Glucose Monitoring
Ceri Jones
2014
Glucose Monitoring
Why? Who?
Benefits of Glucose
Monitoring
 Improve glycaemic control?
 Empowerment
 Hypoglycaemia?
 Intercurrent illness/sick day rules
 Pre-pregnancy, pregnancy
 Driving
 Special clinical situations
 Intensive regimens
Glucose monitoring Studies
 ROSSO
 SMBG decreased diabetes-related morbidity and allcause mortality
 SMBG may be associated with a healthier lifestyle
and/or better disease management
 Faas
 SMBG in T2DM patients questionable needs good RCT
 Coster
 SMBG established in clinical practice optimal use not
established.
 Evidence suggests may not be essential for all
Reasons for not BGM
Cost
The NHS spends approximately £90 million on blood glucose
testing materials. This is 40% more than on oral
hypoglycaemic agents (£64 million).
Inaccuracies
 Out of date strips
 Contaminated strips
 Incorrect meter calibration
 Meter reading incorrectly
 Sticky fingers
 Incorrect sample size
 Temperature of equipment
Rhondda Cynon Taff
12 months Costs 2003-2004
Hazard Warning
 A Department of Health hazard warning notice (HN
(Hazard)(87), stated that all staff should be trained in the use
of Blood Glucose meters including the Quality Assurance
process by appropriate trained staff.
Diabetes UK advise that no member of staff, registered
or otherwise should:-
 perform blood glucose monitoring unless they have a sound
knowledge base of diabetes.
 have received training on blood glucose monitoring using the
meter specific to their place of employment.
 be aware of how to interpret the reading(s) obtained and the
subsequent action to be taken.
POCT
Cwm Taf Health Board’s “Point of Care Testing Policy”
(2010), define Point of Care testing as:-
 “Analytical tests undertaken by non-laboratory
staff outside a recognised diagnostics laboratory”
The policy also states:-
 “Only staff whose training and competence has
been established and documented should use any
Point of Care Testing device.”
Case Study 1

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 result indicated hyperglycaemia and insulin treatment was initiated. A
separate sample sent to the hospital laboratory gave a markedly different result.

A thorough investigation, revealed that the glucose meter should not be used on
patients who were on treatments containing maltose. The patient suffered significant
hypoglycaemia and complications because staff were unaware of this limitation.
Key points
 • Users should be aware of the manufacturer’s instructions and contra-indications for
use.
 • 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
manufacturer’s recommendations.
 • The MHRA does not seek to apportion blame but instead to advise others on how to
avoid similar problems.
Case Study 2
 Outbreaks of hepatitis B were reported from several environments where
blood glucose monitoring was being carried out for multiple patients.
 Thorough investigations identified that care workers were found to be using
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
was implicated in the transmission of the virus.
Key points
 • Be aware that employing the wrong sort of lancing device can cause cross
infection.
 • 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,
by the manufacturer, for taking samples from more than one patient.
 • Users should review current practice to ensure that appropriate devices
are provided and used
BGM Guidelines
NSF Standards 3 and 4
 All children, young people and adults with diabetes will receive a
service which encourages partnership in decision-making, supports
them in managing their diabetes and helps them to adopt and maintain
a healthy lifestyle.
 All adults with diabetes will receive high-quality care throughout their
lifetime, including support to optimise the control of their blood glucose.
 All children and young people with diabetes will receive consistently
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
blood glucose.
BGM Guidelines
NICE Guidelines, 2002
 Self-monitoring should not be considered as a stand
alone intervention.
 Self-monitoring should be taught if the need/purpose is
clear and agreed with the patient.
 Self-monitoring can be used in conjunction with
appropriate therapy as part of integrated self-care.
BGM Guidelines
DUK Position Statement
 People with diabetes should have access to home
blood glucose monitoring based on individual clinical
need, informed consent and not on ability to pay.
 The majority of diabetes care is provided by the
individual. It is essential that people with diabetes be
provided with the education and tools in order to be
able to manage their diabetes for themselves.
Glucose Monitoring
Technology and technique
Technology
Meters
 numbers available
 Not on prescription
 Coding & quality
control
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Lancing Devices
Professional
Individual patient
Single use
Not on prescription
Lancets
 Available on prescription
Quality Assurance
 Training
Quality Control
 Accuracy of equipment
 Reliability of results
 Quality Control solutions
 Meter
 Strips
Quality Control
- when?
 New meter
 New test strips
 Change of Batteries
 Test strips left open
 Meter dropped/damaged
 Unexpected result
Failed Quality Control
 Check expiry dates
 Were tests carried out in correct order
 Repeat levels 1 and 2 again
 Change QC solution & Repeat
 Change test strips (change code)
Lancing Systems
Multiple use device with single use
lancet – patients
Single use lancet - professional
Sharps
 Sharps box should be used
 Sharps must NOT be put in rubbish
 Advice if no sharps box
 Sharps disposal service tel: 01443 494700
Glucose Monitoring
Frequency of testing and when?
Diet & Metformin
 If stable patients should be taught the
principles of HBGM and if appropriate
should monitor once a week fasting
Sulphonylureas
 If stable patients should be taught the
principles of HBGM and encouraged to
monitor twice a week fasting plus at 1
other time
Once daily or BD Insulin
 If stable patients should be taught the
principles of HBGM and encouraged to
monitor twice a day 2-3 times per week.

Basal Bolus Insulin Regimen
 If stable they should be encouraged to
monitor 4 times a day 2-3 times per week.
Factors affecting BG levels
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Food
Exercise
Physical activity
Illness and pain
Medication
OHAs
Insulin
Alcohol
Emotional stress
When to test more frequently?
 Medication is changed
 Insulin started
 Sick day rules / illness
 Risk of hypoglycaemia
 Exercise
 Advised by DSN or P/N
 Driving
 Pregnant/planning a family
Monitoring Errors
 Out of date strips
 Contaminated strips
 Incorrect meter coding
 Incorrect meter
 Hands not clean
 Temperature of equipment
Contraindications
 Severe dehydration
 Hypotension / Shock / Peripheral
Circulatory failure
 Hyperosmolar non-ketotic Coma
(HONK)
 Diabetic Ketoacidosis (DKA)
Venous sample to lab
Home Blood Glucose Monitoring
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
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 BD or
OD insulin should be
taught the principles of
HBGM and encouraged
to monitor twice a day 23 times per week.
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.
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.
Test more frequently if
Continuing education Monitoring
 Frequency
 Quality assurance
 Coding
 Acting on results
 HbA1c
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Medication is changed
Insulin started
Sick day rules / illness
Risk of hypoglycaemia
Exercise
Advised by DSN or P/N
Driving
Pregnant/planning a family
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
 DAFNE
 CSII
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