printed by Preventing bloodborne pathogen transmission during assisted monitoring of blood glucose and insulin administration in long term care Patricia Bosse, MPH 1, Mary Kate Appicelli, MPH 1, Holly Harmon, RN, MBA 2, Peg Shore, MT (ASCP), MSPH, Ph.D., CIC 1, Stephen Sears, MD, MPH 1 1 Maine Center for Disease Control and Prevention, Augusta, ME, 2 Maine Health Care Association, Augusta, ME U.S. Centers for Disease Control and Prevention (CDC) investigated 38 outbreaks of viral hepatitis related to healthcare in the U.S. from % were outbreaks of hepatitis B virus (HBV), of which 75% occurred in long-term care facilities (LTC), of which 87% were associated with infection control breaks during assisted monitoring of blood glucose (AMBG) HBV is a nationally notifiable condition. The prevalence of chronic HBV in Maine has increased steadily since 2010 (figure 1). Blood glucose monitoring is performed to guide therapy for persons with diabetes. Diabetes is one of the top 10 chronic conditions among long-term care residents (figure 2). Assisted monitoring occurs when a licensed healthcare worker assists with or performs testing for an individual. If devices are used on more than one resident, there is the potential for blood borne pathogen transmission. “Neither patients nor providers should be at risk for acquiring HBV, HCV, or other blood borne pathogens when receiving or providing health care.” - U.S. DHHS Action plan for the prevention, care, and treatment of viral hepatitis Twenty-one completed pre-campaign surveys were returned (response rate 21%). Nineteen completed post-surveys were returned (response rate 18%). Only three respondents (from three different LTC facilities) completed both a pre- and a post-campaign survey. Pre-campaign survey respondents worked at their respective facilities for a median of four years. Post-campaign survey respondents worked at their respective facilities for a median of nine years. In the post-campaign survey, respondents commented on the steps they have taken to make changes to infection control practices related to AMBG and assisted insulin administration. The following are some selected responses: “All residents have their own devices (glucometers).” “We now use one glucometer per resident." “Discussion but agreed changes non needed." A selection of pre- and post-campaign survey questions is provided in table 1 (below). We launched an educational campaign on infection control during diabetes care from Oct until Oct The campaign comprised of: Designing a poster to highlight the importance of single use devices (figure 3) Pre-campaign survey of IP’s knowledge, attitudes, and practices of infection control during diabetes care Dissemination of the poster and U.S. CDC’s recommendations to IPs at 101 LTC facilities that are members of the Maine Health Care Association (MHCA) Training of healthcare workers on U.S. CDC’s recommendations for infection control during diabetes care at three professional meetings – 1. 1.Association for Professionals in Infection Control and Epidemiology (APIC) 2. 2.University of Southern Maine’s Patient Safety Academy 3. 3.Maine Health Care Association Fall Conference Post-campaign survey of IP’s knowledge, attitudes, and practices of infection control during diabetes care Poster design – Worked with a graphic designer to create a poster for the educational campaign. Modeled the poster after U.S. CDC’s One & Only Campaign (figure 4). Piloted the poster with a selection of “Champions,” IPs and Medical Directors using a 10 question feedback sheet. Survey design - Designed a Knowledge, Attitudes, and Practices (KAP) survey among IPs at 101 LTC facilities that are members of the MHCA. ed the link to the survey monkey via the MHCA listserv. Alternatively, the survey could be printed, completed, and faxed back. The pre-campaign survey had 13 questions and took an estimated 5-10 minutes to complete. The post-campaign survey had 18 questions – the same 13 questions as the pre-campaign survey along with five new questions. Survey analysis was performed using Survey Monkey and SAS version 9.3. Aggregate results will be shared with all LTC facilities that are members of MHCA. Distributing the surveys via a listserv and not mailed to individuals could have contributed to the low response rate. IPs are extremely busy and may work at multiple facilities. Therefore, the limited response rate could be due to a shortage of time and access to a computer. Since the majority of pre- and post-campaign surveys were completed by different individuals, it is not possible to compare changes in knowledge. Only aggregate changes can be measured. To assess the knowledge of Infection Preventionists (IPs) at LTC facilities in Maine about infection control during diabetes care. To educate IPs at LTC facilities in Maine about U.S. CDC’s recommendations for infection control during diabetes care. BACKGROUND PURPOSE AND OBJECTIVES MATERIALS AND METHODS RESULTS LIMITATIONS BIBLIOGRAPHY CDC. Transmission of hepatitis B virus among person undergoing blood glucose monitoring in long-term-care facilities- Mississippi, North Carolina, and Los Angeles County, California, MMWR 2005;54: CDC. Use of hepatitis B vaccination of adults with Diabetes Mellitus: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2011;60: CDC. Notes from the field: Deaths from acute hepatitis B virus infection associated with assisted blood glucose monitoring in an assisted-living facility- North Carolina, August-October MMWR 2011;60:182. SHEA/APIC Guideline: Infection Prevention and Control in the Long-Term Care Facility, July Thompson ND, Perz JF. Eliminating the blood: ongoing outbreaks of hepatitis B virus infection and the need for innovative glucose monitoring technologies. J Diabetes Sci Technol 2009;3: Figure 3. Campaign poster Figure 1. Incidence of hepatitis B virus – Maine and US, Figure 2. Top 10 chronic conditions among residential care residents National Survey of Residential Care Facilities, 2010 Survey QuestionPre-campaign (N=21)Post-campaign (N=19) Is AMBG performed in your facility?100% What devices are used for AMBG? Lancet80.95%33.33% Fingerstick device42.86%66.67% Glucometer95.24%83.33% Single-use retracting lancet016.67% Is assisted insulin administration performed in your facility?85.7%100% What devices are used? Insulin pen44.44%50% Syringe and single-use vial of insulin16.67%33.33% Syringe and multi-use vial of insulin94.44%66.67% Does your facility have a policy for preventing BBP transmission?100% Does the policy address infection control practices specifically related to AMBG and assisted insulin administration? 57.14%66.67% Have you or your facility taken steps to make changes to policies/practices after having received information from Maine CDC?50% CONCLUSIONS AMBG is both a common practice in LTC and a potential vector for bloodborne pathogens in the absence of infection control. Educating IPs on U.S. CDC’s recommendations is instrumental in preventing outbreaks of viral hepatitis because of their tenure and supervisory role. Fifty percent (50% ) of post-campaign survey respondents made changes to policies/practices after having received information from Maine CDC. More policies addressed infection control practices specifically related to AMBG and assisted insulin administration after the campaign. More IPs began using single-use retracting lancets for AMBG after the campaign. Fewer IPs continued to use a syringe and multi-use vial for assisted insulin administration after the campaign. Adherence to standard infection control practices remains the key in preventing bloodborne pathogen transmission in LTC facilities. Table 1. Selection of pre- and post-campaign survey questions Figure 4. CDC’s One and Only Campaign’s Insulin Pen Poster