Delivering Safe Prescribing of Insulin. Debbie Voigt Diabetes Specialist Nurse NHS Tayside

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2 Delivering Safe Prescribing of Insulin Debbie Voigt Diabetes Specialist Nurse NHS Tayside

3 Outline Insulin use in hospital Concerns about insulin Documentation to improve safety in subcutaneous insulin Intravenous insulin prescribing Resources available to promote safe prescribing

4 National Diabetes Inpatient Audit NHS England 2012 ( patients) 15.3% inpatients had diabetes 41.6% treated with insulin Inappropriate use of IV insulin NHS Tayside audit data ~20 % inpatients have diabetes 40 % treated with insulin 55% older than 75 years

9 How not to prescribe insulin

14 IHI rights of prescribing Right patient Right medicine Right dose Right route Right time Additionally, insulin prescribing requires Right documentation Right monitoring Right storage

15 The Insulin Prescription and Administration Record - IPAR

18 Onset and Duration of Insulin 1 Rapid-acting analogue e.g. Humalog, Novorapid, Apidra Short-acting (soluble) e.g. Humulin S, Actrapid, Insuman Rapid Intermediate acting (isophane) e.g. Insulatard, Humulin I, Insuman Basal Long acting analogue e.g. Lantus or Levemir Rapid acting analogue-intermediate mixture e.g. Humalog Mix25, Humalog Mix50, Novomix Short acting-intermediate mixture e.g. Humulin M3, Insuman Comb 15, 25, 50 1.Krentz AJ and Bailey CJ. Type 2 Diabetes in Practice. The Royal Society of Medicine Press. London p12 These diagrams are schematic only and represent time action profiles. However, the actual time action profile achieved can be variable because of individual variations in absorption, timing and dose of insulin and condition of injection sites.

19 Onset and Duration of Insulin 1 Rapid-acting analogue e.g. Humalog, Novorapid, Apidra Short-acting (soluble) e.g. Humulin S, Actrapid, Insuman Rapid Intermediate acting (isophane) e.g. Insulatard, Humulin I, Insuman Basal Long acting analogue e.g. Lantus or Levemir Rapid acting analogue-intermediate mixture e.g. Humalog Mix25, Humalog Mix50, Novomix 30 Short acting-intermediate mixture e.g. Humulin M3, Insuman Comb 15, 25, 50 1.Krentz AJ and Bailey CJ. Type 2 Diabetes in Practice. The Royal Society of Medicine Press. London p12 These diagrams are schematic only and represent time action profiles. However, the actual time action profile achieved can be variable because of individual variations in absorption, timing and dose of insulin and condition of injection sites.

26 Improvement measure Is insulin prescribed using capital letters? Is insulin prescribed in the legal prescription document? Is insulin dose prescribed without abbreviation u or i u? Has insulin been administered at each time prescribed?

27 Insulin Prescription and Administration Audit Pre Implementation of IPAR 50 charts audited at random throughout hospital Overall 95.5% compliance capital letters used prescription ontpar no abbeviation used insulin administered approriately target not met target met

28 Insulin Prescription and Administration Audit Post Implementation of IPAR 25 charts audited in renal ward using the new IPAR 100% compliance Insulin prescibed using capital letters Insulin prescribed on legal chart (TPAR) No abbreviation Insulin administered as prescribed

29 Additional safety measure In the event of hypoglycaemia: Is appropriate treatment for hypoglycaemia available in the ward? Was the appropriate treatment given to patient? Was blood glucose rechecked in 15 minutes? Has diabetes medication reviewed/reduced?

30 Subcutaneous insulin administration Encourage self administration so long as it is safe to do so Agree prescription with patient Carbohydrate counting and insulin dose adjustment requires some prescription flexibility Monitoring will identify the efficacy of management

33 IPAR evaluation Ongoing audit in progress 200 staff surveyed - feedback positive Less than 20% of staff questioned had time at work to access online diabetes information Support for a national inpatient insulin prescription chart

34 Work in progress IPAR testing in: Ayrshire and Arran Dumfries and Galloway Edinburgh Glasgow Lanarkshire Tayside

35 Intravenous insulin prescribing

36 Intravenous (IV) insulin Diabetic Ketoacidosis (DKA) Hyperosmolar Hyperglycaemic State (HHS) Acute illness Fasting/patients who are unable to tolerate oral intake Prescribing resources Scottish National DKA protocol JBDS HHS guideline Healthcare e-academy and NHS Improving Quality Insulin Safety Suite of e-learning modules: Scotland

37 IV insulin and perioperative guideline Pre printed IV insulin prescription Variable rate insulin scales one size does not fit all Peri-operative management Hypoglycaemia and hyperglycaemia guidance Integrated measures for safety

38 Pre printed IV insulin prescription Add 50 units of soluble insulin (e.g. Actrapid) to 49.5mL to sodium chloride 0.9% (1 unit of insulin per ml = 1mL/hour). Infuse via syringe driver. BG mmol/l Action Plan Scale 1 units/hr Scale 2 units/hr Scale 3 units/hr Scale 4 units/hr < 4 Infuse 50mls 10 % Glucose IV and change to reduced scale e.g. change from Scale 1 to Scale Consider change to a reduced insulin scale If BG > 12 mmol/l consider change to an increased insulin scale. See guideline for hyperglycaemia below >

39 Measurement for IV insulin management Hourly blood glucose (BG) monitoring Aim for BG 5-12 mmol/l Free of hypoglycaemia Check ketones if BG > 12 mmol/l Check U & E s at least daily Safe transition from IV to SC insulin

40 Summary Support is required for non specialist prescribers Documentation can improve safety Resources are available online and at the bedside A portfolio of inpatient diabetes guidelines is available on

41 Acknowledgements Dr Geraldine Brennan, Consultant Diabetologist, Ninewells Hospital Dr Susannah Silver, University of Dundee Nurses, Doctors and Pharmacists NHS Tayside

ONCE ONLY GLUCAGON and Fast Acting Glucose gel (PGD) For nurse administration under Patient Group Direction (Trust wide PGD in place)

ONCE ONLY GLUCAGON and Fast Acting Glucose gel (PGD) For nurse administration under Patient Group Direction (Trust wide PGD in place) ADULT INSULIN PRERIPTION AND BLOOD GLUCOSE MONITORING CHART Ward CONSULTANT DATE OF ADMISSION Please affix Patient s label here Ward Ward.../...year PATIENT NAME....... DATE OF BIRTH... NHS NUMBER.......