Duty Doctor) V03 PPT-PGN-06…2020/10/01 · PPT-PGN-06 – Guidelines Safe Prescribing and Admin of Insulin and oral antidiabetic drug –V03-Iss1-Oct 2020 Part of CNTW(C) 38 - Policy

1 Cumbria Northumberland, Tyne and Wear NHS Foundation Trust PPT-PGN-06 – Guidelines Safe Prescribing and Admin of Insulin and oral antidiabetic drug –V03-Iss1-Oct 2020 Part of CNTW(C) 38 - Policy on Pharmacological Therapies

Pharmacological Therapy Policy Practice Guidance Note

Guidelines for the Safe Prescribing, Administration and Monitoring of Insulin and oral anti-diabetic drugs

(incorporating PPT PGN 02 - Treatment of acute hypoglycaemia in hospitals without an on-site Duty Doctor) V03

Date issued Issue 1 –Oct 2020

Planned review April 2021

PPT-PGN-06 Part of CNTW(C)38 – Pharmacological Therapy Policy

Author/Designation Anthony Young, Acting Deputy Chief Pharmacist – Clinical Services

Responsible Officer / Designation

Tim Donaldson, Trust Chief Pharmacist

Section Contents Page No:

1 Introduction 2

2 Staff competency 2

3 Medicines reconciliation 3

4 Prescribing 3

5 Monitoring 4

6 Supply 5

7 Administration 6

8 Management of Hypoglycaemia 7

9 Management of Hyperglycaemia 9

10 Considerations for care planning 10

11 Preparing for leave and discharge 11

12 Patients at high risk of developing diabetes 11

13 Training 12

14 References 13

Appendix, listed separate to practice guidance note

Number Description

Appendix 1 Blood Glucose Monitoring Chart

Appendix 2 Variable Dose Insulin Chart

Appendix 3 Treatment Algorithm for the management of acute hypoglycaemia

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2 Cumbria Northumberland, Tyne and Wear NHS Foundation Trust PPT-PGN-06 – Guidelines Safe Prescribing and Admin of Insulin and oral antidiabetic drugs–V03-Iss1-Oct 2020 Part of CNTW(C) 38 - Policy on Pharmacological Therapies

1 Introduction 1.1 Caution is required when prescribing and administering medicines for the

management of diabetes in particular, insulin within Cumbria Northumberland, Tyne and Wear NHS Foundation Trust (the Trust/CNTW), as staff may be unfamiliar with their use.

1.2 In general, using insulin is safe. However, there is potential for serious harm if it is not prescribed, administered and handled appropriately. The National Patient Safety Agency (NPSA) identified errors in the use of insulin that have caused harm to patients, and in some cases have caused death. Two errors in particular have been identified by the NPSA as common:

The use of abbreviations such as ‘U’ or ‘IU’ for units. When these abbreviations are written beside the intended dose, this may be ambiguous e.g. 10U may be read as 100

The inappropriate use of non-insulin (IV) syringes, which are marked in millilitres (mls) instead of insulin units. Use of these syringes may lead to the administration of incorrect volumes/ doses of insulin

Other potentially serious errors with insulin include:

Patients being prescribed or dispensed the wrong insulin product

Doses being omitted or delayed

Patients being administered insulin or antidiabetic drugs when their blood glucose measurements are below 4 mmol/l

2. Staff competency 2.1 All staff who are involved in the prescribing, administration and monitoring of

patients prescribed insulin and other oral antidiabetic drugs must feel competent to undertake the relevant tasks and duties outlined in this PGN. If staff do not feel confident or competent they must raise this with their line manager or if it is of immediate concern then nurse in charge of the ward.

2.2 Nursing and nursing associate staff must complete their Medicines Management

competencies (including Medicines Management 03 Management and Administration of Intra-muscular Depot/Injectable Medication

2.3 For further advice on insulin products available, dosing and prescribing of insulin

contact the Pharmacy Department.

http://nww1.ntw.nhs.uk/services/?id=6836&p=5539http://nww1.ntw.nhs.uk/services/?id=6836&p=5539

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3 Medicines Reconciliation

3.1 When a patient with diabetes is admitted, it is important that accurate information is obtained regarding the insulin and / or hypoglycaemic drugs the patient was prescribed prior to admission.

3.2 The patient may have an insulin passport which can provide an accurate

identification of their current insulin name and form (e.g. cartridge/ disposable pens/ vials).

3.3 If the patient does not have an insulin passport this information should

ascertained via another reliable source; the patient/ carer, the GP surgery records, practice diabetic nurse, hospital diabetic services/ clinic.

4 Prescribing 4.1 Prescribers must ensure that insulin doses and other anti-diabetic medicines are

up to date and prescribed accurately and completely. Insulin should be prescribed on the inpatient drug chart. It is advised that regular, static doses are prescribed on the ‘regular medication’ page of the drug chart and when required ‘fast acting’ insulin on the ‘as required medication’ page of the drug chart with clear instructions on when this should be administered.

4.2 Where a patient is prescribed a variable dose insulin regime, the Variable Dose

Insulin Chart (see Appendix 2) should be used for prescribing, administration and monitoring. Individual doses of insulin may be prescribed up to 72 hours in advance in patients who are not acutely unwell and where a prescriber will not be readily available. When a variable dose insulin chart is in use, insulin must still be prescribed on the inpatient drug chart (as per 4.1) with the words ‘See variable dose chart’ written over the administration signature boxes. Nurses must sign the variable dose insulin chart after each administration. They are not required to sign the prescription chart.

4.3 When prescribing insulin it is important that the following information is clear on

the prescription chart:

The brand and administration device of insulin used (e.g. pen, cartridge, vial)

The dose – prescribed in units (written in full and in lower case)

The frequency of administration

Route of injection – subcutaneous.

Guidance for nursing staff for administration in relation to BM readings e.g. Omit if BM < 4mmol/l

4.4 Inpatients prescribed insulin must also be prescribed treatment for hypoglycaemia. The following products must be prescribed in the ‘as required’ section of the prescription sheet:

Dextrose gel - applied inside mouth, between teeth and cheek, which may be repeated after 10-15 minutes, AND

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Glucagon Injection (subcutaneously or intramuscularly)_ o Adults & children > 25kg - 1mg o Children aged 2-17 and < 25kg – 500micrograms

Glucagon should only be used once during the treatment of a hypoglycaemic episode. If glucagon does not work within 10minutes, an ambulance should be called. Glucagon will be ineffective in patients with liver disease, alcohol intoxication, glucocorticoid deficiency, malnourished/starved patients.

4.5 Doses must always be prescribed on the medicine chart in full as “units” spelled

out in lower case.. A National Patient Safety Alert highlighted the risk of using abbreviations such as ‘U’ or ‘IU’ on prescriptions. These abbreviations are identified as a major cause of insulin dosing errors. Any death attributed to this type of error is recorded as a “never event“ by the Department of Health.(The organisation must take steps to design out the possibility of these never events occurring)

4.6 Prescriptions must include the specific adminstration device to be used (e.g. pen, cartridge, vial)

4.7 Particular care must be taken when prescribing insulin with very similar names

(e.g. Humulin-S, Humulin–I, HumulinM3). The route should specify subcutaneous administration.

4.8 Very rarely service users with high levels of insulin resistance may be prescribed

high strength insulin. This insulin is 500 units/ml and must be treated with caution. Prescriptions should denote both the dose in units as well as volume and the insulin should be kept separate from all other insulins and clearly labelled. Pharmacy should be made aware immediately if a service user is admitted on any insulin of strength over 100 units/ml.

5. Monitoring 5.1 For all patients prescribed insulin or antidiabetic drugs, the prescriber must

document the frequency of blood glucose monitoring and the timing in relation to meals, medicines administration and other instructions on the CNTW Blood Glucose Monitoring Chart (see Appendix 1). This must also be recorded in the patient’s electronic care record.

5.2 All blood glucose monitoring results must be recorded on the CNTW Blood

Glucose Monitoring Chart (BM) (appendix 1). This chart gives general guidance for staff about what action to take with results of blood glucose monitoring. The BM chart must be kept with the patient’s prescription chart. This allows for the prescriber to review the BM results and if required seek specialist advice or adjust doses in response to changes in blood glucose control.

5.3 Glucose levels must be checked before every insulin dose. If blood glucose levels

are not checked the reason must be documented with clinical rationale

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5.4 If a variable dose insulin chart is in use, all blood glucose monitoring must be recorded on this chart as instructed by the prescriber or the specific care plan. The CNTW Blood Glucose Monitoring Chart (BM) (Appendix 1) does not need to be used for these patients as this would cause duplication and increase the risk of error.

5.5 The Blood Glucose Monitoring Chart should be scanned into RiO when

completed or stored in the purple RiO support file. 5.6 Where the testing of ketones in the urine is indicated (usually at blood glucose

15.1mmol/l or higher), the results should be recorded in the patient’s RiO records. If the presence of ketones is detected in the urine, medical staff should be informed immediately.

5.7 If a patient refuses to have their blood glucose or urine ketones monitored in line

with their care plan this must be recorded in the patients electronic care record and discussed with the medical staff for review of the treatment plan.

6 Supply 6.1 Insulin is classed as a critical medicine which means it is essential that the

patient receives their prescribed dose and no doses are omitted during a hospital admission. It is therefore very important that insulin supplies for individual patients are ordered on admission and stocks well maintained during admission.

6.2 The nurse in charge must ensure that there is an adequate supply of insulin

syringes, subcutaneous needles and insulin pen needles available on the ward. Non-insulin syringes (i.e. those for IM or IV injection) should never be used for the administration of insulin, as these will increase the risk of error.

6.3 It is preferable to use the patient’s own insulin supply whilst in hospital, for

continuity of supply. However, in order to assure stability of the insulin, it should have been dispensed within the past 28 days (and labelled as such). The general suitability for use of the insulin should be assessed, as per the Trust’s Patient’s Own Drugs (PODs) Assessment Algorithm available via the following link: UHM-PGN-01 - Safe and Secure Medicines Handling and Supply

6.4 If the patient does not bring a supply of insulin into hospital with them then a

supply must be obtained as soon as it is prescribed. 6.5 Insulin supplied from the hospital pharmacy will be labelled with the patient’s

name, date of issue and ‘to be injected subcutaneously as directed’. This insulin may be issued for the purpose of subsequent leaves/discharges, providing the preparation is still current. Before any leave or discharge a member of the clinical team must ensure that if the patient is to self-administer, that the patient understands how to administer their insulin and what dose they are to use.

6.6 After insertion of a cartridge or first use of pen, insulin devices must be labelled

with a date opened sticker. The expiry date of opened pens and cartridges is 28 days. These should not be stored in a fridge. Patient supplies of insulin not

http://nww1.ntw.nhs.uk/services/?id=4638&p=2780&sp=1http://nww1.ntw.nhs.uk/services/?id=4638&p=2780&sp=1

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currently in use, and any vials of stock insulin, should be stored in the medicines fridge.

7 Administration 7.1 If appropriate, patients should be encouraged to self-administer insulin, under the

supervision of a nurse. (Self-Administration policy - Administration of Medicines UHM PGN 03

7.2 DAFNE (Dose adjustment for normal eating)

Some patients are a DAFNE graduate, which means that they have been taught how to estimate the amount of carbohydrate in their food and then calculate the amount of insulin they require to administer. These patients are experts in managing their own insulin and wherever possible they should be encouraged to continue doing so. In the case of mental health patients this is also desirable provided a risk assessment has been completed to identify if they have any thoughts of suicide or self-harm.

7.3 Nurses and nursing associates administering or supervising subcutaneous

insulin must satisfy themselves that the insulin prescription is correct. Patients with capacity who self-administer their insulin at home may be used as a check to ensure that the insulin is their usual product. Where any doubt exists, the nurse must first check and confirm the prescription with the prescriber or ward pharmacist, before administration occurs. The outcome of any queries regarding the prescription should also be recorded in the patient’s RiO records. In the case of a variable insulin dose, or any other changes to the regime, this should be communicated to the ward team at handover.

7.4 Certain brands of insulin is available as 100units/ml and also a higher strength

500units/ml. Care must be taken to ensure the correct strength is administered. 7.5 Nurses and nursing associates administering insulin must use a specific insulin

administration device i.e. an insulin syringe or insulin pen to measure insulin and avoid withdrawing insulin from pen devices or cartridges. Safety needles should be used with pen devices.

7.6 Cloudy insulins (e.g. Humulin I, Insulatard, Insuman, Humulin M3, Humalog

Mixes etc) must be re-suspended by gently rolling and inverting 10 times. Repeat this if insulin is not uniform in consistency. Do not shake to re-suspend.

7.7 Insulin pens should be primed before each use by dialling up 2 units of insulin

and depress plunger to ensure device is operating and needle is patent. If insulin is not see, at the tip of the needle, repeat a further 2 times. If no insulin seen at the tip of the needle, replace needle and dial 2 units. If no insulin seen, use a new device and repeat as above.

7.8 There are four main subcutaneous injections sites – stomach, thighs, buttocks

and arms. Rotating or changing injection sites can help avoid small lumps

http://nww1.ntw.nhs.uk/spider/services/files/1486124107UHM-PGN-03%20-%20AdminOfMeds-V02-Iss4-Sec6.3.2-Feb17.pdfhttp://nww1.ntw.nhs.uk/spider/services/files/1486124107UHM-PGN-03%20-%20AdminOfMeds-V02-Iss4-Sec6.3.2-Feb17.pdf

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developing under the skin. If a patient develops such lumps, use an alternative site and seek advice from medical staff.

7.9 Insert needle into appropriate injection site and steady the bottom of the pen

device as the plunger is depressed. Once plunger stops clicking leave needle in subcutaneous for 10 seconds to allow entire insulin dose to be pushed through needle at an angle of 90 degrees. Withdraw needle and remove from insulin pen and dispose of it in sharps bin. Sign the administration record.

7.10 Staff must be aware of the Trust’s policy, CNTW(C)46 - Inoculation Injury Policy.

If the patient is unable to administer insulin independently and safely dispose of the sharps, the staff member must use an insulin pen with the BD AutoShield duo (safer insulin needle order code FTR 1083). Where insulin is being administered via syringe, the new safer syringe must be used (order codes for insulin syringes are 0.5ml FWD041 and 1.0ml FWD038). For advice on safer sharps contact the Infection Prevention Control team.

8 Management of Hypoglycaemia 8.1 Normal blood glucose levels in non-diabetic people range between 4 and

7mmol/l. Hypoglycaemia is usually said to occur at 3.8mmol/l and so the recommended lower level is 4mmo/l. Many patients are educated by diabetes teams that ‘four is the floor’

8.2 Some patients, especially those with long standing type 1 diabetes, may lose

their awareness of the onset of hypoglycaemia. Hypoglycaemia in the elderly can be difficult to assess and can increase mortality

8.3 It is important that the whole care team are aware of the signs and symptoms to

look out for, as left untreated this can become a medical emergency. Symptoms include:

o Sweating

o Hunger

o Irritability

o Altered behaviour

o Confusion

o Aggression

o Pallor

o Collapse

o Fitting

o Drowsiness/Unconsciousness / coma

o Tachycardia

o Tremor

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Risk Factors for Hypoglycaemia:

Medical Issues

Lifestyle Issues

Tight glycaemic control Increased exercise (relative to usual)

Previous history of severe hypoglycaemia

Irregular lifestyle

Undetected nocturnal hypoglycaemia Increasing age

Long duration of diabetes Alcohol

Poor injection technique Early pregnancy Impaired awareness of hypoglycaemia Breast feeding

Preceding hypoglycaemia (

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9 Cumbria Northumberland, Tyne and Wear NHS Foundation Trust PPT-PGN-06 – Guidelines Safe Prescribing and Admin of Insulin and oral antidiabetic drugs - V03-Iss1-Oct 2020 Part of CNTW(C) 38 - Policy on Pharmacological Therapies

8.4 Appendix 3 is a treatment algorithm that describes how to manage patients who

have hypoglycaemia on an inpatient unit. The ward medical staff should be notified when a patient suffers from a hypoglycaemic episode and specialist advice sought if required.

8.5 Patients prescribed insulin must have dextrose gel and glucagon injection

prescribed on the as required section of the prescription chart (see section 4.4). These are stored as stock items on each ward and held within each of the emergency drug cupboards across the trust.

8.6 Hypoglycaemia can result in an emergency that requires immediate attention

before the emergency services or doctor arrives. Nursing staff should follow the algorithm for the management of hypoglycaemia and administer treatment immediately. If the patient is conscious, the administration of a fast acting carbohydrate will increase blood glucose levels. In all cases preventative measures must be ensured and emergency treatment must be readily available. Where possible, likely causes for the hypoglycaemic episode need to be established and regular insulin treatment reviewed and altered where necessary.

9. Management of hyperglycaemia 9.1 Hyperglycaemia occurs when the blood glucose level is too high. Prolonged

elevation of blood glucose levels may precipitate a medical emergency. It is therefore important that blood glucose is monitored regularly and appropriate action taken in response to out of range levels. As a rule of thumb, consistently raised blood glucose levels of 15mmol/L or above should trigger a prompt review of the current medication regime, which may mean a referral to local diabetic services. This would also indicate that the patient’s urine should be checked for ketones. NB If Ketostix have been prescribed so that urine can be tested for ketones, the date which the box is opened must be recorded on the appropriate documents and replaced 6 months after opening.

9.2 Common causes of hyperglycaemia are detailed below and should be taken into

account when care-planning for individuals (see Section 10.1):

Taking too little medication or missing a dose of medication

Eating too much carbohydrate

Over-treating a hypo

Stress

Infections (for example, colds, bronchitis, flu, vomiting, diarrhoea, urinary infections, skin infections)

9.3 Other possible reasons for an elevated glucose level (particularly in the absence of ketones)

Faulty meter

Steroid therapy

Failure to wash hands before testing

Injection site

Timing of insulin dose

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Cumbria Northumberland, Tyne and Wear NHS Foundation Trust PPT-PGN-06 – Guidelines Safe Prescribing and Admin of Insulin and oral antidiabetic drugs- V03-Iss1-Oct 2020 Part of CNTW(C) 38 - Policy on Pharmacological Therapies

10

Patient becoming less physically active

9.4 Short term complications of hyperglycaemia may include:

Increased urination

Extreme tiredness

Increased thirst

Dry mouth

Headaches

9.5 Prolonged hyperglycaemia may lead to symptoms such as:

Weight loss

Blurred vision

Recurrent infections such as thrush

If not addressed, diabetic emergency may ensue. 9.5.1 The two types of diabetic emergency which may arise from poorly managed

hyperglycaemia are diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemic state (HHS) (Formerly known as hyperglycaemic hyperosmolar non-ketotic coma HONK). Neither DKA nor HHS can be managed in the mental health setting and therefore suspected cases warrant a prompt transfer to local urgent care services; if left untreated these conditions can result in patient death.

9.5.2 If a patient has suspected DKA or HSS emergency 999 services should be called immediately.

9.5.3 It is therefore important that staff are able to identify patients who may be at

higher risk of DKA or HSS and monitor for signs and symptoms accordingly when blood glucose levels are raised in such patients. If necessary, specialist advice should be sought.

9.5.4 Initial signs and symptoms of DKA include: nausea/ vomiting; abdominal pain; loss of appetite; shortness of breath; ketones in the blood/ urine. If a diabetic patient or a patient who is at high risk of developing diabetes is displaying these signs blood sugar levels and urine ketones should be checked immediately.

9.5.5 People with HHS often become ill very quickly. Staff should be vigilant for signs and symptoms of HHS such as: frequent urination; extreme thirst; nausea; dry skin; disorientation.

10. Considerations for care planning

10.1 All patients with diabetes should have a care plan for this. The following should

be considered when writing care plans:

How does the patient usually manage and control their diabetes?

Blood glucose monitoring – frequency and how to manage out of range results

How patients insulin and/or oral hypoglycaemic drugs are managed

Patient specific indicators for hypoglycaemia and hyperglycaemia

Diet and fluids

Regular physical health checks – e.g. weight management

Identification and management of cardiovascular risk factors.

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11

Additional diabetes related physical health monitoring – e.g. foot care, eye checks

Planning for discharge – self-care / self-management – how can the ward staff support this?

11 Preparing for leave or discharge 11.1 Ward staff must confirm that a patient is able to self-administer and self-manage

their diabetes care or organise for primary care support before the patient is considered for leave or discharge form the ward.

11.2 If the patient was receiving primary care support (e.g. district nurse) before

admission, they must be contacted to ensure that this can resume when the patient goes home.

11.3 Insulin will be labelled take as directed and therefore it is important that the

patients understanding of their insulin regimen is checked by the ward staff before they leave the ward.

12 Patients at high risk of developing diabetes 12.1 Risk factors for developing type 2 diabetes include

Age, risk increases with age (over 40 years in white people)

Ethnicity – Risk increased in African-Caribbean, Black African or South Asian (Risk increases again in over 25 year olds) .

High blood pressure

Poor dietary intake

Certain drug treatments e.g. statins, corticosteroids, and combined treatment with a thiazide diuretic plus a beta-blocker

Being overweight especially people with central obesity

Previous Heart Attack

Women with polycystic ovaries, gestational diabetes, or baby weighing over 10 pounds.

Low birthweight for gestational age

People who have schizophrenia, bipolar disorder, depression

Patients receiving antipsychotic medication are at risk of developing metabolic syndrome.

12.2 Many people within our service will have an increased risk of developing type 2

diabetes. It is important that the usual physical health checks are carried out in line with Physical Health Monitoring of Patients Prescribed Antipsychotics and Other Psychotropic Medicines PPT-PGN-08. In addition ward medical and nursing staff should be mindful of the signs and symptoms of diabetes and hypo/hyperglycaemia. The ward should be aware of patients who may be at an increased risk.

12.3 If a patient without diabetes develops signs and symptoms of

hypo/hyperglycaemia, DKA or HSS nursing staff should call for medical help and measure the patient’s blood sugars and if possible urine for ketones, if results show hypo/hyperglycaemia this should be dealt with as per appendix 3.

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12

12.4 Once the initial event has been treated the patient should be referred to the appropriate service for diagnosis and treatment.

12.5 The input of the specialist diabetes team may be necessary during an inpatient

admission. Referral may be required:

Diabetic ketoacidosis/ hyperosmolar/ hyperglycaemic state

Severe hypoglycaemia

Vomiting

Unable to self-manage

Parenteral or enteral nutrition

Foot ulceration

Newly diagnosed diabetes

Patient request

Referral to diabetes team may be required:

Significant educational need

Persistent hyperglycaemia

Possible type 2 diabetes

Stress hyperglycaemia

Poor wound healing

Steroid therapy

Referral to diabetes team not normally required:

Minor, self-treated hypoglycaemia

Transient hyperglycaemia

Simple educational need

Routine dietetic advice

Well controlled diabetes

Good self-management skills

Routine diabetes care

13 Training 13.1 Healthcare Professionals involved in the prescribing preparation, administration

and monitoring of insulin therapy must have the appropriate knowledge and competence for the management of diabetes. A free RCN accredited learning programme is available:

https://www.diabetesinhealthcare.co.uk/lnt/Login.aspx?ts=636322565112572192

https://www.diabetesinhealthcare.co.uk/lnt/Login.aspx?ts=636322565112572192https://www.diabetesinhealthcare.co.uk/lnt/Login.aspx?ts=636322565112572192

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13.2 Healthcare professionals should have knowledge and understanding of the following safety alerts:

NPSA Rapid Response Report NPSA/2010/RRR013, Safer administration of insulin

NPSA alert/2011/PSA003 The adult patient’s passport to safer use of insulin.

14 References

Sussex Partnership NHS Foundation Trust ‘Guidelines for the Safe Prescribing and Administration of Insulin…’ April 2012

Diabetes UK website. Available from: https://www.diabetes.org.uk
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=74287http://www.nrls.npsa.nhs.uk/resources/?EntryId45=130397https://www.diabetes.org.uk/

Documents

Duty Doctor) V03 PPT-PGN-06…2020/10/01 · PPT-PGN-06 – Guidelines Safe Prescribing and Admin of Insulin and oral antidiabetic drug –V03-Iss1-Oct 2020 Part of CNTW(C) 38 - Policy