1. A Self-Study Packet for The Johns Hopkins Hospital Point-of-Care Testing Program ©copyright 2011 Johns Hopkins Hospital All rights reserved

2. 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 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

3. 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: 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: Annual online education Perform QC every 6 months ( Jan-June, July-Dec)

4. 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

5. 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

6. 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.

7. Factors Influencing Accuracy of Test Results Patient Medical Conditions ProblemPotential ImpactRecommendation Patient has peripheral vascular disease or a condition that impairs/decreases circulation to the periphery False low glucose Fingerstick collection not recommended Patient is dehydratedFalse low glucose Fingerstick collection not recommended Patient is in shockFalse low glucose Fingerstick collection not recommended Patient has severe edemaFalse low glucose Fingerstick collection not recommended Patient is hypotensiveFalse low glucoseFingerstick collection not recommended

8. Operator Performance 1. The operator ID used for the glucose meter is the employee’s JHED ID. For legal reasons, Operator’s should NOT share their JHED IDs with other users. 2. Operators that fail to perform quality control (QC) every 6 months 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.

9. Specimen Collection Capillary, venous, neonatal (including cord blood), and arterial whole blood specimens may be used. Remember to use Standard Precautions when obtaining blood samples and performing patient testing.

10. 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)

11. 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

12. 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

13. 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

14. 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

15. Patient Testing

16. Capillary Blood Collection (Fingerstick/Heel Stick) 1. Verify the patient’s ID with 2 unique identifiers: Inpatient: Name & Medical Record Number Outpatient: Name & Birthday 2. Select an appropriate sampling site: 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.

17. 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. Do Not Milk the site. 8. Touch the end of the test strip to the drop of blood. Capillary action will cause the blood to flow in the 4 wells on the test strip. 9. The strip must fill completely upon touching the blood droplet. 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.

18. 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

19. 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. 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 Collection from Arterial or Central Lines (cont’d)

20. 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).

21. Remember… Nova Stat Strip glucometer machine will only read from ( )10-600 ( ) mg/dL. 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.

22. 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.

23. Factors Influencing Accuracy of Test Results Improper Fingerstick Collection ProblemPotential ImpactRecommendation Using a previously punctured site Accumulated fluid will contaminate the blood specimen (decreases glucose) Obtain blood specimen from a fresh, non-punctured site Improperly cleaning the puncture site with alcohol 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 siteMay give a falsely low glucose result Fingerstick collection not recommended

24. Factors Influencing Accuracy of Test Results User-based Problems ProblemRecommendation Not enough blood applied to the test strip 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 Test strips left uncappedUse test strips immediately after removal from vial. Recap vial immediately after removing strip. Vials found uncapped should be discarded.

25. Documentation of Glucose Results 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.

26. 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. Properly collect the patient sample. Document test results, meter ID, date, time, operator initials and care actions.

27. 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

28. 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.

29. Batteries…. The rechargeable battery life expectancy is 18-24 months. If the battery in the meter is dead, swap it with a battery from the tote Make sure there are always 5 batteries in the tote. Batteries are rechargeable, do not throw them away

30. Common Nova StatStrip Glucose Meter Error Codes/Alerts Error Code/Alerts Possible CauseSolutions Memory Full Has not been dockedDock Meter Immediately Memory Low Need to dock soon Battery LowHas not been rechargedCharge/Replace Battery QC Due: xx:xx hrsRun QC after time has lapsed LOCKEDQC not runPerform QC before Patient Testing Test Strip Was RemovedTest cancel, insert new test strip Temperature Meter outside temperature range of 59°F-104°F or (15°C-40°C) Move meter to correct temperature range and run QC Bad SampleInsert a new strip and rerun the test Replace StripInsert another strip Flow ErrorInsufficient sample or sample applied incorrectlyRerun test with a new strip Transfer FailedConnection to server brokenContact POCT Office (52645) Transfer FailedMeter removed from dock before data transfer was complete Re-dock the meter

31. Transmission of Results The Nova Stat Strip glucometer utilizes wireless technology for the transmission of glucose results. The meter must be docked in the docking unit for this transmission to occur.

32. Docking the Nova Stat Strip Glucose Meter Push meter firmly into tote docking station until you see an hourglass appear. Make sure that the yellow light on the tote is lit indicating that there is a wireless connection. You will then see the screen to the left.

33. Docking the Nova Stat Strip Glucose Meter When the meter has successfully connected you will see the screen to the right. The meter has sent results to the POCT office website and received back updates on operators and reagents.

34. 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 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 http://www.insidehopkinsmedicine.org/hpo/policies/6 9/3928/policy_3928.pdf

35. 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 m http://pathology2.jhu.edu/pointofcare/poct/index.cf m