St John Cymru-Wales

Blood Glucose Measurement

Standard Operating Procedure

Date Approved:

February 2015

Date Implemented:

February 2015

Date of Review:

February 2016

Version: 1.3

Document Control
Version:

1.3

Title:

Blood Glucose Measurement SOP

SOP Category:

Clinical / Operations

Date Approved:

February 2015

Date Implemented:

February 2015

Supersedes:

None

Date of Review:

February 2016

SOP Owner:

Healthcare Governance Committee

SOP Approval:

Healthcare Governance Committee

Supporting Documents

Document Name:

Version

Date

Medical Devices Policy

Infection Prevention Control Policy
Approved Equipment Guide
On Duty Guide

Author

Comment

1.0

November 2012

Paramedic Advisor

SOP Developed

1.1

January 2013

Paramedic Advisor

Change of Product

1.2

February 2014

Paramedic Advisor

Supplier Amendment

1.3

February 2015

Paramedic Advisor

Review Date change

of Supplier Information

Blood Glucose Standard Operating Procedure

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1. Introduction
St. John Cymru Wales (hereafter referred to as St John) acknowledges the benefit of
blood glucose monitoring (BM) by approved, appropriately trained members but is also
aware of the potential Health and Safety and Patient Safety impacts of blood glucose
monitoring, identified by the Medicines and Healthcare Regulatory Agency (MHRA),
and will seek to limit these through the use of robust policies and procedures.

2. Purpose
2.1.

St John requires that all parts of its activities and operations have an
understanding of their responsibilities for BM Monitoring. The purpose of this
procedure is to:
a)
b)
c)
d)

ensure compliance with all relevant legislation

outline minimum training requirements for all personnel
identify specific responsibilities
provide all personnel with explicit guidance in the correct procedure for
obtaining a BM, and appropriate calibration and maintenance of the
equipment they hold in line with both Health & Safety and Control of
Infection requirements

3. Scope
3.1.

This procedure will apply to all personnel who have achieved the Enhanced
First Aider or Patient or Emergency Transport Attendant qualification. Due to
the potential for error and adverse events, BM monitoring will be restricted to
the aforementioned skill levels and a thorough training and assessment
package will be in place with annual recertification. Healthcare Professionals
(HCPs) are reminded that national clinical guidelines should be followed at all
times and that they are accountable to their own professional registering
body.

4. Responsibilities
4.1.

Healthcare Governance Committee

The Healthcare Governance Committee is responsible for the development of
this blood glucose monitoring procedure and its review. It has overall control
over this document and is responsible for regularly updating it to ensure this
procedure reflects legislation and recognised best practice.
The Clinical Advisors will be responsible for promoting best practice in BM
monitoring, including advice, support and guidance.

Blood Glucose Standard Operating Procedure

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Particular responsibilities include:

a) Reporting and investigating adverse incidents
b) Creating suitable training sessions which can be delivered to
personnel
c) Being available for clinical advice at all times of activity within St
John
d) Ensuring personnel are aware of their requirements under the
scope of this procedure
e) Being up-to-date on legislation pertaining to BM monitoring
f) Ensuring all personnel receive Hepatitis B immunisation where
applicable and required
County Staff Officers / Line Managers
County Staff Officers / Line Managers hold delegated authority to carry out
inspections on behalf of the Healthcare Governance Committee; of all
members, including HCPs within St John.
Particular responsibilities include:
a) Reporting adverse incidents involving BM monitoring so that these can be
investigated in a timely manner
b) Ensuring that this procedure is followed and BM monitoring is only carried
out by approved personnel who hold the following qualifications:

Enhanced First Aider (EFA),

Patient Transport Attendant (PTA)

Emergency Transport Attendant (ETA)

Healthcare Professional (HCP).

c) Ensuring correct implementation and development of the approved training

package
d) Providing adequate personal protective equipment and clothing for
personnel to suitably reduce the risks associated with BM monitoring
e) Ensuring that personal protection and basic hygiene precautions are
adhered to

Blood Glucose Standard Operating Procedure

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f) Ensuring risk assessments are in place

g) Keeping accurate records to assist in the preparation of reports to the
Healthcare Governance Committee.
All personnel
All personnel (including volunteers and employees) have the following
responsibilities under this procedure:
a) Making themselves familiar with this procedure
b) Adhering to and observing the requirements of St John blood glucose
monitoring procedure, ensuring they have been approved to undertake this
extended role
c) Participating in BM monitoring training and attend / complete updates as
change in procedure or equipment dictates
d) Reporting dangerous or untoward incidents and situations as soon as they
are identified, take action to prevent others being affected and assist with
any resulting investigation.
e) Ensuring that only approved and correctly maintained equipment is used.
f) Ensuring personnel know what action to take should equipment become
damaged, contaminated, or produces erroneous results.
g) Wearing protective clothing and equipment in accordance with relevant
working procedures applicable to the task being undertaken, ensuring that
sharps waste is disposed of safely and in line with national and local
guidance
h) Observing personal protection and basic hygiene precautions

5. Indications for Blood Glucose Monitoring

5.1.

Blood glucose monitoring gives an indication of the bodys glycaemic control

only at the point of testing (NICE, 2004). Within the scope of St John practice,
its primary function would be in the management of patients with Diabetes
Mellitus. However it also has a place in the management of any acutely unwell
patient as part of the patient assessment process. Indications are clearly
highlighted on transport attendant courses.

5.2.

To ensure continuity of care and to present adverse incidents, all BM results

are displayed and interpreted in mmol/l ONLY. This is current best practice in
the United Kingdom for all healthcare organisations (MHRA, 2006). The use
of g/dL is prohibited as a result of this procedure.

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6. Blood Glucose Monitoring Procedure - Equipment

6.1.

As per MHRA guidelines, the information below highlights the only Blood
Glucose Monitoring Equipment for use by St John personnel. No personal
devices are to be used at any time. All of the equipment listed is required.
a) Approved Blood Glucose Machine:
Model :

Accu-Chek Aviva

Supplier:

St John Wales Supplies

Notes:

All Accu-Chek FastClix devices that accompany each

machine, must be discarded with the lancets highlighted
below (c) utilised instead.

b) Approved Blood Glucose Machine Test Strips:

Model :

Accu-Chek Aviva Test Strips (Box of 50)

Supplier:

St John Wales Supplies

Notes:

c) Approved Blood Glucose Lancets:

Model :

Unistik 3 Normal Yellow 3g x 1.8mm (Box 100)

Supplier:

St John Wales Supplies

Notes:

Further equipment required:

d) Blood Glucose Machine Control Solution (for calibration of meter only)
Supplied with Blood Glucose Machine/Meter
e) Sharps Bin & Gloves
f) Clinical Waste Bag

Blood Glucose Standard Operating Procedure

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7. Blood Glucose Monitoring Equipment - Procedure

7.1.

After ensuring the blood glucose machine has been appropriately calibrated,
the following procedure is carried out
1. Explain and ask the patient for their consent to carry out the procedure
2. Adopt appropriate Infection Control methods
3. Prepare equipment and ensure the glucose monitor is fully calibrated
4. Clean the tip of the selected finger with a cleansing wipe or saline & swab
and allow to dry
5. Prepare the test strip, ensuring that it is still in date and load into glucose
monitor
6. Prick the side of the finger with the lancet and squeeze the finger to draw
blood
7. Dispose of the lancet into a Sharps Box
8. Place the drop of blood onto the test strip so that the strip is covered
9. Give the patient a gauze swab and advise them to apply pressure to stop
bleeding
10. Record the reading from the glucose monitor display
11. Dispose of the test strip into a clinical waste bag
12. Remove gloves and wash hands

8. Calibrating the machine and running a control test

8.1.

All blood glucose monitoring equipment should be calibrated at least every six
months or if the integrity of the test strips are suspect and when the result is
not in keeping with the clinical condition of the patient.

8.2.

For the procedure of calibrating the blood glucose machine, refer to the
manufacturers guideline.

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9. Training
9.1.

All personnel undertaking the EFA, PTA and ETA will receive training in how
to correctly carry out the blood glucose monitoring procedure. All personnel
already holding this qualification will receive an additional, mandatory training
course.

9.2.

Monitored training will take place in the form of formative assessments and
completion of the OSCE Record Sheet (Appendix I).

9.3.

Assessments will take place in the form of an Objective Structured Clinical

Examination (OSCE) with a Skills Test 25A (assessment criteria) undertaken
by a registered Paramedic, Nurse, Doctor or IHCD Technician.

9.4.

It is a requirement that all personnel undergo an OSCE on an annual basis to

ensure the required standards are still being met.

9.5.

Assessment and Management of patients suffering a glycaemic emergency

will be undertaken in conjunction with the guidelines contained within the Joint
Royal Colleges Ambulance Liaison Committee (JRCALC) UK Ambulance
Service; Clinical Guidelines.

9.6.

During training, candidates will practice the skill of obtaining a blood sample
utilising their own capillary blood or if verbal consent is given by another
individual; a sample can be obtained from them.

9.7.

All candidates reserve the right to decline carrying out the procedure or
offering a blood sample and therefore can alternatively verbalise the
procedure instead.

9.8.

Repeated samples from an individual should be avoided during training.

10. Reporting incidents, injuries and accidents

10.1. All personnel should be aware that as BM monitoring is not a laboratory test
there is potential for error and they should familiarise themselves with the
contraindications of such monitoring (MHRA, 2006).
10.2. All potential and actual adverse incidents concerning BM monitoring as a
result of meter malfunction should result in the meter being withdrawn from
service, pending investigation. Personnel should be mindful that their first
priority should be the care of their patients; BM monitoring should not delay
patients being removed to an Emergency Department for further management
if required.
Blood Glucose Standard Operating Procedure

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10.3. Any incident involving sharps should be reported immediately to a member of

County Staff and the procedure highlighted in the Infection Prevention Control
Policy should be adhered too.
10.4. In addition to the above procedure, a Patient Report Form (PRF) and an
Adverse Incident / AC3 Form should be completed at the earliest opportunity.
Where appropriate, a RIDDOR notification should also be completed and
submitted without delay.

11. Monitoring of Compliance

11.1. This procedure will be monitored by the Healthcare Governance Committee
and updated accordingly.
11.2. Compliance to this procedure will be regularly checked through local audits
including PRF audits and monitoring.
11.3. Reported breaches of this procedure will be discussed with those concerned
and maybe dealt with under other polices, regulations or legislation.

12. References
Lancing Devices used in Nursing Homes and Care Homes (2006), Medical Device
Alert, Medicine and Healthcare Regulatory Agency, London
National Institute for Clinical Excellence (2004) Type 1 diabetes: diagnosis and
management of type 1 diabetes in children, young people and adults, National
Institute for Clinical Excellence, London
Point of Care Testing Blood Glucose Meter Advice for Health Care Professionals
(2005) Medicine and Healthcare Regulatory Agency, London

Blood Glucose Standard Operating Procedure

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Appendix I

Blood Glucose & Blood Pressure Measurement

Objective Structured Clinical Examination (OSCE)
To prepare you for the final OSCE assessment in Blood Pressure and Blood Glucose Measurement, please ensure that you
allow ample time to practice these skills. Your trainer must witness measurements and complete all elements below prior to
your final assessment. It is not necessary to take blood samples for Blood Glucose during each practice. It is acceptable for
this to be demonstrated in the initial practice and final assessment, with simulation during other attempts.
Blood Pressure Measurement
Procedure

Trainer Initial
1

Blood Glucose Measurement

Procedure

1. Explain and ask the patient for

their consent to carry out the
procedure
2. Adopt appropriate Infection
Control methods

1. Explain and ask the patient for

their consent to carry out the
procedure
2. Adopt appropriate Infection
Control methods

3. Ensure that the patients arm is

free of restrictive clothing

3. Prepare equipment and ensure

the glucose monitor is fully
calibrated

4. Apply the cuff around the arm

firmly with the bladder centred
over the brachial artery

4. Clean the tip of the selected

finger with wipe and allow to dry

5. Advise the patient that the cuff will

temporarily tighten

5. Prepare the test strip, ensuring

that it is still in date and load
into glucose monitor

6. Palpate the radial artery whilst

inflating the cuff until the pulse is
no longer palpable. Note pressure
and deflate the cuff rapidly

6. Prick the side of the finger with

the lancet and squeeze the
finger to draw blood

7. Position stethoscope over the

brachial artery and inflate cuff to
pre-determined pressure

7. Dispose of the lancet into a

Sharps Box

8. Deflate the cuff at a suitable rate

and note the pressure when the
first two consecutive heart beats
are heard = Systolic Pressure
9. Continue to deflate the cuff and
note the pressure when the heart
beat can no longer be heard
= Diastolic Pressure
10. Remove the cuff from the patients
arm

8. Place the drop of blood onto the

test strip so that the strip is
covered
9. Give the patient a gauze swab
and advise them to apply
pressure to stop bleeding
10. Record the reading from the
glucose monitor display

11. Equipment cleaned and prepared

for next patient

11. Dispose of the test strip into a

clinical waste bag

12. Blood Pressure Reading

diagnosed as Normal or
Hyper/Hypotension correctly

12. Blood Glucose Reading

diagnosed as Normal or
Hyper/Hypoglycaemia correctly

Blood Glucose Standard Operating Procedure

Trainer Initial

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