Learning Outcomes

Key Terms

Durable and Nondurable Medical Equipment

The Role of the Pharmacy Technician

Billing and Reimbursement

Clinical Laboratory Improvement Amendments Act (CLIA)

Blood Glucose Monitoring

Meters and Supplies

Blood Glucose Monitoring Process

Insulin Delivery

Injection with Syringes

Insulin Pens

Sharps Disposal

Continuous Infusion

Blood Pressure Monitoring

Blood Pressure Monitors

Monitoring Process

Table 18–1. Common Durable and Nondurable Medical Equipment

Durable and Nondurable Medical Equipment

Medicare defines durable medical equipment (DME) as medical supplies that are

able to withstand repeated use

primarily and customarily used to serve a medical purpose

generally not useful to a person in the absence of an illness or injury

appropriate for use in the home

This equipment is also known as durable medical equipment, prosthetics, orthotics, and supplies.^4–6 The elderly and persons with physical disabilities may need to use durable medical equipment to improve mobility. Wheelchairs, walkers, canes, and crutches are types of durable medical equipment that are used as mobility aids. Durable medical equipment can be used to monitor vital signs, such as blood glucose, blood pressure, and heart rate, or can be used to administer medications, such as a nebulizer or an infusion pump.

Nondurable medical equipment consists of medical supplies that must be discarded after use and often can be used at home or in a medical facility. Examples of commonly used durable and nondurable medical equipment are listed in Table 18-1.

The Role of the Pharmacy Technician

Pharmacies that supply durable medical equipment, prosthetics, orthotics, and supplies can provide an important service for patients. The use of durable and nondurable medical equipment can improve a patient’s quality of life. Persons with impaired mobility often use durable medical equipment. Patients who have diabetes or hypertension can self-monitor their blood glucose and blood pressure at home with medical equipment. The pharmacist can provide education for the use of medical equipment.

The pharmacy technician can assist the pharmacist in maintaining adequate supplies and equipment and be involved in the process of billing insurance for these items.

Billing and Reimbursement

The Centers for Medicare and Medicaid Services require that all suppliers of durable medical equipment, prosthetics, orthotics, and supplies be accredited to bill Medicare Part B. As of January 1, 2010, pharmacies that supply this type of equipment must be Medicare accredited.⁷ Medicare Part B covers 80% of this type of equipment and supplies. The patient must pay 20%, the remaining cost. Persons with Medicaid can have their 20% coinsurance covered. For more information, refer to Chapter 20, Billing and Reimbursement.

Clinical Laboratory Improvement Amendments Act (CLIA)

Several devices that are introduced in this chapter are classified as CLIA-waived products. The Clinical Laboratory Improvement Amendments Act of 1988 (CLIA) established that some clinical tests could be waived from certain laboratory requirements. On February 28, 1992, regulations were published stating that waived tests were defined as simple laboratory examinations and procedures that are approved by the Food and Drug Administration (FDA) for home use.⁸ Therefore, certain home diagnostic tests using blood or urine samples can be used without maintaining requirements as strict as those for laboratory tests.

Durable and nondurable medical equipment and supplies are commonly used in the management of certain diseases, such as diabetes mellitus. Diabetes mellitus is a disease in which there are elevated levels of glucose (sugar) in the blood, which is caused by insulin deficiency and/or insulin resistance (the body not using insulin properly). Diabetes is a prevalent disease; there are currently 23.6 million persons in the United States with diabetes, which is approximately 7.8% of the U.S. population.⁹ In 2007, the estimation of health care costs for the treatment of diabetes was $174 billion.⁹ There are 57 million Americans who have prediabetes, which places them at risk for developing diabetes in the future.⁹ Blood glucose monitoring and insulin therapy are commonly used to manage diabetes and incorporate the use of specific durable and nondurable medical equipment and supplies.

Blood Glucose Monitoring

Blood glucose meters are used to monitor blood glucose, which is also called blood sugar. Self-monitoring of blood glucose provides valuable information to evaluate the impact of lifestyle changes and/or medication therapy in a person with diabetes. Maintaining blood glucose levels that are near normal minimizes complications of diabetes, such as an increase risk of heart disease, stroke, blindness, kidney failure, nerve damage, and amputations. According to the American Diabetes Association, plasma blood glucose levels before meals should be 70–130 mg/dL and <180 mg/dL 1–2 hours after meals.⁹ Blood glucose readings that are consistently higher than goal levels increase the risk of complications.

Monitoring blood glucose is very important to determine if diabetes is under control. Hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose) can be identified with the use of blood glucose meters.

Meters and Supplies

Blood glucose meters are considered to be durable medical equipment; however, in order to obtain the measurement of glucose, the use of nondurable supplies is required. Those supplies include test strips, lancets, and control solution.

Blood glucose meters have similar features, such as an area for a test strip to receive a blood sample and a display of the glucose measurement. Blood glucose meters in the United States display the glucose measurement in milligrams per deciliter (mg/dL). Most meters measure whole blood glucose versus plasma levels of glucose, which is typically 10–15% higher than whole blood. There are meters that calculate a plasma equivalent measure from whole blood. Blood glucose meters vary in features, such as the size of blood sample needed for testing, calibration, testing time, and memory of test results.^10,11 A meter is chosen based on its features and the needs of the patient. There are advantages to using meters that require small blood samples, have automatic calibration, and provide test results in 5 seconds. Meters that are smaller are more convenient to carry. There are audible blood glucose meters that can be used by persons who have visual impairments.

A test strip used in blood glucose monitoring contains a reagent that interacts with a blood sample to generate a blood glucose measurement. Biosensor technology allows the blood sample to be drawn onto the test strip, instead of the blood sample being placed on top of the test strip.¹⁰ Test strips are designed to be used with a specific meter and cannot be interchanged.

Some test strips are stored in a vial, with one strip removed at a time and placed into the meter for each test. Two meters, the Bayer Breeze 2 and Accu-chek Compact Plus, store multiple test strips in a drum or disc, which is placed into the meter.¹² The Breeze 2 uses a disc that contains 10 strips, and the Compact Plus uses a drum that contains 17 strips. For these meters, one test strip is obtained from the meter at the time of testing and discarded after the reading has been generated. The entire drum or disc is removed from the meter when all of the strips are used, and a new drum or disc is then placed in the meter. The meter also keeps track of how many test strips remain in the drum or disc. Test strips should be stored away from heat and humidity and not used after their expiration date. The expiration of test strips can range from 3 to 18 months, depending upon the type of meter.

A lancet (small needle) is used for one-time use to puncture the skin to obtain a blood sample. Lancets can be used with a lancet device, and the depth of puncture can be adjusted. Adjustment in depth of puncture can allow different sizes of blood samples to be obtained. A smaller depth of puncture produces a smaller blood sample. A larger depth of puncture produces a large blood sample and is usually more painful. Some lancets are designed to be used with specific lancet devices, whereas others can be used with most lancet devices. The gauge size (which determines the thickness of the needle) of lancets can vary from 21–33 gauge.¹¹ Lancets with higher numbers are thinner, with the 33-gauge lancet being the thinnest available. Thinner lancets are less painful for patients and can allow for a smaller blood sample to be obtained.

One product, Accu-chek Multiclix, provides six preloaded lancets in a drum.¹³ The drum is placed in the Multiclix lancet device that is designed to prevent the reuse of lancets. The lancet device also provides 11 depth settings. The lancet drum is discarded after the six lancets have been used.

Blood obtained from the fingertip has traditionally been used for testing blood glucose. However, alternate site testing is now available for newer blood glucose meters. The alternate sites include the palm of the hand, the forearm, the thigh, and the calf. A special cover is placed over a lancet device to obtain a blood sample at an alternate site. Blood glucose readings obtained from alternate sites can vary compared with fingertip readings when glucose levels rapidly change, such as after a meal, after injecting insulin, during exercise, and when a person is ill or under stress.¹² Blood samples should be obtained from the fingertip if a person has symptoms of low blood glucose or if the results obtained from the alternate site are out of their usual range of blood glucose.

Control solution is a type of solution that mimics blood and that is used to test the accuracy of a blood glucose meter and test strips.¹² The solution is applied to a test strip; it generates a reading that should be within a certain range. The control solution is specific for a particular meter and may come as low, normal, or high control. The solutions can be categorized as “Level 1” or “Level 2,” representing low or high control. The ranges for each type of control are provided in meter instructions or on the bottle of solution. Control solutions are used to check blood glucose meters at their first use and can be used weekly to determine the accuracy of test strips. The solutions can also be used if a person is unsure whether the meter is providing a correct blood glucose reading. The expiration date of the control solution varies by manufacturer and can range from 3 to 6 months.

Blood Glucose Monitoring Process

The steps for monitoring blood glucose are as follows:¹²

Insulin Delivery

Insulin is a hormone that is produced in the pancreas, which promotes the utilization of glucose, synthesis of protein, and the formation and storage of lipids (fat).^2,15 Different types of insulin vary in their onsets, peaks, and durations of action. Insulin is classified according to its action (rapid-acting, short-acting, intermediate acting, or long-acting). More than one type of insulin may be needed to control blood glucose levels. Depending on the type of insulin, it is injected with or before meals or administered once daily. The insulin concentration that is most commonly used contains 100 units/mL and is available in 3-mL or 10-mL sizes. Various types of insulin are available; the most common are listed in Table 18-2.

Table 18–2. Insulin products

Insulin is injected subcutaneously (under the skin). Traditionally, insulin has been administered using an insulin syringe; however, it can also be administered with insulin pens or as a continuous infusion using a pump. Sites of injection include the abdomen (which is the fastest site of absorption), the back of the arm, the outer thigh, and the hip/buttocks area.¹⁶ The sites of injection should be rotated (inject within a larger area for 1–2 weeks and then move to another area).

Injection with Syringes

Insulin stored in a vial is injected into the skin using syringes. Insulin syringes are available in 30-unit (3/10 mL), 50-unit (0.5 mL), and 100-unit (1 mL) sizes (Figure 18-1).¹⁷ A syringe should be chosen that is close to the number of insulin units injected. Using a smaller volume syringe (3/10 mL) for a small amount of insulin (less than 30 units) allows for more accurate dosing. The 30-unit and 50-unit syringes have 1-unit markings. The 30-unit (3/10 mL) syringes are also available with half-unit markings. The markings on the 100-unit (1 mL) syringes are 2 units each.

The length of the insulin syringe needle can vary from 5/16 inch to 1/2 inch, and the gauge can range from 28 to 31. Longer needle lengths can be used for persons injecting larger amounts of insulin (>50 units per injection). Higher gauge needles are thinner and can therefore be less painful.

For subcutaneous injection of insulin, the individual is advised to “pinch” a large fold of skin and inject the needle into that area of skin at a 45or 90-degree angle. This method minimizes the likelihood of insulin being injected into a muscle. Most persons inject insulin into the skin at a 90-degree angle. However, persons who are thin or who are very muscular may inject insulin at a 45-degree angle.

The steps of insulin injection using a syringe are as follows:¹⁶

1. Wash hands; gather materials (insulin vial, syringe, alcohol prep).

2. Clean site of injection with alcohol prep.

3. Remove needle cover; draw air into syringe that is equivalent to number of insulin units.

4. Inject air into insulin vial.

5. Invert insulin vial, withdraw insulin units, and check for air bubbles while syringe needle remains in vial.

6. If air bubbles are present, push insulin back into vial and withdraw insulin units again. Repeat until there are no large air bubbles present in syringe.

7. Remove syringe from vial. 8. Pinch fold of skin, inject at 45or 90-degree angle. 9. Keep needle in skin for a few seconds; then release skin fold and remove needle from skin.

Figure 18–1. BD syringes. (Courtesy of BD, Becton, Dickinson, and Company, 2010.)