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August 2013

Adult Standardised Subcutaneous Insulin Prescribing Chart

Case for Change

• • • • • • • • Insulin is a high risk medication Reported in top 10 high alert medicines worldwide Nearly 3000 incidents in IIMS Variation in insulin charts, charting; prescription, administration and documentation Variation in access to specialist services and glycaemic management guidance Mobile workforce Need to improve management and patient safety Risk minimisation for patients

Methodology

• • • • • • • Review of NSW and national charts Widespread clinical input Developed standardised chart Pilot - Ryde and Royal Prince Alfred State wide consultation - parallel to State Forms process Chart revised Endorsed by Medication Safety Expert Advisory Committee (MSEAC)

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What does it mean for me?

Separate chart from NIMC Use in adult acute inpatient settings Intravenous and specialty charts - unchanged Document and use differently All glycaemic information linked: • Prescription and administration • • Easier referral to readings Access to best practice guidelines; at bedside Standardised chart = standardised practice; communication, documentation and interpretation Better patient care

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Key principles

Combined monitoring and guidelines - minimise delay in management decisions Clinicians without local guidelines have clear guidelines for: Insulin prescription Insulin administration Management of hypo and hyperglycaemia Safe use of supplemental insulin • • Do not take the place of local guidelines or policies Reduced risk of error

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Four Sections

‾ ‾ ‾ ‾ ‾ ‾ Page 1, including top of page 3: Patient Identification and demographics Alerts Codes for not administering Instructions Guidelines for prescription and administration Special instructions ‾ ‾ Page 2 and 3: Regular, supplemental, once only and telephone orders BGL and ketone monitoring ‾ Page 4: Guidelines for glycaemia management

Patient Identification and demographics

• ‾ ‾ ‾ ‾ ‾ ‾ ‾ All charts require ID label affixed consistent with NIMC MRN Name (family and given) Gender DOB Medical Officer (MO) Address Location

Allergies and Adverse Drug Reactions (ADR)

• • • • Clinical staff to complete Allergies and ADR Select Nil Known, Unknown or; ‾ ‾ If allergy exists document: Name of drug/substance Reaction details ‾ ‾ ‾ Person documenting required to: Sign Print name and; Date the entry

Alerts

• • • • • Prescriber document who to notify if certain criteria met e.g. BGL or ketones out of range If no alerts select Nil All entries signed and dated If alert changed- cross out, sign and date it and enter new alert Enter details in health care record

Reason for not administering

• • • • • Complete when unable to administer insulin Codes to be circled If dose refused, notify prescriber If withheld, document reason in health care record If not available - obtain supply or contact prescriber

Instructions

• • • ‾ ‾ The chart is used for: All insulin prescriptions, except IV Recording BGL and ketones, for patients on subcutaneous insulin ‾ Specify frequency of monitoring (page 3) Unstable BGLs require more frequent monitoring All patient management must also be documented in health care record

Guide: Prescription & Administration

• • • • • • ‾ Daily review and prescription recommended: May order ahead if glycaemic status stable Modify requirements - Peri-operative and modified diets Target BGL range 5-10mmol/L, except pregnancy Do not re - write units, it is pre printed ‾ ‾ Orders: No alterations to original order Discontinue by line through insulin name, 2 oblique lines in administration column on day of discontinuation, sign and date Abdomen is preferred injection site

Additional information and instructions

• ‾ ‾ Indicate if patient is on: Insulin pump Other diabetes medication • ‾ ‾ Special instructions: To communicate information at bedside e.g. supervise using insulin pen Can be completed by any staff member

NB

: All patient management must also be documented in the patients health care records

• Daily orders- may be in advance if stable • Regular subcutaneous orders must contain: ‾ Type of insulin ‾ Date prescribed ‾ ‾ ‾ ‾ ‾ Frequency Time of administration Dose Prescriber’s signature and name printed Prescribers contact • Administration record must contain: ‾ Time given ‾ Initials of administrator ‾ Initials of 2 nd person checking • Before administering regular insulin check if supplemental insulin is ordered and needed

NB:

Two staff to initial and record time given, one of which must be a registered nurse

Supplemental Insulin

• • • • • • Guidelines page 4 Daily review and adjustment of regular insulin during acute phase of illness Not a replacement for regular insulin doses Best given before a meal, in addition to usual insulin If repeated doses needed - consider adjustment of regular doses Prescribed based on preferred range in space provided

Supplemental Insulin

prescription • ‾ ‾ ‾ ‾ ‾ Order must contain: Type of insulin Date prescribed Time of administration- before meals or specify Dose for each BGL threshold Prescribers signature, name and contact

Supplemental Insulin

administration • ‾ ‾ ‾ ‾ ‾ Administration record must contain: Date Time Dose Initials of administrator Initials of 2 nd person checking NB: One nurse must be a registered nurse

Page 3

• • • Blood glucose and ketone monitoring Frequency selected Hypo record and treatment comments (right hand side) Once only subcutaneous insulin (bottom) Telephone orders 4 Most be signed within 24 hrs

• • • • Patients on subcutaneous insulin only Frequency indicated by tick box BGLs - relate to day of insulin administration Hypoglycaemia section- extra BGL and action columns, record episodes and treatment

NB

: All hypoglycaemic episodes should be managed immediately & include assessment for clinical review and must be fully document in health care record

Once Only S/C Insulin

• • Specify date and time dose to be administered Nursing staff must initial and record time insulin administered

Telephone Orders

• • • As per NSW Health policy Refer to local policies Signed within 24 hrs by MO

Page 4

• • • ‾ ‾ ‾ Guidelines for: Management of hypoglycaemia Management of hyperglycaemia Use of supplemental insulin and correction of hyperglycaemia For areas without local guidelines, policy or specialist support Don’t take the place of local guidelines or policy

Acknowledgements

• • Inpatient Management Working Group The many clinicians who have contributed to development and pilot of the Subcutaneous Insulin Medication Chart

Questions, Comments, Observations….

Contact Rebecca Donovan PH: 9464 4626 [email protected]

Melissa Tinsley PH: 9464 4653 [email protected]

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