In March the U.S. Food and Drug Administration (FDA) issued an alert warning of the risk of bloodborne pathogen transmission when insulin injection pens are used on more than one patient. An insulin pen is an injection device with a cartridge or reservoir containing several doses of insulin. A sterile, disposable needle is attached for each use. These pens have become fairly common in acute care settings, replacing the previous multiuse, multipatient vials of insulin, and they are now often used in nonhospital settings as well. The pens have always been intended for single-patient use and are labeled accordingly. Using the pens on more than one patient violates the principles of medical asepsis because blood can enter the pen reservoir or cartridge after injection, possibly transmitting pathogens (such as hepatitis B or C or HIV) to the next patient who uses the same pen.
It was recently reported that nurses at some facilities had used one pen on more than one patient after attaching a new needle for each injection. At one U.S. Army hospital between 2007 and 2009, more than 2,000 patients received insulin injections from pens previously used on other patients. Another army hospital also reportedly reused insulin pens on approximately 15 patients. Some of these patients subsequently tested positive for hepatitis C, but it is unknown whether they had undiagnosed hepatitis C infection prior to that exposure.
A review by Thompson and colleagues published in the May 8, 2008, issue of Acute Care News-letter examined Centers for Disease Control and Prevention data on the transmission of the hepatitis B and C viruses in U.S. nonhospital health care settings between 1998 and 2008. They linked 33 outbreaks involving 448 patients to lapses in basic principles of infection control and aseptic technique. (For more on the study, see "Infection Control: Whose Job Is It?" In the News, April.) None of the exposures would have occurred if the practitioners involved had followed standard precautions and basic principles of medical asepsis.
Thompson and colleagues state that their study very likely underrepresents the number of outbreaks and affected patients because most cases of hepatitis B and C infection are asymptomatic, causing many outbreaks to go undetected or uninvestigated. In addition, many state and local health departments lack the resources to investigate all identified cases. Varying-and possibly insufficient-state regulation of nonhospital health care facilities also contributes to the uncertainty.
Use on more than one patient is only one of the possible problems with insulin pens the Institute for Safe Medication Practices identified; others are
* needlestick injuries, which may occur when a 90[degrees] angle isn't maintained during administration or with use of a needle that doesn't have a needle guard.
* using poor technique, which can result in administration of the incorrect dose. For example, pulling the needle out of the subcutaneous layer during delivery, not holding the pen against the skin for a count of six after delivery, or failing to mix an insulin suspension before use may prevent delivery of the correct dose.
* using pens like vials. Treating a pen cartridge like a vial by withdrawing insulin from the cartridge with a needle and insulin syringe can leave air bubbles in the cartridge, resulting in dosing errors on subsequent use.
* using the wrong type of insulin. Pens are available filled with various types of insulin, including very rapid-onset, short-acting insulins such as aspart (NovoLog) and glulisine (Apidra), and longer-acting insulins such as the combination of aspart protamine suspension with aspart (NovoLog Mix 70/30) and glargine (Lantus).
* dosage displays can easily be misread if they are held upside down. (For more on this topic from the FDA, go to http://bit.ly/P0rWl.)
The most important ways nurses can prevent problems with the use of insulin pens are to follow the basic principles of medical asepsis and observe standard precautions pertaining to blood and bodily fluids. Insulin pens should never be used on more than one patient, and each pen should be labeled with the patient's name to guard against this. Nurses should also follow the manufacturers' recommendations for using the pens. Institutional committees that write policies and procedures should include nurses when creating guidelines that limit the types of pens available, as well as when formulating step-by-step instructions for their use. All nurses and other providers who use insulin pens should attend educational sessions on their use, and nurses should teach patients proper administration techniques, specifically advising them that the pens are never to be shared. (Editor's note: To participate in a discussion on AJN's blog, go to "Are Nurses to Blame for Failures in Infection Control?" at http://bit.ly/tPi83.)