Successful Development and Implementation of Electronic Audit Tool to Assure Compliance with Infection Control Regulations

Common patient equipment, including blood glucometers, are of high focus during various regulatory activities in healthcare settings. Point-of-care blood glucometers (“glucometers”) are known to transmit common bloodborne pathogens including Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and Hepatitis C Virus (HCV). Blood glucometers have complicated and in-depth cleaning standards that are set by the manufacturer. Glucometers are used in various clinical care settings. For my internship at a large academic medical center, I developed and implemented an electronic audit tool starting June 2024 to track compliance rates with updated cleaning procedures and Joint Commission guidelines for glucometer reprocessing. A two-part comprehensive education plan was developed. Part one included development of a standardized education tool called an SBAR (Situation, Background, Assessment, Response) which was distributed to units at the beginning of June 2024. An SBAR is a one-page quick reference sheet describing a situation and the required education for the topic. Part two was an electronic audit tool that was used to track and show compliance with in-the-moment instances of non-compliance which began mid-June and was tracked through the end of September. In June 2024, 279 baseline audits were conducted with only 67.0% of glucometers passing inspection. A total of 46.6% of audited nurses correctly described the cleaning process. In July 2024, 348 audits were conducted, 71.1% of glucometers passed inspection, with 68.7% of audited nurses correctly describing the cleaning process. In August 2024, 107 audits were conducted, 86.2% of glucometers passed inspection with 93.1% of audited nurses correctly describing the cleaning process. For the three-month period, the most common non-compliance issue found was blood on the device (50% in June, 52.6% in July). Electronic audit tools are an innovative way to easily collect, collate, and analyze large amounts of data. We were easily able to demonstrate an improvement in glucometer cleaning compliance post-education during the three-month period for an overall improvement in public health safety within the hospital of interest.