reuse of insulin pens 1123 table 2. Type of Viral Infection at Facilities A and B Total patients requiring lookback notification (exposed cohort)
Human immunodeficiency virus (HIV) results HIV newly identified positivea HIV previously known positiveb
HIV testing inadequate or incompletec HIV status unknownd HIV negative
Hepatitis C virus (HCV) results HCV newly identified positivea HCV previously known positiveb
HCV testing inadequate or incompletec HCV status unknownd HCV negative
Hepatitis B virus (HBV) results HBV newly identified positivea HBV previously known positiveb
HBV testing inadequate or incompletec HBV status unknownd HBV negative
Total patients identified as deceased either before the start of or during the lookback period Total patients tested for≥1 viruses after their exposure Total medical records reviewed
Facility A 718
197 516 718
Facility B 1,073
295 639
1,073
216 497
50e
00 510 00 432 631
51 95e
194 469
714 401 576
17
58 e 75
179 422
46
67e 122 410 478
NOTE. Individual patients may be counted in several categories more than once, therefore total numbers in table will not add up to the total number tested nor the total number in exposed cohort. Table includes all postexposure results gathered from medical record review including
viral test results from routine care as well as lookback test results. aNewly identified positive indicates patients were newly identified positive after the time of the insulin exposure with one of the following positive tests: hepatitis B surface antigen (HBsAg) or HBV viral load or hepatitis B core antibody (HBcAb) alone or HBcAb AND hepatitis B surface antibody (HBsAb);HCVantibody (HCV Ab) with confirmatory testing orHCVviral load; or HIV antibody (HIV Ab) with confirmatory
testing or HIV viral load). bKnown positive indicates patients were identified by medical history or laboratory testing to have a positive test (HBsAg or HBV viral load or HBcAb alone or HBcAb AND HBsAb; HCV Ab with confirmatory testing or HCV viral load; or HIV Ab with confirmatory testing or HIV viral
load) before the time of their exposure. cInadequate indicates testing results are not sufficient to make a determination of their lookback status—for example, a patient with positive HIV orHCVAb results, but confirmatory testing was not performed. Incomplete indicates that specific tests were not ordered or not performed that were necessary in determining potential epidemiologic linkages as required for completion of the lookback investigation—for example, a
patient with a positive HCV Ab result and positive HCV Ab confirmation, but no HCV viral load testing or genotyping performed. dUnknown indicates patient was deceased, lost to follow-up, or refused testing (ie, patient will never be tested). eOne patient was previously known to be positive for HBV and HCV and was exposed at both facilities. Patient is listed here for both facilities.
methods Facility A
In October 2012, during monthly medication cart inspections on inpatient units, single-patient use insulin pens with no patient labels were discovered in medication carts. During interviews with nursing staff, several nurses acknowledged reusing insulin pens on multiple patients but used a new sterile needle for each injection. Owing to lack of labeling, it was unclear how long pens had been in the cart or how many patients had been exposed to each pen. Therefore, anyone receiving glargine insulin by insulin pen (only insulin type given by pen in this inpatient setting) was considered at risk and included in our investigation. Insulin pen use at this facility was discontinued in December 2012.1
Facility B
In January 2013, a national VA review of insulin pen practices was initiated after identification of the Facility A incident. Despite having insulin pens labeled with individual patient information and bar-coded medication administration data, a licensed practical nurse working in a VA Community Living Center reported she reused insulin pens between Community Living Center residents. Additionally, a registered nurse was identified as having reused insulin pens between patients on an inpatient unit. Both nurses reported changing needles between patients but it was unclear how long this practice may have occurred. Therefore, anyone receiving insulin via pen in both Community Living Center and acute care units was considered at risk and included in our investigation.
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