CDC: Use one fingerstick device for each patient
Reuse linked to nosocomial HBV outbreaks
The practice of using capillary blood sampling devices among multiple diabetic patients in hospitals and nursing homes should be discontinued in favor of assigning a single device per patient, epidemiologists at the Centers for Disease Control and Prevention recommend. CDC investigators made the recommendation after investigating two hepatitis B virus outbreaks linked to use of the devices among patients at a New York City hospital and a nursing home in Ohio in 1996.1
"There is the potential for these devices to become contaminated if not used properly, and ideally, patients should have their own blood sampling devices," says Brooke Steele, DO, CDC epidemic intelligence service fellow. "That is the message we are trying to get across to health care providers and others who use the devices to draw blood."
Fingerstick devices are widely used for capillary blood sampling for glucose monitoring in patients with diabetes. Both of the HBV outbreaks were associated with use of fingerstick devices with a pen-like design, consisting of both reusable and disposable components. In the hospital outbreak, HBV was diagnosed in three diabetic patients who had previously been hospitalized in December 1995 on the same medical ward with the suspected index case, a diabetes patient who had acute HBV. All three case-patients had fingerstick capillary blood sampling, and no other common hospital procedure or medication was associated with infection.
A review of records at the hospital identified 11 additional patients with possible nosocomially acquired acute HBV infection diagnosed during January–October 1996, the CDC reports. The 11 patients had no known risk factors for HBV infection, but all had been hospitalized at least once during the six months before diagnosis of their HBV infection. Eight of the 11 patients had been hospitalized on the same two wards, and seven of the eight had the same HBV surface antigen (HBsAg) subtype. The device used in the New York hospital has a combined lancet and end cap assembly that was changed as a unit after each use. The exact mechanism of HBV transmission resulting from use of the device is unclear, but may have occurred by blood contamination of nurses’ gloves or unused lancet caps, the CDC found.
"The actual mechanism of transmission wasn’t clear because they were changing both the base of the device and the lancet between patients," says Eric Mast, MD, medical epidemiologist in the CDC division of viral and rickettsial diseases.
Though the lancet assembly was changed after each finger stick, the pen-like lancet-holding device was used for multiple patients. The package insert for the device recommends disinfecting the lancet-holding device only after visible contamination with blood, the CDC reports.
"So if that became contaminated or gloves weren’t changed, there could be [transmission] because the virus is very stable in the environment," Mast says.
The nursing staff typically performed finger sticks by starting at one end of the ward and moving from room to room, sampling and recording blood glucose levels for patients with diabetes. Improper use of the fingerstick device (e.g., reusing disposable parts) was not reported by the nursing staff. However, nurses reported observing that hands were not always washed nor gloves changed between patients, and used lancet caps were placed in the same box as unused lancet caps, the CDC investigation found.
End caps not changed between patients
"If someone goes along to each patient’s room and does serial fingersticks, they would also need to change their gloves between each patient as well," Mast says. "You can have virus present and the blood won’t even be visible."
In the nursing home outbreak, 11 residents with diabetes who routinely underwent capillary sampling were found to have acute or chronic HBV infection. The device used has a separate lancet and end cap. Because the end cap rests on the finger during blood sampling, it can be contaminated with blood after the lancet pierces the skin, the CDC reports. The package insert for the device indicates that both the lancet and end cap should be replaced after each use. But the CDC found that the end caps were not routinely changed between residents, suggesting that HBV transmission occurred through exposure of subsequent patients to residual blood on the end caps.
"They had about three or four devices and they were using these for over 20 diabetic patients," Steele says. "Initially they had a supply of the disposable end caps, but when they ran out of that supply each of the devices had only one cap left, so that cap was left on the device. [Health care workers] would wipe off the surface with an alcohol-soaked towellete, which is not sufficient to sterilize a device against the hepatitis B virus."
After recognition of the outbreaks, both the hospital and nursing home staff began using individual fingerstick devices for each patient and no additional cases were reported.
Reference
1. Centers for Disease Control and Prevention. Nosocomial Hepatitis B virus infection associated with reusable fingerstick blood-sampling devices Ohio and New York, 1996. MMWR 1997; 46:217-221.
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