National Subcutaneous Insulin Form Pilot NSW Health Version

1
National Subcutaneous Insulin Form Pilot NSW
Health Version
ltltlt Insert name of Project Officer/Team gtgtgt ltltlt
Insert name of Hospital gtgtgt A national pilot
project supported by the Australian Commission
on Safety and Quality in Health Care
2
Background

• Insulin recognised internationally as a high risk
  medicine
• Standardised Insulin prescribing and
  administration forms for adults have been
  implemented in Queensland Health hospitals since
  2008
• Need has been established for a nationally
  standardised form to accompany the National
  Inpatient Medication Chart (NIMC)

3

Monitoring
Communication and Safety
Insulin Administration

Insulin Orders
4
Before you start

• Cross reference the insulin form on the NIMC
• Also cross reference in regular medication order
  to ensure that
• staff refer to the Insulin Subcutaneous Order
• insulin is not omitted from discharge
  medications.
• A sticker is available

or
5
Patient Identification

• Affix the current patient identification label
  (with the patients name printed underneath)
• OR
• As a minimum, the patients name, UR number,
  address, date of birth and gender written in
  legible print

6
Hospital Demographics

• Complete Facility, Year and Ward / Unit

7
Monitoring / Notification Instructions

• Prescriber indicates the BGL Frequency of
  monitoring required
• Default BGL monitoring for inpatients is
  Pre-meals and at 2100hrs
• Consider more frequent BGL monitoring if required

8
Medical Officer to notify / Special Instructions

• The prescriber should document
• who to notify of out of range BGLs or other
  diabetes related concerns
• any Special Instructions
• If no contact name is written, the treating
  prescriber or team will be notified
• After hours the doctor on-call will be notified

9
Diabetes treatment prior to admission

• The prescriber, pharmacist or nurse writes the
  Diabetes treatment prior to admission in the
  space provided
• may include oral diabetes medicines and/or
  insulin types and doses
• optional additional information may include the
  insulin device that the patient was using

10
Blood Glucose Level (BGL) Monitoring Section

• Write the Date at the top of the days column
• Write the patients Diet
• This prompts for re-assessment of insulin
  requirements should the patient be fasting for a
  procedure or be on a diet such as clear fluids

11
BGL Monitoring Section

• Write the Time the BGL is measured
• Perform a BGL according to facility procedure
• Write the BGL in the coloured row corresponding
  to the relevant BGL range
• Note and act on any ALERT instructions in the BGL
  ranges

12
ALERTS (1)

• If the BGL is less than 4 mmol/L
• Initiate hypoglycaemia management (see page 4 of
  chart)
• Notify the treating doctor or doctor on-call
• Tick the Hypo Intervention and Dr Notified boxes
• Perform follow up BGLs and respond accordingly
• Document treatment and response on form and in
  medical record

13
ALERTS (2)

• High ALERT ranges are
• BGL greater than 20 mmol/L
• second consecutive BGL greater than 16 mmol/L
• third consecutive BGL greater than 12 mmol/L
• If BGL is in one of the ALERT ranges
• Notify the treating prescriber or doctor on-call
• Perform a ketone test (urine or blood), document
  result in the Ketones box
• Document the actions taken in the medical record
• Tick the Dr Notified box

14
Insulin Orders (Prescribing)

• A patient may be prescribed any combination of
  Routine, Supplemental, and Stat / Phone Insulin
  Orders
• If a patient with diabetes is not receiving
  subcutaneous insulin, this form should still be
  used for BGL monitoring

15
Routine Insulin Orders (1)

• Six (6) spaces to prescribe routine insulin
• Four (4) spaces with Meal / time pre-printed
• Breakfast
• Lunch
• Dinner
• Pre-Bed
• Use additional sections when a patient requires 2
  insulin types at a single meal / time

• Two (2) additional spaces without the
  pre-printed Meal / time

16
Routine Insulin Orders (2)

• The prescriber must
• Write the type of insulin (full trade name)
  e.g.Mixtard 30/70
• Sign each order
• Print their name in full at least once on the
  form
• Write the date
• Write the dose as a whole number
• Units is pre printed as a watermark
• Initials each dose ordered
• initials is pre printed as watermark
• Insulin doses must be ordered for each day
• It is usually appropriate to also order doses for
  the following morning

17
Routine Insulin Orders (3)

• The prescriber should also write the full trade
  name of insulin type/s in the Administration
  Record e.g.Mixtard 30/70

18
Routine Insulin Orders (4)

• If routine insulin is ceased, the prescriber
  must
• Draw a line through the order
• Do not obliterate the order
• Write the reason for ceasingthe order, the date
  the order was ceased and initials
• When the insulin regimen is being changed, write
  the new order on a new form

Ceased. Changing to mixed insulin prior to
discharge. See new chart
19
Supplemental Insulin Orders (1)

• It is not necessary to prescribe supplemental
  insulin for all patients
• It might be considered for erratic BGLs where
  strict control is required
• Patients may require supplemental insulin if
• their condition, dietary intake or concurrent
  medications are altering insulin requirements
• optimal doses not yet determined
• May be in addition to a routine mealtime or basal
  insulin dose

20
Supplemental Insulin Orders (2)

• Prescribing
• Tick the appropriate Frequency
• Write the Name of insulin, start date and start
  time
• Standardised BGL ranges are pre printed
• if required, different BGL ranges may be used
• Write insulin doses
• suggested doses available in Table 1 (page 1)
• Supplemental order remains valid until changed
  or ceased
• Sign and initial the order
• Review supplemental doses as required
• Changes are validated by initialling changes in
  the corresponding column
• Also write the Name of supplemental insulin in
  the Administration Record

21
Stat / Phone Orders (1)

• Stat Orders
• Document any single dose orders in this section
• The prescriber must verbally inform the nurse
  responsible for the patients care of any stat
  orders

22
Stat / Phone Orders (2)

• Phone Orders
• For Phone Orders nurses document
• the Date the order is received
• the Name of insulin
• the dose (as a whole number)
• Date / time the dose is to be administered
• phone order and the name of prescriber
• the initials of the nurses who received the order
• A second nurse must read back the written order
  to the doctor to confirm and then countersign the
  phone order
• The nurses receiving the phone order must check
  to see if the stat / phone order replaces, or is
  in addition to, other insulin orders
• Phone orders should be signed by the prescriber
  within 24 hours
• The nurse also cross references the phone order
  in the Routine Insulin Orders

23
Insulin Administration

• If clinical judgement indicates that a prescribed
  dose should not be administered, notify the
  prescriber or on-call doctor to review
• Write the code W for withheld and document the
  reason and the action taken in the clinical
  record

24
Administering Routine Insulin

• Mealtime insulin doses are given immediately
  before the patient eats
• Contact prescriber or doctor on-call if the
  patient has been receiving insulin and there is
  not a dose ordered for a meal / time
• Calculate, prepare, check and administer dose in
  line with facility procedure
• Document the time given
• Document the dose administered in the row against
  the correct Name of routine insulin row in the
  Administration Record
• Initial to acknowledge administering the dose
• Patients may have additional orders for the same
  time - check for Supplemental and Stat / Phone
  insulin orders
• Example next slide

25
(No Transcript)
26
Administering Supplemental Insulin

• Review supplemental insulin order and current BGL
  to determine if supplemental dose is required
• Calculate total insulin dose required
• May be in addition to routine insulin dose
• Prepare, check and administer total insulin dose
• Document the time given
• Document the doses or routine and supplemental
  insulin separately in the Administration Record
• Initial to acknowledge administration of the dose
• Example next slide

27
(No Transcript)
28
Administering Stat/ Phone Orders

• Prepare, check and administer dose
• Document the time given
• Document the dose of stat / phone insulin
  administered in the row against the corresponding
  name of Routine insulin
• Sign as having administered the dose
• Cross reference phone orders in the Routine
  Insulin Orders section
• Example next slide

29
(No Transcript)
30
Comments Section

• For documenting communication between members of
  the treating team with regard to insulin therapy
  and diabetes management
• Examples of what to document here include
• Doctor has been notified of the BGL
• hypoglycaemic event has been treated
• patient changed to intravenous insulin.

31
Pharmacy Review

• The clinician undertaking the pharmacy review
  will sign this section as a record that they have
  reviewed the insulin form (on the corresponding
  day) to ensure that all insulin orders are clear,
  safe and appropriate for that individual patient,
  reducing the risk of an adverse drug event

32
Guidelines for Managing Hyperglycaemia Alerts

• To assist inexperienced and non specialist
  clinicians with management of hyperglycaemia in
  hospital inpatients. They provide information
  related to
• ? assessment required when called for a
  Hyperglycaemia Alert
• ? initiation of basal and mealtime insulin and
  adjustment of insulin doses
• ? suggested stat and supplemental doses based on
  weight or previous total daily dose.

1
2
3
33
Management of Hypoglycaemia in Diabetes - Adult

• Has four treatment pathways
• conscious and cooperative
• insulin infusion
• nil by mouth or nil by tube
• oral or tube fed
• Appropriate food choices are listed
• Food choices should be centrally located in each
  ward / unit / outpatient facility
• Each unit should have access to glucose 50
  intravenous 50mL and glucagon 1mg injection to
  use in emergency situations
• Glucose based products are preferred as initial
  treatment
• Non diet products must be used to treat
  hypoglycaemia

Larger example next slide
34
Management of Hypoglycaemia in Diabetes - Adult
35
Diabetes treatment review after hypoglycaemia

• Below the flowchart are guidelines for Diabetes
  treatment review following treated hypoglycaemia
• Diabetes management must be reviewed in response
  to a hypoglycaemic event

36

• Acknowledgement
• This work was developed by Medication Services
  Queensland of Queensland Health and is based on
  the user guide developed to support the State
  Insulin Subcutaneous Order and Blood Glucose
  Record for adults.