CODE: GDL B.4.0
HEALTH SERVICES
NURSING GUIDELINE
TITLE
BLOOD GLUCOSE MONITORING
(Accu-Chek Inform II)
A. Control Test
B. Patient Test
C. Troubleshooting
D. Limitations
CATEGORY: General
Staff competency will require minimum of running a set of controls (one level 1 and one level
2) and one patient test yearly and completing the yearly online e-quiz. Proof of competency
occurs automatically when these requirements are met.
PURPOSE


A.
Rapid bedside measurement of blood glucose levels by electrochemical method.
Collection of quality control information for glucose monitor function, patient results
and operator performance.
Control Test
NURSING ALERT:


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Control test must fall within recommended ranges before performing patient tests.
Both Level 1(Lo) and Level 2(Hi) control solutions must be used when performing a control
test.
Meter display reads “Pass” if acceptable and “Fail” if result is unacceptable. Meter cannot
be used if controls do not pass.
Control testing must be done:
- once a day per monitor for each day of use
- when a container of strips has been exposed to extreme temperatures or humidity
- each time a new container of strips is opened
- if monitor has been dropped
- when test results contradict clinical symptoms
Control solution must be used within 3 months of opening.
(Date bottle with expiration date when first opened).
Approved: June 3, 2015
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HEALTH SERVICES
CODE
GDL B.4.0
EQUIPMENT
1.
2.
3.
4.
Appropriate PPE
Accu-Chek Inform II Monitor ™
Accu-Chek Inform II test strips ™
Accu-Chek Level 1 and Level 2 control solutions ™
PROCEDURE
1.
Turn monitor on.
NOTE: Touch screen will go into sleep mode (dim) after 30 seconds if no input.
Touch screen anywhere to return to working mode.
NOTE: Touch screen will go blank and monitor will power down to save energy if
no input for five minutes.
2.
Press forward arrow button.
3.
Enter or scan operator ID and press forward arrow button using your finger (do not
use tip of your pen or lancet).
4.
Select control test.
5.
Press barcode icon.
6.
Scan barcode on control vial.
NOTE: Strip lot screen will appear.
7. Press barcode icon.
8. Scan barcode icon on strip container.
9. Remove test strip from container and recap container immediately.
10. Insert test strip (yellow target area up, silver bars first) when strip icon appears on
monitor display.
11. Mix control solution gently prior to use.
NOTE: Discarding first drop from bottle of control solution is a good practice
to ensure fresh control solution is being used.
12. Wait for flashing drop icon to appear on monitor display.
13. Hold control solution bottle horizontally and apply control drop to tip of test strip.
Drop will automatically be drawn into strip dosing yellow reaction window.
Approved: June 3, 2015
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HEALTH SERVICES
CODE
GDL B.4.0
14. Remove test strip when “Pass” or “Fail” is displayed.
NOTE: If “Fail” is displayed a comment is required (press comment “cloud”). Test
must be repeated.
15. Select control solution to do second control test.
16. Repeat steps 4 – 15.
17. Turn monitor off.
B. Patient Test
NURSING ALERT:
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
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Wear PPE when performing patient tests.
Glucose values below 11.1 mmol/L are not affected by hematocrit levels.
When glucose values are above 11.1 mmol/L, low hematocrit (less than 0.1) may cause
elevated results and high hematocrit (greater than 0.65) may cause low results.
Accu-Chek Performa test strips are plasma compatible and values are similar to laboratory
results.
Poor peripheral circulation may result in inaccurate results.
Capillary, venous or arterial blood may be used. Do not use blood from EDTA vacutainer.
Monitor should be stored on base unit when not in use to maintain battery charge.
FOR ADULTS:
 Obtain stat lab glucose for monitor results less than 3 or greater than or equal to 25, and
notify attending physician.
 Notify attending physician when monitor results less than 3 or greater than or equal to 25
unless otherwise ordered.
 Monitor Values are indicated by Lo if less than 0.6 or Hi greater than 33.3 on monitor
display.
 DO NOT use hemodialysis patient’s IV access arm for blood glucose testing (arm with AV
graft / fistula).
FOR PEDIATRICS (1 month to age 13):
 Obtain stat lab glucose for monitor results less than 3 or greater than or equal to 20 and
notify attending physician, unless otherwise ordered by physician.
FOR NEONATES (0 to 30 days):
 All symptomatic and at risk neonates are to be tested for abnormal blood glucose.
 Acceptable blood glucose range for a neonate is 2.6-6.0 mmol/L.
 Obtain stat lab glucose for monitor results less than or equal to 2.2 or greater than or equal
to 15 if neonate is in emergency or outpatient department.
 See Appendix A.
Approved: June 3, 2015
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HEALTH SERVICES
CODE
GDL B.4.0
EQUIPMENT
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
PPE
Accu-Chek Inform II Monitor ™
Accu-Chek Inform II test strips ™
Lancing device
Chlorhexidine 0.5% pad, alcohol swab or face cloth with warm soapy water
Gauze pad
Pipette as necessary
Plastic monitor sleeve for isolation (SPD #310422)
Appendix A: Hypoglycemia Guidelines for the at Risk Newborn
Disinfectant wipes
PROCEDURE
1.
Don PPE.
2.
Gather equipment.
3.
Cleanse site with chlorhexidine 0.5% pad, alcohol swab or face cloth with warm
soapy water.
4.
ALLOW TO DRY COMPLETELY.
5.
Prepare lancing device.
NOTE: There are 3 settings for depth on lancet.
Turn end to select appropriate depth (1.3mm, 1.8mm, 2.3mm depth).
Neonate heel puncture must not be more than 2.2mm.
6.
Turn monitor on.
7.
Press forward arrow button.
8.
Enter or scan operator ID. Press forward arrow button.
9.
Select patient test.
10. Enter patient ID (MRN number – 7 digit number) using keypad or scanning patient
armband. Press check mark. Strip lot screen will appear.
11. Select barcode icon.
12. Scan barcode on strip container.
13. Remove test strip from container. Replace container cap.
14. Insert test strip gently into monitor when strip icon appears on monitor display
(yellow target area up, silver bars first). Once strip is correctly inserted, a blood drop
symbol flashes on monitor display and monitor beeps.
Approved: June 3, 2015
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HEALTH SERVICES
CODE
GDL B.4.0
15. Obtain blood sample from patient. (Wipe away 1st drop and use 2nd drop). Hold
sample to tip of strip until window is completely filled with blood and no yellow color
is visible.
NURSING ALERT:

The following may cause false results:
o Not allowing site to dry
o Not wiping away first drop of blood
o Excessive squeezing of finger (or foot for neonates)
Shaded areas illustrate best sites for a finger stick –
sides of fingers between tip of finger and last knuckle.
AVOID very tip of finger, middle of pad and back of
finger.
NOTE:
 Warming test site with a warm cloth to promote increased circulation may
facilitate a larger drop of blood.
 When using a pipette, do not allow blood to enter bulb.
 The heel is preferred puncture site to obtain blood from infants under 3
months of age.
Care should be taken to avoid curvature of heel and
plantar surface of heel, where distance between the
skin and calcaneus nerve is smallest. Neonatal
osteomyelitis of calcaneual (heel bone) resulting from
heel puncture has been reported.
Perform puncture on medial-lateral portion of plantar
surface (outside lines of diagram in shaded area).
Approved: June 3, 2015
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HEALTH SERVICES
CODE
GDL B.4.0
16. Remove test strip after test result appears on screen and dispose in appropriate
container.
17. Select comment code if applicable.
NOTE:
A comment is only required if result is outside of reference range or a
critical value.
18. Press check mark twice to return to main menu.
19. Turn monitor off.
20. Document result in patient’s chart on blood glucose monitoring record (RQHR 284).
21. Wipe monitor with disinfectant cloth after patient test.
C. Troubleshooting
1.
Meter does not turn on
 wait a few seconds and try again
 place meter in base station and ensure it is charging
 take to laboratory
2.
Strip Defect Error (displayed message) (E1507)
 strip is defective – repeat test
 control or patient sample was added before blood drop icon appeared - repeat
 patient result is extremely low, below meter’s measurement range – repeat
 try running a control – strip defect – discard strips – open new vial
 if problem persists take strips and meter to chemistry laboratory
3.
Type Bad Dose (displayed message)
 insufficient blood on test strip
 repeat test with a new test strip and ensure adequate sample
 if problem persists take strips and meter to chemistry laboratory
4.
Base Unit Problem
 light is not illuminated – check connections
 light is flashing – disconnect connections to base unit and then reconnect
 if problem persists call chemistry laboratory
5.
Results do not Transfer
 results are transferred through the hospital wireless system – system may be
down
 if problem occurs on only one meter call the laboratory
 IT may need to be contacted if it is a system wide problem
Approved: June 3, 2015
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HEALTH SERVICES
CODE
6.
Control Error Message
 E332 – Invalid Control Lot Barcode
strip vial barcode was scanned instead of control bottle barcode
new control lot not yet entered in system – contact laboratory
 E333 – Control Level Mismatch
scanned control level was not selected level to be run
7
Warning Messages
 FAIL – control is out of range – repeat
 RANGE – result is out of reference range
 OUT OF CRITICAL RANGE – result is out of critical range
 BATTERY LOW – charge meter in base unit
 CONTROL LOT NOT FOUND – contact chemistry laboratory
 STRIP LOT NOT FOUND – contact chemistry laboratory
GDL B.4.0
NOTE: If unable to resolve problem obtain a replacement meter from chemistry
laboratory @ 4490 (RGH) or @ 2256 (PH)
D. Limitations



Interference from galactose (greater than 0.83 mmol/L), IV administration of ascorbic
acid (less than 0.17 mmol/L)
If patient has impaired peripheral circulation results of capillary samples may not be a
true reflection of the physiological blood glucose (e.g. Severe dehydration, shock,
decompensated heart failure, peripheral arterial occlusive disease)
Triglyceride levels of greater than 20.3 mmol/L may cause elevated results
Approved: June 3, 2015
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HEALTH SERVICES
CODE
GDL B.4.0
REFERENCES
Aziz, K., Dancey, P. Canadian Pediatric Society, Fetus and Newborn Committee.
Pediatric Child Health 2004.9 (10) 723-9. Reaffirmed February, 2014.
Reference #FN04-01. Retreived from
http://www.cps.ca/english/statements/FN/fn04-01.htm.
CLSI C30-A2. (2013) Point of Care Blood Glucose Testing in Acute and Chronic
Facilities, approved Guideline, 3rd Ed. Retrieved from www.clsi.org.
Operators Manual (2011) Accu-Chek Inform II System, Roche Diagnostic Corporation
Revised by:
Date:
Tammy Ottenbreit, MLT, ART, Chemistry Supervisor III, Laboratory,
Balynda Gabora, Jana Poitras, Jana Lowey, Glenys Weisshaar,
Kathy Jellow, Lori Lunnin
March 2012
Revised by:
Date:
Elaine Abrook, CNE
June 2015
Approved by RQHR Procedure Committee:
Date:
June 3, 2015
Regina Qu’Appelle Health Region
Health Services
Nursing Procedure Committee
Approved: June 3, 2015
Page 8 of 10
Appendix A
Guidelines for Hypoglycemia Management of Newborns
Asymptomatic
Symptomatic
Baby shows signs &
symptoms of hypoglycemia
or appears unwell
Baby shows no signs &
symptoms of hypoglycemia
appears well
At risk for
hypoglycemia
No
Yes
Feed within one
hour of age
Routine care
Feed on demand
Chemstrip now,
if <2.6mmol, call
NICU/Nursery, inform
MRP, needs IV fluids
Chemstrip > 2.6
Treat symptoms
As needed
Feed within one
hour of age
Check initial chemstrip at
2 hrs of age & Q2-3 hourly
< 1.8 mmol/l @ 2 hrs
or
< 2 mmol/l @
subsequent checks
1.8 - 2 mmol/l @ 2 hrs
or
2-2.5 mmol/l @
subsequent checks
>2mmol/l @ 2 hrs or
>2.6mmol/l @
subsequent checks
Inform MRP
Feed & recheck
chemstrip in 1 hour
Inform MRP
Call NICU
Needs IV fluids
Remains
<2.6mmol/l
despite feeding
Rises to >
2.6mmol/l after
feeding
Feed Q 2-3 hrly, monitor
chemstrip (before feeds) until
stable x 2
See on the reverse for definitions, risk factors & signs & symptoms of hypoglycemia
Approved: June 3, 2015
Page 9 of 10
Appendix A cont.
Guidelines for Hypoglycemia Management of Newborns
Signs and Symptoms of Hypoglycemia

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Risk Factors for Hypoglycemia
 Maternal hypertension treated with beta
blockers
 Any maternal diabetes (gestational, type I
or II with or without insulin including
single dose)
 SGA – less than10th percentile
 LGA – greater than 90th percentile
 Preterm – less than 37 0/7 weeks
 Cold stress – hypothermia – axilla
temperature less than 36.5 C
 Newborns with medical conditions,
E.g. respiratory distress, sepsis etc.
Jitteriness, Tremors
Episodes of cyanosis
Convulsions
Apnea
Tachypnea
Weak or high-pitched cry
Limpness, lethargy, hypotonia
Difficulty Feeding, refusal to feed
Eye rolling
Sweating, sudden pallor
SGA/LGA PARAMETERS
SGA: less than 10th percentile for birth weight and gestational age
LGA: greater than 90th percentile for birth weight and gestational age
Gestation
(completed
weeks)
Male
Weight in GM
Female
Weight in GM
SGA
Less than or
equal to
LGA
Greater than or
equal to
SGA
Less than or
equal to
LGA
Greater than or
equal to
37
≤ 2552
≥ 3665
≤ 2452
≥ 3543
38
≤ 2766
≥ 3877
≤ 2658
≥ 3738
39
≤ 2942
≥ 4049
≤ 2825
≥ 3895
40
≤ 3079
≥ 4200
≤ 2955
≥ 4034
41
≤ 3179
≥ 4328
≤ 3051
≥ 4154
42
≤ 3233
≥ 4433
≤ 3114
≥ 4251
Code: Gdl.B.4.0
Authors: Tammy Ottenbreit, Balynda Gabora, Jana Poitras,
Jana Lowey, Glenys Weisshaar, Kathy Jellow, Lori Lunnin
Date: March 2012; June 2015
Approved: June 3, 2015
Page 10 of 10