TRIM User Guide to National Insulin Subcutaneous Order and Blood Glucose Record: Adult

Transcription

1 TRIM User Guide t Natinal Insulin Subcutaneus Order and Bld Glucse Recrd: Adult

2 Cmmnwealth f Australia 2012 This wrk is cpyright. It may be reprduced in whle r in part fr study r training purpses subject t the inclusin f an acknwledgement f the surce. Requests and inquiries cncerning reprductin and rights fr purpses ther than thse indicated abve requires the written permissin f the Australian Cmmissin n Safety and Quality in Health Care, GPO Bx 5480 Sydney NSW 2001 r mail@safetyandquality.gv.au Suggested citatin Australian Cmmissin n Safety and Quality in Health Care (2012) User Guide t Natinal Insulin Subcutaneus Order and Bld Glucse Recrd: Adult, ACSQHC, Sydney. Acknwledgment This wrk was develped by Medicatin Services Queensland f Queensland Health and is based n the user guide develped t supprt the State Insulin Subcutaneus Order and Bld Glucse Recrd fr adults. This dcument is available n the Cmmissin web site at User Guide t Natinal Insulin Subcutaneus Order and Bld Glucse Recrd: Adult 2

3 Table f cntents Sectin Page 1. Purpse 4 2. General instructins 4 3. Identificatin and demgraphics Patient identificatin Hspital demgraphics Crss reference with Natinal Inpatient Medicatin Chart (NIMC) 5 4. Mnitring / ntificatin instructins BGL frequency Medical Officer t ntify / special instructins Diabetes treatment prir t admissin 7 5. Mnitring recrd (fr bld glucse levels) Bld Glucse Mnitring 7 6. Insulin rders (prescribing) Rutine insulin rders Supplemental insulin rders Stat / phne rders Stat rders Phne rders Administratin recrd Dcumentatin f insulin administratin Administratin f a rutine insulin dse Administratin f a supplemental insulin dse Dcumenting phne rders and administratin f phne rders Dcumenting administratin f stat rders Examples Rutine insulin Supplemental insulin Phne rders Cmments sectin Guidelines fr Managing Hyperglycaemia Alerts Hypglycaemia Management in Diabetes: Adult Hypglycaemia Management in Diabetes: BGL less than 4mml/L Diabetes treatment review fllwing treated hyperglycaemia Pharmacy review 23 User Guide t Natinal Insulin Subcutaneus Order and Bld Glucse Recrd: Adult 3

4 User Guide t Natinal Insulin Subcutaneus Order and Bld Glucse Recrd: Adult Exceptins: This frm is NOT intended t be used fr children 1. Purpse The purpse f this user guide is t explain hw clinicians shuld use the Insulin Subcutaneus Order and Bld Glucse Recrd: Adult t take full advantage f its safety features. The safety features f the frm prmte cnsistent dcumentatin t assist with accurate interpretatin f subcutaneus insulin rders. The frm is intended t reflect best practice. The specific sectins f the frm assist clinicians t safely prescribe and administer insulin, and t mnitr bld glucse levels (BGLs). The Institute fr Safe Medicatin Practices (ISMP) cnsiders insulin a high risk medicatin. Standardising the cmmunicatin f medicatin infrmatin between dctrs, nurses and pharmacists wrking in hspitals aims t reduce harm t patients frm medicatin errrs. This has been prven by the intrductin f the Natinal Inpatient Medicatin Chart (NIMC). Standardisatin, in additin t reducing patient harm, allws fr a cllabrative apprach t the training f medical, nursing and pharmacy staff in the use f a cmmn frm. Linking all the infrmatin required t manage inpatient diabetes requirements is expected t enable clinical staff t mre effectively manage patient treatment. Fr patients wh are nt treated with insulin, the frm is used fr BGL mnitring. The fllwing are general requirements regarding use f the Insulin Subcutaneus Order and Bld Glucse Recrd: Adult. All authrised prescribers must rder medicines fr inpatients in accrdance with legislative requirements accrding t the relevant state and territry drugs and pisns legislatin. Orders shuld be reviewed daily and when ntificatins f ut-f-range BGLs ccur ensuring apprpriate diabetes management and dsing f insulin. The frm is t be utilised fr all inpatients requiring subcutaneus insulin and/r BGL mnitring unless ward/unit prcedures state therwise. A different insulin chart is required fr the prescribing, administratin and mnitring f intravenus insulin. 2. General instructins All entries are t be written legibly in ink. N matter hw accurate r cmplete an rder, it may be misinterpreted if it cannt be read clearly. Water sluble ink (e.g. funtain pen) shuld nt be used. Black ink is preferred. A medicatin rder is valid nly if the authrised prescriber enters all the required items. All infrmatin shuld be printed. N erasers r whiteut shuld be used. The frm allws rders t be updated daily fr 5 days, after which time the rder must be rewritten n a new frm. The patient s current hspital and ward lcatin shuld be clearly marked n the Insulin Subcutaneus Order and Bld Glucse Recrd Adult: See Sectin 3.2. User Guide t Natinal Insulin Subcutaneus Order and Bld Glucse Recrd: Adult 4

5 3. Identificatin and demgraphics 3.1 Patient identificatin Patient identificatin (ID) n the Insulin Subcutaneus Order and Bld Glucse Recrd Adult is cnsistent with the identificatin required when using the Natinal Inpatient Medicatin Chart (NIMC). A watermark has been included in the patient identificatin sectins n pages 1 and 2 as a reminder that a prescriptin is nt valid unless the patient s identifiers are present. This can be dne in ne f 2 ways: 1. The current patient ID label placed n pages 1 and 2 2. As a minimum, written in legible print, the patient: UR number Name (family and given) Address Date f birth Gender (M = Male; F = Female; I = Indeterminate) The first prescriber must print the patient s name under the label t verify that bth the ID label and the insulin rders relate t the crrect patient. This will reduce the risk f the wrng ID label being placed n the frm which culd lead t the wrng patient receiving insulin. Insulin shuld nt be administered if the prescriber has nt cmpleted the patient identificatin details. In these situatins: Cntact the prescriber urgently as insulin shuld nt be withheld. If the riginal prescriber is nt available, cntact the dctr n-call. 3.2 Hspital demgraphics Cmplete facility, ward / unit and year in this sectin (at the tp right side f page 3). 3.3 Crss reference with Natinal Inpatient Medicatin Chart (NIMC) Tick the BGL/Insulin bx n page 1 f the NIMC. User Guide t Natinal Insulin Subcutaneus Order and Bld Glucse Recrd: Adult 5

6 Crss reference the insulin rder in the NIMC regular medicatins sectin t ensure insulin is nt mitted during hspital admissin and frm discharge medicatins. Crss referencing shuld be dne either by: a) Placing a pre-printed sticker stating that Insulin is Ordered fr this Patient See Insulin / BGL frm, OR b) The authrised prescriber, pharmacist r registered nurse (RN) hand-writing n the sectin if stickers are unavailable. 4. Mnitring / ntificatin instructins 4.1 BGL Frequency The prescriber shuld indicate the BGL Frequency required fr the patient. Default BGL mnitring fr an inpatient is pre-meals and at 21:00hurs. Tick all ptins that apply. Mre than ne bx can be ticked. Cnsider if patient requires mre frequent BGL mnitring e.g. at 0200 hurs if risk f ncturnal hypglycaemia r fasting, and 2 hurs pst-meal if pregnant. If the prescriber des nt indicate the BGL frequency, BGLs shuld be recrded accrding t the Standard mnitring frequency (pre-meals and at 21:00 hrs). The BGL frequency shuld be reviewed and updated regularly in the apprpriate date clumns f the Mnitring Recrd. User Guide t Natinal Insulin Subcutaneus Order and Bld Glucse Recrd: Adult 6

7 4.2 Medical Officer t ntify / special Instructins The prescriber shuld dcument wh t ntify f any BGL that is ut f range r ther cncerns regarding diabetes management. If the name space (n the left side f page 2) is left blank, the resident medical fficer fr the treating team will be ntified. The dctr n-call will be ntified after hurs. Clinicians may dcument any Special Instructins related t the patient s diabetes management in the space prvided (n the left side f page 2). 4.3 Diabetes treatment prir t admissin Clinicians shuld write the Diabetes treatment prir t admissin in the space prvided (in the bttm right hand crner f page 3). This may include ral hypglycaemic agents and/r insulin names and dses. Optinal additinal infrmatin may include the insulin device that the patient uses. 5. Mnitring recrd (fr bld glucse levels) 5.1 Bld glucse mnitring Generally, the BGL target range fr mst inpatients n general wards receiving subcutaneus insulin and/r ral treatments is 4-10mml/L with up t 12mml/L cnsidered reasnable. In the Mnitring Recrd there are tw rws that d nt have any shading (4-8mml/L and mml/L). If BGLs fall within this mnitring range, a dctr is nt required t be ntified unless requested in the Special Instructins r if there are specific cncerns. Certain situatins (e.g. pregnancy) require tighter cntrl. The Special Instructins area can be used t define specific BGL targets and ntificatins. A dctr must be ntified when the BGL is: less than 4 mml/l greater than 20 mml/l the secnd cnsecutive BGL greater than 16 mml/l the third cnsecutive BGL greater than 12 mml/l. T dcument a BGL: The date shuld be dcumented n the tp f the current Date clumn. The nurse r prescriber shuld dcument the Diet the patient is t receive fr the day (e.g. Nil By Muth (NBM), Ttal Parenteral Nutritin (TPN), clear fluids, full diet). This prmpts reassessment f insulin requirements shuld the patient be fasting fr a prcedure r have altered dietary requirements. Dcument the time the BGL is measured in the Time space at the tp f the BGL clumn. User Guide t Natinal Insulin Subcutaneus Order and Bld Glucse Recrd: Adult 7

8 Nte: The example abve uses 24 hur time in the Time spaces Perfrm a BGL accrding t facility prcedure. Write the BGL in the clured rw crrespnding with the relevant range printed t the left and right f the Mnitring Recrd. Nte any instructins in the ALERTS sectin that aligns with that range. If the BGL is less than 4mml/L, initiate hypglycaemia management as per Hypglycaemia Management in Diabetes: BGL less than 4mml/L which is printed n page 4 and ntify the treating prescriber r dctr n-call. Then: Tick the Hyp Interventin bx after initiating hypglycaemia treatment and ensuring patient safety. Perfrm fllw up BGLs accrding t Hypglycaemia Management in Diabetes: BGL less than 4mml/L which is printed n page 4 and respnd accrdingly (see sectin 10). Dcument the hypglycaemia treatment and respnse in the medical recrd. If the BGL is in a high alert range (i.e. greater than 20mml/L r the secnd cnsecutive BGL greater than 16mml/L r the third cnsecutive BGL greater than 12mml/L): Ntify the treating prescriber r dctr n-call Perfrm a urine r bld ketne test, dcument the result in the Ketnes bx and ntify the prescriber f any psitive result. Tick the Dr Ntified bx. If a urine ketne test is perfrmed, the result is dcumented as neg if n ketnes are present r as a + r ++ etc. as indicated n the urine ketne test strip bttle. If a bld ketne test is perfrmed, the result is dcumented as a number (e.g. 0.6 r 1.4 ). Als dcument the actins taken in the medical recrd. Further infrmatin can be dcumented in the Cmments sectin belw and in the medical recrd. User Guide t Natinal Insulin Subcutaneus Order and Bld Glucse Recrd: Adult 8

9 6. Insulin rders (prescribing) Insulin rders are divided int three sectins: Rutine, Supplemental, and Stat / Phne Insulin Orders. Patients may require any cmbinatin f these rders. If n insulin is prescribed fr a patient with diabetes, this frm shuld be used fr BGL mnitring as the alerts and ntificatin prmpts will als apply t patients nt receiving insulin. 6.1 Rutine insulin rders There are six spaces t prescribe rutine insulin in this sectin. Meal times are pre-printed t ensure insulin is given immediately befre a patient eats. All mealtime insulin dses including thse with minute delay in nset f actin are t be given immediately befre the patient eats, when their meal is in frnt f them. Ratinale: In the hspital setting, meal delivery times are variable and if delayed after insulin has been administered, hypglycaemia may result. Prescribing spaces There are fur prescribing spaces with the fllwing Meal / time pre-printed: Breakfast Lunch Dinner Pre-Bed Tw prescribing spaces withut the pre-printed Meal / time; ne at the tp and ne at the bttm f the Rutine Insulin Orders sectin. The additinal prescribing spaces are t be used when a patient has an additinal insulin injectin prescribed at a single meal / time. Fr example, if a patient receives bth their basal insulin and their mealtime insulin at breakfast. In the prescribing space fr the apprpriate meal / time (e.g. Breakfast) write the full trade name f the insulin t be administered in the space marked Name f insulin. Fr premixed insulin specify the insulin type in full (e.g. Mixtard 30/70, Humalg Mix 25, NvMix 30 ). Mixtard r Humalg Mix are nt cmplete rders. Ratinale: Trade names are preferred fr insulin prescribing t avid cnfusin as there are many lk-alike / sund-alike generic insulin names which are nt interchangeable. Additinally, wherever pssible the patient shuld receive the brand f insulin they use r will be using at hme. The prescriber must sign each rder and initial in the grey shaded rw immediately belw the insulin and dse prescribing space (where initials is watermarked). The prescriber must print their name in full at least nce per frm. User Guide t Natinal Insulin Subcutaneus Order and Bld Glucse Recrd: Adult 9

10 At the tp f the first Date clumn in the Rutine Insulin Orders sectin, write the date the dse is t be administered. Write the number f units rdered as a whle number nly in the bx relevant t the meal / time the insulin is t be administered, under the apprpriate date clumn. Units is pre-printed as a watermark. D nt write U r IU as these abbreviatins can cause serius dse administratin errrs (e.g. if 5u is misread as 50 units). Each dse is prescribed in a different space accrding t the meal r time it is t be administered. If the patient has been receiving insulin and n dse is rdered fr the next meal r time, the nurse must call the treating prescriber r the dctr n-call fr a phne rder. The previus day s rder is nt a recurrent dse rder. In the event f a phne rder being required, the nurse writes phne in the apprpriate insulin dse bx f the Rutine Insulin Orders sectin t indicate that a phne rder has been taken. Fr additinal instructin n phne rders, please see the instructins at Sectin 6.3 Stat / Phne Insulin Orders. Insulin dses must be rdered fr each day. When writing up daily dses, it is apprpriate t prescribe dses fr the rest f that day and fr the first dse(s) f the fllwing day. The prescriber may rder insulin dses fr several days when the BGLs have been acceptable and stable in the range f 4-12mml/L. The prescriber rders the insulin dses fr subsequent days in the additinal Date clumns. The new dse supersedes thse written fr previus dates. A new frm must be written by the prescriber after 5 days, r when there is n space t rder dses r recrd BGLs. Immediately after prescribing insulin, the prescriber shuld write the full trade name f the insulin t be administered in the rw/s in the Administratin Recrd sectin with the prmpt Name f rutine insulin. Trade names are preferred in insulin prescribing t avid cnfusin as discussed in Sectin 6.1. Example: Rutine Insulin Orders If rutine insulin is ceased, the riginal rder must nt be bliterated. The prescriber must draw a clear line thrugh the rder, taking care that the line des nt bliterate ther rders. The prescriber must write the reasn fr changing the rder (e.g. cease, change t insulin regimen) and dcument the date the rder was changed, then initial. Nte: the acrnym D/C (discntinued) shuld nt be used fr ceased rders since this can be cnfused with discharge. Always use cease. When the insulin regimen is being changed (nt a dse change, which can be facilitated n the chart) the prescriber must nt verwrite the rder. The riginal rder must be ceased and a new rder written n a new subcutaneus insulin frm. User Guide t Natinal Insulin Subcutaneus Order and Bld Glucse Recrd: Adult 10

11 Example: Ceased Rutine Insulin Orders Ceased. Changing t mixed insulin prir t discharge. See new rder J Simmnds 6.2 Supplemental insulin rders It is nt necessary fr all patients t have supplemental insulin prescribed. It might be cnsidered where glycaemic cntrl has been erratic and strict cntrl is desirable. Supplemental insulin may be in additin t a rutine mealtime r basal insulin dse. It may be required if the: Patient s cnditin, dietary intake r a cncurrent medicatin is altering their insulin requirements Patient has recently cmmenced subcutaneus insulin and ptimal dses have nt yet been determined. Example: Prescriptin fr supplemental dses t be administered with meals Tick the Frequency the supplemental insulin dse is t be administered: With meals nly if the patient is tlerating an ral diet 6 hurly if the patient is receiving cntinuus parenteral nutritin r tube feeding Other (specify) in specific circumstances and specify when it wuld be required. Write the Name f Insulin t be administered in the space prvided. Usually, if the patient is receiving rapid r shrt acting rutine insulin with meals, the same type f insulin is prescribed as supplemental insulin. Write the Start date and Start time that the rders are written. User Guide t Natinal Insulin Subcutaneus Order and Bld Glucse Recrd: Adult 11

12 Standardised BGL ranges, which are clur cded and match the BGL ranges in the Mnitring Recrd, are pre-printed n the frm with a starting BGL range fr supplemental insulin f mml/L. If required, alternate BGL ranges may be used. Dcument the insulin dses in the relevant Start date clumn. The dses shuld be written as a whle number, and be written against the BGL ranges at which they are t be administered. The wrd units is pre-printed as a watermark. The prescriber must sign the rder and print their name in the spaces prvided. The prescriber must als write the full trade name f the supplemental insulin in the Administratin Recrd rw with the prmpt Name f supplemental insulin. The Supplemental Insulin Order remains valid until ceased r changed. This is in cntrast t rutine insulin rders, where dses are required fr each day. Ratinale: Rutine dses shuld be adjusted daily in respnse t the BGLs and the amunt f supplemental insulin required in the previus 24 hurs. Therefre the patient s requirement fr supplemental insulin shuld reduce as rutine insulin dses are adjusted. If necessary review and amend supplemental dse changes as required in the crrespnding date clumns. Changes are validated by the prescriber initialling at the bttm f the crrespnding start date clumn. The Supplemental Insulin Order des nt cntinue past the last usable day n the frm. After cmpletin f a previus frm, Supplemental Insulin Orders must be either : rdered n the new frm if supplemental insulin is t be cntinued, r ceased n the expiring frm t cmmunicate the intentin that the patient is n lnger t receive supplemental insulin. Administratin f the insulin dse is dcumented in the Administratin Recrd sectin (see sectin 6.4). Example: ceasing the supplemental rder Special Nte: Ceased. J Simmnds 14/7/12 SUBCUTANEOUS SLIDING SCALE insulin is NOT RECOMMENDED as sle insulin therapy. BASAL insulin requirements shuld be cnsidered. User Guide t Natinal Insulin Subcutaneus Order and Bld Glucse Recrd: Adult 12

13 6.3 Stat / phne insulin rders Dcument any single stat r phne insulin dse rders in this sectin. Administratin f the insulin dse is dcumented in the Administratin Recrd sectin alng with Rutine dses (see sectin 7.3) Stat rders If the dctr is ntified f an ut-f-range BGL, a stat dse may be rdered. The prescriber must infrm verbally the RN respnsible fr the patient s care f any stat rders Phne rders If a RN takes a phne rder fr any insulin dse (rutine r due t an ut-f-range BGL), the rder is dcumented here. A secnd nurse must read back the written rder t the prescriber t cnfirm that the rder is crrect and then cuntersign the phne rder. The nurse(s) receiving the phne rder must check if the stat / phne rder replaces, r is in additin t, ther insulin rders. Phne rders shuld be signed by the prescriber within 24 hurs. 6.4 Administratin recrd When prescribing insulin, the prescriber shuld write the full trade name in the Administratin Recrd where the rws prmpt Name f rutine insulin and Name f supplemental insulin. If the prescriber has nt written the insulin trade name and the patient requires an insulin dse, the RN r pharmacist may write the full trade name in these rws. User Guide t Natinal Insulin Subcutaneus Order and Bld Glucse Recrd: Adult 13

14 7. Dcumentatin f insulin administratin See examples f dcumenting insulin administratin thrughut this sectin. Administratin f all insulin dses is dcumented in the Administratin Recrd. Prepare and administer insulin accrding t facility prcedure. Dcument the dse administered against the crrespnding Name f rutine insulin r Name f supplemental insulin rw in the Administratin Recrd. Dcument the time insulin is given. Initial in the Nurse 1 initials bx t acknwledge administratin f the dse. The secnd nurse checking the insulin dse shuld initial in the Nurse 2 initials bx. The 2 sets f initials cnfirm the administratin f each insulin dse. A BGL shuld be perfrmed within the 30 minutes befre an insulin dse as it may change significantly prir t insulin administratin if left lnger. Insulin dses administered at mealtimes shuld be given immediately befre a patient eats, when their meal is in frnt f them. Ratinale: In the hspital setting meal delivery times are variable and if delayed after insulin has been administered, hypglycaemia may result. Rutine, Supplemental and Stat / Phne insulin rders may be rdered fr the same time. If s, insulin rders that are the same type f insulin (e.g. shrt-acting) may be administered tgether but must be dcumented separately. If clinical judgement indicates that a prescribed dse shuld nt be administered (e.g. the patient is fasting r vmiting), ntify the prescriber t review the dse. If fr any reasn an insulin dse cannt be administered as rdered ntify the prescriber, enter cde W fr withheld and dcument in the clinical recrd. Nte: It wuld be unusual fr a patient with type ne diabetes t have their insulin dse withheld cmpletely. 7.1 Administratin f a rutine insulin dse After taking and recrding a BGL, check if an insulin dse is t be administered. Nte: sme patients may be prescribed mre than ne type f insulin at a time. In the Rutine Insulin Orders sectin Meal / times (i.e. Breakfast, Lunch, Dinner, Pre-Bed) are preprinted. The dse is prescribed under the current Date clumn. If there is n dse rdered where ne wuld be expected, cntact the prescriber r dctr n-call t determine if a dse is required and t prvide a phne rder if it is. Calculate and prepare ttal insulin dse (Rutine +/- Supplemental +/- Stat / Phne). Cnfirm the insulin type and dse is crrect with anther apprpriately trained nurse. Check lcal prcedure t determine whether different types f insulin can be mixed in the syringe. Administer the insulin. Dcument the time insulin is given in the Time given rw f the Administratin Recrd t accurately reflect the time f administratin (which may be slightly different frm the time the BGL is recrded). Dcument the administratin as utlined abve. User Guide t Natinal Insulin Subcutaneus Order and Bld Glucse Recrd: Adult 14

15 7.2 Administratin f a supplemental insulin dse Review the Supplemental Insulin Orders and check whether supplemental insulin is required at that Meal / time accrding t the BGL ranges fr which it is prescribed. Calculate and prepare the dse f insulin t be administered (and which may be in additin t a rutine mealtime dse). Administer the insulin and dcument the administratin in the Administratin Recrd as utlined abve. Supplemental insulin and rutine insulin f the same type (e.g. shrt-acting) and due at the same time may be administered tgether but must be dcumented separately. 7.3 Dcumenting phne rders and administratin f phne rders If a RN takes a phne rder fr any insulin dse (Rutine r because BGL requires ntificatin), the rder is dcumented here. Nte: A secnd nurse must read back the rder dcumented by the first RN t the dctr t cnfirm it is crrect and then cuntersign the phne rder. The nurse(s) receiving the phne rder must check t see if the Stat / Phne rder replaces r is in additin t ther insulin rders. Dcument the administratin f phne rder insulin in the Administratin Recrd as utlined previusly. Als crss reference the rder by writing phne in the dse bx in the Rutine Insulin Orders. The phne rder must be signed by the authrised prescriber, r therwise cnfirmed in writing accrding t facility prcedure. 7.4 Dcumenting administratin f stat rders If the Medical Officer attends the ward and prescribes a single dse in the Stat / Phne Insulin Orders, then he/she must verbally infrm the RN respnsible fr the patient s care. Prepare and administer the insulin and dcument the administratin in the Administratin Recrd as utlined previusly. User Guide t Natinal Insulin Subcutaneus Order and Bld Glucse Recrd: Adult 15

16 7.5 Examples Rutine insulin The patient is prescribed 8 units f rapid acting insulin as a rutine insulin dse fr breakfast n 11/7/12. The BGL is 12mml/L. Eight (8) units f insulin are rdered in the Rutine Insulin Orders. There are n supplemental r stat / phne insulin rders, s the dse t be administered remains 8 units f rutine rapid-acting insulin. The time f administratin 0730 is dcumented in the Time given rw. 8 units f rapid-acting insulin is administered and dcumented as 8 : the ttal dse administered in the relevant rw f the Administratin Recrd. The nurses shuld initial t dcument the administratin as utlined abve. User Guide t Natinal Insulin Subcutaneus Order and Bld Glucse Recrd: Adult 16

17 7.5.2 Supplemental insulin At lunchtime n 12/7/12, the patient is prescribed 8 units f rapid-acting insulin as a rutine insulin dse. The BGL is 12.5mml/L. By checking the Rutine, Supplemental and Stat / Phne Insulin Orders sectins, it can be seen that with a BGL f 12.5mml/L the patient is t be administered 8 units f rutine rapid-acting and 4 additinal units f supplemental rapid-acting insulin. There is n stat / phne rder. The ttal insulin dse f 12 units f rapid acting mealtime insulin (8 units f rutine rapid acting insulin plus 4 units f supplemental rapid acting insulin) is prepared and administered as a single injectin. The time 12:45 is dcumented in the Time given rw. The 8 units f rutine rapid acting insulin are dcumented in the Administratin Recrd against the crrect rw with the prmpt Name f rutine insulin. The 4 units f supplemental rapid-acting insulin are dcumented in the Administratin Recrd against the rw with the Name f supplemental insulin prmpt Prepared and administered as a single dse f 12 units but dcumented as Rutine Insulin and Supplemental insulin dses User Guide t Natinal Insulin Subcutaneus Order and Bld Glucse Recrd: Adult 17

18 7.5.3 Phne rders On the 14/7/12 there is n insulin rdered fr lunchtime. As the patient has been receiving rutine insulin, the nurse ntifies the prescriber that the lunchtime BGL is 8mml/L. A phne rder is made fr 9 units f rapid-acting insulin t Nurse 1 wh initials t cnfirm receipt f the rder. Nurse 2 reads the written phne rder back t the prescriber t cnfirm and cuntersigns receipt f the rder. Nurse 1 writes phne in the Rutine Insulin Orders dse bx t indicate that a phne rder has been taken. Nurse 1 and Nurse 2 then prepare the rdered insulin dse. Nurse 1 and Nurse 2 then administer the insulin and write the time as 12:45 in the Time given rw. They write 9 as the units administered and initial under the dse. The prescriber signs the phne rder within 24 hurs. The nurse als crss references the phne rder in the Rutine Insulin Orders, s that clinicians are aware a phne rder has been taken. User Guide t Natinal Insulin Subcutaneus Order and Bld Glucse Recrd: Adult 18

19 8. Cmments sectin This area (belw the Administratin Recrd) is fr dcumenting cmmunicatin between members f the team caring fr the patient regarding insulin therapy and diabetes management. Examples f what can be dcumented here are that: the dctr has been ntified f the BGL a hypglycaemic event has been treated the patient has been changed t intravenus insulin. 9. Guidelines fr Managing Hyperglycaemia Alerts The Guidelines fr Managing Hyperglycaemic Alerts (n page 1) have been included t assist inexperienced and nn-frequent prescribers and ther clinicians. They are nt designed t decrease autnmy r specialist input. If there are any clinical cncerns, senir medical fficer advice shuld be btained. The guidelines prvide infrmatin related t: assessment required when called fr a Hyperglycaemia Alert initiatin f basal and mealtime insulin and adjustment f insulin dses suggested stat and supplemental dses based n weight r previus ttal daily dse.

20 1 2 3 User Guide t Natinal Insulin Subcutaneus Order and Bld Glucse Recrd: Adult 20

21 10. Hypglycaemia Management in Diabetes: Adult 10.1 Hypglycaemia Management in Diabetes: BGL Less than 4mml/L This flw diagram (n page 4) has been designed t standardise the management f hypglycaemia in adults treated in the hspital setting (emergency department, inpatients and utpatients). The flw diagram has fur treatment pathway ptins based n the patient s current cnditin, treatment and dietary status. These are determined by whether the patient is: cnscius and cperative receiving insulin via an intravenus insulin infusin nil by muth r nil by tube receiving fd rally r by tube. Lists f apprpriate fd chices are supplied fr use as initial and fllw-up treatment accrding t the diet the patient is receiving. Fd chices are determined frm the standard ptins available at the site. Sites are encuraged t ensure that the chsen fd chices are in a central lcatin in each ward, unit and utpatient facility. Each ward, unit and utpatient facility shuld have access t intravenus glucse 50% and glucagn 1mg injectin t use in emergency situatins. Glucse based prducts are preferred as initial treatment. Diet (lw kiljule) prducts must nt be used t treat hypglycaemia. User Guide t Natinal Insulin Subcutaneus Order and Bld Glucse Recrd: Adult 21

22 User Guide t Natinal Insulin Subcutaneus Order and Bld Glucse Recrd: Adult 22

23 10.2 Diabetes treatment review fllwing treated hyperglycaemia Diabetes management must be reviewed in respnse t a hypglycaemic event and clinicians shuld refer t the Diabetes treatment review fllwing treated hypglycaemia guidelines 11. Pharmacy review It has been clearly demnstrated that inpatients benefit frm a clinical pharmacist review f their medicatin regimen. Assciated activities such as liaisn with medical and nursing staff, clarificatin f rders, supply and administratin infrmatin are necessary t ensure safe and effective utcmes fr patients. Patients nt seen by a clinical pharmacist during their stay are at greater risk f an unfavurable medicine related utcme. The clinician undertaking pharmacy review shuld sign the Pharmacy Review sectin (n the bttm right side f page 3) as a recrd that they have reviewed the insulin frm (n the crrespnding day) t ensure that all insulin rders are clear, safe and apprpriate fr that individual patient, therefre reducing the risk f an adverse drug event. User Guide t Natinal Insulin Subcutaneus Order and Bld Glucse Recrd: Adult 23