The federal investigation of New Hampshire's Exeter Hospital hepatitis outbreak linked to suspicions of drug diversion by a healthcare worker reveals an underappreciated potential source of infection in all healthcare organizations—the inadequate cleaning of blood glucose monitors.
"It's not well appreciated in the healthcare community that these devices should be cleaned and disinfected in between patients; that's something that's only now being realized," says Joseph Perz, Prevention Team Leader for the Division of Healthcare Quality and Promotion for the Centers for Disease Control and Prevention.
"Sometimes the first time that a facility is even aware of that requirement, unfortunately, is when they undergo inspection," Perz says. He adds that disease investigators have in the last few years, "identified a lack of cleaning and disinfection of the monitors as a potential contributor to [infection] transmission, and that's why you're seeing this standard now being enforced."
That's what happened at Exeter last month. A hepatitis outbreak infecting at least 31 patients this spring was linked to one infected healthcare provider accused of diverting drugs and allowing syringes he allegedly injected in himself to be reused on patients in the hospital's cardiac catheterization lab.
When state officials on behalf of the Centers for Medicare & Medicaid Services last month conducted their complaint inves tigation, they discovered that in addition to poor narcotic drug control, the hospital did not have a policy "for the cleaning of glucometers between patient use," according to the report.
To date, no Exeter Hospital patients are known to have been infected through unsanitary use of glucose monitors.
The report found, however, that personnel "on five nursing units, 3 East, 4 West, ICU, emergency dept. and the PCU (progressive care unit) identified no consistent methodology for the cleaning of glucometers after each patient use, some units reported cleaning only after use in precaution rooms, and one unit demonstrated a sample document indicating that the cleanings were done in the morning and at night," the report said.
Not properly cleaning a glucometer isn't the biggest infection control procedural lapse in a hospital setting, Perz explains. Far worse is reuse of fingerstick devices used to draw the blood and put it on a test strip on more than one patient.
Also bad practice is when insulin pens are used on more than one patient. "The greatest risk involves devices that go from patient to patient, and make direct contact with the patient," Perz explains.
But the glucometer can also be a source of infection among patients through healthcare workers, or even gloves or articles of clothing that imperceptibly touch the device.
Here's how that can happen. The healthcare worker draws the blood from the patient's finger, puts it on a test strip and then inserts it into a nearby glucometer, where a few minutes later the monitor calculates a glucose level.
The provider, however, may have a microscopic quantity of the prior patient's blood on his or her glove, and inadvertently transfers the pathogen to the exterior of the glucometer.
The blood test strip is discarded in a receptacle for hazardous materials. The healthcare worker discards his or her used gloves and puts on a new pair for the next patient.
The same or another health provider touches the glucometer, transferring the blood particles onto the fresh pair of gloves or skin, and then carries that infection to the next patient.
Perz says that most of the evidence of glucose monitoring causing healthcare-associated infections comes from long-term care settings. "Most of these outbreaks involved re-use of finger stick devices, but there were several outbreaks...where we did not find evidence of a fingerstick device being reused, and we hypothesized that the glucometer may have been a factor."
Perhaps even more important, when investigators see such errors, "we often see issues related to hand hygiene or glove use," or other recommended prevention activities that aren't being done, he says.
How each glucometer should be cleaned and with what type of cleaning material depends on the type of device. Manufacturers are now required by the U.S. Food and Drug Administration to include specific cleaning instructions with the meters' packaging.
No Exeter Hospital patients are known to have been infected through unsanitary use of glucose monitors, New Hampshire state epidemiologist Sharon Alroy-Preis says. And no investigation or patient lookback is planned.
"I'm not sure how it would be possible to look back and check, we don't know what we would be looking for," she explains.
Even if patients were infected, they may not show symptoms.
She says, however, that the state will be on the lookout for patients who show up with otherwise unexplained viral or bacterial infections that aren't linked to Exeter Hospital's catheterization lab.
For Perz, the entire experience at Exeter Hospital relays an important lesson.
"The narcotics tampering that's alleged is a great example of a risk that previously was largely overlooked. And that's very concerning. But at the same time, I would say that the risks around unsafe diabetes care in healthcare settings, specifically around blood glucose monitoring and administration, have also been overlooked."