Blood Glucose Measuring in the Pre-Hospital Setting

1. Blood Glucose Measuring in the Pre-Hospital Setting

2. Purpose • To prepare Certified First Responders (CFR) and EMT- Basics (EMT-Bs) with current certification to utilize a blood glucose measuring device (glucometry) when operating under NY State – approved BLS protocols for Altered Mental Status (AMS), in accordance with: • NYS DOH Policy Statements 05-04, 12-01 • Revised NYS BLS Protocol for AMS (M-2) • Suffolk County EMS Medical Director / Suffolk REMAC Standard of Care 2. To provide a review of diabetic and neurologic (CVA/TIA and Seizure) emergencies.

3. Education & Training Objectives • Indications to perform glucose test • How to obtain blood sample • Instruction on glucometer operation • What to do with test result • Proper disposal of sharps / contaminants • Proper action for blood borne pathogen exposure • Proper documentation

4. Note Information within this presentation should be tailored to the specific glucometer used by the ambulance service and should include a review of the manufacturer’s instructions. Documentation of successful completion of this training, by signing the Attestation of Completion Form and completing the hands-on skills review, is required for authorization to perform blood glucose monitoring in the field

5. Agency Responsibility • Ensure compliance with Suffolk County EMS Policy and NY State EMS BLS Protocol • Provide information to the agency’s inclusion in the CLIA Permit-Waiver** • Procure equipment • Provide training and re-training as needed • Establish an agency policy for equipment calibration and maintenance, per manufacturer’s recommendations

6. What is CLIA and why do we need a Permit-Waiver? • The use of blood glucometry equipment and the measurement of a patient’s blood sugar constitutes use of laboratory-acquired specimen data to diagnose and treat a patient • NY State DOH regulations contained in the Clinical Laboratories Evaluation Program (CLEP) require that laboratories, including ambulance services, meet State DOH standards for “laboratories” as a function of the Clinical Laboratories Improvement Amendments (CLIA). • Blood glucometry is a permit-waived test as defined as a simple laboratory examination and procedure that has an insignificant risk of an erroneous result • Suffolk County EMS holds the Multi-Site Permit-waiver for the entire EMS System with each ambulance service listed as an “off-site” laboratory

7. What is CLIA and why do we need a Permit-Waiver? • The permit-waiver application and fee is submitted bi-annually by Suffolk County EMS. • The permit expires every 2 years, current permit effective until April 19, 2015. • If you are affiliated with an ambulance service in Suffolk County operating at the ALS level, your agency already has the proper permit-waiver in place. • If you are affiliated with an ambulance service in Suffolk County operating at the BLS level, or if you are in a BLS-First Response (BLS-FR) agency, your administration has been asked to provide site specific information so we can add your BLS agency to the list of off-site laboratories. Failure to comply will result in your agency being unable to perform blood glucometry. • The CLIA Permit-waiver requires that the agency comply with manufacturer's recommendations for glucometer maintenance and calibration/control testing and documentation.

8. Changes in protocol • As approved by the NY State Commissioner of Health, and adopted by the NYS DOH Bureau of EMS, the Suffolk County EMS Medical Director, in conjunction with the Suffolk REMAC, has authorized the implementation of the revised NY State AMS protocol, which includes 2 new skills for BLS providers: • obtaining blood sugar readings to assist in the identification of hypoglycemia; and the • administration of intranasal naloxone to patients with opiate/opioid overdose.

9. Glucometry Devices • Typical glucometer used to check blood sugar levels. • Many different types and models.

10. Per NY State DOH requirements, the use of “dextrostix” are prohibited. A glucometer must be used.

11. Indications for BG Measuring Patient signs and / or symptoms consistent with • Acute Stroke • weakness, facial droop, slurred speech • Aphasia (inability to speak), dysarthria (difficulty pronouncing words) and hemiparesis (one-sided weakness), hemiplegia(inability to move one side of body) • Altered Mental Status • confusion, disorientation • Diabetic Emergencies • Opiate/Opioid Overdose • Seizure/Post-Seizure

12. Use of Glucometer • Equipment needed: • Exam gloves • Alcohol prep pads • Glucometer • Test strips • Cotton balls or gauze pads • Band-aid • Lancets • Sharps container and proper waste disposal container

13. Device Variations • Some glucometers turn on automatically when the test strip is inserted. • Know the features of the glucometer your agency uses.

14. Manufacturer-Specific Maintenance • Set up requires identification of: • Proper batch number for test strips • Routine control testing • Calibration when necessary • Documentation of control testing and calibrating • Follow manufacturer’s directions

15. Care of the Blood Glucometer • Handle with care! • Do NOT expose to excessive heat, humidity, cold, dust, or dirt • Clean as directed by manufacturer • Store the glucometer and supplies in the case provided by the manufacturer

16. Blood Glucometer Errors Can result from: • Improper calibration of glucometer • Lack of glucometer maintenance and cleaning • Battery failure • Test strip failure • Codes on strip container and glucometer don’t match * Proper care and maintenance of glucometers can help prevent these errors

17. NY State EMSBASIC LIFE SUPPORT PROTOCOLSuffolk County EMSBLOOD GLUCOMETRY POLICY • NOTE: The use of blood glucometry may be of clinical benefit in cases of known history of diabetes controlled by medication with suspected diabetic emergencies, seizure, stroke/CVA, opiate/opioid overdose and behavioral emergencies, and may provide agencies with information necessary to help determine the appropriate treatment and hospital destination for patients with s/s of stroke/CVA. • BLS providers should refer to the most current New York State BLS Altered Mental Status protocol (M-2) ; M-2 revision has been officially published and referred under NYS Policy Statement 13-10

18. Suffolk County EMS BLS Blood Glucometry Policy • Request Advanced Life Support (ALS) but do not delay transport to the hospital waiting for ALS, or to perform blood glucometry • It is understood that the applicable New York State DOH Basic Life Support (BLS) Protocols are always to be initiated in conjunction with this policy, particularly for AMS, suspected stroke/CVA, seizure, overdose, and behavioral emergencies. • Assess the situation for potential or actual danger. If the scene/situation is not safe, retreat to a safe location, create a safe zone, and obtain additional assistance from a police agency.

19. Suffolk County EMS BLS Blood Glucometry Policy • Persons suspected of a behavioral emergency must be presumed to have an underlying medical or traumatic condition causing the AMS. All suicidal or violent threats or gestures must be taken seriously. • These patients should be in police custody if they pose a danger to themselves or to others. If the patient poses a danger to themselves or others and police are not present, summon police for assistance. • Consider the use of soft restraints per current policy to protect the patient and yourself

20. Suffolk County EMS BLS Blood Glucometry Policy • Perform patient assessment. This protocol is intended for use for any adult patient presenting with the Signs and/or Symptoms of : • stroke • seizure activity; • syncopal episode; • opiate/opioid overdose • previously diagnosed history of diabetes and whose complaints are consistent with signs and symptoms of hypoglycemia. • NOTE: Altered Mental Status denotes a change in the patient’s mentation from their usual status as defined by anyone who is familiar with the patient……OR…….. • the EMS provider reasonably believes the patient’s GCS is usually 15 and the patient presents with a GCS less than 15.

21. Suffolk County EMS BLS Blood Glucometry Policy • Obtain blood sample via finger stick, perform blood glucose testing and document on the PCR. Be prepared to pass this information along to responding ALS personnel. If blood glucose is less than (<) 65 mg/dl AND the patient is conscious with an intact gag reflex: • Administer 1 Tube Oral Glucose (24 grams) between the patient’s cheek and gum or on patient’s tongue. Use caution and avoid creating a choking hazard. If necessary, the patient may self-administer Oral Glucose. • Begin transport to the hospital

22. Suffolk County EMS BLS Blood Glucometry Policy • Reassess blood glucose after five (5) minutes. If blood glucose remains less than (<) 65mg/dL,AND AMS is present AND the patient is conscious with an intact gag reflex: • Administer a second tube of Oral Glucose(24 grams) between the patient’s cheek and gum or on patient’s tongue. Use caution to avoid creating a choking hazard. If necessary, the patient may self-administer Oral Glucose. • if the BG is less than (<) 65 but the AMS resolves or the patient goes back to baseline, withhold further oral glucose • If needed…..reassess blood glucose after another five (5) minutes. If blood glucose remains less than 65mg/dL,AND AMS is not resolved the patient is conscious with an intact gag reflex: • Administer a third tube Oral Glucose (24 grams), per above procedure

23. Suffolk County EMS BLS Blood Glucometry Policy • Contact Medical Control to discuss cancellation of responding ALS ambulance or for hospital destination decision if blood glucose is greater than 65mg/dL and ALL of the following conditions exist: • The patient is alert with a GCS of 15 -OR - For cases where the patient’s usual GCS is less than 15, the patient’s usual level of mentation has been restored; • The patient has a diagnosed history of diabetes; AND • The patient does not present with any complaints that require ALS intervention. • If the patient chooses to RMA after administration of glucose • Provide post-call signal 34 to Suffolk County Medical Control to register your call with the system.

24. NY STATE BLS PROTOCOL

27. Fingerstick Procedure For Accurate Glucose Results Credit to: Duke University

28. Choose the finger carefully • Best locations for a finger stick is the 3rd and 4th fingers of the non-dominant hand. • Avoid the 2nd and 5th fingers if possible. • Perform the stick off to side of the center of the finger. • NEVER use the tip or center of the finger. Credit to: Duke University

29. Massage or Warm the site • Avoid fingers that are cold, cyanotic, swollen, scarred or covered with a rash. • Massage to warm the finger and increase blood flow by gently squeezing from hand to fingertip 5-6 times. Credit to: Duke University

30. Clean and Dry the site • Cleanse fingertip with 70% isopropyl alcohol • Wipe dry with clean gauze or allow to air dry. • Caution: Alcohol can falsely elevate or lower blood glucose results. Credit to: Duke University

31. Finger Stick location • Using a sterile lancet, make a skin puncture just off the center of the finger pad. • Wipe away the first drop of blood (which tends to contain excess tissue fluid). Credit to: Duke University

32. Do not milk finger • If necessary, apply lightpressure to the surrounding tissue until another drop of blood appears. • Avoid "milking." The drop of blood must be big enough to fill the strip completely. • NOTE: Do NOT squeeze or apply strong repetitive pressure to the site. This may result in hemolysis or increase tissue fluid in the blood causing incorrect glucose results. • Caution: Free flowing blood is necessary to obtain reliable results. Increased pressure beyond that necessary to hold the finger can result in inaccurate results. Credit to: Duke University

33. BG Procedure • The glucometer reading indicates the amount of glucose in the patient’s blood stream.

34. What are we measuring? • The amount of glucose in the blood.

35. Blood Sugar Level Yields high blood –sugar levels

36. Hyperglycemia and Hypoglycemia • Both lead to diabetic emergencies. • Hyperglycemia: Blood glucose is above normal. • Result of lack of insulin • Untreated, results in DKA

37. Hyperglycemia and Hypoglycemia • Hypoglycemia: Blood glucose is below normal. • Untreated, results in unresponsiveness and hypoglycemic crisis • Signs and symptoms of hyperglycemia and hypoglycemia are similar.

38. Hyperglycemia and Hypoglycemia

39. What Now? Properly dispose of sharp Treat the Patient Document Results

40. Administering Glucose • If the blood glucose reading is less than (<) 65 mg/dl and the patient is awake w/ intact gag reflex, let patient them squeeze oral glucose into his/her mouth

41. Administering Glucose w/ Tongue Depressor • If patient awake w/ intact gag reflex, open the patient’s mouth. • Place the tongue depressor on the mucous membranes between the cheek and the gum (bucchal) with the gel side next to the cheek. • Repeat as needed, per protocol and policy.

42. Differential Pre-hospital Impressions • Since many of the signs and symptoms of hypoglycemia mimic those of other illnesses / events , it has become the standard of care to use blood glucometry in assisting the provider in determining both a hospital destination and what further intervention during transport is warranted. Some common conditions that hypoglycemia might mimic: • Overdose (Especially Alcohol and Opiates/Opioids) • TIA/CVA (including aphasia, dysarthria and hemiparesis) • Postictal state • In essence, all of these can manifest in “AMS” • Therefore, the modification to the NYS AMS Protocol, to include: • Nasal Narcan administration at the BLS level • Glucometry

43. Hypoglycemia versus Opioid Overdose • If the patient’s blood glucose is greater than (>) 65 mg /dl, the patient is not “hypoglycemic” and other causes of AMS should be explored • Given the new treatment options of inhalation narcan, consider opioid overdose if the patient has AMS and respiratory depression with pinpoint pupils

44. Hypoglycemia versus Stroke/CVA • If patient’s blood glucose is greater than (>) 65 mg/dl and their respiratory rate is normal and there is no evidence of opioid overdose….consider stroke/CVA

45. Hypoglycemia versus Stroke/CVA • Perform initial assessment • Mental status • ABC • Vital Signs • Obtain relevant history • OPQRSTI • Time symptom onset / last seen normal • Sz activity? • Recent illness, injury, surgery • Focused Physical Examination • Glasgow Coma Score • Cincinnati Prehospital Stroke Screen • Blood glucose • Signs of trauma

46. Opioid Overdose The signs and symptoms of opioid overdose and the administration of inhalation narcan are covered in the required on-line video review and skills affirmation process Congratulations, you have successfully completed the education phase of blood glucometry

47. The next step • All CFRs and EMT-Bs will be required to participate in the BG practical skill at the agency level

48. Case Study 1 You are treating a 59 year old male patient, with a sudden onset of altered mental status and lethargy per bystanders. History includes bone cancer, Type II diabetes, high blood pressure. He is on glucophage for his diabetes, wears a fentanyl patch for pain management, and takes labetalol for his hypertension. Physical exam reveals that the patient responds to painful stimuli by groaning, his pupils are bilaterally constricted, respiratory rate is 4 breath per minute, B/P is 110/70 and heart rate is 66 regular and strong. You perform a blood sugar via finger stick, the glucometer shows 100 mg / dl. Your field impression is: Hypoglycemia 3. Opioid Overdose 2. Stroke / CVA 4. Hypertensive Crisis What is the appropriate treatment for this patient? Oral Glucose 3. Oxygen an 6 lpm via nasal cannula 2. Inhalation narcan 4. Allow the family to give him his glucophage

49. Case Study 2 You are treating a 56 year old female patient, with a sudden onset of altered mental status, with difficulty in speaking. History includes heart disease with several TIAs. Patient’s daughter states that the patient was fine all morning, and went into the room when she “heard a sound of breaking glass.” Daughter also states that the patient returned from an overseas airline flight several days ago. Patient takes no medications on a regular basis. Physical exam reveals that the patient’s eyes are opened spontaneously, pupils are normal in size, equal and reactive, respiratory rate is 14 breath per minute, B/P is 140/90 and heart rate is 72 regular and strong. Because of the AMS, you perform a blood sugar via finger stick, the glucometer shows 88 mg / dl. Cincinnati Prehospital Stroke Screen reveals that the patient has pronator drift with concurrent facial droop and cannot speak normally. Your field impression is: Hypoglycemia 3. Opioid Overdose 2. Stroke / CVA 4. Acute Myocardial Infarction What is the appropriate treatment for this patient? Oral Glucose3. Assist the patient with her prescribed nitroglycerine 2. Follow NYS BLS Stroke/CVA Protocol 4. Inhalation Narcan

50. Case Study 3 You are treating a 26 year old male patient, with a sudden onset of altered mental status, which you are told progressed to “unconsciousness” prior to your arrival on a construction site. The supervisor states that the job needed to be finished so he ordered the crew to work through lunch. He states that he “thinks the patient has sugar problems” and “just returned to work several days ago after recovering from an on-the-job back injury.” Physical exam reveals that the patient is A&O x 3, speaking well, pupils are normal in size, equal and reactive, respiratory rate is 18 breath per minute, B/P is 126/84 and heart rate is 80 regular and strong. Because of the AMS, you perform a blood sugar via finger stick, the glucometer shows 50 mg / dl. Your field impression is: Hypoglycemia 3. Opioid Overdose Stroke / CVA 4. Complications from Back Injury What is the appropriate treatment for this patient? Oral Glucose 3. Oxygen, and transport to the closest Trauma Center 2. Low Dose Aspirin 4. Inhalation narcan