ACCU-CHEK Inform Glucose Meter Point-of-Care Testing (POCT) 2012-2013 Training Developed by Kim Lloyd-Watts MT(ASCP) & Kelly Banasky, BSN, RN

Expectations All employees are expected to follow the policy and procedures when using the glucometer Shortcuts may seem convenient in accomplishing work; however they result in error and faulty medical decision making based on that error Failure to follow policy and procedure places patients, the hospital, and you at risk and subjects you to disciplinary action At the end of this competency, you will complete, sign and return the written test to your glucometer rep You will demonstrate utilization of the ACCU-CHEK Inform properly in front of your trainer to complete validation.

Identity Theft Operator ID: is the number used to identify you as the individual performing a glucose test. This is usually your Employee ID. YOU are legally responsible for all tests completed under YOUR operator ID and YOUR name is logged with every glucose test performed using YOUR ID. Letting another person use your operator ID or scan your badge violates hospital policy and opens you up to risk of dismissal; furthermore, it compromises patient safety and trust of the institution. If improper use is performed under your operator ID, you are responsible, regardless if another individual used your identity Treat your operator ID like your social security number, you would not loan it out, do not allow anyone to use your operator ID.

Emergencies The ONLY time the training label may be used outside of training is for an emergency or Code Blue and the person is NOT a registered patient or identifiable. When this occurs, you must follow up with the POCT office at 4450 or Lab with the following information: “Attention POC Coordinator” and the following: Your Name Location Date and Time of test Result Patient name and Financial number Doing this immediately correctly identifies the patient so the results can interface to the patients electronic record.

Specifics on the Inform Accu-Check Meter Measures glucose from a capillary sample (finger stick) Interpretation of the results/Reference ranges (non-fasting) Adult Normal :70 – 115 mg/dL Critical: < 50 mg/dL OR > 400 mg/dL Neonate Normal: 35 – 115 mg/dL Critical: < 35 mg/dL KEYPOINT: Patient’s with hematocrits < 20% or >55% can NOT be tested with the glucometer. A lab draw must be performed. All Clinical Areas Critical Values: Adult Critical Values <50 or > 400 mg/dL Neonate Critical Values are < 35mgdL

Inpatient Critical Value Response Critical values obtained by any patient care assistant or technical partner must be reported immediately to the care nurse for patient assessment All critical values must be repeated by a different operator using a sample from a new lancet puncture. For repeated results < 50: Treat the Patient For repeated results > 400: order Glucose confirmation; lab draw Any actions taken must be entered in the meter using comment codes (i.e. “Repeated”, “Dr. Notified”, “Lab Draw”, etc. All Clinical Areas Critical Values: Adult Critical Values <50 or > 400 mg/dL Neonate Critical Values are < 35mgdL

Emergency Department Critical Value Response Critical values obtained must be immediately reported to the physician caring for the patient for treatment orders. Any actions taken must be entered in the meter using comment codes (i.e. “Repeated”, “Dr. Notified”, “Lab Draw”, etc. Additionally, any actions taken must be documented in the patient EMR with follow up assessment of patient response to treatment. All Clinical Areas Critical Values: Adult Critical Values <50 or > 400 mg/dL Neonate Critical Values are < 35mgdL

Too Little Blood The strip has a little yellow window that must be entirely filled with blood. If the yellow window is not completely filled in with the sample, faulty result will occur. Obtaining a blood sample must be performed correctly every time to ensure safe and accurate care are given to the patient. There is 15 seconds to add additional blood to the yellow window if it is not entirely filled. TOO LITTLE BLOOD

Too Little Too Late Your patient is due for a glucose reading and you are trying to hurry to get to your lunch. The yellow window is filled approximately ½ of the way. The result reads 360, you document the result. The same patient receives insulin based on the documented result. An hour later, the same patient becomes clammy, and is acting belligerent. A repeat accu-check is obtained and the result is LO LO 360

Right before the accu-check was obtained, routine labs were drawn and sent. The lab results come back revealing the patient’s glucose was 156, not 360. Clinical decision was made based on the erroneous results from improper filling of the yellow window within the strip. Rushing through process and taking shortcuts, or neglecting to follow correct practice may result in errors. ALWAYS follow the process correctly.

Patient Safety Expectations ALL Garden City Hospital patients are to have an identification armband on during inpatient or outpatient stay. Identification bands serve to identify the patient throughout their stay and further serve to prevent errors. It is a patient right to have safe care while in the hospital. History demonstrates harm results from bypassing correct procedure. Correct identification of the patient ensures safe practice Chart labels are NOT an acceptable patient identifier. Using a chart label for scanning with the glucometer violates the patient’s right to safe care and violates hospital policy. ONLY the identification band on the patient can be utilized during the scanning process prior to obtaining a glucose reading.

Hospital and Patient Safety Expectations ALL employees trained and tested annually on glucometer use are expected to uphold hospital policy and procedures. Convenient shortcuts seem like the work is faster but place patients at risk for harm. Improper use of the glucometer can and will result in disciplinary measures and is easily tracked through monitoring the operator ID’s.

Who’s on First? You’re covering your co-worker’s patients while he/she is on break and one of their patients requires an Accu-check prior to lunch. The patient, Mrs. Nancy Taylor is often confused and tries to bite staff whenever procedures are needed. Knowing this, you start by scanning a chart label from the patient’s chart before entering the room so you can get the procedure done quicker. Mrs. N. Taylor’s result is 600, you go to document the result in the chart and tell the nurse that “Mrs. Taylor’s blood sugar is 600.” The nurse says, “thank you, I will chart it”.

You come back from lunch and your patient Ms You come back from lunch and your patient Ms. Judy Taylor is unconscious and diaphoretic. The nurse who you informed about the 600 blood sugar is asking you, “Didn’t you say that Ms. Taylor’s blood sugar was 600? We gave her insulin” You realize the wrong patient received insulin, Mrs. Nancy Taylor should have received the insulin, but instead Ms. Judy Taylor got the insulin. A month later, you are summoned to a sentinel event review. The lab presents two reports at the sentinel event review Mrs. Nancy Taylors glucose results for the date and time of the mix-up indicated her blood sugar was 590. The lab identified that no accucheck was completed on that same date and time for Mrs. Nancy Taylor AND The accu-check you obtained was on a Bob Taylor and the account number is incomplete, with results matching the said date and time indicating you scanned a label and not the identification band. Can you defend scanning a chart label or any bar code other than the patient identification arm band?

Patient Testing Procedure Start by scanning your Operator ID Barcode, if you do not have a barcode, you may manually enter your Operator ID Select “Patient Test” on the screen Scan the patients Identification band on the patient’s arm or in some cases, the ankle. The patients name will appear for you to verify correct patient. If the arm identification band is not attached to the patient, but is taped to the bed, in the chart box, at the nursing station, or found laying in the patient room, it may not be used KEYPOINT: Scanning a chart label is dangerous practice. Failure to scan patient identification armband is a direct violation of hospital policy and places the patient, yourself and the hospital at risk. Always IDENTIFY THE PATIENT with 2 identifiers Refer to the hospital Patient Identification policy

After properly scanning the patient identification armband, scan the barcode located on the side of the strip vial Remove a strip from the vial. Immediately re-cap the vial tightly. Insert the strip with the yellow window facing up KEYPOINTS: If the vial is without the cap, DO NOT USE the strips. The test strip contains sensitive pH paper, which will change with exposure to environmental air or moisture. Once the strip is exposed to air the patient results are affected. The strip must be used within 3 minutes of removing from vial

Always clean the puncture area first using a alcohol wipe and dry with a clean cotton/gauze pad Puncture the area with the lancet Wipe away the first drop of blood with a dry gauze and use the second drop for testing. Touch and hold the second drop of blood to the curved edge of the strip; there is a vacuum in the curved edge to pull the blood into the sample area. Ensure the yellow window is completely filled; if not, add more specimen within 15 seconds. KEYPOINTS: Proper procedure must be followed when obtaining a finger or heel stick sample. Do NOT use the alcohol wipe to clear away the first drop of blood; it will contaminate the sample The test must be repeated if the yellow window is not completely filled within 15 seconds

Contraindications Some patient medications falsely elevate the glucometer result. Do NOT obtain a glucometer/accucheck test on patients who take the following medications: Peritoneal Dialysis Solution (Extraneal) Immune Globulin Intravenous-Human (Octagam 5%) Rho (D) Immune Globulin Intravenous-Human (WinRho SDF-Liquid only form) d-Xylose (D-Xylose USP) ANY patient on ANY of the above mentioned meds must have glucose testing performed by the laboratory Any Patients on a Maltose Therapy

Control Procedure Start by scanning the barcode on your badge Select “Control Test” and follow the prompts Scan the barcode on the control vial. Scan the barcode on the glucose strip vial Remove the strip from the vial KEYPOINTS: Recap the strip vial immediately to maintain pH of strips. Controls must be done every 24 hours. If controls are not done, the glucometer will not allow you to proceed to patient testing

With the yellow window facing up, gently insert strip into meter Gently mix the control by inverting the vial 5-10 times or by rolling between the palms Place a drop of the control solution to the curved edge of the yellow window on the left side The result of “PASS” indicates the control is within successful range. Repeat the control test on the other vial of control solution by following the above steps KEYPOINTS: If the result indicates “FAIL”, select “COMMENT”, and indicate next step, then repeat test. If “FAIL” is resulted again, bring the entire glucometer set (case and meter) to the Sterile Processing in the basement and obtain a loaner meter. Report two consecutive failures to the lab Point of Care personnel

Special Considerations with Controls & Strips Level 1 & Level 2 controls must both be run every 24 hours and in the following situations: Every time a new vial of test strips is opened If the meter is dropped When troubleshooting the meter When patient test results contradict the patient’s clinical symptoms When opening a new vial of strips, switch out the Code Key that comes with the vial of strips Replacement of the code key must be done when the meter is turned off If you open the meter and come across an opened vial of strips, assume they are affected and faulty, dispose and obtain another vial.

Troubleshooting & Meter Maintenance & Cleaning If the meter indicates “Operator ID is invalid”, you must complete your annual competency/training. In this situation, contact your departments glucometer rep. The meter absolutely must remain charging in the docking station when not in use. This allows transmission of patient test results to the lab and maintains the glucometer battery Policy and procedure on POCT is in the POC manuals on each unit and also in the hospital Policy and Procedure book Scanning is designed to prevent user error, if you must manually enter a number, always double check the number typed in before you select “Enter” For broken meter cases, complete the green troubleshooting card completely and include description of the problem. Bring broken meter and case set to sterile processing and obtain a loaner set. The meter may be cleaned by using a Cavi-Wipe, and documented cleaning must occur with each use.

Some patients have decreased peripheral blood flow, making a capillary sample difficult to obtain. For this situation, do NOT milk the finger!!! Instead, prior to starting: Apply a warm cloth to the finger Allow the hand to dangle for gravity Gently massage finger to promote circulation Error Flags: In this situation, repeat the test using a new capillary sample from a new puncture site on the same meter HI: the blood glucose may be (higher than) > 600 mg/dL LO: the blood glucose may be (lower than) < 10 mg/dL If the repeated test results indicate error flag, request glucose confirmation by lab

For these Error Flags: Error-83: There is a problem with the strip, it is either defective OR the patient’s blood glucose may be extremely low (<10 mg/dL) Strip Defect: the test strip may be damaged Error-88-Bad Dose: there is not sufficient enough sample on the strip In these situations: Repeat the test on the patient using a new strip, and a fresh sample from a new capillary puncture If the Error Flags repeat again, take the entire glucometer set to Sterile Processing in the basement and fill out the green troubleshooting card located in the glucometer case.

When the meter, base unit, or carrying case is contaminated, or appears soiled from use, the items must be cleaned Ensure the meter is turned off and the base unit is unplugged prior to cleaning Carefully wipe surfaces with a CAVI-Wipe After cleaning, dry thoroughly to make sure no streaks remain on the touch screen KEYPOINTS: DO NOT allow cleaning solution to get into the connector at the bottom of the meter or the base unit. Visually verify that no solution is seen at the completion of cleaning. If cleaning solution does get on connector, dry thoroughly with a cloth or gauze pad before returning the meter to the base unit

If scanning becomes a problem or there are visible smudges: Use a clean, dry cloth to wipe the scanner window located on the bottom side of the meter. Disinfect the meter after each use for Point of Care Testing To disinfect the meter: Use an alcohol wipe or a CAVI wipe after use. Return the meter to the docking station immediately to ensure proper battery charge. SPECIAL Circumstances: Isolation Patients In situations where a patient is isolated and requires glucose monitoring, the meter must be covered with a glove, with the glove opening at the top where the strip is. Afterwards, the meter must be carefully and thoroughly disinfected with a CAVI wipe x 2 and documented as cleaned.

Completion of Education and Return Demonstration When you take your written test and complete your return demonstration, you are acknowledging that you have reviewed this material and you will follow the policies and procedures for proper use of the glucometer. Please turn in your completed exam to your point of care rep or glucometer rep for your area. Additionally, you will need to demonstrate to your rep or designated person, the correct process for utilizing the glucometer

Quiz/Test Section Instructions: The next few slides will have the test questions. Obtain the Test Answer Sheet from the glucometer rep or designee and answer the questions that are on these slides After answering the questions, bring answer sheet to glucometer rep or designee for demonstration.

Question 1: You open a new vial of strips. What do you do next? Write open date on new vial of strips Change Code key Run Controls All of the above

Question 2 If you are having trouble obtaining a capillary sample, try which of the following: Milk the finger Massage finger to promote circulation Warm the finger prior to puncture All of the above B & C

Question 3: The meter is not working, will not turn on or shows an Error message. What do you do next? Call your glucometer rep Call the Point of Care Coordinator Fill out green trouble shooting card completely Take meter and case to sterile processing and pick up loaner set None of the above All of the above C & D

Question 4: What is the risk involved if a label or something other than the patient armband is used to scan? Erroneous result reporting Loss of glucometer privileges Missing patient information Escalation up the discipline pathway Violation of patient safety rights All of the above None of the above

Question 5 Please indicated what is the risk with running a glucometer test with the test strip filled only part way: Inaccurate results No risk Erroneous clinical decision making based on results None of the above A and C

Question 6 How do you maintain communication with the lab and charge meter at the same time? Place the meter near the computer on the desk Keep in the glucometer case Keep in charger/downloader unit Keep in the dirty utility room

Question 7 How many seconds do you have to add more specimen to the strip if it is not completely full? 0 seconds 5 seconds 15 seconds 30 seconds

Question 8 Do not use strips found in vial with no cap or that are loose in the glucometer case? True False

Question 9 To clean and maintain the glucometer which of the following should be done? Rinse with soap and water and document meter cleaned after each use Wipe with CAVI wipe or Alcohol prep pad and document meter cleaned after each use No cleaning is necessary It is housekeeping’s responsibility every day

Question 10 Prior to puncture, thoroughly clean finger with an alcohol prep pad, allow to dry, then obtain sample from second drop after wiping first drop with gauze. True False

Completion After completion of this quiz, please bring quiz answer sheet to your glucometer rep or designee to demonstrate competency in procedure 80% is the passing score on this quiz Competency must be demonstrated to the glucometer rep or designee to continue use of the glucometer New hires must repeat this at 6 months post hire date, then annually. Thank you for your time and participation.