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

2. 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 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:

3. 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:

4. 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:

5. 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:

6. 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:

7. 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:

8. 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:

10. 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:

11. 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:

12. 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:

13. 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:

14. 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:

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. Once Only S/C Insulin Specify date and time dose to be administered
Nursing staff must initial and record time insulin administered

22. Telephone Orders As per NSW Health policy Refer to local policies
Signed within 24 hrs by MO

23. 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

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

25. Questions, Comments, Observations….

26. Contact Rebecca Donovan PH: Melissa Tinsley PH: .