DIABETES - CAPILLARY BLOOD GLUCOSE MONITORING for ADULTS.

Transcription

1 Title: DIABETES - CAPILLARY BLOOD GLUCOSE MONITORING for ADULTS. Ref No: 2346 Version 1 Classification: Guideline Directorate: Organisation Wide Due for Review: 01/10/21 Document Control Responsible for review: Diabetes Specialist Nurse Ratified by: Care and Clinical Policies Sub Group Clinical Lead for Diabetes Clinical Director of Pharmacy Applicability: All Staff who perform blood glucose monitoring. Exceptions: This policy does not apply to Children under 18 yrs. Contents 1. Purpose 2. Introduction 3. Cautions & Interferences 4. Clinical indications for blood glucose monitoring 5. Competencies. 6. Hospital staff: staff and Torbay Hospital acute areas Roles and Responsibilities 6.2. Training and Supervision Supplies 7. Community staff: staff, community hospitals and clinical services Roles and Responsibilities 7.2. Training and supervision 7.3. Supplies 5.5. Monitoring and Auditing 8. Performing a blood glucose test 9. Appendices 1. Purpose Capillary blood glucose (CBG) monitoring provides an immediate measurement of a patient s blood glucose level using near patient testing, which allows on-going assessment of diabetic control. The purpose of this guideline is to ensure that all CBG measurements are accurately performed by health professionals that are appropriately trained, ensuring that patient care and safety is optimised. 2 Introduction This policy aims to ensure that CBG monitoring is carried out to high standard throughout Torbay & South Devon NHS Foundation Trust (TSDFT). The only meters which are approved for use by Healthcare Professionals on adults in these locations are the Roche Performa and Roche Inform II meters. These meters have been approved by the NHS Supply Chain for TSDFT use (GP s can access meters on the formulary directly from the companies). Version 1 (September 2018) Page 1 of 15

2 In certain clinical situations CBG measurements may be unreliable and these are listed as Cautions. It is important that nursing staff are aware that any unexpected meter result must be checked with a Laboratory glucose measurement. 3. Cautions about blood glucose measurement: Blood glucose meter measurement may not give reliable results if the meter result is not in keeping with the patient s clinical status or if contra-indications listed below are clinically observed or suspected. In this case a laboratory measurement of glucose by venous sample should be carried out. CONTRA-INDICATIONS Peripheral circulatory failure Severe dehydration Extremes of haematocrit Hyperlipidaemia EXAMPLES Hyperglycaemic Hyperosmolar State(HHS) with or without ketosis, hypotension, shock and peripheral vascular disease, decompensated heart failure NYHA New York Heart Association- Class IV Vomiting, diarrhoea, dehydration due to prescription drugs (e.g. diuretics), inability to recognise or respond to thirst sensations. Sustained uncontrolled diabetes No effects with haematocrits between 10% and 65% Triglycerides >20.3mmol/l Test Interferences TEST INTERFERENCE EFFECT WITH ADVANTAGE METER Galactose Vitamin C (Ascorbic Acid) No effect with Galactose levels <0.83 mmol/l No effect with Ascorbic acid <170 μmol/l Anticoagulants No effect with Lithium heparin or EDTA. (Ethylenediamine Tetraacetic Acid) Iodoacetate or fluoride-containing anticoagulants are not recommended Temperature Humidity No effects at temperatures between 8-44 o C No effect at humidity levels between 10-90% Version 1 (September 2018) Page 2 of 15

3 4. Clinical indications for blood glucose monitoring: Patients with confirmed or suspected Diabetes mellitus. Patients with suspected diabetes who have a raised CBG (³11.0 mmol/l) must have the result confirmed by a Laboratory glucose or HbA1c for diagnosis In patients with Diabetes, CBG should be carried out as follows: (a) Patients with Diabetic Ketoacidosis (DKA) 1490 or Hyperosmolar Hyperglycaemic State (HHS) 0022 refer to Care Pathway (via ICON search bar) in Acute Hyperglycaemia Guideline.0021 For use of CBG in ketoacidosis see list of cautions (Page 2). (b) Patients on Variable rate Intravenous Insulin Infusions (VRIII) should have hourly CBG with adjustment of IV insulin and glucose/potassium or saline/potassium infusions according to the result. (c) All patients with diabetes during acute illness should have 4hrly CBG monitoring pre-meal, pre-bed and overnight. (d) Stable Diabetes Mellitus where the clinical problem is not metabolic. Patient must have their CBG recorded on a Trust meter at least twice a day but can additionally perform self-tests and administer their own insulin injections if the self-administration paperwork has been completed.(found via search box on ICON) Any variations on the above frequency of testing should be discussed with medical staff and recorded in the patient s notes. All patients receiving Total Parenteral Nutrition (TPN), not only diabetic patients, should have CBG monitored every 6 hrs for the first 36 hours. Providing the glucose level is stable the glucose should be checked once every 24hrs while the patient is on TPN. Ref CP042 Parenteral Nutrition All patients receiving high doses of steroids, that is more than 20mg Prednisolone or equivalent. See Ref Steroid induced hyperglycaemia Patients with pancreatic disease such as pancreatitis and carcinoma. Patients with altered levels of consciousness of unknown aetiology. Note: Results on these patients should always be confirmed by a Laboratory glucose measurement. In other situations if a patient is unwell the health care professional (HCP) should check the CBG and discuss with a clinician if the level is outside the normal range for that patient. Note: When blood glucose measurement is to be performed on a patient appropriate precautions must be undertaken in accordance with Health and Safety policy. Written and signed records must be kept of the time and result of each CBG measurement taken. Charts for Regular Diabetes and Intensive Insulin are available for this purpose. Medical staff should be informed if a result falls outside any parameters agreed with, in a timely manner. Version 1 (September 2018) Page 3 of 15

4 5. Competences All HCP s must be aware of their responsibility for maintaining their own competence according to their professional body. The DOH (2013) guidelines reinforce this stating "Only staff whose training and competence has been established and recorded should be permitted to carry out blood glucose testing". This is to ensure that correct procedures for use, potential sources of error and what to do with abnormal or unexpected results are followed. TSDFT strongly advise that nursing staff employed by GP practices and intermediate care facilities follow this guidance. For the purpose of this policy the term Skilled Non- Registered (SNR) describes the worker who has a role or task delegated to them. The registered professional is on a register for that profession. Ref 1716 The following groups of staff are eligible for training: Registered professionals- ( if required training of CBG can be delegated to a Registered HCP ie agency nurse who has undertaken certified Roche training) Where our workforce is reliant on registered agency nurses/paramedics or where newly registered health practitioners are awaiting specialist training from ROCHE TSDFT registered trained staff in CBG should demonstrate and briefly assess the registered health professional in the use of the CBG machine in their specific working environment. Skilled Not Registered. - staff must document the blood glucose result and inform a qualified nurse of the result within that working day. If the blood glucose is out-side the individualised range agreed for that person it should be reported to the nurse in charge immediately. 6. HOSPITAL- staff and Torbay Hospital acute areas Roles and Responsibilities The ward/unit manager is responsible for ensuring that staff, receive training in the use of glucose meters. A record of training will be held by the ward/unit manager. All staff trained in the use of the Roche Inform II meters are registered on the COBAS IT1000 database. (A Clinical Chemistry & Immunochemistry Analyser). They are issued with a certificate via the database that is renewable annually. Provided 3 patient samples are analysed within the last 60 days of the year the certificate is renewed automatically. The ward manager is responsible for organising the re-training of staff. Annual training is required for staff on acute wards and a minimum of 2 years for other areas. The ward manager must ensure that only staff who have been trained perform glucose meter testing. The ward manager is responsible for ensuring that Internal Quality control is carried out and recorded appropriately. The ward manager/link nurse must ensure that the External Quality control sample is analysed and that the result is returned to the Laboratory promptly. For Accreditation and the ability to operate an audit trail, all capillary glucose results must be recorded. This record must include unequivocal patient identity, time of test, the result, relevant Quality Control (QC) results and the identity of the user. Result must be identified as a capillary blood glucose result and not a plasma glucose result from the Laboratory. The mechanism for the transfer of results to the patient notes must be unambiguous and monitored by senior staff. If patients are unable to self-monitor the nurse must use the Hospital system. Additional tests done by patients using their own equipment must be clearly identified as self-tests in the notes or on the Regular Diabetes chart. Version 1 (September 2018) Page 4 of 15

5 6.2. Training and Supervision The Link Nurse Trainer will train and update all staff in their area that perform blood glucose monitoring on their ward or area, annually. Annual training will include reference to relevant Trust Policies, Contra-indications for monitoring and possible test interferences and assessment of competency.(see competency document 2205) The Link Nurse Trainer will maintain an up to date record of all the staff trained and forward a copy of this to the POCT Co-ordinator in Laboratory Medicine every 3 months. The Link Nurse Trainer will inform the POCT Co-ordinator and the Medical Devices Trainer if any member of staff declines training or update sessions. The Link Nurse Trainer will attend regular update sessions provided by the Roche Nurse Educator. These sessions will provide any opportunity to discuss any queries or problems with training. It is the responsibility of the Link Trainer to ensure that the blood glucose monitoring equipment is maintained according to Trust Health & Safety and Infection control policies Supplies New/Replacement/faulty glucose meters will be issued by: Point of care Team, Biochemistry department, Torbay Hospital or (Mon-Fri hrs). Answer phone available. At all other times refer samples to the Laboratory for plasma glucose analysis or use an alternative Performa / Inform II meter if available. Provision of Test Strips and IQC can be obtained from Torbay Hospital Pharmacy Monday to Friday - 08:45 until 17:00 Saturday - 08:30 until 12:30 Sunday - 09:00 until 12:30 Provision of AccuChek single use lancets are obtained through Agresso or ward top-up. 7. COMMUNITY- staff, community hospitals and clinical services. 7.1 Roles and Responsibilities This is a level 3 invasive procedure and all SNR s must be delegated the task by a Registered Professional who will be held accountable. The task must be documented in the patient/client care plan with a record of blood glucose readings. Each Registered HCP or SNR nurse should have a meter available where appropriate. Community Nurse Leads are responsible as follows: Will maintain an accurate record of staff members who have attended training and achieved specific learning outcomes regarding capillary blood glucose monitoring. Access the trust IT system for EQA results of their team members and ensure appropriate action is taken if staff has not submitted their EQA result for that month. If the staff member repeatedly fails to return EQA results to Torbay Hospital removal of the glucose meter will need to take place. Internal Quality Control (IQC) is to be recorded in the QA logbooks at the point of care site. One logbook is to be used per meter, with the meter s serial number recorded in the logbook. This document is a legal document and must be retained when full for 10 years. These logbooks have been provided by the point of care team and are subject to audit. Community Nurse Leads should ask to see a random selection (at least 3 per week) of their teams QA logbooks to ensure compliance readiness for audit. Failure to provide evidence of quality control may result in the removal of the blood glucose meter. Must ensure that only staff trained to perform glucose testing are issued with a meter Will ensure that staff should attend update training on blood glucose monitoring, every two years, as a minimum requirement. Version 1 (September 2018) Page 5 of 15

6 Regular reassessment of the SNR s competence is at the RN s discretion but must not exceed 6 months Ref Training and Supervision The Department of Health (DOH) has issued advice for health professionals entitled Point of Care testing Blood Glucose meters (DOH 2013) cose_meters_-_point-of-care_testing.pdf It highlights the need for training and a strict quality control programme to reduce the risks of poor performance in blood glucose monitoring outside the laboratory. Only Registered HCP s that have attended a mandatory initial training session arranged via Roche Diagnostics will be able to perform capillary blood glucose monitoring. SNR s must attend the mandatory initial training session arranged via Roche Diagnostics but must also be followed by a period of supervised practice and assessment by their zone lead nurse/team manager or a designated assessor.( see competency document 2059 for TSDFT employed staff and 2060 for non-tsdft staff) Certificates will be issued as proof of attendance at the training sessions. External assessment of trained staff will be made through the External Quality Assurance (EQA) programme run by the Laboratory at Torbay Hospital on alternate months for Torbay & South Devon Supplies Provision of Meters, batteries, QC record books and workstations Blood Glucose Meters will be provided for all Registered Nurses and SNR s following training as previously detailed. When needed, replacement blood glucose meters will be issued by: Point of care Team, Biochemistry department, Torbay Hospital or Provision of Test Strips and IQC can be obtained from Torbay Hospital Pharmacy Provision of Owen Mumford Unistik 3 Comfort lancets is available via FP10 prescription Provision of AccuChek single use lancets are obtained through Agresso. These devices are a pre-set single-patient use safety lancet and are completely disposable into a sharps bin after one use 8. Monitoring and Auditing applies to all areas acute and community a) Quality Assurance (QA) DOH (2011) emphasises the importance of QA procedures. The use of QA ensures that the meter and strips are working correctly and that the operator s technique is satisfactory. If QA is not performed regularly by all staff performing glucose testing, the correct patient results cannot be guaranteed. There are two parts to effective QA procedures; Internal Quality Control (IQC) & External Quality Assurance (EQA). b) Internal Quality Control (IQC) All users are to perform IQC before using the meter for the first time and under the following circumstances: Every day in high user areas or before the first patient of the day in low user areas. If the result does not agree with the clinical picture. Version 1 (September 2018) Page 6 of 15

7 After a battery has been changed. When a new vial of test strips is opened. If the cap is left off or has not been replaced correctly on the vial of test strips. If the meter is dropped or damaged. In the event that an IQC value is outside the manufacturer s stated range for that IQC, the following procedure should be adhered to; Firstly, repeat the IQC. If the value is still outside of the stated range open a new bottle of IQC material. Always mark the side of a new IQC bottle with a new expiry date 3 months from the current date. Perform the IQC. If the IQC is still out of range open a new box of test strips and repeat the fresh IQC. If this does not produce an IQC value within the manufacturer s stated range contact the laboratory. Please also refer to appendix 1: SOP for the use of Roche Accu-Chek Performa glucose meter for pictorial detail on IQC. c) External Quality Assurance (EQA) On alternate months for Torbay & South Devon NHS Foundation Trust samples from the Biochemistry department will be sent to each named nurse who has a glucose meter, this will include the SNR. The sample should be tested in exactly the same way, as would blood or IQC (see appendix 1). The results should be recorded and returned to the laboratory within 7 days. The nurse should also document the result in the quality control logbook. The EQA results are available on the trust IT system web page database entitled Community nurse teams. Two pages are available for the nurse to check the results; namely Glucose results and No results. They should check for inadequate meter performance and ensure that the individual is aware of this and remove from operational use and ensure replacement. Failure to comply with the scheme may result in the removal of the blood glucose meter. Community Nurse Leads should access their team members results also and monitor the No results page for persistent non returners of EQA sample results and take appropriate action. If a nurse is on an extended period of leave for whatever reason the Community Nurse Lead can inactivate that relevant meter asset number to stop further samples being sent out by Biochemistry. Once the nurse returns to work the Community Nurse Lead can then reactivate the glucose meter asset number so that the nurse starts receiving EQA samples again. This system is available on the trust IT system web page Community Nurse Leads. 9. Performing a Blood Glucose Test Please see appendix 1 SOP for the use of Roche Accu-Chek Performa Glucose meter Written and signed records must be kept of the time and result of each capillary glucose measurement taken. 6. Appendices Appendix 1 SOP for the Use of Roche Accu-Check Performa Glucose Meter Version 1 (September 2018) Page 7 of 15

8 Appendix 1 For the use of Roche Accu-Check Performa Glucose Meter Standard Operating Procedure (SOP) Prepared by: Diabetes Nurse Specialist Presented to: Care and Clinical Policies Sub Group Ratified by: Care and Clinical Policies Sub Group Date: 18 April 2018 Date: 18 April 2018 Review date: April 2021 Relating to policies: Capillary Blood Glucose Monitoring Purpose of this document Capillary blood glucose monitoring provides reliable near patient testing, which allows on-going assessment of diabetic control. The purpose of this SOP is to ensure that all capillary blood glucose (CBG) measurements are accurate and performed by health professionals that are appropriately trained, ensuring that patient care and safety is optimised. For the purpose of this policy the term Skilled Non- Registered (SNR) describes the worker who has a role or task delegated to them. The registered professional is on a register for that profession Scope of this SOP The only meters which are approved for use by Healthcare Professionals on adults within TSDFT are the Roche Performa and Roche Inform II meters which are used for monitoring blood glucose levels in patients being treated for diabetes. The meter must not be used as a tool for diagnosing diabetes in patients who exhibit diabetic symptoms. Competencies required This policy is for use by Registered Nurses (RN) and all other practitioners who undertake blood glucose monitoring, from here on referred to as Skilled Not Registered (SNR s). This is a level 3 invasive procedure and all SNR s must be delegated the task by a Registered Professional who will be held accountable. As with any level 3 procedure, the task must be documented in the patient/client care plan and record of blood glucose readings. Each RN or SNR nurse should have a meter available where appropriate. Health & Safety / COSHH 2 ACCU-CHEK PERFORMA CONTROL SOLUTIONS. COSHH PRIORITY GROUP 3. Wear gloves. 3 ACCU-CHEK PERFORMA TEST STRIPS. COSHH PRIORITY GROUP 3. Wear gloves. Patients covered Adult patients who require capillary blood glucose monitoring by Torbay & South Version 1 (September 2018) Page 8 of 15

9 Devon NHS Foundation Trust Procedure: Equipment Roche ACCU-CHEK Performa Glucose Meter. Roche ACCU-CHEK Performa 2-Level Controls. Roche ACCU-CHEK Performa Glucose Test Strips. Roche ACCU-CHEK Single use Lancets or Owen Mumford Unistik 3. Reagents The ACCU-CHEK Performa Glucose Test Strips have reagents confined to the testing area which has the following composition: Mediator (unspecified): 5.78% Glucose dehydrogenase: 13.18% Buffer: 16.35% Stabiliser: 2.5% Non-reactive ingredients: 62.18% Quality Assurance (QA) DOH (2013) emphasises the importance of QA procedures. The use of QA ensures that the meter and strips are working correctly and that the operator s technique is satisfactory. If QA is not performed regularly by all staff performing glucose testing, the correct patient results cannot be guaranteed. There are two parts to effective QA procedures; Internal Quality Control (IQC) & External Quality Assurance (EQA). All users are to perform IQC before using the meter for the first time and under the following circumstances: Every day in high user areas or before the first patient of the day in low user areas. If the result does not agree with the clinical picture. After a battery has been changed. When a new vial of test strips is opened. If the cap is left off or has not been replaced correctly on the vial of test strips. If the meter is dropped or damaged. In the event that a IQC value is outside the manufacturer s stated range for that IQC solution, the following procedure should be adhered to; Firstly, repeat the IQC. If the value is still outside of the stated range open a new bottle of QC material. Always mark the side of a new IQC bottle with a new expiry date 3 months from the current date. Perform the IQC. If the IQC is still out of range open a new box of test strips and repeat the fresh IQC. Version 1 (September 2018) Page 9 of 15

10 If this does not produce an IQC value within the manufacturer s stated range contact the laboratory. IQC results are to be recorded in the QA logbooks at the point of care site. One logbook is to be used per meter, with the meter s serial number recorded in the logbook. This document is a legal document and must be retained when full for 10 years. These logbooks have been provided by the point of care team and are subject to audit. Community Nurse Leads should ask to see a random selection (at least 3 per week) of their teams QA logbooks to ensure compliance readiness for audit. Failure to provide evidence of quality control may result in the removal of the blood glucose meter. All individuals and areas where Performa meters are held are subject to the EQA scheme, which is run on an alternate monthly basis for either Torbay or Southern Devon by the Point of Care Team within the Biochemistry Dept. at Torbay Hospital. Results of this are displayed on the trust IT system and Community Nurse Leads should access this information on after completion of the alternate monthly External Quality Control. They should check for inadequate meter performance and ensure that the individual is aware of this and remove from operational use and ensure replacement. Failure to comply with the scheme may result in the removal of the blood glucose meter. Sample Requirements Venous, arterial or capillary blood can be used. Procedure Obtaining Consent - Explain and discuss the procedure with the patient in order to ensure he/she understands and is able to give informed consent (NMC 2015). Where informed consent has not been obtained from the client in either setting, the nurse must be able to demonstrate that a multi-disciplinary assessment has been made including an assessment of capacity. Appropriate documentation must be completed to demonstrate that any decision to proceed has been made in the best interests of the client. (Mental Capacity Act 2005 section 1 at the end of this document). The glucose result must be documented in the patient/client care plan. Version 1 (September 2018) Page 10 of 15

11 ONLY STAFF WHO HAVE BEEN TRAINED AND ASSSESSED AS COMPETENT TO DO SO CAN USE THE ACCU CHEK PERFORMA METER FOR BLOOD GLUCOSE POINT OF CARE TESTING. Inform II test strips, IQC solution from Torbay Hospital Pharmacy Unistik 3 Lancets order via FP10 prescription or AccuChek single use lancets via Aggresso. Replacement meters, batteries, QC record books and Workstations - from Biochemistry at Torbay Hospital 1. Code/Calibrate the Meter - before using the meter for the first time and every time a new box of test strips is opened. Turn meter off. Remove code chip if there is an old one in the meter and discard. Insert new code chip until it clicks in place with the code number facing the front of the meter. Leave in place until new box of test strips are opened. 2. Screen Check - every time the meter is turned on. Press and hold the On Button to check for screen damage do not proceed if any part of the screen is missing. Release On Button to display code number to check meter is calibrated correctly (must match number on pot of test strips). 3. Performing Internal Quality Control (IQC) - Daily. May be weekly in low use areas but always before patient test. - After opening a new pot of strips, if strips are stored incorrectly or pot is left open. - After an unexpected patient result, if the meter is dropped, batteries are or to check meter performance. changed How? - Turn meter on. Insert Inform II test strip into meter in direction of arrows. - Check code number on screen matches test strip pot. - Select level of Accu-Chek Performa Glucose Control Solution. Date with 3 month expiry date (NB ensure the 3 month expiry date after opening is also within overall expiry date). Place meter on a flat surface. - Mix IQC, remove lid and wipe tip with tissue. Squeeze bottle to form a drop Version 1 (September 2018) Page 11 of 15

12 and touch the front edge of the test strip do not put blood on top of test strip. - Flashing egg timer displayed when sufficient sample added and test is processing. - Glucose result is displayed in mmol/l the result appears on the display, along with the control bottle symbol and flashing L. Do not remove the test strip yet. Press once to mark the result as a Level 1. Press twice to mark the result as a Level 2. - Record result and full details in QA record book (NB this is a legal record). - Press and release (on-off button) to set the control level in the meter. (The range is printed on the test strip container label). Err and the control result alternate on the display if the result is out of range repeat IQC until result is within range. - Repeat for other level of IQC). Only proceed with patient testing if both levels of IQC have been tested and are within the quoted acceptable range within the last 24 hours SAMPLE HANDLING - ALWAYS WEAR GLOVES & FOLLOW TRUST INFECTION CONTROL PROCEDURES - DISPOSE OF SHARPS SAFELY IN LINE WITH TRUST POLICY - GAIN CONSENT (as described before) - SEE TEST STRIP PACK INSERT FOR CONTRAINDICATIONS & TEST INTERFERENCES BEFORE PROCEEDING. 4. How to use the Owen Mumford Unistik 3 Trigger button Comfort Lancet Hold the device and twist off the sterility cap by twisting it in either direction. Throw the sterility cap away. Ensure the finger is clean and dry (use soap and water, not alcohol swabs or cotton wool). You should have already washed and dried your own hands before starting the test. Hold the lancet firmly against the side of the finger (no lower than the nail bed and avoiding the tip. Avoid the index finger and thumb). Press the purple button. Allow 5 secs to elapse then milk blood down finger to form a drop Protective Cap For babies and neonates refer to department guidelines for selection of lancing device and its correct use Version 1 (September 2018) Page 12 of 15

13 5. How to Test Blood Glucose - Switch meter on. Do screen check. Check code on meter matches code on vial of test strips in use. - Remove test strip from vial and replace cap immediately (the lid contains a desiccant which preserves the integrity of the strips). - Insert test strip (yellow window facing up) into test strip slot. - When blood drop symbol flashes on display apply drop of blood to front edge of strip with the curve (do not place blood drop on top of the strip). - Blood is drawn into strip automatically. Hold finger against front edge of strip until blood completely fills yellow window. - When sufficient blood is applied, an egg timer flashes on the display until measurement is complete. Blood glucose result is displayed in mmol/l. Remove strip from meter and discard along with the lancet in appropriate waste container for clinical waste and sharps. What do these screen messages mean and what action do you need to take? OR Blood glucose may be higher than the measuring /L range i.e. greater that 33.3 mmol/l Blood glucose may be lower than the measuring range i.e. less than 0.6 mmol/l TAKE URGENT ACTION Check internal quality control, repeat patient test to confirm, SEND URGENT VENOUS SAMPLE FOR LAB VERIFICATION and inform medical staff For troubleshooting, other screen messages & error codes see Performa QA Log Book & Guide to Use or SOP. Contact Blood Glucose POC Coordinator in Biochemistry, or ) for further advice. For Blood Glucose POCT - NORMAL BLOOD GLUCOSE RANGE: 4 10 mmol/l TAKE ACTION IF: BLOOD GLUCOSE < 4 mmol/l TREAT AS HYPO PER PROTOCOL BLOOD GLUCOSE > 20 mmol/l REQUEST MEDICAL REVIEW BLOOD GLUCOSE <0.6 OR >33.3 mmol/l - SEND URGENT LAB GLUCOSE NB For Neonatal & Paediatric ranges & action limits refer to local guidelines Version 1 (September 2018) Page 13 of 15

14 Cleaning and Decontamination of Equipment Cleaning If the equipment has not been contaminated with blood staff should follow the established local cleaning protocols for medical equipment. All point of care equipment should be added to the local equipment cleaning list and regularly cleaned as per the schedule. Decontamination The manufacturer recommendations in conjunction with Infection Control are as follows: - The Performa blood glucose meter must be decontaminated following each and every patient use Blood should be removed from the meter using Clinell wipes. Any residue should be wiped off with a dry paper towel. This decontamination procedure must be carried out for the meter &/or the box before returning the meter to the laboratory for any maintenance Maintenance will not be performed on any equipment returned to the Point of Care Team without decontamination having first taken place, as directed by Infection Control. Results and Interpretation Results are shown on the meter display screen, and recorded in the patient notes. USE OF THE MEMORY FUNCTION SHOULD BE AVOIDED AS THE METERS ARE FOR MULTIPLE PATIENT USE AND THE MEMORY FUNCTION IS DESIGNED FOR SINGLE PATIENT USE ONLY. Any result below 0.6 mmol/l or above 20 mmol/l that does not fit the clinical picture should be verified by sending a venous blood specimen to the laboratory for random blood glucose testing. (Reference: Roche Accu-Chek Performa Ward Manual). Reporting Internal Quality Control (IQC) results are recorded in the QA Logbook provided by the laboratory. The patient result must be documented in the patient/client care plan. Version 1 (September 2018) Page 14 of 15

15 Monitoring tool Standards: Item % Exceptions Internal Quality Control, log book completed weekly 100 Sick leave, annual leave, maternity leave External Quality Assurance sample result returned to Biochemistry Department at Torbay Hospital on alternate months 100 Sick leave, annual leave, on maternity leave Version 1 (September 2018) Page 15 of 15

16 Document Control Information This is a controlled document and should not be altered in any way without the express permission of the author or their representative. Please note this document is only valid from the date approved below, and checks should be made that it is the most up to date version available. If printed, this document is only valid for the day of printing. Ref No: 2346 Document title: Diabetes Capillary Blood Glucose Monitoring To ensure that all capillary blood glucose (CBG) Purpose of document: measurements are accurate and performed by health professionals that are appropriately trained, ensuring staff that patient care and safety is optimised. Date of issue: 1 October 2018 Next review date: 1 October 2021 Version: 1 Last review date: Author: Diabetes Specialist Nurse Directorate: Organisation Wide Equality Impact: The guidance contained in this document is intended to be inclusive for all patients within the clinical group specified, regardless of age, disability, gender, gender identity, sexual orientation, race and ethnicity & religion or belief Committee(s) approving the Care and Clinical Policies Group Meeting document: Clinical Lead for Diabetes and Endocrinology Date approved: 27 September 2018 Links or overlaps with other All TSDFT Trust Strategies, policies and procedure documents policies: 1490 Patients with Diabetic Ketoacidosis (DKA) Hyperosmolar Hyperglycaemic State (HHS) Acute Hyperglycaemia Guideline CP042 Parenteral Nutrition Steroid induced hyperglycaemia Supervision, Accountability and Delegation of Activities to SNR staff Diabetes in adults, diagnosis of 2205 Diabetes: capillary blood glucose monitoring - competency document for Roche Performa meter 2059 CBG monitoring for SNR staff employed by TSDFT 2060 CBG monitoring for SNR staff not employed by TSDFT Have you considered using Equality Impact Assessment? Does this document have implications regarding the Care Act? If yes please state: Please select Yes No Does this document have training implications? If yes please state: Does this document have financial implications? If yes please state: Is this document a direct replacement for another? If yes please state which documents are being replaced: Diabetes Capillary Blood Glucose Monitoring Document Control Information Version 1 (September 2018) Page 1 of 1

17 Document Amendment History Date Version no. Amendment summary Ratified by: 1 October New Care and Clinical Policies Group Meeting Clinical Lead for Diabetes and Endocrinology Clinical Director of Pharmacy Diabetes Capillary Blood Glucose Monitoring Document Control Information Version 1 (September 2018) Page 1 of 1

18 The Mental Capacity Act 2005 The Mental Capacity Act provides a statutory framework for people who lack capacity to make decisions for themselves, or who have capacity and want to make preparations for a time when they lack capacity in the future. It sets out who can take decisions, in which situations, and how they should go about this. It covers a wide range of decision making from health and welfare decisions to finance and property decisions Enshrined in the Mental Capacity Act is the principle that people must be assumed to have capacity unless it is established that they do not. This is an important aspect of law that all health and social care practitioners must implement when proposing to undertake any act in connection with care and treatment that requires consent. In circumstances where there is an element of doubt about a person s ability to make a decision due to an impairment of or disturbance in the functioning of the mind or brain the practitioner must implement the Mental Capacity Act. The legal framework provided by the Mental Capacity Act 2005 is supported by a Code of Practice, which provides guidance and information about how the Act works in practice. The Code of Practice has statutory force which means that health and social care practitioners have a legal duty to have regard to it when working with or caring for adults who may lack capacity to make decisions for themselves. The Act is intended to assist and support people who may lack capacity and to discourage anyone who is involved in caring for someone who lacks capacity from being overly restrictive or controlling. It aims to balance an individual s right to make decisions for themselves with their right to be protected from harm if they lack the capacity to make decisions to protect themselves. (3) All Trust workers can access the Code of Practice, Mental Capacity Act 2005 Policy, Mental Capacity Act 2005 Practice Guidance, information booklets and all assessment, checklists and Independent Mental Capacity Advocate referral forms on the trust IT system. Infection Control All staff will have access to Infection Control Policies and comply with the standards within them in the work place. All staff will attend Infection Control Training annually as part of their mandatory training programme. Diabetes Capillary Blood Glucose Monitoring The Mental Capacity Act Version 1 (September 2018) Page 1 of 1

19 Rapid (E) quality Impact Assessment (EqIA) (for use when writing policies) Policy Title (and number) Policy Author Version and Date An (e) quality impact assessment is a process designed to ensure that policies do not discriminate or disadvantage people whilst advancing equality. Consider the nature and extent of the impact, not the number of people affected. Who may be affected by this document? Patients/ Service Users Staff Other, please state Could the policy treat people from protected groups less favorably than the general population? PLEASE NOTE: Any Yes answers may trigger a full EIA and must be referred to the equality leads below Age Yes No Gender Reassignment Yes No Sexual Orientation Yes No Race Yes No Disability Yes No Religion/Belief (non) Yes No Gender Yes No Pregnancy/Maternity Yes No Marriage/ Civil Partnership Yes No Is it likely that the policy could affect particular Inclusion Health groups less favorably than Yes No the general population? (substance misuse; teenage mums; carers 1 ; travellers 2 ; homeless 3 ; convictions; social isolation 4 ; refugees) Please provide details for each protected group where you have indicated Yes. VISION AND VALUES: Policies must aim to remove unintentional barriers and promote inclusion Is inclusive language 5 used throughout? Yes No NA Are the services outlined in the policy fully accessible 6? Yes No NA Does the policy encourage individualised and person-centred care? Yes No NA Could there be an adverse impact on an individual s independence or autonomy 7? Yes No NA EXTERNAL FACTORS Is the policy a result of national legislation which cannot be modified in any way? Yes No What is the reason for writing this policy? (Is it a result in a change of legislation/ national research?) Who was consulted when drafting this policy? Patients/ Service Users Trade Unions Protected Groups (including Trust Equality Groups) Staff General Public Other, please state What were the recommendations/suggestions? Does this document require a service redesign or substantial amendments to an existing Yes No process? PLEASE NOTE: Yes may trigger a full EIA, please refer to the equality leads below ACTION PLAN: Please list all actions identified to address any impacts Action Person responsible Completion date AUTHORISATION: By signing below, I confirm that the named person responsible above is aware of the actions assigned to them Name of person completing the form Signature Validated by (line manager) Signature Version 1 (September 2018) Diabetes Capillary Blood Glucose Monitoring Rapid (E) quality Impact Assessment Page 1 of 2

20 Please contact the Equalities team for guidance: For South Devon & Torbay CCG, please call or For Torbay and South Devon NHS Trusts, please call or This form should be published with the policy and a signed copy sent to your relevant organisation. 1 Consider any additional needs of carers/ parents/ advocates etc., in addition to the service user 2 Travelers may not be registered with a GP - consider how they may access/ be aware of services available to them 3 Consider any provisions for those with no fixed abode, particularly relating to impact on discharge 4 Consider how someone will be aware of (or access) a service if socially or geographically isolated 5 Language must be relevant and appropriate, for example referring to partners, not husbands or wives 6 Consider both physical access to services and how information/ communication in available in an accessible format 7 Example: a telephone-based service may discriminate against people who are d/deaf. Whilst someone may be able to act on their behalf, this does not promote independence or autonomy Version 1 (September 2018) Diabetes Capillary Blood Glucose Monitoring Rapid (E) quality Impact Assessment Page 2 of 2

21 Clinical and Non-Clinical Policies Data Protection Torbay and South Devon NHS Foundation Trust (TSDFT) has a commitment to ensure that all policies and procedures developed act in accordance with all relevant data protection regulations and guidance. This policy has been designed with the EU General Data Protection Regulation (GDPR) and Data Protection Act 2018 (DPA 18) in mind, and therefore provides the reader with assurance of effective information governance practice. The UK data protection regime intends to strengthen and unify data protection for all persons; consequently, the rights of individuals have changed. It is assured that these rights have been considered throughout the development of this policy. Furthermore, data protection legislation requires that the Trust is open and transparent with its personal identifiable processing activities and this has a considerable effect on the way TSDFT holds, uses, and shares personal identifiable data. Does this policy impact on how personal data is used, stored, shared or processed in your department? Yes No If yes has been ticked above it is assured that you must complete a data mapping exercise and possibly a Data Protection Impact Assessment (DPIA). You can find more information on our GDPR page on ICON (intranet) For more information: Contact the Data Access and Disclosure Office on dataprotection.tsdft@nhs.net, See TSDFT s Data Protection & Access Policy, Visit our Data Protection site on the public internet Version 1 (September 2018) Diabetes Capillary Blood Glucose Monitoring Clinical and Non-Clinical Documents Data Protection Page 1 of 1