In my hospital nurses were required to order a stat lab serum glucose whenever they had a critically High or Low Fingerstick result. My question was...Why?
Ordering a Stat Serum Glucose to Confirm Glucometer (Fingerstick) Reading
This is a case where the policy did not seem to make sense.
At my facility, the blood glucose monitoring procedure called for the nurse to order a stat serum glucose in the event of a critically low or high fingerstick value.
(Critical blood glucose values at my facility are defined as less than 50 mg/dL or greater than 500 mg/dL for adults and less than 25 mg/dL or greater than 200 mg/dL for neonates).
Let's say you perform a fingerstick on your adult patient which results in a value of 48 (critically low value). According to the procedure, you would immediately call Lab for a stat serum glucose. If the patient were symptomatic, you would also immediately implement the Hypoglycemic Protocol and administer either D50 or oral carbs, depending on if they can safely swallow or not.
As an educator preparing to do competency testing at our annual Skills Fair, I, of course, planned to teach from the policy and procedure- but I have to say, this made no sense to me.
My question was "What is the rationale for ordering a stat serum glucose when the fingerstick result is critically low or high?" I asked several key people in Lab and Nursing.
Here are 3 conversations I had with various decision-makers while attempting to understand the rationale:
Conversation #1
Me: "What is the rationale for ordering a stat serum glucose when the fingerstick result is critically low or high?"
Answer: "To verify the low result"
Me: "Samples must be drawn at the same time or within a few minutes of each other to have a valid comparison. How long does it take Lab to get to the floor for a stat? Realistically?"
Answer: "For a stat? 15-30 minutes"
Me: "Right....."
Conversation #2
Me: "What is the rationale for ordering a stat serum glucose when the fingerstick result is critically low or high?"
Answer: "Well, the machine might be wrong. We have to check it"
Me: "Actually our machines are top-performing and we have the most recent model. They even correct for low hemoglobin and hematocrit. They are checked regularly by Bio-Medical Engineering and Quality Controls (QC) are performed every 24 hours. If we assume the glucometers are inaccurate perhaps we shouldn't use them on patients."
Conversation #3
Me: "What is the rationale for ordering a stat serum glucose when the fingerstick result is critically low or high?"
Answer: "We don't want to treat a patient if it's wrong"
Me: "Oh..except...wait, we do treat them based on the fingerstick results. Our protocol/policy says to treat symptomatic hypoglycemia. Are you saying we should wait for Lab to come draw and call the result before we give D50 to a symptomatic hypoglycemic patient ?"
In the end, the only real argument was 'Well... because we've always done it that way"
My colleague and fellow Educator Debbie and I embarked on a mission to change the policy. Our goal was to ensure patient safety, and to not impede nurse workflow with unnecessary interventions.
We know that blood glucose values can change quickly depending on the clinical condition of the patient. We sought out Lab's expertise and discovered that glucometer results are considered to be accurate and acceptable if the comparison serum glucose specimen s within 15 mg/dL for results less than 75 mg/dL or +20 mg/dL for glucose results greater than 74 mg/dL.
We re-wrote our policy accordingly. Now it reads: "If a critical value is obtained":
Repeat the (fingerstick) test to confirm the result
If test result is not confirmed, i.e., the second test value varies by more than 10%, obtain a stat Lab draw
Notify MD if test is confirmed and the result is outside expected parameters for that patient
Select or enter a relevant comment in the glucometer
Follow Hypoglycemia Protocol for symptomatic patients
It makes sense and allows the nurse to intervene quickly and care for his/her patient.
Take a look at your policies. If they don't add value, don't help patients and/or aid in nurse workflow... it may be time to make a change!
