BLS Glucometer Training Program Presented by: Emergency Resource Management

1. BLS Glucometer Training ProgramPresented by:Emergency Resource Management 

3. Physiology The body uses glucose and oxygen to create energy Without a proper glucose level, organs can malfunction The brain is very sensitive to glucose levels Abnormal levels may result in permanent brain cell death

4. Diabetes Problems with management of glucose Glucose is a simple sugar from digested carbs Insulin is a hormone produced in the pancreas Insulin enables glucose to pass into the cells

5. Normal Serum Blood Glucose Levels (SBGL) Infant: 40 to 90 mg/dl Child: <2 y/o - 60 to 100 mg/dl Child: >2 years to adult - 70 to 105 mg/dl Elderly over 50 y/o may have a normal increase to approx. 126 mg/dl

6. Diabetes � Type I Usually juvenile onset May have onset after pancreatic trauma / disease Insulin is not produced Usually take Insulin injections (IDDM) Likely to have complications such as: heart disease, HTN, postural HTN, kidney failure and nerve disorders.

7. Diabetes � Type II Usually adult onset� Peripheral insulin resistance Produce insulin � but not enough Usually diet controlled or takes oral meds to stimulate insulin production (NIDDM) If severe enough, insulin injections may be necessary Not likely to experience hypoglycemia Likely to have same complications as Type 1, but may also include blindness.

8. Hyperglycemia Too much sugar Cells are not taking on glucose Slow onset May be asymptomatic or even a first presentation of diabetes

9. DKA Diabetic Keto Acidosis High sugar and metabolic acidosis Symptoms AMS Rapid (Kussmaul) respirations Rapid weak pulse Sweet/Fruity (acetone) odor May appear drunk Appear dehydrated (dry, warm skin & sunken eyes) Deadly

10. Hypoglycemia Not enough sugar Missed meals Too much insulin Infection & other stressors Symptoms � AMS - Normal to Rapid Resp. May appear drunk - Normal to low BP Lethargy, shaky - Vertigo, headaches Tachycardia - Diaphoretic Anxious / combative - Seizure / coma / Death

11. BLS Glucometry High or low levels of glucose can have many presentations Difficult to make accurate diagnosis on presentation alone The glucometer gives you a definitive number to base your treatment Performed on all ages of patients

12. Historical Concerns Can BLS personnel accurately operate glucometers? Can BLS personnel safely operate glucometers? Can BLS glucometery increase the efficiency of the EMS system? Of course they can! But�..

13. PT. Assessment is Critical ! At no time is the use of a Glucometer a priority. The use of the glucometer is only after all quality pt. assessments and associated interventions have been delivered. Never base a pt. care decision solely on the findings of a glucometer

14. BLS Glucometry Team approach Simultaneous rather than serial care Facilitates scene leadership The best scene management and hence patient care comes from a paramedic minimally committed to tasking but to the integration of information and directing of patient care. Think how we as MD�s manage ill patients in the ED. We direct more than do.The best scene management and hence patient care comes from a paramedic minimally committed to tasking but to the integration of information and directing of patient care. Think how we as MD�s manage ill patients in the ED. We direct more than do.

15. Meeting the Needs of Providers Workload / staff disparity Syncope example Of course some systems may be different hence it is an option at the discretion of the medical director. Syncope example Of course some systems may be different hence it is an option at the discretion of the medical director.

16. Indications Altered Mental Status Abnormal behavior Syncope Seizure Unconscious General illness / malaise Diabetic related Stroke Overdose of unknown medication Pediatric resuscitation Other

17. Glucometry Indications to perform glucose test How to obtain blood sample (finger stick vs. IV sample). Instruction on glucometer operation What to do with test result? Proper disposal of sharps / contaminants Proper action for blood borne pathogen exposure

18. Glucometer Operation � QA Check Document the Lot No. and Exp. Date of the test solution. Document the Lot No. and Exp. Date of Pt. Test Strips being used. Hold round end of test strip with gray electrode side up and insert into meter until it stops. The meter will run a self check and then flash a droplet signal. Gently rock the control bottle before opening. Squeeze a small drop onto a nonabsorbent surface. DO NOT apply solution to the test strip directly. Touch the tip of the test strip to the drop of solution. The solution is automatically pulled �sipped� into the strip � hold until the meter beeps. Leave the strip in until meter shows readings. Remove and document the readings. The meter turns off when you remove the strip.

19. Obtaining Blood Sample Personal BSI protection Equipment required Gloves Alcohol prep (70%) � DO NOT use povidone or iodine. Allow alcohol to dry. Lancet Band Aid (or similar self adherent bandage) Aseptic technique Safety lancet operation - disposal

20. Blood Glucose Monitoring and Risks for Bloodborne Pathogen Transmission

21. Blood Glucose Monitoring and Risks for Bloodborne Pathogen Transmission Fingersticks = Percutaneous Exposures Transmission risks are highest in long term care and other settings where multiple persons require fingersticks HBV most common but HCV also reported Outbreaks in 1990s led CDC/FDA to recommend fingerstick devices dedicated to single patients

22. Recent HBV Outbreaks Associated with Blood Glucose Monitoring 2004 �CA �Assisted Living Center �8 cases* �Roundtable setting; no glove use or handwashing �2003 �MS �Nursing Home �15 cases (2 deaths)* �One glucometer and FS device per nursing station �2003 �NC �Nursing Home �8 cases* �Dedicated fingerstick devices in use �Contamination of other shared diabetes care equipment such as glucometers (one per station) �2005 �VA �Assisted Living (2) �11 cases (1 death)

23. Shared Glucometer as Potential Vehicles for BBP Transmission �Multicenterhospital survey found 30% of glucometers had blood contamination* �Most facilities lack schedule for cleaning meters or specify only daily cleaning �On-meter test strip dosing format associated with higher contamination risk Failure to clean and disinfect between patients may lead to glove contamination / inoculation

24.  RecommendedInfection Control Practices Restrict fingerstick devices to individual patients Optimally, use only single-use lancets that permanently retract upon puncture Never reuse lancets or needles/syringes Change gloves after every procedure that involves potential exposure to blood (e.g., fingersticks) Perform hand hygiene after removing gloves and before touching supplies intended for other patients

25. RecommendedInfection Control Practices �If glucometers must be shared�Clean and disinfect the device between patients�Select device designed for institutional use �Consider devices that do not require test strip to be inserted while blood is applied Reduce fingerstick procedures to the minimum necessary for appropriate diabetes management

26. ID Appropriate Puncture Sites Adult & Children over 1 y/o Fingers, 3rd or 4th on the palmar side, trying to stay off the pads of the fingers when possible. Contradictions for puncture sites Old puncture sites Epidermal damage, scarring Desire of the pt.

27. Glucometer Operation Hold round end of test strip with gray electrode side up and insert into meter until it stops. The meter will run a self check and then flash a droplet signal. Touch the tip of the test strip to the drop of blood. The blood is automatically pulled �sipped� into the strip � hold until the meter beeps. Leave the strip in until meter shows readings. Remove and document the readings. The meter turns off when you remove the strip. Remove and place lancet into sharps container.

28. Poor sample factors Do Not use any test strips that are more than 6 mos. old from date on bottle when bottle was opened. Do Not press strip against any surface. Allow drops to be �sipped� into the strip on its own. Do Not use smeared or clotted blood samples. Do Not let blood stand for more than 20 sec.�s before using.

31. Await result� approx. 20 sec.�s

33. Glucometer Operation Each may be different � standard operation follows. You must learn your own equipment

34. What to Do with the Data If SBGL is below 80 and the patient is able to follow commands and has 1 or more S/S of hypoglycemia: Administer 1 tube Oral glucose If SBGL is over 200 and symptomatic: Transport In both cases contact ALS for specific therapy Record test results on PCR treatment line

35. QI Review Review each PCR in which the blood glucose is tested on a patient Keep statistics for the blood glucose tests by presenting problem Document how many patients had abnormal glucose levels Refer to the Medical Director every case when abnormal levels were discovered Document how many times ALS was called and how many times the ALS intercept occurred

36. Agency Responsibility Sponsor Hosp. Medical Director / OEMS approval CLIA Waiver - inspections Annual Training and retention Daily Equipment calibration check Cleaning/maintenance as per mfg. Guides Each employee/member should review and be familiar with the meters Operating Manual

37. Questions?