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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
• 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 DonovanPH: 9464 4626
Melissa Tinsley PH: 9464 4653
