NURSING GUIDELINE TITLE BLOOD GLUCOSE MONITORING (Accu-Chek Inform II) A. Control Test B. Patient Test C. Troubleshooting D.

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1 : NURSING GUIDELINE TITLE BLOOD GLUCOSE MONITORING (Accu-Chek Inform II) A. Control Test B. Patient Test C. Troubleshooting D. Limitations CATEGORY: General Staff competency will require minimum of running a set of controls (one level 1 and one level 2) and one patient test yearly and completing the yearly online e-quiz. Proof of competency occurs automatically when these requirements are met. PURPOSE Rapid bedside measurement of blood glucose levels by electrochemical method. Collection of quality control information for glucose monitor function, patient results and operator performance. A. Control Test NURSING ALERT: Control test must fall within recommended ranges before performing patient tests. Both Level 1(Lo) and Level 2(Hi) control solutions must be used when performing a control test. Meter display reads Pass if acceptable and Fail if result is unacceptable. Meter cannot be used if controls do not pass. Control testing must be done: - once a day per monitor for each day of use - when a container of strips has been exposed to extreme temperatures or humidity - each time a new container of strips is opened - if monitor has been dropped - when test results contradict clinical symptoms Control solution must be used within 3 months of opening. (Date bottle with expiration date when first opened). Approved: June 3, 2015 Page 1 of 10

2 EQUIPMENT 1. Appropriate PPE 2. Accu-Chek Inform II Monitor 3. Accu-Chek Inform II test strips 4. Accu-Chek Level 1 and Level 2 control solutions PROCEDURE 1. Turn monitor on. NOTE: Touch screen will go into sleep mode (dim) after 30 seconds if no input. Touch screen anywhere to return to working mode. NOTE: Touch screen will go blank and monitor will power down to save energy if no input for five minutes. 2. Press forward arrow button. 3. Enter or scan operator ID and press forward arrow button using your finger (do not use tip of your pen or lancet). 4. Select control test. 5. Press barcode icon. 6. Scan barcode on control vial. NOTE: Strip lot screen will appear. 7. Press barcode icon. 8. Scan barcode icon on strip container. 9. Remove test strip from container and recap container immediately. 10. Insert test strip (yellow target area up, silver bars first) when strip icon appears on monitor display. 11. Mix control solution gently prior to use. NOTE: Discarding first drop from bottle of control solution is a good practice to ensure fresh control solution is being used. 12. Wait for flashing drop icon to appear on monitor display. 13. Hold control solution bottle horizontally and apply control drop to tip of test strip. Drop will automatically be drawn into strip dosing yellow reaction window. Approved: June 3, 2015 Page 2 of 10

3 14. Remove test strip when Pass or Fail is displayed. NOTE: If Fail is displayed a comment is required (press comment cloud ). Test must be repeated. 15. Select control solution to do second control test. 16. Repeat steps Turn monitor off. B. Patient Test NURSING ALERT: Wear PPE when performing patient tests. Glucose values below 11.1 mmol/l are not affected by hematocrit levels. When glucose values are above 11.1 mmol/l, low hematocrit (less than 0.1) may cause elevated results and high hematocrit (greater than 0.65) may cause low results. Accu-Chek Performa test strips are plasma compatible and values are similar to laboratory results. Poor peripheral circulation may result in inaccurate results. Capillary, venous or arterial blood may be used. Do not use blood from EDTA vacutainer. Monitor should be stored on base unit when not in use to maintain battery charge. FOR ADULTS: Obtain stat lab glucose for monitor results less than 3 or greater than or equal to 25, and notify attending physician. Notify attending physician when monitor results less than 3 or greater than or equal to 25 unless otherwise ordered. Monitor Values are indicated by Lo if less than 0.6 or Hi greater than 33.3 on monitor display. DO NOT use hemodialysis patient s IV access arm for blood glucose testing (arm with AV graft / fistula). FOR PEDIATRICS (1 month to age 13): Obtain stat lab glucose for monitor results less than 3 or greater than or equal to 20 and notify attending physician, unless otherwise ordered by physician. FOR NEONATES (0 to 30 days): All symptomatic and at risk neonates are to be tested for abnormal blood glucose. Acceptable blood glucose range for a neonate is mmol/l. Obtain stat lab glucose for monitor results less than or equal to 2.2 or greater than or equal to 15 if neonate is in emergency or outpatient department. See Appendix A. Approved: June 3, 2015 Page 3 of 10

4 EQUIPMENT 1. PPE 2. Accu-Chek Inform II Monitor 3. Accu-Chek Inform II test strips 4. Lancing device 5. Chlorhexidine 0.5% pad, alcohol swab or face cloth with warm soapy water 6. Gauze pad 7. Pipette as necessary 8. Plastic monitor sleeve for isolation (SPD #310422) 9. Appendix A: Hypoglycemia Guidelines for the at Risk Newborn 10. Disinfectant wipes PROCEDURE 1. Don PPE. 2. Gather equipment. 3. Cleanse site with chlorhexidine 0.5% pad, alcohol swab or face cloth with warm soapy water. 4. ALLOW TO DRY COMPLETELY. 5. Prepare lancing device. NOTE: There are 3 settings for depth on lancet. Turn end to select appropriate depth (1.3mm, 1.8mm, 2.3mm depth). Neonate heel puncture must not be more than 2.2mm. 6. Turn monitor on. 7. Press forward arrow button. 8. Enter or scan operator ID. Press forward arrow button. 9. Select patient test. 10. Enter patient ID (MRN number 7 digit number) using keypad or scanning patient armband. Press check mark. Strip lot screen will appear. 11. Select barcode icon. 12. Scan barcode on strip container. 13. Remove test strip from container. Replace container cap. 14. Insert test strip gently into monitor when strip icon appears on monitor display (yellow target area up, silver bars first). Once strip is correctly inserted, a blood drop symbol flashes on monitor display and monitor beeps. Approved: June 3, 2015 Page 4 of 10

5 15. Obtain blood sample from patient. (Wipe away 1 st drop and use 2 nd drop). Hold sample to tip of strip until window is completely filled with blood and no yellow color is visible. NURSING ALERT: The following may cause false results: o Not allowing site to dry o Not wiping away first drop of blood o Excessive squeezing of finger (or foot for neonates) Shaded areas illustrate best sites for a finger stick sides of fingers between tip of finger and last knuckle. AVOID very tip of finger, middle of pad and back of finger. NOTE: Warming test site with a warm cloth to promote increased circulation may facilitate a larger drop of blood. When using a pipette, do not allow blood to enter bulb. The heel is preferred puncture site to obtain blood from infants under 3 months of age. Care should be taken to avoid curvature of heel and plantar surface of heel, where distance between the skin and calcaneus nerve is smallest. Neonatal osteomyelitis of calcaneual (heel bone) resulting from heel puncture has been reported. Perform puncture on medial-lateral portion of plantar surface (outside lines of diagram in shaded area). Approved: June 3, 2015 Page 5 of 10

6 16. Remove test strip after test result appears on screen and dispose in appropriate container. 17. Select comment code if applicable. NOTE: A comment is only required if result is outside of reference range or a critical value. 18. Press check mark twice to return to main menu. 19. Turn monitor off. 20. Document result in patient s chart on blood glucose monitoring record (RQHR 284). 21. Wipe monitor with disinfectant cloth after patient test. C. Troubleshooting 1. Meter does not turn on wait a few seconds and try again place meter in base station and ensure it is charging take to laboratory 2. Strip Defect Error (displayed message) (E1507) strip is defective repeat test control or patient sample was added before blood drop icon appeared - repeat patient result is extremely low, below meter s measurement range repeat try running a control strip defect discard strips open new vial if problem persists take strips and meter to chemistry laboratory 3. Type Bad Dose (displayed message) insufficient blood on test strip repeat test with a new test strip and ensure adequate sample if problem persists take strips and meter to chemistry laboratory 4. Base Unit Problem light is not illuminated check connections light is flashing disconnect connections to base unit and then reconnect if problem persists call chemistry laboratory 5. Results do not Transfer results are transferred through the hospital wireless system system may be down if problem occurs on only one meter call the laboratory IT may need to be contacted if it is a system wide problem Approved: June 3, 2015 Page 6 of 10

7 6. Control Error Message E332 Invalid Control Lot Barcode strip vial barcode was scanned instead of control bottle barcode new control lot not yet entered in system contact laboratory E333 Control Level Mismatch scanned control level was not selected level to be run 7 Warning Messages FAIL control is out of range repeat RANGE result is out of reference range OUT OF CRITICAL RANGE result is out of critical range BATTERY LOW charge meter in base unit CONTROL LOT NOT FOUND contact chemistry laboratory STRIP LOT NOT FOUND contact chemistry laboratory NOTE: If unable to resolve problem obtain a replacement meter from chemistry 4490 (RGH) 2256 (PH) D. Limitations Interference from galactose (greater than 0.83 mmol/l), IV administration of ascorbic acid (less than 0.17 mmol/l) If patient has impaired peripheral circulation results of capillary samples may not be a true reflection of the physiological blood glucose (e.g. Severe dehydration, shock, decompensated heart failure, peripheral arterial occlusive disease) Triglyceride levels of greater than 20.3 mmol/l may cause elevated results Approved: June 3, 2015 Page 7 of 10

8 REFERENCES Aziz, K., Dancey, P. Canadian Pediatric Society, Fetus and Newborn Committee. Pediatric Child Health (10) Reaffirmed February, Reference #FN Retreived from CLSI C30-A2. (2013) Point of Care Blood Glucose Testing in Acute and Chronic Facilities, approved Guideline, 3 rd Ed. Retrieved from Operators Manual (2011) Accu-Chek Inform II System, Roche Diagnostic Corporation Revised by: Tammy Ottenbreit, MLT, ART, Chemistry Supervisor III, Laboratory, Balynda Gabora, Jana Poitras, Jana Lowey, Glenys Weisshaar, Kathy Jellow, Lori Lunnin Date: March 2012 Revised by: Elaine Abrook, CNE Date: June 2015 Approved by RQHR Procedure Committee: Date: June 3, 2015 Regina Qu Appelle Health Region Health Services Nursing Procedure Committee Approved: June 3, 2015 Page 8 of 10

9 Appendix A Guidelines for Hypoglycemia Management of Newborns Asymptomatic Baby shows no signs & symptoms of hypoglycemia appears well Symptomatic Baby shows signs & symptoms of hypoglycemia or appears unwell At risk for hypoglycemia No Yes Chemstrip now, if <2.6mmol, call NICU/Nursery, inform MRP, needs IV fluids Feed within one hour of age Routine care Feed on demand Feed within one hour of age Check initial chemstrip at 2 hrs of age & Q2-3 hourly Chemstrip > 2.6 Treat symptoms As needed < hrs or < 2 subsequent checks hrs or subsequent checks 2 hrs or subsequent checks Inform MRP Feed & recheck chemstrip in 1 hour Inform MRP Call NICU Needs IV fluids Remains <2.6mmol/l despite feeding Rises to > 2.6mmol/l after feeding Feed Q 2-3 hrly, monitor chemstrip (before feeds) until stable x 2 See on the reverse for definitions, risk factors & signs & symptoms of hypoglycemia Approved: June 3, 2015 Page 9 of 10

10 Guidelines for Hypoglycemia Management of Newborns Appendix A cont. Signs and Symptoms of Hypoglycemia Jitteriness, Tremors Episodes of cyanosis Convulsions Apnea Tachypnea Weak or high-pitched cry Limpness, lethargy, hypotonia Difficulty Feeding, refusal to feed Eye rolling Sweating, sudden pallor Risk Factors for Hypoglycemia Maternal hypertension treated with beta blockers Any maternal diabetes (gestational, type I or II with or without insulin including single dose) SGA less than10th percentile LGA greater than 90th percentile Preterm less than 37 0/7 weeks Cold stress hypothermia axilla temperature less than 36.5 C Newborns with medical conditions, E.g. respiratory distress, sepsis etc. SGA/LGA PARAMETERS SGA: less than 10th percentile for birth weight and gestational age LGA: greater than 90th percentile for birth weight and gestational age Gestation (completed weeks) SGA Less than or equal to Male Weight in GM LGA Greater than or equal to SGA Less than or equal to Female Weight in GM LGA Greater than or equal to Code: Gdl.B.4.0 Authors: Tammy Ottenbreit, Balynda Gabora, Jana Poitras, Jana Lowey, Glenys Weisshaar, Kathy Jellow, Lori Lunnin Date: March 2012; June 2015 Approved: June 3, 2015 Page 10 of 10