BROKEN HILL HEALTH SERVICE by alendar

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									                   BROKEN HILL HEALTH SERVICE
                     (All Wards/Emergency Department)

POLICY NO:           BH 8.7

SUBJECT:             Blood Glucose Monitoring

SOURCE:              ICU/CCU

ORIGINAL DATE:       November 2000

REVISED DATE:        December 2003

POLICY:

•   Safe, effective and appropriate monitoring of the blood glucose level (BGL)
    for both Type l and Type ll diabetic patients.

•   Blood glucose levels (BGL’s) are performed by appropriately skilled and
    accredited Registered and Enrolled Nurses.

•   Blood glucose levels are documented only on recognised Far West Area
    Health Service stationery specifically designed for recording blood glucose
    levels.



OUTCOMES:
• The diabetic patient will be appropriately managed through timely
  monitoring of blood glucose levels for the particular type of diabetes (Type
  l/Typell) and accurate recording of blood glucose levels

•   The diabetic patient is to be taught to self-monitor their own blood glucose
    levels accurately with appropriate education.


PROCEDURE:
• Blood Glucose level recording shall be performed on a drop of capillary
  blood from the sides on the fingertips of the non-dominant hand.

•   The dominant hand should only be used for sampling when the above site
    does not yield sufficient blood or is unsuitable.

•   Blood glucose monitoring is only to be performed on a Glucometer
    approved and tested by the Far West Area Health Service Bomedical
    Engineering Department.
MONITORING

                     TYPE                               FREQUENCY
Type l                                        Pre breakfast (fasting)
                                              Pre Midday meal
                                              Pre Evening meal
                                              2 hours post evening meal
Type ll on insulin                            Pre breakfast (fasting)
                                              Pre Midday meal
                                              Pre Evening meal
                                              2 hours post evening meal
Type ll – Diet controlled/Oral medications    Pre breakfast (fasting)
                                              2 hours post breakfast
                                              2 hours post midday meal
                                              2 hours post evening meal

•   If fasting both Typel and Type ll diabetic patients should have blood
    glucose monitoring 4 hourly.

•   The diabetic patient on a sliding scale insulin regime should have their
    blood glucose level performed 4 hourly and/or as necessary.

•   If the diabetic patient shows signs and symptoms of hyper or
    hypoglycaemia then blood glucose testing should be performed regardless
    of when last taken or when next due.

•   Hypoglycaemic episodes should be treated with the Hypoglycaemia Kit
    located in each ward as per Broken Hill Policy 8.3 Treatment of
    hypoglycaemic episode using Hypoglycaemic Kit.


Blood glucose levels outside the range of 4.0 – 10.0mmol/L should be brought
to the attention of the treating Medical Officer.


REFERENCE DOCUMENTS:

Diabetic management Chart – Broken Hill Health Service

Cohen M 1996 “diabetes: a handbook of management” 6th Ed. International
Diabetes Institute/Sevier Laboratories. Victoria
                      BROKEN HILL HEALTH SERVICE
                                         (ICU/CCU)

POLICY NO:               BH 8.7a

SUBJECT:                 Blood Glucose Monitoring and Sliding Scale Insulin

SOURCE:                  ICU/CCU

ORIGINAL DATE:           November 2006

REVISED DATE:            December 2009

POLICY:

•   Safe, effective and appropriate monitoring of the blood glucose level (BGL)
    for both Type l and Type ll diabetic patients.

•   Blood glucose levels (BGL’s) are performed by appropriately skilled and
    accredited Registered and Enrolled Nurses.

•   Blood glucose levels are documented only on recognised Greater Western
    Area Health Service stationery specifically designed for recording blood
    glucose levels.

•   Sliding Scale Insulin is appropriately commenced to ICU/CCU patients as
    per policy regimen.



OUTCOMES:
•   The diabetic patient will be appropriately managed through timely monitoring of blood
    glucose levels for the particular type of diabetes (Type l/Typell) and accurate recording of
    blood glucose levels
•   The diabetic patient is taught to self-monitor his or her own blood glucose levels
    accurately with appropriate education.
•   An optimum BGL of 6.5 mmol is achieved by utilising the Sliding Scale regime.



PROCEDURE:
•   Blood Glucose level recording shall be performed with a drop of capillary blood from the
    sides on the fingertips of the non-dominant hand.
•   The dominant hand should only be used for sampling when the above site does not yield
    sufficient blood or is unsuitable.
•   Blood glucose monitoring is only to be performed on a Glucometer approved and tested
    by the Greater Western Area Health Service Biomedical Engineering Department..
MONITORING

   •   All Medical and Surgical patients admitted to ICU/CCU, without a diagnosis of type I
       or type II diabetes, are to have their BGL’s taken TDS. The times are as follows;
       0600, 1400 and 2200. If the patients BGL is greater than 10 mmol then the Q4h
       Sliding Scale regimes listed below are to be initiated and the Medical Officer notified.
   •   The Medical Officer may elect not to commence this protocol, however all variances
       to this regime must be documented with reasoning.
   •   All type I and type II diabetic patients admitted to ICU/CCU are to have their BGL
       performed 4 hourly fasting or otherwise.
   •   Monitoring times are as follows: 0200, 0600, 1000, 1400, 1800 and 2200.
   •   If the diabetic patient shows signs and symptoms of hyper or hypoglycaemia then
       blood glucose testing should be performed regardless of when BGL last taken or
       when next due.
   •   Hypoglycaemic episodes should be treated with the Hypoglycaemia Kit located in
       each ward as per Broken Hill Policy 8.3 Treatment of hypoglycaemic episode using
       Hypoglycaemic Kit.
   •   Formal fasting Blood Glucose Levels are to be taken upon admission to ICU/CCU.



The following Sliding Scale Insulin regime (for type I and type II) is to be
attended for patients tolerating an oral diet.


Q4h Blood Sugar Level (mmol)                    Novo-rapid (units S/C)
          0-5 mmol                                          Nil
        5.1 – 8 mmol                                      4 units.
        8.1 – 12 mmol                                    8 units.
       12.1 – 16 mmol                                    12 units.
       Above 16.1 mmol                                   20 units.


The following Sliding Scale Insulin regime (type I and type II) is to be attended
for fasting patients.


Q4h Blood Sugar Level (mmol)                    Novo-rapid (units S/C)
        0 – 5 mmol                                           Nil.
      5.1 – 8 mmol                                        4 units.
      8.1 – 12 mmol                                     8 units.
     12.1 – 16 mmol                                     12 units.
     Above 16.1 mmol                                    20 units.

                                           PLUS

Fasting patients are to have an intravenous infusion of 5% Dextrose. 100 mls
per hour unless otherwise indicated by the Medical Officer (Infusion rate
should be increased if BGL is below 4 mmol/l).

   •   Blood glucose levels outside the range of 4.0 –20.0mmol/L should be
       brought to the attention of the treating Medical Officer.
This policy is designed to be a method of Blood Glucose treatment in
Intensive Care settings, not a diagnostic tool. If non-diabetic patients exceed
fasting BGL’s of 7 mmol or random BGL’s of 11.1 mmol they are be referred
to their GP once the acute phase of their illness has passed. Alternatively the
Medical Team prior to discharge can arrange a formal diagnosis or once the
patient has passed the acute phase of their illness.

This policy is designed to meet international standards for Intensive Insulin
Therapy and Blood Sugar Monitoring in Intensive Care Units.


REFERENCE DOCUMENTS:

Diabetic management Chart – Broken Hill Health Service

Cohen M 1996 “diabetes: a handbook of management” 6th Ed. International
Diabetes Institute/Sevier Laboratories. Victoria

Malhotra, Atul 2006 “Intensive Insulin in Intensive Care”. The New England
Journal of Medicine, Vol 354(5).

Van den Berghe, 2006 “Intensive Insulin Therapy in the Medical ICU”. The
New England Journal of Medicine, vol 354(5).
Appendix: Intensive Care Insulin Therapy and BGL Monitoring flow chart.




 Is the patient a
 known diabetic                              NO
 (type I or type II)




                                       To have TDS
         YES                           BGL’s while in
                                       ICU/CCU.


                                       If BGL >10
                                       mmol to
                                       commence Q4h
                                       Sliding Scale.




     FASTING.
                                             NO.




                                       Commence Q4h
         YES.                          Sliding Scale
                                       regime.




 Commence Sliding
 Scale regime plus                     Any deviation to Sliding
 5% Glucose                            Scale Insulin policy/flow
 infusion @                            chart to be clearly
 100ml/hr                              documented and the Medical
                                       officer to be informed.


Intensive Insulin and Blood Glucose Monitoring Flow chart as per Policy 8.7a.

								
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