Contents 1902
Title:
Diabetes - Capillary Blood Glucose Monitoring
Policy (Community)
Directorate:
Operations
Responsible
for review:
Heidi Clarke
Ratified by:
Care and Clinical Policies sub group
Applicability:
All Nursing Staff
Ref No:
Version: 3
Classification:
Due for Review: 09/04/17
Document Control
1902
Contents
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Purpose…………………………………………………………………………………………...........
Introduction……………………………………………………………………………………............
Roles and Responsibilities…………………………………………………………………………….
Main Body of the document………………………………………………………………………….
Training and supervision………………………………………………………………………..........
Monitoring and Auditing……………………………………………………………………………….
References…………………………………………………………………………………………….
Equality and Diversity …………………………………………………………………………………
Further Information ……………………………………………………………………………………
Appendices…………………………………………………………………………………………….
Document Control Information………………………………………………………………………….
Mental Capacity Act and Infection Control Statement……………………………………………….
Quality Impact Assessment (QIA) ……………………………………………………………………..
1
Purpose
This policy aims to ensure that capillary blood glucose monitoring is carried out to high standard
throughout Torbay & Southern Devon Health and Care NHS Trust the only capillary blood glucose
meter approved for use on adults staff employed by Torbay & Southern Devon Health and Care
NHS Trust is the Roche Performa System.
2
Introduction
Capillary blood glucose monitoring provides reliable near patient testing, which allows on-going
assessment of diabetic control. The purpose of this guideline is to ensure that all capillary blood
glucose measurements are accurate and performed by health professionals that are appropriately
trained ensuring that patient care and safety is optimised.
3
Roles and Responsibilities
This policy is for use by all practitioners including Registered Nurses (RN) and NVQ level 2 & 3
Health Care Assistants who undertake blood glucose monitoring. Support Workers Intermediate
Care (SWIC), Assistant Practitioners and Trainee Assistant practitioners. 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 nurse should have a meter available where appropriate.
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4
Capillary Blood Glucose Monitoring
4.1 Risk Management Whilst using a capillary blood glucose meter has the advantages of rapid
production of results, prompt treatment and the involvement of patients with their own care, adequate
measures must be taken to ensure accurate results. If the tests are not performed with care and
attention to technique, the results can be erroneous and dangerous (Rosindale et al 2005, Rosindale
et al 2004, Sharpe 1993).
Please Note: ‘Neither the strips nor the meters have completely fail-safe mechanisms. Therefore it
falls on the individual user (usually the nurse) to be aware of the factors, which could lead to
inaccuracies. It is not enough just to know how to use the equipment’ (Walford, S., Clark, P., Allison,
S.P 1980)
Written and signed records must be kept of the time and result of each capillary glucose measurement
taken (appendix 1).
4.2 Limitations/Uncertainty of Measurement
 The meter will give results for glucose in the range of 0.6-33.3 mmol/L.

The meter should only be operated within the temperature range of 6-44 C.

A minority of patients may be affected by a number of test interferences and contra-indications.
Substance
Interference Limit
Interference due to treatments
Ascorbic Acid
>3mg/dL
Interference due to medical conditions
Galactose
>0.83 mmol/L
Triglycerides
>20.3 mmol/L
Haematocrit
No effect
Contra-indications
Severe dehydration,
Hypotension, Shock
Peripheral circulatory failure
Hyperosmolar non ketotic
coma (HONK)
Diabetic ketoacidosis (DKA)

Therapeutic Range
N/A
Physiological Range
<0.28 mmol/L
0.34-3.70 mmol/L
Should be between
10%+65%
The recommendation from the MHRA is that a
venous sample should be sent to the
laboratory for verification
If the meter result is not in keeping with the patients clinical status or
if contra-indications are clinically observed/suspected or
the patient has a history of the relevant conditions
Then laboratory measurement of glucose by venous sample should be carried out.
.
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4.3 Performing a Blood Glucose Test
Please see appendix 1 – SOP for the use of Roche Accu-Chek Performa Glucose meter
4.4 Finger Pricking devices
Spring-loaded lancing devices are preferable than using stand-alone lancets, as they have been
proved to be less painful to the patient.
In diabetic patients without clinically evident neuropathy, finger-prick devices proved to be significantly
less painful than lancets both immediately and 1 minute after a procedure of capillary blood sampling.
(Veglio-Sivier R et al 1996).
There are a number of devices available at this time, however, there are very few that are suitable for
multi-patient use.
There are a number of reported cases of Hepatitis B being transmitted through finger pricking devices
and of needle stick injury to healthcare professionals (MHRA 2011). For this reason we now
recommend that the only device to be used is for single-patient use only. Currently in Torbay &
Southern Devon Health and Care NHS Trust the ‘Unistik 3 Comfort’ (Owen Mumford) device is
available. This device is a pre-set single-patient use safety lancet and is completely disposable into a
sharps bin after one use. This eliminates the risk of cross infection and also reduces the risk of needle
stick injury.
4.5 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.
New/Replacement/faulty glucose meters will be issued by: Point of care Team, Biochemistry
department, Torbay Hospital 01803 655250 or 655254
Provision of Test Strips and IQC can be obtained from Torbay Hospital Pharmacy 01803 655501.
Provision of Owen Mumford Unistik 3 Comfort lancets is available through Oracle
5 Training and Supervision
5.1 The Department of Health (DOH) has issued advice for health professionals entitled ‘Point of Care
testing – Blood Glucose meters’ (DOH 2011). 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.
5.2 Only Registered Nurses 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. Those who assess Health Care Assistants must be a holder of the NVQ A1 Assessor
qualification (formerly D32/33) and refer to healthcare competency BDS2 ‘obtain and test capillary
blood samples’ as a recognised minimum standard for the SNR’s to complete.
5.3 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 & Southern Devon.
5.4 Training responsibilities of Community Nurse Leads:
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Will maintain an accurate record of staff members who have attended training and
achieved specific learning outcomes regarding capillary blood glucose monitoring.
Access I-Care 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 trained staff perform glucose testing and are issued with a meter
Will ensure that staff should attend update training on blood glucose monitoring, every
two years, as a minimum requirement.
Nurses must be aware of their responsibility for maintaining their own competence (Nursing and
Midwifery Council (NMC) 2015).
Torbay & Southern Devon Health and Care NHS Trust strongly advise that nursing staff employed by
GP practices follow this guidance.
The DOH (2011) 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.
The following groups of staff are eligible for training:
 Registered nursing staff
Skilled Not Registered. All untrained 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 range of 4 14 mmol/l i.e. blood glucose levels below 4 or above 14 should be reported to the nurse in charge
immediately
6.
Monitoring and Auditing
6.1 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).
6.2 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.
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.
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 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 2: SOP for the use of Roche Accu-Chek Performa glucose meter for
pictorial detail on IQC.
6.3 External Quality Assurance (EQA)





On alternate months for Torbay & Southern Devon 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 I-Care 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 re-activate
the glucose meter asset number so that the nurse starts receiving EQA samples again. This
system is available on I-Care web page ‘Community Nurse Leads’.
Access for both web pages and database for Community Nurses and Community Nurse Leads
is through the Deputy Head of Nursing
7.
References
 Medicines and Healthcare products Regulatory Agency (MHRA) lancing devices for obtaining
blood Monitoring. June 2009. Drug safety Update Vol 2, Issue 1.
 Medicines and Healthcare products Regulatory Agency (MHRA) Point of Care Testing – Blood
Glucose Meters. Advice for Health Professionals. Department of Health. 2011. London. Crown.
 National Institute for Clinical Excellence (NICE) 2004 Type 1 diabetes - Type 1 diabetes: Diagnosis
and management of Type 1 diabetes in children, young people and adults. Clinical Guideline 15.
London. Crown
 National Institute for Clinical Excellence (NICE) 2009 Type 2 diabetes – The management of Type
2 diabetes. London. Crown.
 National Institute for Clinical Excellence (NICE). (2011) Quality Standards for Diabetes in Adults.
London. Crown.
 Nursing and Midwifery Council (2015). The Code. Professional standards of practice and
behaviour for nurses and midwives. London UK.
 Rosindale S (2005). A Study of the Accuracy of Blood Glucose Results from Meters in the
Community. Journal of Diabetes Nursing Vol 9 (8) 291 - 296
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Rosindale S, Bower L, Farleigh E, Francis M, Drew C, Cooke P (2004) A Community study of
accuracy of blood glucose meter results. Journal of Diabetes Nursing Vol 8 (7) 272 – 276
Sharpe S (1993). Blood glucose monitoring in the intensive care unit. British Journal of Nursing Vol
2 (4): 209.
Veglio-Sivier R, Trento M, Porta M. (1996) Finger-Pricking Devices: Are They less Painful than
Lancets? Diabetes Medicine Vol.13: 598
Walford S, Clark P, Allison S.P (1980) ‘The influence of renal threshold on interpretation of urine
test for glucose in patients’. Diabetes Care 3: 672-674
Medicines and Healthcare products Regulatory Agency (MHRA) Point of Care Testing – Blood
Glucose Meters. Advice for Health Professionals. Department of Health. 2011. London. Crown.
8.
Equality and Diversity
8.1
This document complies with the South Devon Healthcare Foundation Trust and Torbay and
Southern Devon Health and Care NHS Trust Equality and Diversity statements.
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9. Appendices
Appendix 1
Standard Operating Procedure
Title: For the Use of Roche Accu-Chek Performa Glucose meter
Prepared by: Sam Rosindale
Presented to: Care & Clinical Policies
Ratified by: Care & Clinical Policies
Links to policies:
Capillary Blood Glucose Monitoring
Date: June 2015
Date: 15/06/2015
Review date: June 2016
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 measurements are accurate and performed by health professionals that
are appropriately trained ensuring that patient care and safety is optimised.
1 Scope of this SOP – The only capillary blood glucose meter approved for use on adults and to
use within Torbay & Southern Devon Health and Care NHS Trust is the Roche Accu-Chek Performa
System. The Roche Accu-Chek Performa Glucose Meter is 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 all practitioners including Registered Nurses (RN)
and NVQ level 2 & 3 Health Care Assistants who undertake blood glucose monitoring. Support
Workers Intermediate Care (SWIC), Assistant Practitioners and Trainee Assistant practitioners. 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. Each
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 &
Southern Devon Health and Care NHS Trust staff
Procedure:
Equipment
Roche ACCU-CHEK Performa Glucose Meter.
Roche ACCU-CHEK Performa 2-Level Controls.
Roche ACCU-CHEK Performa Glucose Test Strips.
Roche Safe-T Pro Plus Lancets.
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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 (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).
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.
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.
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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 I-Care 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 2008).
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 patient/client care plan.
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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.
4
Inform II test strips, IQC solution – from Torbay Hospital Pharmacy
Unistik 3 Lancets – order from Oracle
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
changed or to check meter performance.
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
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.
- “OK” and the control result alternate on the display if the result is in range.
(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.
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Only proceed with patient testing if both levels of IQC have been
SAMPLE
HANDLING
- ALWAYS
GLOVES
& FOLLOW range
TRUST within
INFECTION
CONTROL
tested
and are
within WEAR
the quoted
acceptable
the last
24
PROCEDURES
hours.
 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
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.
Trigger button
Protective
Cap
For babies and neonates refer
to departmental guidelines for
selection of lancing device
and its correct use.
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.
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What do these screen messages mean and what action do you need to take?
OR
Blood glucose may be
higher than the measuring
range i.e. greater than 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, 01803 655250 or 655254) 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
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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
patient use
must be decontaminated following each and every
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 InterpretationResults 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.
Monitoring tool
Standards:
Item
Internal Quality Control, log book completed weekly
External Quality Assurance sample result returned
to Biochemistry Department at Torbay Hospital on
alternate months
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%
100
100
Exceptions
Sick leave, annual leave,
maternity leave
Sick leave, annual leave,
maternity leave
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10.
Document Control Information
11.
Mental Capacity Act and Infection Control Statement
12.
Quality Impact Assessment (QIA)
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11.
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:
Document title:
Purpose of document:
Date of issue:
Version:
Author:
Directorate:
Equality Impact:
Committee(s) approving the
document:
Date approved:
Links or overlaps with other
policies:
Capillary Blood Glucose Monitoring Policy
Safe and accurate blood glucose monitoring by
healthcare professionals
Next review date: April 2017
April 2015
Last review date:
3
Samantha Rosindale
Operations
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
Care and clinical policies
June 2015
All SDHCFT Trust Strategies, policies and procedure
documents
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Yes
No
Does this document have training implications?
If yes please state:
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Does this document have financial implications?
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Is this document a direct replacement for another?
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Document Amendment History
Date
Oct 2009
August 2012
Amendment
Version no.
summary
1
new
2
rebadged
Collated by Clinical Effectiveness
Version 3 (APRIL 2015)
Ratified by:
Samantha Rosindale
Samantha Rosindale
Title of document
Page 15 of 17
12.
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 iCare
http://icare/Operations/mental_capacity_act/Pages/default.aspx
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.
Collated by Clinical Effectiveness
Version 3 (APRIL 2015)
Title of document
Page 16 of 17
13.
Quality Impact Assessment (QIA)
Please select
Who may be affected by this
document?
Patient / Service Users
☒
Visitors / Relatives
☐
General Public
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Voluntary / Community
Groups
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Trade Unions
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GPs
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NHS Organisations
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Police
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Councils
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Carers
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Staff
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Other Statutory
Agencies
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Others (please state):
Does this document require a service redesign, or substantial amendments to an existing
process?
☐
If you answer yes to this question, please complete a full Quality Impact Assessment.
Are there concerns that the
document could adversely
impact on people and
aspects of the Trust under
one of the nine strands of
diversity?
Age
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Disability
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Gender re-assignment
☐
☐
Pregnancy and maternity
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Marriage and Civil
Partnership
Race, including
nationality and ethnicity
Religion or Belief
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Sex
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Sexual orientation
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☐
If you answer yes to any of these strands, please complete a full Quality Impact Assessment.
If applicable, what action
has been taken to mitigate
any concerns?
Who have you consulted
with in the creation of this
document?
Note - It may not be sufficient
to just speak to other health &
social care professionals.
Patients / Service Users
☒
Visitors / Relatives
☐
General Public
☐
Voluntary / Community
Groups
☐
Trade Unions
☐
GPs
☒
NHS Organisations
☐
Police
☐
Councils
☐
Carers
☐
Staff
☒
Other Statutory
Agencies
☐
Details (please state):
Collated by Clinical Effectiveness
Version 3 (APRIL 2015)
Title of document
Page 17 of 17
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