Neonatal hypoglycemia is one of the most common metabolic disturbances encountered in the immediate postnatal period, with an incidence ranging from 5% to 15% in at-risk infants such as those born preterm, small-for-gestational age (SGA), large-for-gestational age (LGA), or infants of diabetic mothers (IDMs) [1,2]. While severe and prolonged episodes of hypoglycemia are associated with acute neurological injury and long-term neurodevelopmental impairment, the clinical significance of mild or transient hypoglycemia remains debated [3,4]. Because many episodes are asymptomatic, guidelines recommend routine glucose monitoring of high-risk neonates during the first 12–24 hours of life [5]. Bedside glucometers have become the most commonly used screening tool in neonatal intensive care units (NICUs), owing to their portability, rapid turnaround time, and minimal blood volume requirements [6,7]. However, their analytical performance in neonates is variable due to technical limitations such as hematocrit interference, enzyme specificity, and calibration bias [8,9]. Moreover, errors in sample collection—including inadequate hand hygiene, improper site preparation, squeezing of the heel, and incorrect handling of strips—can further compromise accuracy and reliability [10,11]. Such errors may result in both false-low and false-normal readings, leading to unnecessary interventions or missed diagnoses [12]. In addition to pre-analytical issues, the absence of routine quality control (QC) checks for glucometers in many neonatal units poses a further risk, as devices may drift out of calibration without detection [13]. The combination of operator-dependent factors and lack of QC makes neonatal glucometer use highly vulnerable to error. Despite this, point-of-care glucometers remain integral to hypoglycemia screening, as confirmatory plasma glucose measurements often take longer to process and are not feasible for repeated monitoring. Clinical audits represent an effective quality improvement (QI) strategy in hospital practice. By systematically measuring adherence against established standards, identifying deficiencies, implementing corrective interventions, and re-auditing, audits provide a structured mechanism for ensuring safe and reliable patient care [14]. Previous studies have demonstrated the utility of audits in areas such as neonatal resuscitation, hand hygiene, and antibiotic use; however, very few have specifically addressed glucometer use in neonatal hypoglycemia screening [15]. Against this background, we undertook an audit of glucometer use in our NICU. The objectives were to (i) assess adherence to recommended procedural standards, (ii) evaluate gaps in practice, (iii) implement corrective interventions through training and visual aids, and (iv) re-audit to determine the effectiveness of these measures. This study aimed to ensure accurate, reliable, and safe glucometer use for the timely diagnosis and management of neonatal hypoglycemia.

Study Design This was a prospective observational clinical audit conducted in two sequential cycles as part of a quality improvement initiative in the Neonatal Intensive Care Unit (NICU). The audit was structured in accordance with standard clinical audit methodology: identification of problem, establishment of standards, measurement of practice, implementation of change, and re-audit. Study Setting and Duration The audit was conducted in the phlebotomy room of the NICU of Maheshwara Medical College & Hospital, Chitkul, a tertiary care teaching hospital. The total duration of the study was three months, from March 2024 to May 2024, divided as follows: • Cycle 1 (baseline audit): 60 days • Intervention phase: 5 days • Cycle 2 (re-audit): 30 days Ethical Considerations Prior to initiation, written permission was obtained from the unit chief, nursing superintendent, hospital superintendent, and the Institutional Ethical Committee. As the audit involved direct observation of routine procedures and did not alter standard patient management, it was considered low-risk. Data were anonymized, and no identifiable patient information was recorded. Audit Standards The standards were derived from: 1. AIIMS Protocols in Neonatology, which define best practices for neonatal capillary blood sampling and glucose monitoring. 2. Manufacturer’s User Manual (Accu-Chek Active, ISO-certified glucometer). Audit thresholds were defined as: • Satisfactory: ≥90% adherence • Partially satisfactory: 70–89% adherence • Minimal adherence: <69% adherence Participants and Sampling • Cycle 1: Observations were made during glucose screening of 25 neonates identified as “at risk” for hypoglycemia (preterm, small-for-gestational-age, large-for-gestational-age, or infants of diabetic mothers). • Cycle 2: Following interventions, 10 additional neonates undergoing the same screening process were observed. Inclusion criteria: All neonates undergoing routine bedside glucose monitoring with a glucometer. Exclusion criteria: Neonates requiring venous sampling only or those with contraindications for heel prick. Checklist and Data Collection A structured 13-point checklist was developed based on procedural standards. Each step of the procedure was directly observed by the auditing pediatrician and, where applicable, errors were corrected in real time to ensure patient safety. The checklist covered: 1. Hand hygiene (handwashing vs sanitizer use) 2. Heel pre-warming 3. Cleaning with sterile water and gauze 4. Avoidance of alcohol wipes 5. Allowing the puncture site to dry 6. Wiping the first drop of blood 7. Avoidance of heel squeezing 8. Avoidance of rubbing strip against skin 9. Correct heel site selection (medial/lateral plantar surface) 10. Correct procedural positioning and handling of neonate 11. Application of gauze pressure after puncture 12. Avoidance of adhesive dressings 13. Weekly control checks of glucometer 14. Intervention Phase After completion of Cycle 1, the following corrective interventions were implemented: • Didactic training sessions: Two interactive theory classes with practical demonstrations on correct glucometer technique. • Visual aids: Preparation and display of a pictorial stepwise poster in the phlebotomy room as a quick reference for nursing staff. • Real-time feedback: Reinforcement of correct steps during ongoing procedures. Cycle 2 (Re-Audit) One month after the interventions, the audit was repeated using the same checklist on 10 neonates to assess improvement in adherence. Data Analysis All data were recorded on printed proformas and entered into a structured database. Results were expressed as absolute numbers and percentages. Adherence was graded against predefined thresholds, and Cycle 1 vs Cycle 2 comparisons were made to evaluate the impact of interventions.

The audit was conducted in two sequential cycles covering 35 neonates screened for hypoglycemia in the NICU. A total of 25 neonates were observed in Cycle 1, followed by 10 neonates in Cycle 2 after staff training interventions. Results are summarized below. Cycle 1 Findings In the first audit cycle, adherence to procedural standards was only partial, with several key deficiencies observed (Table 1). Table 1: Audit Findings – Cycle 1 (n = 25 neonates) Parameter Assessed Standard Correctly Performed n (%) Non-compliant n (%) Handwashing (not sanitizer) Required 14 (56%) 11 (44%) Heel pre-warming Required 23 (92%) 2 (8%) Cleaning with sterile water & gauze Required 23 (92%) 2 (8%) Avoidance of alcohol wipes Required 23 (92%) 2 (8%) Area allowed to dry Required 25 (100%) 0 (0%) Wiping the first drop Required 20 (80%) 5 (20%) Heel squeezing avoided Required 15 (60%) 10 (40%) Strip not rubbed against skin Required 20 (80%) 5 (20%) Correct heel site (medial/lateral plantar) Required 20 (80%) 5 (20%) Correct procedural technique Required 20 (80%) 5 (20%) Pressure applied after puncture Required 25 (100%) 0 (0%) Avoidance of adhesive dressings Required 25 (100%) 0 (0%) Weekly control checks of glucometer Required 0 (0%) 25 (100%) Overall, the first cycle demonstrated partial adherence, with the most concerning lapses being: inadequate hand hygiene (44%), heel squeezing (40%), and absence of glucometer control checks (100%). Cycle 2 Findings Following targeted interventions (theory classes, demonstrations, and pictorial posters), adherence improved markedly in the second cycle (Table 2). Table 2: Audit Findings – Cycle 2 (n = 10 neonates) Parameter Assessed Correctly Performed n (%) Non-compliant n (%) Handwashing (not sanitizer) 10 (100%) 0 (0%) Heel pre-warming 10 (100%) 0 (0%) Cleaning with sterile water & gauze 10 (100%) 0 (0%) Avoidance of alcohol wipes 10 (100%) 0 (0%) Area allowed to dry 10 (100%) 0 (0%) Wiping the first drop 10 (100%) 0 (0%) Heel squeezing avoided 9 (90%) 1 (10%) Strip not rubbed against skin 10 (100%) 0 (0%) Correct heel site (medial/lateral plantar) 10 (100%) 0 (0%) Correct procedural technique 10 (100%) 0 (0%) Pressure applied after puncture 10 (100%) 0 (0%) Avoidance of adhesive dressings 10 (100%) 0 (0%) Weekly control checks of glucometer 10 (100%) 0 (0%) In Cycle 2, overall adherence reached >90%, with only one instance of heel squeezing reported. Comparative Analysis The comparative summary of the two audit cycles is presented in Table 3, which highlights the positive impact of training interventions. Table 3: Comparative Summary of Audit Findings (Cycle 1 vs Cycle 2) Parameter Assessed Cycle 1 Correct (%) Cycle 2 Correct (%) Change After Intervention Handwashing (not sanitizer) 56% 100% ↑ Improved Heel pre-warming 92% 100% ↑ Improved Cleaning with sterile water & gauze 92% 100% ↑ Improved Avoidance of alcohol wipes 92% 100% ↑ Improved Area allowed to dry 100% 100% ↔ Maintained Wiping the first drop 80% 100% ↑ Improved Heel squeezing avoided 60% 90% ↑ Improved Strip not rubbed against skin 80% 100% ↑ Improved Correct heel site (medial/lateral plantar) 80% 100% ↑ Improved Correct procedural technique 80% 100% ↑ Improved Pressure applied after puncture 100% 100% ↔ Maintained Avoidance of adhesive dressings 100% 100% ↔ Maintained Weekly control checks of glucometer 0% 100% ↑ Markedly Improved Adherence Grading Based on AIIMS audit thresholds, overall adherence levels improved from partially satisfactory in Cycle 1 to satisfactory in Cycle 2 (Table 4). Table 4: Overall Adherence Grading (Based on Audit Thresholds) Adherence Level Definition (per AIIMS/ISO Standards) Cycle 1 (n=25) Cycle 2 (n=10) Satisfactory >90% compliance 0 10 (100%) Partially satisfactory 70–89% compliance 25 (100%) 0 Minimal adherence <69% compliance 0 0 Common Errors in Cycle 1 The most frequent errors and their potential clinical implications are summarized in Table 5. Table 5: Common Errors Identified in Cycle 1 Error Type Frequency n (%) Clinical Implication Use of sanitizer instead of handwash 11 (44%) Risk of contamination; reduced asepsis Heel squeezing 10 (40%) Hemolysis; interstitial dilution → false low glucose First drop not wiped 5 (20%) Inaccurate glucose due to tissue fluid contamination Strip rubbed against skin 5 (20%) Strip contamination; erroneous reading No glucometer control checks 25 (100%) Device reliability not assured Summary of Results • Cycle 1: Partial adherence with critical lapses (hand hygiene, heel squeezing, no QC checks). • Cycle 2: Satisfactory adherence (>90%) following interventions. • Key Improvement: Weekly quality control of glucometers rose from 0% to 100%, and overall compliance shifted from partially satisfactory to satisfactory.

This audit demonstrated that while glucometer use is the most common method for screening neonatal hypoglycemia in the NICU, its reliability is highly dependent on correct technique and regular quality control. In the first audit cycle, only partial adherence to recommended procedural standards was observed, with critical deficiencies such as improper hand hygiene, heel squeezing, and absence of glucometer control checks. Following targeted interventions through staff training and visual reminders, adherence improved markedly in the second cycle, with overall compliance exceeding 90%. Our findings are consistent with the growing body of evidence that pre-analytical factors substantially influence the accuracy of point-of-care testing in neonates. For example, Wadsworth et al., 2005 [11] showed that heel squeezing and inadequate wiping of the first blood drop can lead to interstitial fluid contamination and spuriously low glucose readings. Similarly, Hume et al., 1999 [12] emphasized that bedside glucometer values may be unreliable unless strict sampling protocols are followed. These observations are directly reflected in our Cycle 1 results, where 40% of cases involved heel squeezing and 20% did not wipe the first blood drop, both of which are established contributors to analytical error. Hand hygiene was another area of non-compliance, with 44% of staff using sanitizer instead of proper handwashing. This finding mirrors broader concerns in neonatal care, where lapses in infection control remain common despite well-established guidelines (Jayashree et al., 2014 [15]). Since neonates are immunologically vulnerable, adherence to handwashing protocols is not only critical for accurate testing but also for infection prevention. The complete absence of weekly glucometer quality control checks in Cycle 1 highlights a major systemic gap. According to Sacks, 2014 [10], neglecting device calibration and quality control is a significant cause of erroneous glucose readings, particularly in critical care settings. International guidelines recommend regular internal and external quality checks for point-of-care devices to ensure reliability (WHO, 2017 [5]; Accu-Chek Manual, 2021 [13]). By introducing QC awareness and ensuring staff adherence, our audit achieved 100% compliance in Cycle 2, which represents one of the most impactful improvements. From a clinical perspective, inaccurate glucose measurements may lead to both overtreatment (unnecessary IV glucose infusions causing iatrogenic hyperglycemia) and undertreatment (missed hypoglycemia episodes with potential neurodevelopmental consequences). Beardsall, 2010 [7] noted that many neonatal hypoglycemia cases are asymptomatic, and reliance on inaccurate point-of-care readings risks either inappropriate reassurance or unwarranted intervention. Our audit supports this concern, as procedural lapses observed in Cycle 1 could have directly compromised patient management. The success of our intervention phase underscores the effectiveness of quality improvement strategies in neonatal care. Educational sessions, visual reminders, and direct feedback were sufficient to achieve sustained improvement within one month. This is consistent with the work of Jayashree et al., 2014 [15], who demonstrated that structured audit-feedback cycles significantly improved adherence to ICU protocols. Similarly, NICE, 2012 [14] recognizes the clinical audit cycle as a powerful tool for closing the gap between evidence and practice. Nevertheless, while our audit improved procedural adherence, it does not address the analytical limitations of glucometers themselves. Studies have shown that neonatal hematocrit levels significantly influence glucometer readings, leading to underestimation of glucose in polycythemic infants (McKinlay et al., 2015 [8]; Wight and Marinelli, 2014 [9]). Hence, while improving procedural accuracy is critical, confirmatory laboratory plasma glucose testing should remain the gold standard in cases of suspected or persistent hypoglycemia. Strengths and Limitations The main strength of this audit is its structured methodology, including direct observation, immediate correction of errors, and re-audit to evaluate the impact of interventions. Moreover, the findings have direct applicability in routine NICU practice, as the interventions used (training and posters) are low-cost and easily replicable. However, there are some limitations. The sample size was relatively small (25 neonates in Cycle 1 and 10 in Cycle 2), which may limit generalizability. Additionally, the audit was conducted in a single NICU, and adherence rates may differ across institutions with varying staffing, workload, and culture of quality assurance. Furthermore, the audit focused on procedural adherence and did not include a formal comparison of glucometer values with laboratory plasma glucose, which could have provided further insight into analytical accuracy. Implications for Practice Our findings highlight the necessity of continuous staff training, visual reinforcement, and structured re-audits to maintain adherence to procedural standards. Hospitals should mandate regular QC checks of glucometers and integrate audit findings into routine clinical governance. Future studies should explore the integration of point-of-care testing with automated QC tracking and evaluate outcomes in larger multicenter audits.

Glucometers remain indispensable for hypoglycemia screening in the NICU, but their reliability hinges on correct technique and quality control. This audit demonstrates that structured training and visual aids markedly improve adherence, thereby enhancing patient safety. Regular re-audits and incorporation of procedural checks into routine nursing practice are recommended.

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