blood glucose in-office lab testing fall 2016 · •pp: post prandial (number of hours since last...
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Blood Glucose In-Office Lab
Testing
Fall 2016
Judy Perrigin MT(ASCP), OD
UHCO
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Point of CareTesting (POCT)
• Bedside / chairside / EMS
• Rapid, immediate results
• Easy, almost fool proof
• CLIA waived uses devices / kits FDA
approved for home use by consumers
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OSHA
• Concerned with employee and patient safety
• Universal Precautions, Blood Borne Pathogens Rules – Must keep log of all injuries from contaminated sharps
– Employees must “have a say” in selection of protective devices
• Offer, at employer’s expenses, hepatitis injections to any employees who could be expected to come in contact with blood or other potentially infectious materials
• Requires use of gloves for those performing finger sticks and testing – Non-latex preferred
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OSHA
• Gloves: required for
finger sticks
• must have non-latex
available
• Wash hands before &
• After gloving
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Latex sensitivity
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Latex covers
• Rare but can cause conjunctivitis in sensitive patients
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OSHA
• Biohazard bags &
boxes. Hardsides for
sharps, bags for soft
items
• Disposal
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CLIA
• CMS regulates all lab tests on humans
except research via Clinical Laboratory
Improvement Amendments 1988
• Objective of the CLIA program is to ensure
quality laboratory testing
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• All entities who perform even 1 lab test,
including waived tests, on materials from
the human body for purpose of dx,
prevention, or treatment of any condition
must register with CLIA
– Required even if not charging
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CLIA Certificate
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CLIA registration
• www.cms.gov/clia/
• CLIA categorizes laboratory tests
according to complexity & states staff
qualifications needed for each
– Waived
– Moderate / PPM
– Complex
• The CLIA application form: CMS-116
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Diabetes
• Diabetes is 7th leading cause of death in
USA
• Leading cause of blindness in US
• 57 million people have pre-diabetes
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Who to screen for DM
• Sx or asx patients who are overweight or
obese
• Systemic or ocular diabetic sxs
• Family hx especially siblings & parents
• Ethnic predisposition
• Ocular indications
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Ethnic pre-disposition
• Hispanic Americans
• Native Americans
• South Asian Americans (Pakastani, Indian,
etc)
• African Americans
• Pacific Islanders
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Diabetic retinopathy
• How at risk is the diabetic patient for
proliferative retinopathy?
– How well-controlled is the patient?
• Fasting plasma glucose
• Glycosylated Hgb (A1C)
– Diabetics strive for <7% or closest to normal can get
without causing hypoglycemia
• Protein in urine (proteinuria): strong predictor
• Blood lipids: especially high LDL &/or low HDL
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DM patients case hx
Ask them what their glucose and A1C
values usually are
• Ask them if they self- test glucose or A1C
– How often, when was last check?
• Ask when was last physical exam
• Ask if smoke, how much & how long
• Ask when last dental exam was
• Ask when last foot exam was
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Why ask about the foot exam?
• More DM hospitalization days due to foot ulcers &
complications than other causes
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American Diabetes Association
• ADA site www.diabetes.org
– THE experts on everything diabetes
– Layperson & professional sections
– Continual updates
– Dx criteria
– Diabetic risk test available
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Abbreviations
• FPG: fasting plasma glucose, one of the 2
tests of choice for dx of DM
• PG: plasma glucose
• Random / casual glucose test: anytime of
day without regard to last meal
• A1C: glycosylated hemoglobin: 1 of the
tests of choice for dx of DM: NEWLY
recommended by ADA for Dx
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• PP: post prandial (number of hours since
last caloric intake
• Fast period for glucose testing: minimum
of 8hrs (if want fasting specimen)
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Blood Glucose Dx Ranges ADA
• Normoglycemia
– FPG: 70 to 100mg/dl
– 2 hr OGT <140mg/dl
• IGT Impaired glucose metabolism/pre-
diabetes
– FPG 100-125mg/dl
– 2 hr OGT 140-199 mg/dl
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• Diabetes mellitus
– FPG > 126mg/dl or
– 2 hr OGT > 200 mg/dl or
– Sxs of diabetes & random value of >200mg\dl
– OR
– A1C 6.5% or greater
– For dx using blood glucose measurements should have abnormal tests results on 2 different days
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IFG or IGT
• Impaired or pre-diabetic
• Risk factor for developing DM
• Variable study results re if intervention
such as exercise, diet, etc prevent these
people from progressing to DM
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Low glucose values on screening
(non-diabetics)
• May be error in technique-not enough
blood on strip or taking too long to
completely apply the blood to strip. Retest.
• May be due to long interval since last
intake of calories; extra long fast
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Unexpected or abnormal PG
results
• Rerun the test
• Rerun the control
• Refer if still abnormal
– Counsel need to see PC for further testing.
Could indicate diabetes but physical exam
and more testing needed for accurate dx as
other conditions, various meds and not
diabetes could have caused the elevated
glucose values.
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Who to refer
• Refer to pt’s PC if in
impaired or diagnostic
range
• Provide f/u to verify
that those referred
sought and received
assistance
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OGT or OGTT: oral glucose
tolerance test
• Patient fasts for minimum of 8 hours
• Blood and urine specimens tested for glucose values fasting, and after drinking standard amount of glucose solution
• Fasting and 2 hour values are the most useful
• Not currently used much except for GDM or unclear cases
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CPT CODES
• Blood glucose testing CPT 82962
• Finger puncture or other cap blood CPT
364.16
• Venipuncture blood collection CPT 364.15
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In-office blood glucose screening
procedure
• Inquire how long since last caloric intake
• Run control before sticking patient
• Perform finger stick and test patient
• Apply pressure and bandaid
• Record results of control, patient, time of
day, hours since last caloric intake
• Interpret results, counsel patient, refer if
indicated, tell when to ck glucose again
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Control
• Control solutions contain known amounts of substance being measured
• Must run each day that tests are run & by each person running tests that day, whenever open new box of strips, whenever get unexpected test results
• Must be recorded in patient’s chart and in log
• Run exactly in same manner as test
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What should the control read?
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If the control reads too high or too
low
• Could be due to:
– Reagents: strips or control soln
– Technique of the person performing the test
– Faulty instrument-out of calibration: must
return to manufacturer
– Do not stick or test the patient if control is out
of range
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Finger “sticks”
• Use only instruments
which self –retract
i.e. safety lancets
• Fresh lancets will be
capped
• Dispose of in
hardside sharps
containers
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• Patient & clinician should wash & dry their
hands
• Clinician must wear gloves
• Verify that using a new sterile lancet
(capped)
• Select patient finger that is non-callused,
clean with alcohol & dry
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Wash & dry hands, clean selected
finger with alcohol
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Dry with clean cotton or gauze
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Cap indicates new unused lancet
Only use devices which self-retract
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Choose fleshy non-callused finger
• Grip finger tightly
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Milk if needed
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• Good sample Not enough blood & too spread out
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AST
• Alternate site testing approved for some
meters and puncture devices
– For patients who do multiple sticks per day
– Calf, thigh, palm, forearm
– Nerve endings/pain receptors less concentrated
• Not recommended for general screening
purposes
– Less reliable if low or fluctuating results, or
immediately following meals or exercise
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For all meters
• Only use meters approved for in-home use/CLIA waived
• Do not reuse test strips-must use fresh strip for each test or control.
• Control should be run before the patient. Do not test the patient if the control value is not correct.
• Be sure the meter is on when the blood is applied.
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• Apply blood to edge not top or bottom of
strip
• Do not remove the finger from the strip too
quickly.
• Reading will appear after allotted time
– Just a few seconds
Follow instructions for that particular meter
EXACTLY.
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Meter being used today
• Embrace by Omnis
Health
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• Insert contact bars end of test strip into
meter
• Temperature sensitive-won’t run if room
too hot or cold
• When the blood drop symbol appears,
apply a drop of blood or control to the
marked edge of the strip. Reads in 6 sec
• Manually remove used strip without
touching blood & place in sharps
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Disposal of BH Waste
• Place all used strips into sharps container
• Place used lancet into sharps container
• Place soft contaminated gauze, gloves,
and aprons into BH bag
• Disinfect work areas before and after use
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Counseling / Patient Education
• Refer if in impaired or diabetic range
• When plasma glucose results are normal
– Only a screening test: doesn’t absolutely rule
out diabetes
– Recheck in 1-3 years depending on age,
family hx, personal hx
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Assignment
• Record diabetic case hx
• Perform control test properly
• Perform finger stick properly on partner
• Measure value correctly on partner
• Record, interpret, and record what you
would tell the patient
• Turn in assignment for grading
• Dispose of used materials properly