Adult Standardised Subcutaneous Insulin Prescribing Chart August 2013 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) 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 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 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 2nd 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 record must contain: ‾ ‾ ‾ ‾ ‾ Date Time Dose Initials of administrator Initials of 2nd person checking NB: One nurse must be a registered nurse administration 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] .