No more fingersticks in ICU?

Sun0408, ASN, RN · Jun 16, 2015

We aren't doing that, however, if the result is too low or too high we have to get a lab draw to confirm before we treat.

runsalot · Jun 16, 2015

Our protocol is changing just for PTs on pressors

Swellz · Jun 16, 2015

We aren't doing that, however, if the result is too low or too high we have to get a lab draw to confirm before we treat.

We have the same policy on my floor. I just SMILE and say, "It's that time again!" when they're q1 hour.

MunoRN, RN · Jun 16, 2015

I'd be curious what the "ton of research" is, I'm not aware of any at all that shows finger-sticks should not be used in the ICU. Glucometers use the amount of hemoglobin present in a sample to calculate the blood glucose, so it really doesn't make much of a difference if they have edematous fingers. There has been a trend recently though to use samples off of lines less as they can be inaccurate and present a source of infection, which would contradict the practice change where you work.

Regardless of the source, glucometers as well as samples sent to a central lab have a margin of error and this is where the "ton of research" lies; goal ranges should be higher than they were in the past, they should be approx 110-180. In other words, the research that's out there say it's the goal range that matters, where you get the sample from doesn't really matter, but fingersticks are preferred.

scottaprn · Jun 16, 2015

The reference list for this article is a good place to start.

Bad Request

Though the article is about an ESRD the discussion of the limits of glucometers is very solid. In particular sources 8-14 are worth reading. They are listed below.

Khan, A.I., et al. (2006) The variability of results between point-of-care testing glucose meters and the central laboratory analyzer. Archives of Pathological Lab Medicine, 130, 1527-1532.
Kanjii, S., et al. (2005) Reliability of point-of-care testing for glucose measurement in critically ill adults. Critical Care Medicine, 33, 2778-2785. doi:10.1097/01.CCM.0000189939.10881.60
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Ginsburg, B.H. (2009) Factors affecting blood glucose monitoring: Sources of error in measurement. Journal of Diabetes Science and Technology, 3, 903-913.
Nichols, J.H. (2011) Blood glucose testing in the hospital: Error sources and risk management. Journal of Diabetes Science and Technology, 5, 173-177.
Roche Diagnostics (2013) Hematocrit variable study protocol for glucose meter evaluations.
Gijzen, K., et al. (2012) Is there a suitable point-of-care glucose meter for tight glycemic control? Evaluation of one home-use and four hospital-use meters in an intensive care unit. Clinical Chemistry and Laboratory Medicine, 50, 1985-1992.
Critchell, C.D., et al. (2007) Accuracy of bedside capillary blood glucose measurements in critically ill patients. Intensive Care Medicine, 33, 2079-2084.

core0 · Jun 17, 2015

Hello all,
Questions for you... is everyone still doing fingerstick blood sugars in their ICU? As of yesterday we are no longer allowed to. We can either draw off a central line or PICC, or we have to use a butterfly to get a sample (we can choose arterial or venous sample in our accucheck). Our director says that there has been a ton of research that shows there have been many incidents/deaths because of inaccurate readings, and soon this will be mandated. I believe this is mainly in grossly edematous patients, as the serous fluid you get in the fingerstick does not contain the same glucose as the blood. (new grad here, so if my though process is wrong let me know!) I asked to see the research and haven't gotten anything yet. Just curious if this is only us, or if anyone else is doing the same. My concerns are BSI's going up due to frequent access of lines, or even needle sticks increasing. Plus, what about the DKA patient who has no line and needs 1hr glucose checks? They are going to get stuck an awful lot. Or what about the patients that get downgraded and are still very edematous, this protocol change is only in ICU..their fingerstick will be still be inaccurate regardless of what floor they are on. I want to do best for my patient, just curious if anyone else has gone this route. Thanks!

Dumb rule. There is a lot of confusion on this. The FDA correctly pointed out that POC glucometers have not been tested in critically ill patients. They proposed a rule that basically took POC glucometers outside of the CLIA waiver process. It would mean that hospitals would have to jump though a lot of hoops to use glucometers in the ICU. This lead the Joint Commission to adopt the proposed rule as their rule. After the outcry over this, the FDA withdrew their proposed rule. Their is currently a group from the critical care societies looking at this. In the meantime most hospitals continue to use POC glucometers.

Part of the problem is the FDA never defined critically ill. Critical illness is a spectrum and some critically ill patients will have changes in capillary glucose and some won't.

There is one POC glucometer that is FDA approved for critically ill patient and most of the major manufacturers are doing the clinical trials now so I would expect this to be a non issue by the end of the year.

The real issue is not POC glucometers, but that we need to be more aware of glucose control in critically ill patients.

This article sums up the points pretty well.

Glucose Testing in Hospital Environments

Nalon1 RN/EMT-P, BSN, RN · Jun 17, 2015

Our protocol is changing just for PTs on pressors

Thats what ours is also. The thought is that on pressors, your hands will be vasoconstricted, you may not get an accurate reading. When they first told us, they said any critically ill patient with a central line will have their POC sample drawn from the central line. We asked for clarification of "critacal" since we have some patients with central lines that are stable but getting things like TPN and such. We also made the argument of increased chances of infection with multiple central line accesses.

ccer99 · Jun 17, 2015

Thanks for the input! I haven't found any research and when I asked again all I got was FDA white papers...going to be mandated soon...and no research lol. When I have a day off I'm going to look around some more. I'll definitely look more into goal ranges etc, thanks again :)

ccer99 · Jun 17, 2015

Thank you again for all the info and articles, I appreciate the input and knowledge. Looks like I have a lot of reading to do :)

Here.I.Stand, BSN, RN · Jun 24, 2015

We do line draws for pts on therapeutic hypothermia, and per our discretion if the pt's fingers appear vasoconstricted (cold, cyanotic). Or if a pt is verbal and refuses fingersticks (I've had pts say "they said I wouldn't need to be poked if I got this line, so I'm not getting poked.")

Otherwise, the concern about CLABSI is quite prevalent in my ICU.

VANurse2010 · Jun 24, 2015

This policy change seems like an excellent way to have more central line infections. Strong work, folks.