Neonatal Intensive Care Unit (NICU)

At the Dekalb Medical Center at the Neonatal Intensive Care Unit (NICU), Heel Stick, a small procedure used to measure blood glucose (BG) by pricking the heel, is often performed on newborns (Vedder, & Sawyer, 2015). Also, at the Special Care Nursery (SCN), the Accu-Chek, a hand-held device that calculates the BG level is performed to check the BG level of neonates. In exposure to these two methods of BG intake, the accuracy in analyzing BG in both tests is of interest. Through research and review of literature, this paper will explore the methodology and accuracy of both BG tests and describe why this variety exists.
According to the US National Library of Medicine (NML), National Institutes of Health (NIH) (2006), most health care settings

prefer the traditional method of capillary samples for BG check, using the Accu-Chek within first few hours of life.

Particularly, such tests are performed to examine immediate neonatal hypoglycemia on high-risk newborns, such as babies born with low birth weight, small for gestational age, large for gestational age, and asphyxia. Based on the current evidence-based practice, this kind of testing is not consistent in newborns and is prone to occurrence of sample or performance errors (NML/NIH, 2006). Even though there are some discrepancies, Accu-Chek is often used in NICU because it is a point of care test (POCT), requires small volume of blood, and the result can be obtained within 5-10 seconds. On the other hand, the Heel Stick is performed on newborns to measure BG levels and newborn screenings, which yield accurate readings by sending it to laboratory. According to Vedder, et al. (2015), the Heel Sticks are discouraged in newborn patients if there

are significant risks of injury, infections, anomaly, and edema at the sampling area of heel, otherwise it is a safe method that gives accurate readings and preserves access for future IV lines. Since the Heel Sticks are needed for newborn screening, BG checks can be performed at the same time. Due to some inconsistence results compared with laboratory reference values, the Accu-Chek is less reliable for use in hospital in newborns populations (Thomas, et al. 2008). Proper evidence-based method of BG monitoring is vital in the clinical setting, where rapid detection of hypoglycemia is required in very high-risk patients. In fact, NICU and SCN of Dekalb Medical Center do not have one particular method of BG check. Nurses in NICU and SCN perform either of the methods, according to their ease without focusing on accuracy of each method.
Method for searching
A search on Database, CINAHL, PubMed, EBSCOhost, National Institutes of Health (NIH), and National Library of Medicine (NML) were used to research on accuracy of the Accu-Chek versus heel stick for blood sugar check on newborns. The keywords used in databases searched term were “blood glucose”, “blood glucose monitoring system”, “point-of-care testing (POCT)”, “neonatal hypoglycemia”, “Heel Sticks”, “Accu-Chek AND analytical accuracy”, “total measurement error”, “ High risk AND Newborn”, and “evidence based practice”. In fact, the search yielded some articles that reveled the current evidence-based practice on newborn screening, BG check, disadvantages, and advantages of performing heel sticks over other methods of BG test. In addition, the search also discussed the evidence-based practice on performing Accu-Chek as POCT that revealed less benefits, and low accuracy on test results comparing to other test that examine the BG results at Laboratory. There were limited research studies on the less than 24 hours newborns, where as major researches were done on the neonates who were more than 24 hours old. There were some research articles that focused on accuracy of performing BG test using Heel Stick versus Accu-Chek methods, and few researches done to determine which method to implement.
Literature Review
Joseph (2013) summarizes and reviews the accuracy of the Accu-Chek monitoring method for BG test.

The study done on the POCT glucose meter shows that evaluating the venous blood from 600 patients from different NICU achieved less desired degree of accuracy and exactness. In this study, 98.8% of the Accu-Chek glucose meter’s value range within ±20 mg/dl of the average laboratory analysis values (Joseph, 2013). A study done by Nuntnarumi, Chittamma, Pongmee & Goonthon (2011) revealed Accu-Chek, has mean bias of 95%, test discrepancy of 78%, and BG test result within 20% of the laboratory analyzer value. Another research done to check the accuracy of Accu-Chek along with other two BG measuring meters devices discovered errors and inaccuracy on 4 out of 155 newborn infants that have incidence of hypoglycemia (Thomas, Signal, & Harris, 2014). This illustrates that accuracy on determining the hypoglycemic events on newborns could lead to discrepancies on using these POCT devices in hospitals. The evidence-based practice research done by Harris, Weston, Battin, & Harding (2014), discussed the importance of doing heel stick, which is more accurate and reliable than any other methods. In his research, 180 surveys were sent and 127 (71%) responded the survey. Most of the responders (126 out of 127, 99%) reported that BG of newborn was measured using heel stick sampling during hospital stay. These level III nurseries have protocols to prevent hypoglycemia whose blood glucose are <40

mg/dl in first 4 hours of life. Even though some babies are asymptotic, prophylactic treatment had been implemented due to high-risk factors for hypoglycemia by performing heel stick.
Proposed EBP Changes
Based on the research that had been reviewed, I would suggest some evidence-based practice changes at Dekalb Medical Center. First, I would do more research on evidence-based practice on performing Accu-Chek versus Heel Stick to determine the accurate BG of newborns in clinical settings. From the research done by Joseph, J. I. (2013), made clear that Accu-Chek is less reliable than heel stick method on examining BG level on newborns. Based on the evidence discussed on this article, I would recommend on performing proper Heel Stick on newborns to prevent the neonatal hypoglycemia.
Vedder & Sawyer (2015) discussed evidence-based research on safe practice of Heel Sticks that could minimize the numbers of venipuncture for other laboratory tests such as general blood chemistries, complete blood counts (CBCs), toxicology, newborn screening, and blood gas analysis. Therefore, I would recommend minimizing the numbers of venipuncture to perform on the newborn screenings and other lab tests by performing the heel stick.
As discussed by Harris, et al. (2014), neonatal hypoglycemia protocol is the priority to implement on babies born with high-risk conditions. Immediate intervention for low BG level and other unknown conditions prevent the fetal risk and promote satisfactions. I would recommend Dekalb Medical Center to implement hypoglycemic protocol, perform proper heel stick to get accurate laboratory test results of BG along with other conditions that have not yet been diagnosed.