Glucose MonitoringGlucose MonitoringCeri JonesCeri Jones

March 2013March 2013

Benefits of Glucose Benefits of Glucose MonitoringMonitoring

Improve glycaemic control? Empowerment Hypoglycaemia?Hypoglycaemia? Intercurrent illness/sick day rulesIntercurrent illness/sick day rules Pre-pregnancy, pregnancyPre-pregnancy, pregnancy DrivingDriving Special clinical situationsSpecial clinical situations Intensive regimensIntensive regimens

ReasonsReasons for not BGM for not BGMCostCost

The NHS spends approximately £90 million on blood glucoseThe NHS spends approximately £90 million on blood glucose

testing materials. This is 40% more than on oraltesting materials. This is 40% more than on oral

hypoglycaemic agents (£64 million).hypoglycaemic agents (£64 million).

InaccuraciesInaccuracies Out of date stripsOut of date strips Contaminated stripsContaminated strips Incorrect meter calibrationIncorrect meter calibration Meter reading incorrectlyMeter reading incorrectly Sticky fingersSticky fingers Incorrect sample sizeIncorrect sample size Temperature of equipmentTemperature of equipment

Rhondda Cynon Taff 12 months Costs 2003-2004

BGM GuidelinesBGM GuidelinesNSF Standards 3 and 4NSF Standards 3 and 4 All children, young people and adults with diabetes will receive a All children, young people and adults with diabetes will receive a

service which encourages partnership in decision-making, supports service which encourages partnership in decision-making, supports them in managing their diabetes and helps them to adopt and maintain them in managing their diabetes and helps them to adopt and maintain a healthy lifestyle. a healthy lifestyle.

All adults with diabetes will receive high-quality care throughout their All adults with diabetes will receive high-quality care throughout their lifetime, including support to optimise the control of their blood lifetime, including support to optimise the control of their blood glucose.glucose.

All children and young people with diabetes will receive consistently All children and young people with diabetes will receive consistently high-quality care and they, with their families and others involved in 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 their day-to-day care, will be supported to optimise the control of their blood glucose. blood glucose.

BGM GuidelinesBGM Guidelines

NICE Guidelines, 2002NICE Guidelines, 2002

Self-monitoring should not be considered as a stand Self-monitoring should not be considered as a stand alone intervention.alone intervention.

Self-monitoring should be taught if the need/purpose is Self-monitoring should be taught if the need/purpose is clear and agreed with the patient.clear and agreed with the patient.

Self-monitoring can be used in conjunction with Self-monitoring can be used in conjunction with appropriate therapy as part of integrated self-care.appropriate therapy as part of integrated self-care.

BGM GuidelinesBGM Guidelines

DUK Position StatementDUK Position Statement People with diabetes should have access to home People with diabetes should have access to home

blood glucose monitoring based on individual clinical blood glucose monitoring based on individual clinical need, informed consent and not on ability to pay. need, informed consent and not on ability to pay.

The majority of diabetes care is provided by the The majority of diabetes care is provided by the individual. It is essential that people with diabetes be individual. It is essential that people with diabetes be provided with the education and tools in order to be provided with the education and tools in order to be able to manage their diabetes for themselves. able to manage their diabetes for themselves.

Glucose monitoring StudiesGlucose monitoring Studies ROSSOROSSO

SMBG decreased diabetes-related morbidity and all-SMBG decreased diabetes-related morbidity and all-cause mortality cause mortality

SMBG may be associated with a healthier lifestyle SMBG may be associated with a healthier lifestyle and/or better disease management and/or better disease management

FaasFaas SMBG in T2DM patients questionable needs good RCTSMBG in T2DM patients questionable needs good RCT

Coster Coster SMBG established in clinical practice optimal use not SMBG established in clinical practice optimal use not

established. established. Evidence suggests may not be essential for allEvidence suggests may not be essential for all

TechnologyTechnology

Meters numbers available Not on prescription Coding & quality

control

Lancing Devices Professional Individual patient Single use Not on prescription

Lancets Available on prescription

Monitoring Errors

Out of date stripsOut of date strips Contaminated stripsContaminated strips Incorrect meter codingIncorrect meter coding Incorrect meterIncorrect meter Hands not cleanHands not clean Temperature of equipmentTemperature of equipment

Quality AssuranceQuality Assurance

TrainingTraining

Quality ControlQuality Control

Accuracy of equipment Reliability of results Quality Control solutions Meter Strips

Quality ControlQuality Control- when?- when?

New meterNew meter New test stripsNew test strips Change of BatteriesChange of Batteries Test strips left openTest strips left open Meter dropped/damagedMeter dropped/damaged Unexpected resultUnexpected result

Failed Quality ControlFailed Quality Control

Check expiry datesCheck expiry dates Were tests carried out in correct orderWere tests carried out in correct order Repeat levels 1 and 2 againRepeat levels 1 and 2 again Change QC solution & Repeat Change QC solution & Repeat Change test strips (change code)Change test strips (change code)

Lancing SystemsLancing Systems

Multiple use device with single use Multiple use device with single use lancet – patientslancet – patients

Single use lancet - professionalSingle use lancet - professional

SharpsSharps

Sharps box should be used Sharps box should be used Sharps must NOT be put in rubbishSharps must NOT be put in rubbish Advice if no sharps boxAdvice if no sharps box Sharps disposal service tel: 01443 494700Sharps disposal service tel: 01443 494700

Factors affecting BG levels

Food Exercise Physical activity Illness and pain Medication OHAs Insulin Alcohol Emotional stress

Home Blood Glucose Monitoring

Continuing education Monitoring Frequency Quality assurance Coding Acting on results HbA1c

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

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

Test more frequently if Medication is changed Insulin started Sick day rules / illness Risk of hypoglycaemia Exercise Advised by DSN or P/N Driving Pregnant/planning a family

DAFNE CSII

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.

If stable people controlled with BD or OD insulin should be taught the principles of HBGM and encouraged to monitor twice a day 2-3 times per week.

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

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 basal bolus insulin should be taught the principles of HBGM and encouraged to monitor 4 times a day 2-3 times per week.

ContraindicationsContraindications

Severe dehydration Severe dehydration

Hypotension / Shock / Peripheral Hypotension / Shock / Peripheral Circulatory failure Circulatory failure

Hyperosmolar non-ketotic Coma Hyperosmolar non-ketotic Coma (HONK)(HONK)

Diabetic Ketoacidosis (DKA)Diabetic Ketoacidosis (DKA)

Venous sample to labVenous sample to lab