Transcript Glucose - Johns Hopkins Pathology

A Self-Study Packet for The Johns Hopkins Hospital Point-of-Care Testing Program
©copyright 2015
Johns Hopkins Hospital
All rights reserved
Overview and Objectives
 This module provides an introduction to the JHH policy
for performing bedside blood glucose monitoring.
 At the conclusion of the module the learner will be able to:
 State training and maintenance of competency requirements with point of
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care testing ( POCT ) for blood glucose
Define indications for blood glucose monitoring
Identify how to perform a blood glucose test using the Nova StatStrip
Glucose meter
State procedure for obtaining capillary, venous, neonatal, and arterial
blood specimen for glucose POCT
Identify limitations of POCT
Define operator responsibilities with POCT
Training and Competency
1.
Only those operators who have completed training and
have demonstrated competency may perform POCT
blood glucose testing.
2.
The Training program will consist of:
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Attending a defined in-service session on the glucose
meter.
Passing a written examination
Demonstrating competence through the proper
performance and interpretation of quality control.
3. Maintaining competency:
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Annual online education
Perform 2 levels of QC
Reasons for Point of Care Blood
Glucose Monitoring
 On-going management of blood glucose in
patients with diabetes
 Rapid detection of extreme blood glucose
concentrations in patients who:
 are in a coma
 have symptoms that suggest hypoglycemia or
hyperglycemia
Monitoring of patients:
 who have diabetes
 who are receiving Parenteral Hyperalimentation
 who are receiving medications which affect blood
glucose concentration
 after liver or pancreas operative procedures
 with post-op or post procedure elevations in
glucose secondary to stress
 with infection
 undergoing renal dialysis
 hyperglycemia
Point-of-Care Glucose analysis IS NOT used
to diagnose Diabetes Mellitus
 Bedside whole blood glucose monitoring is used
to supplement laboratory analysis of blood
glucose
 Patients will still require periodic laboratory
testing of blood glucose levels.
Factors Influencing Accuracy of Test Results
Patient Medical Conditions
Problem
Potential Impact
Recommendation
Patient has peripheral
vascular disease or a
condition that
impairs/decreases
circulation to the
periphery
False low glucose
Fingerstick collection not
recommended
Patient is dehydrated
False low glucose
Fingerstick collection not
recommended
Patient is in shock
False low glucose
Fingerstick collection not
recommended
Patient has severe edema
False low glucose
Fingerstick collection not
recommended
Patient is hypotensive
False low glucose
Fingerstick collection not
recommended
Operator Performance
The operator ID used for the glucose meter is the
employee’s JHED ID.
1.

For legal reasons, Operator’s should NOT share their JHED
IDs with other users.
2. Operators that fail to perform quality control (QC) or fail
to take their yearly quiz, will be removed from the meter
and unable to perform testing

Operators that are removed from the meters will need
to repeat the training program.
NOTE: If your QC is due within 28 days, when you scan your
JHED ID barcode, the meter will give you a message that your
QC is due.
Specimen Collection
Capillary, venous, neonatal and arterial whole
blood specimens may be used.
Remember to use Standard Precautions
when obtaining blood samples and
performing patient testing.
Quality Control (QC)
 All glucose meters require QC every 24 hours
 Patient testing will not be allowed until the QC has
been performed satisfactorily
 All test strips and control bottles must be dated when
opened with the opened date and expiration date.
 This is a Laboratory Regulatory Requirement!
 Example: O: 3/11/11 X: 6/11/11 NN
 O=opened X= expired
NN= Nancy Nurse (your initials)
Nova Statstrips®
 Once opened, test strips are good for
180 days or manufacturer’s expiration
date
 TIP: the vial is labeled with an icon
to remind you of the expiration date
180
 Store at room temperature and tightly
capped
 No interference from medications,
oxygen, uric acid, acetaminophen,
bilirubin, maltose, galactose, xylose or
hematocrit
Control Solutions
 Once opened, solutions
are good for 90 days or
until expiration date on
the vial.
 TIP: the vial is labeled
with an icon to
remind you of the
expiration date 90
QC Procedure
 Log-in by scanning your user barcode
 Each operator will have a barcode with their JHED ID
 Choose QC
 Scan the vial of test strips
 Scan Control solution, level 1
 Place the test strip into the meter
 Gently mix control solution, discard the first drop then
apply drop to strip
 After 6 seconds, view results (PASS/FAIL)
 FAIL requires a comment
 Discard test strip
 Repeat procedure with Level 3 control solution
QC Procedure
 If QC fails, the following troubleshooting steps
should be taken:
 Repeat control test, record comment on meter
 Open new set of controls and repeat test
 Open new test strips and repeat test
 If QC continues to fail after these
steps….. STOP TESTING.
 Contact the POCT Office for assistance
Patient Testing
Capillary Blood Collection
(Fingerstick/Heel Stick)
1. Verify the patient’s ID with 2 unique identifiers:
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Inpatient: Name & Medical Record Number
Outpatient: Name & Birthday
ALWAYS scan the csn number into the glucose
meter (WE NO LONGER USE MRNs for the meter)
2. Select an appropriate sampling site:
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Palm side of the finger tip
Lateral or medial plantar surface of the infant heel
3. Warm the site if needed.
4. Clean site with 70% alcohol and ALLOW TO AIR DRY.
5. Perform the puncture just off-center of the fingertip or
infant heel.
Capillary Blood Collection (cont’d)
6.
Wipe off the first drop of blood, using a gauze.
7.
Allow a small drop of blood to form by gently applying
intermittent pressure.

8.
Touch the end of the test strip to the drop of blood.
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9.
Do Not Milk the site.
Capillary action will cause the blood to flow in the 4 wells on
the test strip.
The strip must fill completely upon touching the blood
droplet.
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Do not touch the test strip to the blood droplet a second
time.
Discard the test strip and repeat with a new strip.
10.
Discard all contaminated patient materials in
appropriate biohazard containers.
11.
Dispose of used lancets into sharps container.
Blood Collection from
Arterial or Central Lines
1. Verify the patient’s ID with 2 unique identifiers.
2. Ensure the line is clear before obtaining the sample.
3.
Discard appropriate volume of blood in a waste syringe.
4.
Attach a lithium heparin blood gas syringe to the line
and draw the sample.
5.
Cap the syringe and gently mix by inverting the syringe
10 times.

This allows the anticoagulant to properly mix with the blood
sample.
6. Uncap the syringe and discard a small amount of the
blood sample before dosing the test strip.
Blood Collection from
Arterial or Central Lines
(cont’d)
7.
Gently push on the syringe plunger to allow a drop of blood to
form on the end of the syringe.
8.
Touch the blood drop to the end of the test strip.
9.
The strip must fill completely upon touching the blood droplet.
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Do not touch the test strip to the blood droplet a second time.
Discard the test strip and repeat with a new strip.
10. Flush the line, when test is completed.
11. Discard all contaminated patient materials in an approved
biohazard container.
12. Dispose of used syringes in sharps container.
Blood Glucose Reference Ranges
(* Diabetes Care,2003;26:3160)
Normal Fasting
60-99 mg/dL
Newborn (0-7days) 45-110 mg/dL
Glucose values of 100-125 mg/dL indicate impaired fasting
glucose
Casual plasma glucose between 140-200 mg/dL should be checked
with a fasting plasma glucose test (Saudek & Margolis, 2009).
Remember…
 Nova Stat Strip glucometer machine will only read
from ( )10-600 ( ) mg/dL.
 If the result is >600 or <10, retest using a new strip. If
the same HI or LO reading is obtained, run a QC.
 The RN is authorized to send a STAT blood glucose
specimen to the critical care lab to confirm accuracy
of the glucometer when the result is > 400,
inconsistent with the patient current physical status
or previous glucose values.
Reporting of Values

UAPs (Clinical Associates, Clinical Technicians and
Clinical Nursing Externs) will notify the patient’s
Registered Nurse of ALL Point-of-Care blood glucose
results.
 Registered Nurses and Licensed Practical Nurses will
notify the provider immediately for blood glucose levels
greater or less than the parameters specified in the written
orders.
 Document in the patient’s record:
 Name of the provider that was notified
 A read-back of the Critical Action value has occurred
and been verified.
Factors Influencing Accuracy of Test Results
Improper Fingerstick Collection
Problem
Potential Impact
Recommendation
Using a previously punctured
site
Accumulated fluid will
contaminate the blood
specimen (decreases glucose)
Obtain blood specimen from a
fresh, non-punctured site
Residual alcohol causes rapid
hemolysis and adversely
affects glucose results (
increases glucose)
Allow puncture site to air dry
after cleansing with alcohol
Not wiping away the first drop
of blood
Excess tissue fluid in blood
specimen (decreases glucose)
Wipe away first drop of blood
after the puncture is
performed
Milking the puncture site to
obtain the blood drop
Hemolysis and /or
contamination of blood with
tissue fluids
Hold the puncture site
downward and apply gentle,
intermittent pressure proximal
to the puncture site
Edema at the puncture site
May give a falsely low glucose
result
Fingerstick collection not
recommended
Improperly cleaning the
puncture site with alcohol
Factors Influencing Accuracy of Test Results
User-based Problems
Problem
Not enough blood applied to the test
strip
Recommendation
If the test strip does not fill completely:
• Discard the test strip
• Repeat the test with a new strip.
Test strip not fully inserted into the
meter
Strip must be fully inserted into the
meter before dosing with a sample
Test strips/Controls stored at
temperature extremes
Test strip and controls must be stored
according to manufacturer’s
instructions
Use test strips immediately after
removal from vial.
Test strips left uncapped
•Recap vial immediately after removing
strip.
•Vials found uncapped should be discarded.
Documentation of Glucose Results
 Test results will automatically upload to the electronic
medical record.
 If required by your unit, test results, the Meter ID number,
date, time and operator initials are documented on the
nursing flow sheet or the electronic medical record.
 If the Meter ID number is not present on the EPR meter
list for the unit, type in the complete Nova StatStrip Meter
ID number (example: OSL4A, not 4A).
 Specific interventions will be documented on the MAR
and/or in the Notes section under Response to
Intervention.
Operator Responsibilities
 Clean the meter after each patient use!
 Record open dates on test strips and control solutions.
 Dispose of outdated test strips and control solutions.
 Perform QC with the appropriate control solutions (Discard the first
drop).
 Document any failed QC results and corrective actions.
 Enter/scan the correct patient history number into the meter. It is
ALWAYS better to scan the CSN number
and override if necessary than to manually
enter the CSN number. Please don’t enter the
MRN number!
 Properly collect the patient sample.
 Document test results, meter ID, date, time,
operator initials and care actions.
Cleaning of the Meter
 Wipe meter with a Sani-Cloth® wipe
 Squeeze out any excess liquid
 If meter screen develops a light film, wipe with
alcohol wipe or a gauze moistened with water.
 Do not spray solutions on the meter!
 This could damage the internal electronics
Battery Replacement
 Replace battery when “battery low” message appears
 The battery is a rechargeable lithium battery
 Press Power button to enter Sleep Mode
 Push down on 2 cover latches on the back of the meter
 Push up on the battery latch to release the battery
 Remove old battery and replace with charged battery
 Insert new battery into the bottom first
 Replace cover
 Place drained batter into docking station to recharge
 The light on the charger station should be red, if you don’t see the
light, the battery is in backwards.
Batteries….
 The rechargeable battery life
expectancy is 18-24 months.
 Batteries should be removed from
use and properly disposed of if
they exhibit any of the following
conditions
 Has exceeded its expiration date
 Swelling, cracking or damage to
battery case
 Leakage
 Failure to hold a charge
Common Nova StatStrip Glucose Meter
Error Codes/Alerts
Error
Code/Alerts
Possible Cause
Solutions
Battery Low
Has not been recharged
Charge/Replace Battery
QC Due: xx:xx hrs
LOCKED
Run QC after time has lapsed
QC not run
Test Strip Was Removed
Temperature
Perform QC before Patient Testing
Test cancel, insert new test strip
Meter outside temperature range of 59°F-104°F or
(15°C-40°C)
Move meter to correct temperature range
and run QC
Bad Sample
Insert a new strip and rerun the test
Replace Strip
Insert another strip
Flow Error
Insufficient sample or sample applied incorrectly
Rerun test with a new strip
Transfer Failed
Connection to server broken
Contact POCT Office (52645)
Transfer Failed
Meter removed from dock before data transfer
was complete
Re-dock the meter
Transmission of Results
 The Nova Stat Strip glucometer utilizes wireless
technology for the transmission of glucose results.
 Eliminates the need to return the meter to the
docking station for communication with the server.
 However, the meter must be returned to the
docking station for battery recharging and to
download operator and reagent updates.
Radio and Network Connection Status
 The Radio and Network Connection Status is
displayed via icons on the Screen Title Bar.
Radio status is displayed as follows:
Radio is ON and connected to the WAP (wireless access point) with the strongest signal strength.
Radio is ON and connected to the WAP with approximately ¾ signal strength.
Radio is ON and connected to the WAP with approximately 1/2 signal strength.
Radio is ON and connected to the WAP with approximately 1/4 signal strength.
Radio is ON with no signal, or no connection to the AP. In this state, the meter may be in the process
of attempting association with the local Wireless Access Point (WAP).
is OFF or no connection to WAP.
Network Connection status is displayed as follows:
Meter has established a connection and is communicating with the server.
Meter has not established communication with the server.
Summary
 The Nova Stat Strip glucometer utilizes wireless
technology for the transmission of blood glucose results.
 The procedure for QC and patient testing using POCT
testing may be found in HPO
Blood Glucose testing
 http://www.insidehopkinsmedicine.org/hpo/policies/41
/150/policy_150.pdf
Nova Stat Strip Blood Glucose meter
 http://www.insidehopkinsmedicine.org/hpo/policies/6
9/3928/policy_3928.pdf
Resources
The Point-of-Care Testing Program Office
is located in CMSC SB-201
Phone: 955-2645
Hours: Monday –Friday,
8am-4pm
POCT Website:
http://pathology2.jhu.edu/pointofcare/poct/index.cf
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