> the skin is NOT visibly dirty? ****
>
> ****
>
> In summary, if you don’t swab, you are consistent with the guidelines, but
> the guidelines are seriously flawed (at least you won’t be responsible
> then). It is certainly reassuring that the natural infection rate is very
> low, and statistically you are unlikely (but it is possible) to see any
> adverse event. It is clear that i.m. injections and other types of
> injections are biologically and clinically different and bear a different
> infection risk. Also, the deeper an injection is, the more complicated
> infections can get (examples on the complicated end are joint injections,
> corticosteroid injections, or more complicated injections). ****
>
> ****
>
> Best regards, Matthias. ****
>
> ****
>
> — ****
>
> Matthias Maiwald, MD, FRCPA ****
>
> Consultant in Microbiology ****
>
> Adj. Assoc. Prof., Natl. Univ. Singapore ****
>
> Department of Pathology and Laboratory Medicine ****
>
> KK Women’s and Children’s Hospital ****
>
> 100 Bukit Timah Road ****
>
> Singapore 229899 ****
>
> Tel. +65 6394 8725 (Office) ****
>
> Tel. +65 6394 1389 (Laboratory) ****
>
> Fax +65 6394 1387****
>
> ****
>
> *From:* ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] *On
> Behalf Of *Franciska Ferreira
> *Sent:* Monday, 25 March, 2013 8:54 AM
> *To:* AICALIST@AICALIST.ORG.AU
> *Subject:* RE; Alcohol swab before injections****
>
> ****
>
> Hi All,****
>
> ****
>
> There is still an ongoing debate whether we should use an alcohol swab
> before administering clexane, vaccines and insulin. Any ideas please?****
>
> I know the latest practice in regards administering clexane is to not
> swab.****
>
> ****
>
> I just want to advise my team from a infection control point of view with
> facts to stand on.****
>
> ****
>
> Kind Regards****
>
> ****
>
> *Franciska Ferreira*****
>
> *INFECTION PREVENTION & CONTROL /WOUND MANAGEMENT CONSULTANT*****
>
> Burnside War Memorial Hospital****
>
> 120 Kensington Road, Toorak Gardens, SA 5056****
>
> *t:** *08 8202 7222 *f:** *08 8407 8573 e:
> fferreira@burnsidehospital.asn.au****
>
> ****
>
> ****
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