STANDARDISATION OF BLOOD GLUCOSE MONITORS IN ENFIELD

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                 BLOOD GLUCOSE MONITORING
                           FOR
                    COMMUNITY NURSING

                                       Duty of Care Statement

Should the content or operation of this policy be challenged on any grounds whatsoever
then the impact on the past, present or future duty of care to patients will be taken to be
              a primary factor in deciding the outcome of that challenge.




Title                  PROTOCOL FOR BLOOD GLUCOSE MONOITORING FOR
                       COMMUNITY NURSING IN EPCT
Summary                Information for staff in the community who care for patients with
                       diabetes who require blood glucose monitoring

Date of Review         August 2008
Approved via           Joint Staff Committee
Distribution           All Directorates and all Staff via the Intranet and the public via the
                       FOI
Related Documents      Insulin policy
Further Information    Debbie Hicks – Nurse Consultant – Diabetes
                       Kit McAuley – Diabetes Specialist Nurse/Facilitator
This document          New policy
replaces
                        BLOOD GLUCOSE MONITORING PROCEDURE
                                       FOR
                          COMMUNITY NURSING IN ENFIELD PCT



INTRODUCTION:

Monitoring of capillary blood glucose is recognised as playing an important role in the effective
management of people with diabetes when it is used in the correct manner. Blood glucose
monitoring provides instant information about the effectiveness of a person with diabetes
management plan.
It is advocated by many sources including Diabetes UK (DUK – 2007), the International
Diabetes Federation (IDF - 2005) and NICE (2002) for people who need to:

   1.   Monitor the effectiveness of diabetes therapy on a day to day basis
   2.   Monitor effectiveness of lifestyle interventions
   3.   Detect poor glycaemic control
   4.   Detection of hypoglycaemia
   5.   Monitor glycaemic control during times of illness

Enfield PCT have put in place recommendations for blood glucose monitoring for patients as
part of the Diabetes Care Pathway and are found in this documentation as Appendix 1

The purpose of this policy is to ensure that blood glucose monitoring is carried out safely,
accurately and by the appropriate people. It is also to augment the annual training sessions for
EPCT staff.

These guidelines are for use with the Lifescan Ultra 2 glucose meter ONLY and must be
adhered to at all times.

Focus is put on individual responsibilities for staff to undertake Internal Quality Control (IQC)
and External Quality Assurance (EQA) and systems have been put in place by EPCT to ensure
best practice. It is expected that all staff who undertake blood glucose monitoring will ensure full
compliance with the following policy.

This policy is applicable to all registered users in the following teams within EPCT:

1. All District Nursing Teams including Out of hours staff / Twilight nursing
2. Intermediate Care staff
3. Magnolia Unit
4. Community Matrons
HOW TO BECOME A REGISTERED USER:

Registered users are staff who have either:

1.
        Received training organised by the Diabetes Nursing Team in collaboration with
         Lifescan representatives
        Have received a certificate of training
        Are undertaking annual updates

2.
        Have been assessed as competent by a Registered General Nurse, who has
         undergone training
        Have completed training checklist (Appendix 2)
        Submitted this documentation to Debbie Hicks, Nurse Consultant – EPCT and
        Have received an interim certificate (Appendix 3) for blood glucose monitoring.

TRAINING:

Prior to being issued with a certificate of training and a blood glucose meter, all relevant staff
will attend a study session that covers the following:

Table 1:

Training session will include                              Objective of training

Full meter training to include routine maintenance and Basic principles of measurement
coding of meter                                             Understanding of error codes and
                                                            troubleshooting
Preparation of patient                                      Basic principles of measurement and
                                                            patient understanding. Knowledge of
                                                            contra-indications
Specimen collection and lancet training                     Basic principles of measurement and
                                                            correct technique for collection of
                                                            samples
Application of the specimen to the meter                    Correct technique and use of the
                                                            meter
Procedure for reading and recording results                 Accurate     record   keeping    and
                                                            knowledge of normal values
Dealing with abnormal or unexpected results                 Knowledge of operator dependent
                                                            steps
Quality control                                             Mechanism for coding, IQC and EQA
Health and Safety, especially cross infection               Relevant aspects of Health and
                                                            Safety and Infection Control
EQA registration and procedure                              Understanding of the importance of
                                                            returning results
Ordering supplies                                           Understand how to ensure supplies
                                                            are ordered correctly
Issue of training certificates and distribution of meters & For evidence of attendance, portfolio
log books
CODING OF METER:

Coding of meter should take place every time a new pack of strips is opened. This will calibrate
the machine to the strips that will be used. The following procedure should be carried out

Table 2:

                    Procedure                                        Rationale

Use only One Touch Ultra test strips with One To ensure compatability of strips and
Touch Ultra 2 meter                               meter
Ensure meter and strips are:
 Approximately the same temperature before
  you test.
 Testing is done within operating temperature To ensure accuracy of results
  range (6 – 44 0 C) Try to test as close to room
  temperature as possible.

When opening test strips for the first time ensure To ensure strips are valid and are not
within expiry date and label clearly when pot is used after 3 months of opening
opened for the first time
Check the code on the test strip vial before
inserting the strip
Wash and dry hands                                  To maintain hygiene
                                                    To avoid contamination of strip
Insert a test strip into test port to turn on meter To turn meter on
After the black start-up screen appears, the meter
will display the code from the last test change the
numerical code to match the code on the test strip
vial using the arrows                             To match vial code and meter code

The new code number will flash on the display for
three seconds then briefly stop flashing after which
the APPLY BLOOD screen will be visible
QUALITY ASSURANCE:

The need for quality assurance and training in the use of blood glucose meters was identified in
a Department of Health hazard warning notice (HN (Hazard)(87) 13). This notice states that the
treatment of patients can be adversely affected by the use of blood glucose meters by untrained
staff and without quality control procedures.
It is the responsibility of each healthcare professional using a meter to ensure that Quality
Assurance testing is carried out.

 DECISIONS REGARDING CHANGES IN PATIENT TREATMENT SHOULD NOT BE MADE
  UNLESS THE METER USED HAS BEEN FULLY QUALITY ASSURED (EQA NO MORE
           THAN 1 MONTH AGO AND IQC WITHIN PREVIOUS 24 HOURS)

Internal Quality Control (IQC) using Control solution:

This should be carried out daily if the meter is used on a daily basis. If the meter is used
intermittently, it should be carried out weekly, or before being used for a patient test. IQC should
also be performed if:
        The meter is dropped or receives a physical shock
        The integrity of the strips is suspect
        The function of the meter is suspect
        An improbable result is obtained.

Results from IQC should be recorded in the meter log book which will be kept for 10 years.
This test should be carried out using only the solution supplied by Lifescan. This will be given
out 3 monthly to EPCT staff who are registered users and who are enrolled in the Q Point
Quality Assessment Scheme.

Equipment:

Hand hygiene facilities
One Touch Ultra 2 blood glucose meter
Test strips
Gloves
Quality Control test solution
QA diary

Table 3

                  Procedure                                           Rationale

Ensure meter is in the OFF position                To start test
Check the code on test strip vial                  To ensure compatability of strips and meter
Insert a test strip to turn on meter               To ensure meter is switched on
Match code on meter with code on test strip        To calibrate meter
vial
Mark the test as a control solution test as per    To ensure differentialtion between QC solution
manufacturers instructions                         and blood sample
Prepare and apply control solution                 To carry out test
Read and record result in log book                 To ensure audit trail and good record keeping
Check results are in range (see strip vial)        To ensure meter and strips are working
                                                   properly
External Quality Assurance (EQA)

EPCT work closely in collaboration with Q Point and Lifescan to ensure that all meters in use
within the PCT are fully monitored.

   1. It will be the responsibility of the team leader to keep an up to date log / register of all
      users. ( see Appendix 5)
   2. If a member of the team leaves, the allocated meter will be withdrawn from use in the
      following way:
      a) The meter history log book (Appendix 4) will be completed and retained by team
      leaderand Qpoint will be informed.
      b) Meter will be returned to a central holding bank administered by Service Manager
   3. All new staff will undertake a training session by the designated trainer on induction and
      added to EQA register and Lifescan informed. This process is outlined in “How to
      become a registered user”


   Monthly returns from Q Point will be sent individual Service Manager and Kit McAuley for GP
   practices involved in the meter standardisation scheme.

   The following table outlines action to be taken if EQA fails

Table 4:

              EQA Code given                                      Action to be taken
PROCEDURE FOR BLOOD GLUCOSE METER USE:

The correct collection of capillary blood glucose samples is important to:
   1. Generate accurate results
   2. Prevent infection
   3. Prevent permanent injury in cases of long term monitoring

The following procedure should be adhered to at all times.

Equipment:

Hand hygiene facilities
One Touch Ultra 2 blood glucose meter
Test strips
Unilet single use lancing device
Sharps container
Cotton wool / gauze swabs
Gloves
Patient record

Table 5:

                  Procedure                                          Rationale

Identify patient, obtain consent and               To ensure correct identity, gain informed
cooperation                                        consent and understanding.
Wash and dry your hands, apply gloves and          To maintain hand hygiene and prevent cross
apron                                              infection
Ensure that patient has washed hands in warm       Warming fingers can increase blood flow
soapy water.                                       Many household products can affect blood
Ensure rinsed well and dry completely              glucose readings
Remove testing strip from pot and replace lid      To prevent deterioration of remaining strips
immediately
Insert test strip into meter and ensure meter      To ensure compatability of strips and meter
coded (see table 2)
Use Unilet lancing device and puncture finger      Less painful
on the side of the fingertip (outer aspect)        To prevent damage to nerve endings in
                                                   fingertips
Gently squeeze or massage fingertip to get a
round drop of blood
If the blood smears do not use this sample.        To ensure correct sample size obtained
Dry the area and gently squeeze another drop
of blood, if still not effective, puncture a new
site with a new lancet
Apply     sample      as    per    manufacturers   To ensure accuracy of reading
instructions
Press cotton wool or gauze to puncture site    To stop blood flow from finger
Read result and take action if outside target  To ensure prompt treatment of hypo and
range                                          hyperglycaemia (see Hypoglycaemia Policy,
                                               sick day rules and onward referral guidance)
Record results in patient record and meter log Good record keeping and to ensure an audit
book                                           trail
STORAGE OF GLUCOSE METER, STRIPS AND QUALITY CONTROL SOLUTIONS:

You have been issued with a One Touch Ultra 2 meter. This meter should ideally be carried in
the Lifescan workstation.

The workstation should be stored in a cool, dry place below 30 o C but it should not be
refrigerated. It is essential to be cautious when carrying the workstation in your vehicle as it can
be prone to extremes of temperature. A dust free environment is essential. The workstation
should be kept away from direct sunlight and heat.

When you are using the test strip vial and the control solution vial it is essential to close the vial
immediately after use to avoid contamination and damage.

Test strips should be stored in their original vial only and the “in use” date (date when opened)
should be clearly labelled on the vial on the appropriate line. Any unused test strips in the vial
should be disposed of after the “in use” date. The “in use” date is 3 months after the vial has
been opened for the first time.

All registered users will be sent a control solution every three months with Qpoint EQA returns.
It is essential to replace the control solution three monthly when it is received. The date opened
should be written on the vial.


FREQUENCY OF BLOOD GLUCOSE MONITORING:

Each request for blood glucose monitoring should be assessed on an individual basis. The
frequency of blood glucose profiling should be based on the professional judgement of the
Registered Nurse.

The guidelines overleaf (guidelines for home visits by District Nurses to perform capillary blood
glucose monitoring alone) will help to assess the indications for blood glucose monitoring.

It is, however, expected that blood glucose monitoring should take place in the following
circumstances:

          Prior to insulin injection
          If hypoglycaemia is suspected
          If hyperglycaemia is suspected
          Patient found unwell or confused
GUIDELINES FOR HOME VISITS BY DNs TO PERFORM CAPILLARY BLOOD GLUCOSE
MONITORING ALONE:

Many District Nurses are being requested to do home visits on patients to perform random
blood glucose monitoring. This is a valuable service but potentially very time consuming. To
ensure appropriate utilization of District Nurse time in this area the following guidance has been
formulated for consideration

Table 6:

                 Action                                         Rationale

Baseline information prior to request
The patient should have a confirmed         No clinical indication for home blood glucose
diagnosis of diabetes.                      monitoring in non-diabetic patients. Home blood
                                            glucose monitoring cannot be utilised to make a
                                            formal diagnosis of diabetes.
Current HbA1c                               HbA1c is the recommended method of long term
(Within the last 8 weeks).                  monitoring of diabetes control (NICE 2002).
                                            HbA1c gives an indication of control over the
                                            preceding 8-12 weeks.
Indications
Capillary monitoring provides additional    HbA1c is the recommended method of long term
information not available from HbA1c        monitoring of diabetes control (NICE 2002).
monitoring.
Concerns re hypoglycaemia                   Home blood glucose monitoring can help to
                                            identify specific times when hypoglycaemia may
                                            be a high risk and assist in identifying which
                                            treatment requires adjusting.
Significant treatment change                Home blood glucose monitoring can provide
                                            immediate information re the effectiveness of
                                            treatment adjustment.
Significant change in patient’s medical     Acute fluctuations can occur in patient’s blood
condition                                   sugar profiles during episodes of acute illness
                                            requiring treatment adjustment.
Supporting the patient in achieving self-   Self-blood glucose monitoring is the preferred
blood glucose monitoring.                   option but some patients may require a period of
                                            support to achieve independence.
Format of input
Specified time-frame e.g. 2 weeks           Indefinite home blood glucose monitoring without
                                            review is of no clinical benefit and potentially a
                                            waste of valuable district nursing resources.
Pattern of monitoring specified e.g.        Timing of blood glucose monitoring is important
daily, twice per day.                       for readings to be of any value. Ideally, including
                                            pre and post meal tests
Named reviewer and date specified at        Blood glucose results need to be reviewed by an
the time of the request                     appropriate health care professional who has the
                                            knowledge to adjust relevant treatments if
                                            required.
STRIP ORDERING :

The team leader will need to ensure that there are enough strips and lancets available for the
number of people with diabetes on the team caseload who require blood glucose monitoring.

Ensure that entire packs of strips are shared within your team 1 box of Lifescan strips will
contain 2 individual packs of 25 strips. These packs have individual calibration codes on the
side of each pack.

Do not take strips from one vial and place in another vial

Each site will receive 1 box of 100 lancets / year free of charge from Lifescan

There are six designated ordering points throughout the PCT. Any queries about the ordering
points should be discussed with the individual Service Manager.



TREATMENT OF HYPOGLYCAEMIA:

See EPCT policy for hypoglycaemia for Health Care Professionals within the Primary Care
Setting


HYPERGLYCAEMIA:

Signs and symptoms

          Blood glucose levels reading above 10 mmols/l clinicallyindicate hyperglycaemia
          Thirst
          Passing urine more frequently
          Loss of appetite
          Weight loss
          Blurred vision
          Genital itching due to thrush

If patient has any of the following symptoms, test for ketones in the urine:

          Nausea and/or vomiting
          Abdominal pain
          Drowsiness
          Confusion
          Laboured breathing

If a ketones trace is present in the urine contact the patients General Practitioner immediately.
If medium or above ketones are present in the urine, the patient should be sent IMMEDIATELY
to Accident and Emergency.

               THESE SYMPTOMS MUST BE TREATED AS AN EMERGENCY

CONTACT GP IF:
     A pattern of raised blood glucose results becomes apparent
     The raised blood glucose levels are persistent
     The patients condition has deteriorated
References:

Diabetes UK Position statement on self monitoring of glucose levels
http://www.diabetes.org.uk/About_us/Our_Views/Position_statements/Self-
monitoring_of_blood_glucose/

International Diabetes Federation (IDF;2005) Clinical guides task force. Global guidelines for
type 2 diabetes. IDF, Brussels

MHRA Point of care testing advice leaflet
http://www.mhra.gov.uk/Publications/Postersandleaflets/CON2015499

NICE Diabetes guidelines(2002)
http://www.nice.org.uk/guidance/index.jsp?action=byID&o=10912




Written            June 2008
Review date        June 2009
                                            APPENDIX 2

               CHECKLIST OF TRAINING TO BECOME A REGISTERED USER OF
                            LIFESCAN ONE TOUCH ULTRA 2

On completion of this form, please fax to:
Debbie Hicks, Nurse Consultant – Diabetes on 020 8344 3192.

On receipt, a certificate of training will be issued by the Diabetes Nursing Team and this
certificate will enable the staff member to receive a One Touch Ultra 2 meter.

Name of Trainee (please print clearly)

Team:

Status: (please delete) Permanent staff / Bank Staff
Name of Assessor (please print clearly)

                                    Assessor initials           Trainee initials

Turning meter on and meter
coding
Storage of meter, strips, QA
solution,
Setting meter language, date
and time
Testing process

Using lancet

Recording and interpretation of
results
Attaching flags and comments
to results
Control solution testing (IQA)

External Quality Control

Error messages

Strip ordering and replacement
batteries
Treatment of hypoglycaemia

Treatment of hyperglycaemia

Importance of regular updates

I have carried out the training as outlined above and agree that the person named above
should become a registered meter unit.

Signature of assessor____________________________________
                       APPENDIX 3
      INTERIM BLOOD GLUCOSE MONITORING CERTIFICATE




                  This certifies that



_________________________________________________



          has undergone training for use of
   Lifescan One Touch Ultra 2 blood glucose meter




 ______________________________________________


                  Debbie Hicks
         Nurse Consultant – Diabetes EPCT
                                         APPENDIX 4

                         Meter history logbook / Meter change form

If there is a change of meter user it is essential to fill out this form and fax to
Debbie Hicks – Nurse Consultant on 020 8344 3192


TEAM NAME:


TEAM BASE:


METER SERIAL NUMBER:


NAME OF PREVIOUS REGISTERED USER:


NAME OF CURRENT USER:




SIGNATURE


PRINT NAME
                                      APPENDIX 5
                        TEAM USER LOG – COMMUNITY NURSING
                            Please insert your team name here

 All meters that are allocated to your team (including any spare meters) MUST be recorded.

                  The PCT will not take any responsibility for any results
                      that do NOT have evidence of EQA and IQC


Meter serial   First Name           Surname                  Address of Base                 Permanent (P)
 number                                                                                        Bank (B)
                                                                                               Spare (S)
   e.g.           Debbie               Hicks                   Forest PCC                         P
wwf39acdz                                                  308A Hertford Rd N9




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