Adult Standardised Subcutaneous Insulin Prescribing Chart 9 June 2010 Adult Standardised Subcutaneous Insulin Prescribing Chart August 2013 Date of Presentation:

Case for Change Insulin is a high risk medication 9 June 2010 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 Insulin - widely considered a high risk medication by the Institute of Safe Medication Practices (ISMP), the Australian Safety and Quality Commission and the CEC High risk medication Doesn't mean errors are more common, but when given incorrectly the consequences are more devastating Incorrect administration of insulin can cause significant harm NSW Health Policy Directive “High-Risk Medicines Management” All facilities to review medicines and identify those that are high risk and action to address risks Incidents Frequently reported in top 10 high alert medicines worldwide CEC- 2010 identified nearly 3000 incidents related to insulin in IIMS Variation in charts and Availability of specialist services and access to guidelines Smaller hospitals, diabetes management conducted without specialist diabetes teams or advice. Many JMO’s and nurses find diabetes management and insulin adjustment challenging. Junior staff ,esp after hours, need guidance and ‘easy access to immediate information at the bedside’. Mobile workforce Agency, JMO move between facilities   Date of Presentation:

Methodology Review of NSW and national charts 9 June 2010 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) Review of charts across NSW Widespread clinical input metropolitan, regional & rural- over 35 clinicians Liaised with ACSQHC Chart developed based on SWAHS chart (in 2007) Piloted and audited successfully Survey of 142 RMOs and nurses, 80% found it useful, easy to understand or self explanatory Development of a standardised chart Pilot at Ryde & Royal Prince Alfred, February 2012 -Wagga Wagga nominated as the rural hospital site, later withdrew prior to commencement of pilot phase. Evaluation conducted Statewide consultation in parallel with State Forms process Feedback reviewed by In Hospital Diabetes Management workgroup Chart finalised and endorsed   Date of Presentation:

What does it mean for me? Separate chart from NIMC 9 June 2010 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 Review of charts across NSW Date of Presentation:

9 June 2010 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 Addition of guidelines, BGL and ketone monitoring and insulin prescription designed to reduce errors and guide appropriate clinical decision making. Consistent insulin prescription, administration and documentation Consistent diabetes care and management Reduced insulin errors Improved patient care Added to chart: - Page 1: Instructions for using the subcut chart - Page 1: Guidelines for insulin prescription and administration - Page 1: Special instructions box - Page 4: Hypo management algorithm - Page 4: Guidelines for management of hyperglycaemia - Page 4: Guide to use supplemental and correction doses of insulin intended for use by clinicians in NSW public hospitals that do not have a local guideline / policy or specialist support. Do not take the place of local policies and may be used in areas where local policies do not exist Reduce risk of error Date of Presentation:

Four Sections Page 1, including top of page 3: Page 2 and 3: Page 4: 9 June 2010 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 Date of Presentation:

Patient Identification and demographics 9 June 2010 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 Date of Presentation:

Allergies and Adverse Drug Reactions (ADR) 9 June 2010 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 Who completes it? MO, nursing staff and pharmacists required to complete the Allergies and Adverse Drug Reactions (ADR) details for all patients If nil or unknown: Tick ‘Nil known’ or ‘Unknown’ If an allergy or ADR exists then document: Name of drug/substance Reaction details Sign, print, initial and date the entry Any information added to the ADR section after the initial interview must be signed by the person adding the information in the designated area All ADR must also be recorded in the patients’ health care record Date of Presentation:

9 June 2010 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 The prescriber should document who to notify if the patient meets certain criteria such as BGL or ketone levels that are out of range. If no alerts- tick ‘Nil’ box Prescriber adding information must document initials in the designated area. If the alert is changed then the prescriber must cross the entry out, sign, date it and enter the new alert. Details should also be entered in the patient’s health care records The alert section should be completed for each new chart Date of Presentation:

Reason for not administering 9 June 2010 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 When it is not possible to administer the prescribed subcutaneous insulin, the reason for not administering must be documented by entering the appropriate code and circling it on the administration record. Circle the code so it will not accidentally be misread as someone’s initials. If the patient refuses the insulin dose, then the prescriber must be notified. If the insulin is withheld, the reason must be documented in the patient’s health care record. If the insulin is not available on the ward, it is the nurse’s responsibility to notify the pharmacy and/or to obtain a supply of that insulin, or to contact the prescriber to advise that the insulin is not available. Alerting the prescriber will enable an alternative insulin to be prescribed. Date of Presentation:

Instructions The chart is used for: 9 June 2010 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 Date of Presentation:

Guide: Prescription & Administration 9 June 2010 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 Date of Presentation:

Additional information and instructions 9 June 2010 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 If the patient is on a subcutaneous insulin pump Prescribe on the chart and write “insulin pump “ below the order Tick appropriate box- If the patient is receiving other diabetes medication or On a subcutaneous insulin pump Special instructions Can be completed by any staff member to communicate information at the bedside, e.g. ‘please supervise the patient using their insulin pen’ ‘change from 6mm to 4mm pen needles’ ‘poor hypoglycaemic awareness so BGL target range is 6-14mmol/L’ type of insulin device e. g “insulin pen”. NB: All patient management must also be documented in the patients’ health care records Date of Presentation:

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 Administration record must contain: Date Time Dose Initials of administrator Initials of 2nd 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 Rebecca.Donovan@aci.health.nsw.gov.au Melissa Tinsley PH: 9464 4653 melissa.tinsley@aci.health.nsw.gov.au .