In their May 2021 Newsletter, The Joint Commission relayed increasing concerns regarding observations of staff not following proper infection control practices with both the use of glucometers and during insulin administration. These observations have been to such a degree of concern for infection risk that organizations have received Immediate Threat citations. Staff are not following proper protocols and practices as prescribed by their equipment manufacturer’s instructions for use (IFU) and the Centers for Disease Control (CDC) guidelines for infection control practices for glucometer use and insulin administration.
How sure are you that your organization is following acceptable practice? Are your patients being subjected to infection control risks?
The Risk Is Real
The CDC has documented in their guidance that there have been 15 confirmed outbreaks of Hepatitis B Virus associated with blood glucose monitoring, although they state that this number is much higher given under reporting and under recognition. Other blood borne infections, such as Hepatitis C and HIV are also thought to have been transmitted through poor infection control practices. Many of these incidents are thought to have been the result of using single use devices such as fingerstick lancets and sharing of insulin pens for multiple patients. Other tasks such as not cleaning and disinfecting glucose meters between patients and failing to perform proper glove use/hand hygiene between fingerstick procedures also contribute to these infections.
Infection Control is Critical
The use of lancing devices to extract a blood sample for glucose testing has been a particular concern for surveyors. The use of lancet pens, that are used between patients with the lancets exchanged after use, have been a particular cause for concern. These devices, although some are approved for multi-patient use, have proven to be the source for most cross contamination and are recommended by the CDC as being single patient use only. Manufacturers have created single patient use, auto-disabling lancets that have mitigated the infection control risk by removing the need for cleaning and disinfecting reusable lancing devices. However, ensure that your organization is storing these devices appropriately and monitoring them for expiration dates.
Blood glucose monitors should be assigned to single patients for use; however, if this is not practical, the device must be cleaned and disinfected as per the instruction for use (IFU). If the manufacturer does not provide an IFU for cleaning and disinfecting, the CDC is advising that the device should not be shared between patients. Cleaning and disinfecting require that staff initially clean the device to remove all visible soil (blood, etc.) prior to disinfecting the device with an approved product specified within the IFU. IMPORTANT: without removing visible soil, the device cannot be disinfected!
Insulin pens should be assigned and labeled to single patients. Multi-dose vials of insulin should be assigned and labeled for single patients whenever possible. If multiple patients will be using a single vial, strict adherence to the cleaning and disinfecting processes is essential to avoid contamination from equipment, supplies and other environmental factors.
Meticulous hand hygiene and the use of gloves is imperative to prevent cross contamination and will be observed by the survey teams. Staff should wear gloves whenever there is a potential for exposure to blood and body fluids. Gloves should be changed whenever there has been potential contact with blood or body fluids and before touching clean surfaces. Hand hygiene must always be performed prior to touching supplies or clean devices intended for use on other patients.
Training and Competency is Key for Success
Development and execution of a comprehensive training and competency program is essential to ensure that staff are aware of the processes of safely monitoring blood glucose and administering insulin. Any training and competency program must address the issues of infection control to include hand hygiene, glove use, cleaning and disinfecting of equipment, acquisition of blood samples, prevention of cross contamination, and aseptic technique with insulin preparation and administration. This requires that the organization assesses the staff member’s skills in these tasks which should include return demonstration or direct observation of the performance of the skill. The Joint Commission standard HR.01.06.01, EP6, mandates that staff competency is reassessed every three years or more frequently as determined by the organization (or law/regulation). Organizations should ensure they have their glucose monitoring and insulin administration competencies re-evaluated as required by this standard.
Monitoring for Performance
Organizations often struggle with following up on staff to ensure that they are performing tasks as defined by policy. Through our own consultants’ observations, it is clear that staff are struggling to follow the CDC guidelines but, what is also concerning, is that organizational leadership has not been monitoring their staff for performance with blood glucose monitoring and insulin administration. It is imperative that clinical leaders, including infection control staff, are observing team members perform the necessary steps with blood glucose monitoring and insulin administration. Conducting these performance audits would make an ideal focused rounding opportunity for leadership to ensure their staff are able to perform per policy and also ensure they have the necessary tools and equipment to support safe patient care. Identified issues should be considered for initiating Performance Improvement activities that could be included in their report during the Data Management sessions during survey.
Summary
Infection Control is one of the most cited chapters by The Joint Commission during survey. The risk of cross contamination between patients with blood borne pathogens during blood glucose monitoring and insulin administration have been voiced by the CDC and The Joint Commission. Organizations would do well to review their current practice, including their training/competency programs, to ensure their team members are following approved guidelines. Leaders should ensure they are monitoring compliance and addressing identified concerns. See the references below for more resources and details.
References:
Infection Prevention during Blood Glucose Monitoring and Insulin Administration: https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html
The Joint Commission Online, May 5, 2021 Newsletter:
https://www.jointcommission.org/-/media/tjc/newsletters/jc-online-may-5-2021.pdf