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No more fingersticks in ICU?

Posted

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!

Edited by ccer99
spelling error

Sun0408, ASN, RN

Specializes in Trauma Surgical ICU. Has 4 years experience.

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.

Our protocol is changing just for PTs on pressors

Swellz

Specializes in oncology, MS/tele/stepdown. Has 6 years experience.

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

Specializes in Critical Care. Has 10 years experience.

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.

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.

  1. 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.
  2. 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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  3. Ginsburg, B.H. (2009) Factors affecting blood glucose monitoring: Sources of error in measurement. Journal of Diabetes Science and Technology, 3, 903-913.
  4. Nichols, J.H. (2011) Blood glucose testing in the hospital: Error sources and risk management. Journal of Diabetes Science and Technology, 5, 173-177.
  5. Roche Diagnostics (2013) Hematocrit variable study protocol for glucose meter evaluations.
  6. 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.
  7. Critchell, C.D., et al. (2007) Accuracy of bedside capillary blood glucose measurements in critically ill patients. Intensive Care Medicine, 33, 2079-2084.

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

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.

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 :)

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

Specializes in SICU, trauma, neuro. Has 16 years experience.

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

Has 6 years experience.

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

James Bond

Specializes in Pediatrics. Has 30 years experience.

I called and spoke to the FDA in regards to this. The person I spoke to, who was a nurse thought it was a ridiculous idea to either place a central line or stick someone on an hourly basis. I have also yet to see any research that's been done on the pediatric population that I work with in regards to this mandate but that's not stopping implementation. Unfortunately, my facility has implemented this based on location. If your an overflow patient adult or pediatric and located in an ICU bed you will be subject to this. As mentioned before in this thread what, lies at the root of this is a lack of what defines a critical patient. Leave it to the regulators and bureaucrats who in the name of patient safety have found a way to elevate the potential for risk and injury.

Sun0408, ASN, RN

Specializes in Trauma Surgical ICU. Has 4 years experience.

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.

Can I just say how dangerous I think this practice is for a critical low. Sorry pt that is unresponsive with a BG level of 14, I can't treat you until lab comes up, stick you and we get the results!!!!

You're right--we treat a symptomatic low blood sugar. If we have a patient who is talking to us, following commands, etc and their blood sugar reads 30's, I'll get a lab confirmation. If they're symptomatic I'll treat while sending a lab confirmation. If our lab proves the POC wrong (only happened once the past 3 years) I'll tell the ICU doc and he'll usually tell me to give an extra few units of insulin or ride it out.

If if you're drawing blood sugars from a PICC are you wasting blood or do you have all of your PICCs set up to some sort of vamp? Wasting blood every time seems outrageous when they're on q1 hour checks.

Old post but any research found??? I was following a nurse that told me I have to draw blood from the A-line when a patient is on vasopressors or hypothermia treatment. It isn't a large amount, we take a syringe and draw back a TINY amount (just the tip) and tap it onto the glucose strip.

When I was with my preceptor she said she's never heard of it and unless their fingers are black, we can do finger sticks.

I just want to get the right answer!!!

vera4130

Specializes in ICU. Has 4 years experience.

Old post but any research found??? I was following a nurse that told me I have to draw blood from the A-line when a patient is on vasopressors or hypothermia treatment. It isn't a large amount, we take a syringe and draw back a TINY amount (just the tip) and tap it onto the glucose strip.

When I was with my preceptor she said she's never heard of it and unless their fingers are black, we can do finger sticks.

I just want to get the right answer!!!

Arterial line is best. Especially if they are on pressors or cold (hypothermia protocol), or even have very calloused hands. When I have an art line available I never use finger sticks.

James Bond

Specializes in Pediatrics. Has 30 years experience.

I have heard nothing new on this. Since the disclaimer from the package insert on the strips says the should not done via a finger stick on ICU patients we are mandated to do it that way. I agree it's probably best for someone who's on invasive drips and probably has a number of invasive lines. However, when you are taking care of a 1 year old that is awake and alert and doing what 1 year olds do the odds are pretty slim someone is going to place an invasive line solely for the purpose of doing POC blood glucose levels. I have seen more then a few children that fall into this category. Unfortunately there still exist no clear definition on what constitutes a critical patient other then an admit to the ICU. If any studies were done on the patient who is not in a shock like state or pediatric age group to validate how relevant this process is for them I would love to see them.