Glucose MonitoringGlucose MonitoringCeri JonesCeri Jones

20142014

Glucose MonitoringGlucose Monitoring

Why? Who? Why? Who?

Benefits of Glucose Benefits of Glucose MonitoringMonitoring

Improve glycaemic control? Empowerment Hypoglycaemia?Hypoglycaemia? Intercurrent illness/sick day rulesIntercurrent illness/sick day rules Pre-pregnancy, pregnancyPre-pregnancy, pregnancy DrivingDriving Special clinical situationsSpecial clinical situations Intensive regimensIntensive regimens

Glucose monitoring StudiesGlucose monitoring Studies ROSSOROSSO

SMBG decreased diabetes-related morbidity and all-SMBG decreased diabetes-related morbidity and all-cause mortality cause mortality

SMBG may be associated with a healthier lifestyle SMBG may be associated with a healthier lifestyle and/or better disease management and/or better disease management

FaasFaas SMBG in T2DM patients questionable needs good RCTSMBG in T2DM patients questionable needs good RCT

Coster Coster SMBG established in clinical practice optimal use not SMBG established in clinical practice optimal use not

established. established. Evidence suggests may not be essential for allEvidence suggests may not be essential for all

ReasonsReasons for not BGM for not BGMCostCost

The NHS spends approximately £90 million on blood glucoseThe NHS spends approximately £90 million on blood glucose

testing materials. This is 40% more than on oraltesting materials. This is 40% more than on oral

hypoglycaemic agents (£64 million).hypoglycaemic agents (£64 million).

InaccuraciesInaccuracies Out of date stripsOut of date strips Contaminated stripsContaminated strips Incorrect meter calibrationIncorrect meter calibration Meter reading incorrectlyMeter reading incorrectly Sticky fingersSticky fingers Incorrect sample sizeIncorrect sample size Temperature of equipmentTemperature of equipment

Rhondda Cynon Taff 12 months Costs 2003-2004

Hazard Warning Hazard Warning A Department of Health hazard warning notice (HN (Hazard)A Department of Health hazard warning notice (HN (Hazard)

(87), stated that all staff should be trained in the use of Blood (87), stated that all staff should be trained in the use of Blood Glucose meters including the Quality Assurance process by Glucose meters including the Quality Assurance process by appropriate trained staff.appropriate trained staff.

Diabetes UK advise that no member of staff, registeredDiabetes UK advise that no member of staff, registeredor otherwise should:-or otherwise should:-   perform blood glucose monitoring unless they have a sound perform blood glucose monitoring unless they have a sound

knowledge base of diabetes. knowledge base of diabetes. have received training on blood glucose monitoring using the have received training on blood glucose monitoring using the

meter specific to their place of employment.meter specific to their place of employment. be aware of how to interpret the reading(s) obtained and the be aware of how to interpret the reading(s) obtained and the

subsequent action to be taken. subsequent action to be taken.

POCTPOCT

Cwm Taf Health Board’s “Point of Care Testing Policy” Cwm Taf Health Board’s “Point of Care Testing Policy” (2010), define Point of Care testing as:-(2010), define Point of Care testing as:-

““Analytical tests undertaken by non-laboratory Analytical tests undertaken by non-laboratory staff outside a recognised diagnostics laboratory”staff outside a recognised diagnostics laboratory”

The policy also states:- The policy also states:-    ““Only staff whose training and competence has Only staff whose training and competence has

been established and documented should use any been established and documented should use any Point of Care Testing devicePoint of Care Testing device.”.”

Case Study 1Case Study 1 A person with Diabetes on a complex regimen of treatments was admitted to a hospital A person with Diabetes on a complex regimen of treatments was admitted to a hospital

intensive care unit . A blood glucose was measured using a blood glucose meter, a high intensive care unit . A blood glucose was measured using a blood glucose meter, a high result indicated hyperglycaemia and insulin treatment was initiated. A separate sample result indicated hyperglycaemia and insulin treatment was initiated. A separate sample sent to the hospital laboratory gave a markedly different result. sent to the hospital laboratory gave a markedly different result.

A thorough investigation, revealed that the glucose meter should not be used on A thorough investigation, revealed that the glucose meter should not be used on patients who were on treatments containing maltose. The patient suffered significant patients who were on treatments containing maltose. The patient suffered significant hypoglycaemia and complications because staff were unaware of this limitation. hypoglycaemia and complications because staff were unaware of this limitation.

Key points Key points • • Users should be aware of the manufacturer’s instructions and contra-indications for Users should be aware of the manufacturer’s instructions and contra-indications for

use. use. • • Such information should be incorporated into training of all staff using such a device. Such information should be incorporated into training of all staff using such a device. • • In this case, the device itself was not faulty, but was used contrary to the In this case, the device itself was not faulty, but was used contrary to the

manufacturer’s recommendations. manufacturer’s recommendations. • • The MHRA does not seek to apportion blame but instead to advise others on how to The MHRA does not seek to apportion blame but instead to advise others on how to

avoid similar problems. avoid similar problems.

Case Study 2Case Study 2 Outbreaks of hepatitis B were reported from several environments where Outbreaks of hepatitis B were reported from several environments where

blood glucose monitoring was being carried out for multiple patients. blood glucose monitoring was being carried out for multiple patients. Thorough investigations identified that care workers were found to be using Thorough investigations identified that care workers were found to be using

lancing devices intended for self-use (by one patient only) to take blood lancing devices intended for self-use (by one patient only) to take blood samples from multiple patients. This use of the wrong sort of lancing device samples from multiple patients. This use of the wrong sort of lancing device was implicated in the transmission of the virus. was implicated in the transmission of the virus.

Key points Key points • • Be aware that employing the wrong sort of lancing device can cause cross Be aware that employing the wrong sort of lancing device can cause cross

infection. infection. • • Use a disposable single-use lancing device where the entire device is Use a disposable single-use lancing device where the entire device is

thrown away after use, or employ a reusable lancing device that is intended, thrown away after use, or employ a reusable lancing device that is intended, by the manufacturer, for taking samples from more than one patient. by the manufacturer, for taking samples from more than one patient.

• • Users should review current practice to ensure that appropriate devices Users should review current practice to ensure that appropriate devices are provided and usedare provided and used

BGM GuidelinesBGM GuidelinesNSF Standards 3 and 4NSF Standards 3 and 4 All children, young people and adults with diabetes will receive a All children, young people and adults with diabetes will receive a

service which encourages partnership in decision-making, supports service which encourages partnership in decision-making, supports them in managing their diabetes and helps them to adopt and maintain them in managing their diabetes and helps them to adopt and maintain a healthy lifestyle. a healthy lifestyle.

All adults with diabetes will receive high-quality care throughout their All adults with diabetes will receive high-quality care throughout their lifetime, including support to optimise the control of their blood lifetime, including support to optimise the control of their blood glucose.glucose.

All children and young people with diabetes will receive consistently All children and young people with diabetes will receive consistently high-quality care and they, with their families and others involved in high-quality care and they, with their families and others involved in their day-to-day care, will be supported to optimise the control of their their day-to-day care, will be supported to optimise the control of their blood glucose. blood glucose.

BGM GuidelinesBGM Guidelines

NICE Guidelines, 2002NICE Guidelines, 2002

Self-monitoring should not be considered as a stand Self-monitoring should not be considered as a stand alone intervention.alone intervention.

Self-monitoring should be taught if the need/purpose is Self-monitoring should be taught if the need/purpose is clear and agreed with the patient.clear and agreed with the patient.

Self-monitoring can be used in conjunction with Self-monitoring can be used in conjunction with appropriate therapy as part of integrated self-care.appropriate therapy as part of integrated self-care.

BGM GuidelinesBGM Guidelines

DUK Position StatementDUK Position Statement People with diabetes should have access to home People with diabetes should have access to home

blood glucose monitoring based on individual clinical blood glucose monitoring based on individual clinical need, informed consent and not on ability to pay. need, informed consent and not on ability to pay.

The majority of diabetes care is provided by the The majority of diabetes care is provided by the individual. It is essential that people with diabetes be individual. It is essential that people with diabetes be provided with the education and tools in order to be provided with the education and tools in order to be able to manage their diabetes for themselves. able to manage their diabetes for themselves.

Glucose MonitoringGlucose Monitoring

Technology and techniqueTechnology and technique

TechnologyTechnology

Meters numbers available Not on prescription Coding & quality

control

Lancing Devices Professional Individual patient Single use Not on prescription

Lancets Available on prescription

Quality AssuranceQuality Assurance

TrainingTraining

Quality ControlQuality Control

Accuracy of equipment Reliability of results Quality Control solutions Meter Strips

Quality ControlQuality Control- when?- when?

New meterNew meter New test stripsNew test strips Change of BatteriesChange of Batteries Test strips left openTest strips left open Meter dropped/damagedMeter dropped/damaged Unexpected resultUnexpected result

Failed Quality ControlFailed Quality Control

Check expiry datesCheck expiry dates Were tests carried out in correct orderWere tests carried out in correct order Repeat levels 1 and 2 againRepeat levels 1 and 2 again Change QC solution & Repeat Change QC solution & Repeat Change test strips (change code)Change test strips (change code)

Lancing SystemsLancing Systems

Multiple use device with single use Multiple use device with single use lancet – patientslancet – patients

Single use lancet - professionalSingle use lancet - professional

SharpsSharps

Sharps box should be used Sharps box should be used Sharps must NOT be put in rubbishSharps must NOT be put in rubbish Advice if no sharps boxAdvice if no sharps box Sharps disposal service tel: 01443 494700Sharps disposal service tel: 01443 494700

Glucose MonitoringGlucose Monitoring

Frequency of testing and when?Frequency of testing and when?

Diet & MetforminDiet & Metformin

If stableIf stable patients should be taught the patients should be taught the principles of HBGM and if appropriate principles of HBGM and if appropriate should monitor should monitor once a week fasting once a week fasting

SulphonylureasSulphonylureas

If stableIf stable patients should be taught the patients should be taught the principles of HBGM and encouraged to principles of HBGM and encouraged to monitor monitor twice a week fasting plus at 1 twice a week fasting plus at 1 other timeother time

Once daily or BD InsulinOnce daily or BD Insulin

If stableIf stable patients should be taught the patients should be taught the principles of HBGM and encouraged to principles of HBGM and encouraged to monitor monitor twice a day 2-3 times per week.twice a day 2-3 times per week.

  

Basal Bolus Insulin Regimen Basal Bolus Insulin Regimen

If stableIf stable they should be encouraged to they should be encouraged to monitor monitor 4 times a day 2-3 times per week.4 times a day 2-3 times per week.

Factors affecting BG levels

Food Exercise Physical activity Illness and pain Medication OHAs Insulin Alcohol Emotional stress

When to test more frequently?When to test more frequently?

Medication is changedMedication is changed Insulin startedInsulin started Sick day rules / illness Sick day rules / illness Risk of hypoglycaemiaRisk of hypoglycaemia ExerciseExercise Advised by DSN or P/NAdvised by DSN or P/N DrivingDriving Pregnant/planning a familyPregnant/planning a family

Monitoring Errors

Out of date stripsOut of date strips Contaminated stripsContaminated strips Incorrect meter codingIncorrect meter coding Incorrect meterIncorrect meter Hands not cleanHands not clean Temperature of equipmentTemperature of equipment

ContraindicationsContraindications

Severe dehydration Severe dehydration

Hypotension / Shock / Peripheral Hypotension / Shock / Peripheral Circulatory failure Circulatory failure

Hyperosmolar non-ketotic Coma Hyperosmolar non-ketotic Coma (HONK)(HONK)

Diabetic Ketoacidosis (DKA)Diabetic Ketoacidosis (DKA)

Venous sample to labVenous sample to lab

Home Blood Glucose Monitoring

Continuing education Monitoring Frequency Quality assurance Coding Acting on results HbA1c

If stable people controlled on diet alone or diet and Metformin and/or Glitazones and/or Acarbose should be taught the principles of HBGM and if appropriate should monitor once a week fasting

Patients should not buy their own meters, these will be provided free of charge via the practice nurse. Practices to keep a stock of meters (arranged via the diabetes facilitators) for PWD

Test more frequently if Medication is changed Insulin started Sick day rules / illness Risk of hypoglycaemia Exercise Advised by DSN or P/N Driving Pregnant/planning a family

DAFNE CSII

Test strips and lancets should not be issued on a repeat prescription. They should be requested from the practice nurse six monthly or yearly

HbA1c is an excellent indicator of long-term control.

If stable people controlled with BD or OD insulin should be taught the principles of HBGM and encouraged to monitor twice a day 2-3 times per week.

There should be no blanket ban on Home Blood Glucose Monitoring (HBGM) Individual needs change, some may need to test more frequently than others. HbA1c is an excellent indicator of long-term control

If stable people controlled with Insulin secretagogues and diet should be taught the principles of HBGM and encouraged to monitor twice a week fasting plus at 1 other time

If stable people controlled with basal bolus insulin should be taught the principles of HBGM and encouraged to monitor 4 times a day 2-3 times per week.