FIT4Safety Injection Safety in UK and Ireland

Optimising Diabetes Care

FIT4SafetyInjection Safety

in UK and Ireland

Safety of Sharps in Diabetes Recommendations

1st Edition

FIT4SafetyRecommendations for Best Practice in Safety

Objectives

• Help individuals and organisations identify risk associated with sharps and accidental blood or body fluid exposure

• Raise awareness of EU Directive 2010/32 Sharps Injuries

• Support individuals and organisations to apply the new EU Directive to clinical practice in their field of care

• Inform individuals and organisations using contemporaneous evidence-based practice to minimise risk and promote safer practice

• Facilitate opportunities in which best practice can be discussed, developed, implemented and evaluated throughout UK and Ireland

Forward

The EU Directive 2010/32 (1) sets out a new legal framework for the management of sharps and needlestick injuries (NSI). The new regime which must be fully transposed into UK and Irish law by May 2013 has focused attention on the need to provide greater protection to all healthcare workers, downstream workers and others who are at risk of sharps injury.

The Directive sets out to:• Ensure safest possible working

environment• Prevent workers’ injuries by medical

sharps• Protect workers and patients at risk• Require the establishment of

integrated policies in control and prevention specialist…

- Risk assessment - Risk prevention - Training - Information awareness• To require implementation of follow

up and response procedures.

The Forum for Injection Technique (FIT) body has responded to the need to improve injection technique through a range of evidence based recommendations, education, training & materials and support. FIT will now extend its remit to include sharps safety as a natural progression and development of its role.

In October 2011, 57 leaders in the field of injection technique and sharp safety from 14 different countries convened in Brussels to attend the Workshop on Injection Safety in Endocrinology (WISE)54. The group from the UK delegates included Consultant Nurses and Specialist Nurses in Diabetes along with Infection Control and Prevention Specialist and a Medical General Practitioner. This group later formed to become the FIT4Safety group.

The WISE meeting delegates explored data from large survey of NSI which took part in Europe in 2010 (appendix 4). Data from this survey demonstrated clearly the risk that sharps and accidental blood exposure pose in diabetes care.

The survey demonstrated that diabetes care has one of the highest risks for sharps injury across all healthcare settings.

The EU Directive 2010/32 makes it very clear that injuries experienced by many clinicians as a result of sharps and accidental blood exposure must be prevented. The Directive sets out a number of measures that will help eliminate the risk of exposure or if unavoidable reduce it to as low a level as possible by:

• Eliminating the unnecessary use of sharps

• The use of medical devices incorporating safety-engineered mechanisms where indicated

• Banning the practice of recapping or re-sheathing

• Implementing safe procedures for the use and disposal of sharps

• Use of effective disposal procedures• Use of clearly marked safe sharps

disposal containers• Keeping containers close to areas

where sharps are used• Maintaining safe work systems to

prevent the risk of infection• Use of personal protective equipment• Use of vaccinations.

FIT4Safety is committed to supporting the implementation of the Recommendations in order to protect all those at risk of sharps injury and accidental blood exposure. Commitment is also made to developing the Recommendations in such a way that as many people as possible can influence its advice.

FIT4Safety welcomes comments, suggestions and advice thus ensuring that the recommendations are fully informed, contemporaneous and pragmatic both now and in the future.

Debbie HicksNurse Consultant – Diabetes Enfield Community Services, BEH-MHT(FIT Chair)

Su DownsNurse Consultant – Diabetes Somerset Partnership NHS Foundation Trust (FIT Board Member)

Dr Debra AdamsProgramme Specialist; Healthcare Associated Infection (FIT Board Member)

Dr David Millar-JonesGPwsi Diabetes, Associate Specialist Diabetes, South Wales

Fiona KirklandNurse Consultant – Diabetes South Staffordshire Primary Care Trust

Hillary WhittyDiabetes Specialist Nurse NHS Forth Valley

Joan AllwinkleDiabetes Specialist Nurse Scotland

June JamesNurse Consultant – Diabetes Leicester General Hospital

Patricia CoadyDiabetes Specialist Nurse (Ireland) Cork University Hospital

Sian BodminDiabetes Specialist Nurse South Wales

Vanessa FarringtonDiabetes Specialist Nurse Hampshire Hospital NHS Foundation Trust

FIT4Safety UK and Ireland will provide evidence-based best practice information which encompasses all people at risk of needle stick injury and accidental blood or other body fluid exposure. The aim of these recommendations is to protect individuals and prevent injury. The goal of ensuring that risk assessment and safe practice are the norm will be accomplished through raising awareness, education, training and easily accessible information.

32 FIT4Safety Recommendations for Best Practice in Safety

Reference this report as: FIT4Safety (2012) Injection Safety in UK and Ireland; Safety of Sharps in Diabetes Recommendations1st Edn. FIT4Safety, UK http://www.fit4diabetes.com/united-kingdom/fit-safety-recommendations/

5STRONGLY RECOMMENDED

RECOMMENDED

UNRESOLVED ISSUE

At least one randomised controlled study

At least one non-randomised (or non-controlled or epidemiologic) study

Consensus expert opinion based on extensive patient experience.

4 FIT4SafetyRecommendations for Best Practice in Safety

Attendees to WISE agreed that for the strength of a recommendation the following scale would be used

STRONGLY RECOMMENDED RECOMMENDED UNRESOLVED ISSUE

For the scientific support the following scale was used.

At least one randomised controlled study At least one non-randomised (or non-controlled or epidemiologic) study Consensus expert opinion based on extensive patient experience.

Thus each recommendation is followed by both a letter and number (i.e. A2). The letter indicates the weight a recommendation should have in daily practice and the number, its degree of support in the medical literature. The most relevant publications bearing on a recommendation are also cited. There are comparably few randomised clinical trials in the field of injection technique (compared, for example, with blood pressure control) so judgements such as ‘strongly recommended’ versus ‘recommended’ are based on a combination of the weight of clinical evidence, the implications for patient therapy and the judgement of the group of experts.

These recommendations apply to the majority of people with diabetes using injectable therapy, but there will inevitably be individual exceptions for which these rules must be adjusted.

The WISE (Workshop on Injection Safety in Endocrinology) Recommendations: Diabetes & Metabolism 2012. Vol 38. informed these recommendations and we thank the editors of Diabetes & Metabolism for permission to use material from this article.

“Diabetes UK both welcomes and supports the FIT initiative. Good injection technique leads to good blood glucose control which is vital in preventing the long term complication of diabetes. As so many people with diabetes are now being prescribed injectable medication, this is a timely and important enterprise whch will bring great benefit to them.” Simon O’Neill, Director of Care, Information and Advocacy Diabetes UK.

“The Safer Needles Network welcomes the extension of FIT’s remit to include sharps safety and its work in improving injection technique. The EU Sharps Directive comes into legal force across Europe in May 2013 and requires risk assessment to be carried out, the elimination of workers exposure by safe disposal, the elimination of unnecessary use of sharps and the provision of training and safety engineered devices. We join with FIT4Safety in ensuring that these simple measures are implemented to prevent the risk of sharps injury and accidental blood exposure.” Dr. Paul Grime Chair of the Safer Needles Network

“The vision of the Infection Prevention Society is that no person is harmed by a preventable infection. We welcome the evidence-based and common-sense advice contained in this document, which will help protect those involved in the management of diabetes from sharps injury and subsequent risk of infection.”Tracey CooperIPS President

Key

Endorsements

Supported by medical technology company Becton, Dickinson U.K. Limited. (www.bddiabetes.

co.uk) BD and BD Logo are trademarks of Becton, Dickinson and Company. ©2012 BD”

7STRONGLY RECOMMENDED

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“BD is committed to raising awareness of the risks faced by healthcare workers and the methods for improving safety. BD has made significant investments, as well as dedicating human resources and technical innovation, to the task of reducing sharps injuries. BD fully supports the FIT4Safety initiative. These recommendations, if followed, will go a long way toward reducing needles stick injuries and accidental blood exposure, thus protecting individuals from injury in the work place and beyond. With the EU Directive transposition into UK and Irish Law imminent, the superb work FIT4Safety is doing, will help healthcare workers and their employers put into practice, improved safety measures in advance of the impending legislation.”Carol Phillips Business Manager UK & Ireland BD Medical-Diabetes Care

“Advances in the treatment of diabetes have led to an increase in the number of injectable therapies available. Correct technique is of paramount importance in order to ensure the benefits of injectable therapies such as insulin and GLP-1s. The Forum for Injection Technique (FIT) provides comprehensive evidenced based guidelines to improve the safety of healthcare workers and the process and education of self injection technique for people with diabetes. As a company committed to improving the care of patients with diabetes and those who care for them, Lilly Diabetes UK & Ireland welcomes the FIT4Safety initiative as an important step in supporting diabetes care in the United Kingdom. Ian DaneSenior DirectorEli Lilly & Company

“Sanofi is a diversified company that strives to improve the care for people with diabetes on insulin therapy. We are proud to support the FIT (Forum for Injection Technique) initiative, which is aiming to improve current practice by promoting best practice and sharing up-to-date scientific evidence. We support FIT in highlighting the importance of good injection technique to ensure people with diabetes on insulin therapy achieve the greatest benefit from their medication. We look forward to working with FIT to achieve our common goals.” Thomas Butler Product Manager - Insulins, Sanofi Diabetes

“Novo Nordisk fully endorse the FIT4Safety initiative. The benefits of modern injectable medications for the treatment of diabetes can only be fully realised through the use of correct injection technique. Novo Nordisk believe it is essential that Healthcare Professionals understand the importance of good injection technique and convey this to people with diabetes under their care.”Peter Kjeldgard Marketing Manager, Novo Nordisk

Endorsements

Endorsements

Supported by medical technology company Becton, Dickinson U.K. Limited. (www.bddiabetes.

co.uk) BD and BD Logo are trademarks of Becton, Dickinson and Company. ©2012 BD”

98 STRONGLY RECOMMENDED

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1 In accordance with a new EU Directive12 and its transpositions into member-state legislation, use of sharps (Clause 3: defi nition 4) must be carried out using safety engineered devices where available.13

This obligation covers all sharps used in diabetes management in the hospital and healthcare sector e.g. settings both private and public where healthcare takes place and might include; hospital, primary care, ambulances, care homes, schools, prisons, nurseries, caregivers in home settings, etc. 14

3 The use of safety devices where available should be considered for people with diabetes who self care, e.g. those known to be positive for HIV, HBV and HCV.

4 Where there are vulnerable people within the household of someone with diabetes, safety engineered devices should be made available. This also includes those who have limited access to safe sharps disposal.

5 HBV vaccination must remain individual choice but be available free-of-charge where there is occupational risk.

1 Sharp devices represent a risk for the transmission of blood-borne pathogens to the user in the event of a NSI or muco-cutaneous blood exposure.4

2 This risk can also extend to “downstream” workers (not the original user e.g. technical and kitchen personnel, cleaning persons, rubbish removers, incinerators and general public) if they receive an accidental NSI or muco-cutaneous blood exposure involving infectious material.5

3 Studies have shown that the incidence of NSI among Healthcare Workers (HCW) giving injections to patients with diabetes or drawing blood with lancets is just as high, or higher, than workers in other departments or wards.6

4 The prevalence of HBV, HCV and HIV in patients with diabetes is reported to be as high, or higher, than in healthy individuals or in patients with other disease states.7-9

5 The priority for employers must be to secure the safest possible workplace. The Management of Health and Safety at Work Regulations 1999 make it a legal requirement for employers to carry out risk assessment of their activities. This should identify the measures they need to have in place to comply with their duties under health and safety. This should be achieved through a combination of awareness raising, information, risk assessment, preventing or controlling the risk, safe disposal of sharps and reporting incidents53 (Appendix 1).

6 Risk assessment will have to be undertaken in all situations where there is the potential for exposure to any sharps injury.12

7 Elements of any risk assessment will have to take into account a number of criteria which, must include but is not limited to: technology, work organization, working conditions, education and training to identify how exposure can be eliminated. This must include consideration of alternative systems of working and technology.12 [clause 5:3]

European Legislation

2.0

Risks

1.0


RECOMMENDED

UNRESOLVED ISSUE




1 NSI awareness campaigns must be carried out regularly and should include all persons in potential contact with medical sharps.41

2 All persons at risk must receive appropriate education and training on ways to minimize risk, including the importance of following optimal injection or lancing techniques, using available safety devices and using Personal Protective Equipment (e.g. gloves).42

3 Education and training should begin in nursing and medical schools and be continued thereafter on a yearly basis. It should be regular, across all shifts, and be repeated to take into account staff turnover.42

4 Needle and lancet recapping must be forbidden. Workers must understand why this is the case and manufacturers should design sharps protection mechanisms which make recapping impossible.43

5 Healthcare Providers must encourage reporting of NSI, near misses and incorrect technique within a ‘no blame’ culture. Central review of these reports must take place regularly to facilitate policy change and assess educational needs.

6 Review and appraisal of the effectiveness of education and training and of adherence must be performed at regular intervals. A ‘no blame’ reporting system for violations must be put in place, linked where possible into existing adverse event reporting systems. Procedures for what to do following a NSI must be posted in critical locations (Appendix 3 & 4).

7 Attention must be paid to proper use of safety devices. If they are not activated because of user inattention, forgetfulness or lack of training, they provide no additional risk reduction over conventional (non-safety) devices. Therefore adequate training must be in place.44

8 In all settings suitable sharps disposal containers must be easily reached and located at the point of care, at or below eye level. The containers should be disposed of every 3 months even if not full, by the licensed route in accordance with local policy.** Containers should be lockable and single-use devices which bear a warning such as “Needles can seriously damage the health of others. Please ensure safe disposal”.45

9 Procedures for what to do in the event of a NSI must be clearly communicated (Appendix 3 & 4). Formal protocols with named clinical care contacts must be available in all areas where sharps are used.

1 When introduced into healthcare settings where a culture of safety has been fostered and appropriate training given, safety-engineered devices can signifi cantly and sustainably decrease the incidence of NSI.20-26

2 In accordance with EU Directive, workers (Clause 3: defi nition 1) should be involved in the evaluation and selection of devices used in their healthcare setting. Key participants in this evaluation should at least include experienced end users, infection control & prevention professionals, occupational health experts, risk management and trainers.27

3 A safety device for diabetes injections must, include the features outlined in Appendix 1.28

4 Any health care setting (EU Directive Ref. 12 clause 3 defi nition 2), which uses insulin pens must follow a strict one-patient/one-pen policy.29

5 When pens are used, the optimal safety device must protect against sharps injury from both the patient and non-patient (cartridge) ends of the needle.30

6 When syringes are used, only safety-engineered ones must be accepted and the protective mechanism must be integral to the device.31

7 All workers must be encouraged and supported to report NSIs.

8 Manufacturers must assess NSI’s reported with safety devices for possible device failures to design out identifi ed risks and defects.

9 Performance and reliability data must be made available on each safety device at the time of market introduction.

1 Since safety mechanisms will not protect against NSI through lifted skin folds, the use of shorter needles (e.g. 4-5mm pen needles) without a lifted skin fold is recommended35, 36. Of note, very young children or extremely slim or muscular adults may still need to raise a skin fold. 37, 38


Education and Training (Creating a ‘Safety Culture’)

5.0

Device Implications

Injection Technique Implications

3.0 4.0

NICE clinical guidelines. March 2012. Infection: Prevention and control of healthcare-associated infections in primary and community care “http://publications.nice.org.uk/infection-cg139/guidance” \l “standard-principles” http://publications.nice.org.uk/infection-cg139/guidance#standard-principles


RECOMMENDED

UNRESOLVED ISSUE




1 Safe sharps disposal systems must be present in each region, should be well known to all persons in contact with sharps and should be enforced consistently. Legal and societal consequences of non-adherence to these regulations should be made known.51

2 Proper disposal and personal responsibility must be taught to patients from the initiation of diabetes injection therapy by the dispensing clinician (including pharmacists) and reinforced throughout the literature, personal consultation and education process.52

3 The avoidance of potential adverse events in the patients’ surroundings (e.g. NSI to children, schoolmates, fellow workers) as well as to service providers (e.g. rubbish collectors and cleaners) must be emphasized.

4 Packaging for sharp devices should carry warnings regarding safe disposal and risks to other people.

5 Under no circumstances should sharps of any description be disposed of into the public/household refuse system.

10 While HBV vaccination must be population-wide, at a minimum it should be a mandatory offering by the employer to all workers exposed to sharps. Vaccination status should be reviewed with each employee and all should be made aware of consequences of non-vaccination.46

11 HBV vaccination must remain individual choice but be available free-of-charge where the work environment places the person at risk.

1 Cost effectiveness studies suggest that the savings from reductions in sharps injuries with safety devices may offset or compensate for the increased price per device. Additional studies, focused on sharps used in diabetes management, should be carried out. 49, 50


Awareness and Responsibility

7.0

Value

6.0 5.0

Education and Training (Creating a ‘Safety Culture’)

1514

Appendix 2

Always Events and Safety Compliance Bundle

Reproduced with kind permission of Dr. Debra Adams, January 2012.

Appendix 1*What defi nes a safety device

DURING USE:

1 The safety feature can be activated using a one-handed technique, or routine use of the device causes the safety mechanism to deploy automatically after the sharp has been used.

2 The safety feature does not obstruct vision of the tip of the sharp.

3 The device offers a good view of any aspirated fl uid.

4 The safety device does not require more time to use than a non-safety device.

5 The safety feature works appropriately with a wide variety of hand sizes.

6 The device is easy to handle while wearing gloves.

7 The device will work with all required syringe, pen devices and needle sizes.

8 The device provides a better alternative to traditional recapping.

AFTER USE:

10 There is a clear and unmistakable change (audible and/or visible) that occurs when the safety feature is activated.

11 The safety feature operates reliably.

12 The exposed sharp is permanently blunted or covered after use and prior to disposal.

13 The device is no more diffi cult to dispose of after use than non-safety devices.

TRAINING:

14 The user does not need extensive training for correct operation.

15 The design of the device should be intuitive to use.

16 It is not easy to skip a crucial step in proper use of the device.

*These criteria represent optimal target features which may not be achievable in every device; they do not represent an exhaustive list and may evolve as engineering innovations appear.


Appendix 1 Appendix 2

8.0 8.0

* Costigliola V, Frid A, Letondeur C, Strauss K. Needlestick injuries in European nurses in diabetes. Diabetes & Metabolism. 2012. Vol. 38. January (S9-S14).

ALWAYS EVENTS – THE PREVENTION OF SHARPS INJURIES Y/NIt is expected that;

• All healthcare providers in whatever setting will comply with the EU Council Directive 2010/32/EU by May 2013.

• All healthcare providers will risk assess the need for safety engineered devices (SED) when utilizing sharps in all scenarios.

• All users of sharps should be trained and instructed not to re-cap any sharps devices.

• All healthcare establishments will have in place sharps safety reporting through local governance systems (e.g. Infection Prevention and Control, Occupational Health and Safety, Risk Management et al) to monitor sharps injuries, evaluate potential trends associated with sharps injuries, audit practice, and co-ordinate the trialling and introduction of SED.

• Users of sharps will be involved in trialling and choosing the SED to be used.

• Users of SED will be trained how to optimally use and dispose of the device.

• All users of sharps/SED will be provided with appropriate sharps disposal containers for use at the point of care.

• All sharps will be disposed of in a safe and appropriate manner.

• All sharps disposal containers will be collected appropriately and disposed of according to National guidance.

• All sharps injuries will be reported appropriately through the local reporting system.

1716

Appendix 3

WHAT TO DO IF YOU RECEIVE A SHARPS INJURY**

If you suffer an injury from a sharp:

• Encourage the wound to gently bleed, ideally holding it under running water.

• Wash the wound using running water and plenty of soap.

• Don’t scrub the wound whilst you are washing it.

• Don’t suck the wound.• Dry the wound and cover it with a

waterproof plaster or dressing.• Seek urgent medical advice

(for example from your Occupational Health Service), as effective prophylaxis (medicines to help fi ght infection) are available

• Report the injury to your employer.

** http://www.hse.gov.uk/healthservices/needlesticks/index.htm

Appendix 4

ACTION FOLLOWING A PUNCTURE WOUND FROM A NEEDLE***

• Encourage the wound to bleed, do not suck the wound – rinse thoroughly under running water. If water is not available, cleansing wipes provided in fi rst aid kits should be used. Cover the wound with a dry plaster/dressing.

• Formally record the incident including details of action taken.

• Seek medical advice and treatment immediately – contact the nearest Accident and Emergency department.

*** Health and Safety Executive. Handling needles in the waste and recycling industry (Waste19 08/07)

ALWAYS EVENTS – THE PREVENTION OF SHARPS INJURIES SCORE

Alternatively, Safety Bundle Approach might be as follows:

SAFETY COMPLIANCE SCORE

Scores <100% require an action plan

to be developed and implemented.


Appendix 2

8.0

Appendix 3 Appendix 4

8.0 8.0

COMPLIANCE SAFETY STANDARD Y/N

1 Healthcare providers are aware of the deadline (May 2013) and the implications associated with EU2010/32.

2 Healthcare providers have risk assessed the need for safety engineered devices (SED) when utilizing sharps in all scenarios e.g. diabetic syringes, vaccinations, needle/syringe, cannulas, suture, lancets, blades etc.

3 Users of sharps are trained to, and do not re-cap any sharps device.

4 Healthcare providers have developed an Inoculation Injury Review Group (e.g. Infection Prevention and Control, Occupational Health and Safety, Risk Management et al) to monitor NSI, evaluate potential trends associated with NSI, audit

practice, and co-ordinate the trialling and introduction of SED.

5 Users of sharps are involved

in trialling and choosing the SED to be used (see Appendix 1 of WISE).

6 Users of “sharps” have been trained in how to optimally operate/activate, and use the SED.

7 Users of sharps/SED have been provided with appropriate sharps disposal containers for use at the point of care.

8 Sharps are disposed of in a safe and appropriate manner.

9 Management policies have been determined to ensure that sharps disposal containers are collected promptly and are disposed of according to National guidance.

10 Home users are informed of how sharps disposal containers should be stored in the home and how disposal of the boxes may be actioned.

Questionnaire for nurses giving injections to patients with diabetes in hospital setting

GIVING INJECTIONSTO PATIENTS WITH DIABETES*

= 10 nurses

Total Number = 634Percent = 100%

Countries and Nurses participating in survey

Who gives the diabetes injection in the hospital?

Safety background in hospitals

634 nurses participated from 13 western European countries and Russia. Most replies (69%) came from nurses on Endocrine/diabetes wards or Internal Medicine wards and most participants were currently injecting patients with diabetes at least twice a day. 623 nurses out of 634 (98%) had experience treating patients who used insulin pens at home and 541 nurses out of 634 (78%) had patients who used syringes at home, hence the majority of nurses were familiar with both devices.

Russia

Greece

NL

Belgium

France

Spain

Italy

Switzerland

UK

Denmark

Sweden

Germany

Ireland

Finland

10.7%

3.2%

9.8%

6.5%

5.8%

17.8%

9.3%

1.9%

10.3%

2.7%

2.7%

14.2%

1.9%

3.3%

12%

21%

33%

31%

3

Staff are involved in 64% cases 33.0 Patient where possible12.0 Initially staff then the patient takes over21.0 Both staff and patient throughout the stay3.0 Other31.0 Always staff

However, there were considerable differences bycountry with several southern European countries mainly entrusting staff to give the injections while northern European countries allowed the patients to give their own injections.

Most hospitals have a written policy on the prevention of NSI, (14.4% haven't); but nurses are not always aware of them.

67% of the nurses had not attended any training on the prevention of NSI and only 13% had attended one in the last year.

When Policies on safer practices are available nurses are often unfamiliar with them (29%) or untrained in NSI prevention (67%).

Does your hospital have a written policy on the prevention of NSI?

Yes and I'm familiar with it

Yes, but not familiar with it

No written policy

Does your hospital conduct training which includes the topic of NSI?

Yes, and l've attended(within the last year)

Yes, and l've attended(more than a year ago)

Yes, but l've not attended

No, not that l'm aware of

*Costigliola V, Frid A, Letondeur C, Strauss K. Needlestick injuries in European nurses in diabetes. Diabetes & Metabolism. 2012. Vol. 38. January (S9-S14).

Almost a third of nurses surveyed (32%) report suffering a NSI sometime in the past while giving an injection to a person with diabetes. The percentages by country are given below. These injuries put nurses at risk of blood-borne pathogens such as HBV, HCV and HIV.

The results indicate a high frequency of improper disposal of just-used sharps by nurses in hospitals and similar facilities, in the EU. Education on the seemingly innocuous practices of recapping needles, storing unprotected needles temporarily on a tray, trolley or cart and unscrewing used pen needles with one’s hands would go a long way to reducing NSI risk.

Percentage of Nurses by Countrywho acknowledge suffering a NSI while giving injections to persons with diabetes

Russia

Greece

NL

Belgium

France

Spain

Italy

Switzerland

UK

Denmark

Sweden

Germany

Ireland

Finland

25

55

23

19.5

43.2

39.8

30.5

33.3

15.4

29.4

50

42.2

16.7

40

Removing pen needle is a critical and dangerous step,the user's fingers must come very close to the exposed tip. Nurses were asked how they performed this step.

Unsafe practices such as recapping pen needles continue to be practiced at high rates. Chart above lists the timing and circumstances for the NSIs.

Method for Removing Pen Needles after UseWhen changing pen needles, how is needle removed?

Timing and Circumstances of reported NSlsDid the injury occur?

I unscrew it with my fingers

The patient unscrews it

I unscrew it with an instrument such as clamps or tweezers

I use a specifically designed needle remover

I twist it off using the top of the sharps container

I do not remove it

Other

8.9

57.3

6.0

7.3

13.5

1.0

6.1

Device and circumstances which cause NSI 57% unscrew pen needles using their fingers.

32% have suffered an NSI while giving a diabetic injection.

29% of NSI injuries occurred while recapping a used needle.

Before use of item

During use of item

Passing instruments

While recapping a used needle

While putting item into sharps container

After disposal (e.g. item protruding from opening

of sharps container or piercing side of replaced cap)

Injured by patient holding the contaminated needle

Other

13

2.4

29.5

16.1

3.1

2.1

14

19.9

Nurses who had suffered a NSI with pen needles were asked which end of the needle caused the injury.

Most of them were injured by the patient end of the needle but nearly 1 out of 10 reported being injured by the cartridge end.

Severity of the injury Nurses who had had NSls rated them as 'superficial to moderate' (based on amount of resultant blood flow) in almost all cases (96%).

ln 80% of cases the source patient's identity was known and the sharp item was 'contami-nated' (known previous percutaneous exposure to patient) in almost half the cases (43%).

Of those who received a NSI, 49% occurred with a conventional (non-safety) syringe, 44% with a conventional pen needle, 1.2% with a safety syringe and 0.4 with a safety pen needle.

This confirms what previous studies [1, 2, 3, 4] have shown: NSI rates fall dramatically after safety devices are adopted.

Timing and Circumstances of reported NSlsThe sharp item was:

Uncontaminated

Unknown

Contaminated

Severity of the injury

43% sharp items were contaminated.

Pen injection devices aspirate human cells back into the cartridge. [5-6] These potentially infectious cells can then be deposited back into the needle and then transmitted accidentally through both ends should a NSI occur.

After the injuryNSls were reported to the proper authorities in 2/3 of cases.Chart below shows the reasons given for not reporting a NSI.

If you didn’t report the NSI, what was the reason?

67.2 I didn’t think the incident presented a health risk

8.8 I was too busy at the time

2.7 I was too embarrassed

0.9 I thought reporting might have negative repercussions for my job/career

0.0 I did not want to know the answer

20.4 Other

Reasons given for not reporting NSIs

20.4

67.28.8

2.70.9

If you reported it, were you required to take any of the following steps?*

8.3 Take prophylactic medication(s)

79.5 Have my blood taken for tests

53.6 Blood taken from the source patient to determine their sero-status

12.3 Change my working habits/department

2.4 Stop working for a time

Steps taken immediately after a reported NSI

Did any of the following occur after your accident?

3.1 Depression, crying spells, sleep or eating abnormalities

0.8 Tension in family or marriage/partner relationships

2.7 Panic attacks, excessive worry, inability to work

6.6 Other emotional disturbances

86.0 No emotional disturbances

Emotional Consequences of NSIs

79.553.6

12.3

2.4

8.3

86.0

6.6

2.73.1

0.8

Cartridge EndPatient End

HBV is stable in dried blood for at leastseven days and HCV for at least 16 hours [62], thus NSI with devices used previously can still be infectious. Not all healthcare workers (HCW) are covered by HBV vaccination; in fact the European range is from 30-90% depending on the country and branch of medicine [63]

Risk assessment:NSI with diabetes needles or lancing devices are one of the highest frequency sharps injury in the healthcare setting. [61]

Some health care workers believe that because people with diabetes inject with short thin needles they represent little risk of injury.

What is a ‘safety device’?

During use:1. The safety feature can be activated using a

one-handed technique OR

2. Routine use of the device causes the safety mechanism to deploy automatically (i.e. passively) immediately after the sharp has been used

3. The safety feature does not obstruct vision of the tip of the sharp

4. The device offers a good view of any aspirated fluid

5. The safety device does not require more time to use than a non-safety device

6. The safety feature works appropriately with a wide variety of hand sizes

7. The device is easy to handle while wearing gloves

8. The device will work with all required syringe and needle sizes

9. The device provides a better alternative to traditional recapping

After use:10. There is a clear and unmistakable change

(audible and/or visible) that occurs when the safety feature is activated

11. The safety feature operates reliably

12. The exposed sharp is permanently blunted or covered after use and remains so until and after disposal

13. The device is no more difficult to dispose of after use than non-safety devices

14. The user does not need extensive training for correct operation

15. The design of the device suggests proper use

These criteria represent optimal target features which may not be achievable in every device; they do not represent an exhaustive list and may evolve over time.

Safety Devices A ‘safety device’ requires that once in safe mode, the safety feature(s) protect against accidental sharps injury until safe disposal. In addition for diabetes treatment, shorter needle lengths should be used so as to prevent having to raise a skinfold for injection, therefore avoiding “through-and-through” NSI. [64]

The initial purchase costs of safety injection devices may be higher than conventional ones. Yet a number of studies reveal that the significant reduction in NSI and other complications soon offset and often recover these costs. [65, 66, 67]

7days

HBV is stable in dried blood for at least seven days

16hours HCV is stable in dried blood for at least 16 hours

Generic risk matrix for medical devicesincorporating needles*

RISK

by

amou

nt o

f bl

ood

expo

sure

per

dev

ice

RISK by amount of blood exposure per device

Critical IV Catheter BloodCollection

IM Injection Lancet

Acupuncture BloodSplashes

SurgicalDevices

No Patient Contact

HeparinInjection

InsulinInjection

Serious

Medium

Low

Seldom Sometimes Often Frequently

Risk is not acceptable. Action to address risk is very urgently required.

Risk is not acceptable. Action to address risk is required.

Risk is acceptable. Standard precaution appropriate.

* Prof. A. Wittmann, presented at WISE 2011 (10)

Risk Classification

BD, BD Logo and BD Micro-Fine are trademarks of Becton, Dickinson and Company. © July 2012 BD.

2322

1 Council Directive 2010/32/EU, Offi cial Journal of the European Union, L134/71.

2 http://eurlex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2010:134:0066:0072:EN:PDF.

3 Tarantola A, Abiteboul D, Rachline A. Infection risks following accidental exposure to blood or body fl uids in health care workers: A review of pathogens transmitted in published cases. Am J Infect Control 2006;34:367-75.

4 EU Commission for Employment, Social Affairs and Inclusion, New legislation to reduce injuries for 3.5 million healthcare workers in Europe, 8th March 2010.

5 Perry J, Parker G, Jagger J EPINet Report: 2004 Percutaneous Injury Rate. International Healthcare Worker Safety center, August 2007. Available at: http://healthsystem.virginia.edu/internet/safetycenter/

6 Kiss P, De Meester M, Braeckman L. Needle stick injuries in nursing homes: The prominent role of insulin pens. Infect Control Hosp Epidemiol 2008;29:1192-4.

7 Lee JM, Botteman MF, Nicklasson L, Cobden D, Pashos CL. Needlestick injury in acute care nurses caring for patients with diabetes mellitus: a retrospective study. Curr Med Res Opin 2005;21:741-7.

8 Demir M, Serin E, Göktürk S, Ozturk NA, Kulaksizoglu S, Ylmaz U. The prevalence of occult hepatitis B virus infection in type 2 diabetes mellitus patients. Eur J Gastroenterol Hepatol 2008;20:668-73.

9 Simó R, Hernández C, Genescà J, Jardí R, Mesa J. High prevalence of hepatitis C virus infection in diabetic patients. Diabetes Care 1996;19:998- 1000.

10 Mondy K, Overton ET, Grubb J, Tong S, Seyfried W, Powderly W, Yarasheski K. Metabolic syndrome in HIV infected patients from an urban, midwestern US outpatient population. Clin Infect Dis 2007;44:726-34.

11 Sibanda T. Needle stick injuries are a preventable healthcare hazard. BJOG 2008;115:1579.

12 Council Directive 2010/32/EU, Offi cial Journal of the European Union, L134/71, http://eurlex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ: L:2010:134:0066:0072:EN:PDF.

13 EU Commission for Employment, Social Affairs and Inclusion, New legislation to reduce injuries for 3.5 million healthcare workers in Europe, 8th March 2010.

14 Article 3.2 says that where risk cannot be eliminated the employer shall take appropriate measures to minimise the risks. Appropriate measures to minimise the risks would include the provision by employers of safer needle devices. (Cf. NHS Employers, Implementation advice on sharps agreement, 12th October 2010) The Directive specifi cally requires: “eliminating the unnecessary use of sharps by implementing changes in practice and on the basis of the results of the risk assessment, providing medical devices incorporating safety-engineered protection mechanisms”. Council Directive 2010/32/EU, Offi cial Journal of the European Union, L134/71 and Council Directive 2010/32/EU, Offi cial Journal of the European Union, L134/69.

15 Watterson L. Sharp Thinking. Nursing Standard. October 2005;20:20- 22.

16 PHASE study group (Italy) Rischio biologico e punture accidentali negli operatori sanitari. Series Lauri Edizioni, Milano 2001 and 2003. ISBN 88 86867 08 5; 88 86867 12 3.

17 Wittmann A, Köver J, Hofmann F, Kralj N. Übertragene Blutvolumina nach Nadelstichverletzungen an s.c. Kanulen, Dokumentations – CDROM uber 49. Jahrestagung der DGAUM 2009:382- 4.

18 CDC Case - Control Study of HIV Seroconversion in Health-Care Workers After Percutaneous Exposure to HIV- Infected Blood - France, United Kingdom, and United States, January 1988- August 1994. MMWR 1995;44:929- 33

19 Yazdanpanah Y, DeCarli G, Migueres B, Lot F, Campins M, Colombo C, et al. Risk factors for hepatitis C virus transmission to health care workers after occupational exposure: a European case-control study. Clin Infect Dis 2005;41:1423-30.

20 Adams D, Elliott TSJ. Impact of safety needle devices on occupationally acquired needle stick injuries: a four- year prospective study. J Hosp Infect 2006;64:50- 5.

21 Tarantola A, Golliot F, Astagneau P, Fleury L, Brucker G, Bouvet E; CCLIN Paris- Nord Blood and Body Fluids (BBF) Exposure Surveillance Taskforce. Four-year surveillance from the Northern France network, Am J Infect Control. 2003;31:357- 63.

22 Cullen BL, Genasi F, Symington I et al. Potential for reported needlestick injury prevention among healthcare workers in NHS Scotland through safety device usage and improvement of guideline adherence: an expert panel assessment. J Hosp Infect 2006;63:445- 51.

23 Mendelson MH, Lin- Chen BY, Finkelstein- Blond L, Bailey E, Kogan G. Evaluation of a Safety IV Catheter (IVC) (Becton Dickinson, INSYTE™ AUTOGUARD™): Final Report Eleventh Annual Scientifi c Meeting Society for Healthcare Epidemiology of America, 2001 SHEA, Toronto, Canada.

24 Louis N, Vela G, Groupe Projet. Évaluation de l’effi cacité d’une mesure de prévention des accidents d’exposition au sang au cours du prélèvement de sang veineux. Bulletin Épidémiologique Hebdomadaire 2002;51:260- 1.

25 Lamontagne F, Abiteboul D, Lolom I, Pellissier G, Tarantola A, Descamps JM, Bouvet E. Role of safety-engineered devices in preventing needlestick injuries in 32 French hospitals. Infect Control Hosp Epidemiol 2007;28:18- 23.

26 Tuma SJ, Sepkowitz KA. Effi cacy of Safety- engineered device implementation in the prevention of percutaneous injuries: a review of published studies. Clin Infect Dis 2006;42:1159- 70.

27 Adams D, Elliott, TS. Safety-engineered needle devices: evaluation prior to introduction is essential. J Hosp Infect 2011;79:174-5.

28 Based on OSHA documents available at: http://www.osha.gov/index.html.

29 Sonoki K, Yoshinari M, Iwase M, Tashiro K, Iino K, Wakisaka M, et al. Regurgitation of blood into insulin cartridges in the pen-like injectors. Diabetes Care 2001;24:603- 4.

30 Costigliola V, Letondeur C, Frid A, Strauss K. Needlestick injuries in European hospital nurses giving injections to patients with diabetes 2012 (published in this same supplement).

31 Adams D, Elliott TSJ. A comparative user evaluation of three needle protective devices. Br J Nurs 2003;12:470-4.

32 Kreugel G, Keers JC, Jongbloed A, Verweij- Gjaltema AH, Wolffenbuttel BHR. The infl uence of needle length on glycemic control and patient preference in obese diabetic patients. Diabetes 2009;58:A117.

33 Kreugel G, Beijer HJM, Kerstens MN, ter Maaten JC, Sluiter WJ, Boot BS. Infl uence of needle size for SC insulin administration on metabolic control and patient acceptance. Europ Diab Nursing 2007;4:1-5.

34 Schwartz S, Hassman D, Shelmet J, Sievers R, Weinstein R, Liang J, Lyness W. A multicenter, open- label, randomized, two-period crossover trial comparing glycemic control, satisfaction, and preference achieved with a 31 gauge × 6mm needle versus a 29 gauge × 12.7mm needle in obese patients with diabetes mellitus. Clin Ther 2004;26:1663- 78.

35 Hirsch L, Klaff L, Bailey T, Gibney M, Albanese J, Qu S, Kassler-Taub K. Comparative glycemic control, safety and patient ratings for a new 4 mm\32G insulin pen needle in adults with diabetes Curr Med Res Opin 2010;26: 1531–41.

36 Strauss K, Hannet I, McGonigle J, Parkes JL, Ginsberg B, Jamal R, Frid F. Ultra- short (5mm) insulin needles: trial results and clinical recommendations. Pract Diabetes Intern 1999;6:22-5.

37 Lo Presti D, Ingegnosi C, Strauss K. Skin and subcutaneous thickness at injecting sites in children with diabetes: ultrasound fi ndings and injecting recommendations. J Pediatr 2012 (in press).


References References

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2524

38 Birkebaek NH, Solvig J, Hansen B, et al. A 4mm needle reduces the risk of intramuscular injections without increasing backfl ow to skin surface in lean diabetic children and adults. Diabetes Care 2008;31:e65.

39 WHO Patient Safety Curriculum Guide Multi-professional Edition World Health Organization 2011. Available on the WHO web site (www.who.int).

40 Prüss- Üstün A, Rapiti E, Hutin Y. Sharps Injuries: Global burden of disease from sharps injuries to health-care workers. Environmental Burden of Disease Series, No. 3. World Health Organization, Geneva 2003. Available at: http://whqlibdoc.who.int/publications/2003/9241562463.pdf.

41 Brusaferro S, Calligaris L, Farneti F, Gubian F, Londero C, Baldo V. Educational programmes and sharps injuries in health care workers. Occup Med (Lond) 2009;59:512- 4.

42 Jagger J, Perry J, Gomaa A, Phillips EK. The impact of U.S. policies to protect healthcare workers from bloodborne pathogens: The critical role of safety-engineered devices. J Infect Pub Health 2008;1:62- 71.

43 Council Directive 2010/32/EU, Offi cial Journal of the European Union, L134/71 and Council Directive 2010/32/EU, Offi cial Journal of the European Union, L134/69.

44 Adams D. To the point: needlestick injuries, risks, prevention and the law. Brit J Nurs 2011;20:3356- 9.

45 Technical Rules for Biological Agents (TRBA 250 Point 4.1.1.4) published by the German Bundesanstalt für Arbeitsschutz und Arbeitsmedizin (Federal Institute for Occupational Safety and Health, see www.baua.de).

46 Vos D, Gotz HM, Richardus JH. Needlestick injury and accidental exposure to blood: The need for improving the hepatitis B vaccination grade among health care workers outside the hospital. Am J Infect Control 2006;34:610- 2.

47 Larmuseau D. Safety products, for everyone’s (fi nancial) benefi t (Les produits de sécurité, un avantage (fi nancier) pour tous). Study sponsored by and used with kind permission of UNAMEC, The Belgian Association for producers and/or distributors of medical devices.

48 Guillaudin M, Tortolano L, Bouche V, Jumel C, Borget I, Tilleul P. Cost-effectiveness of safe needles for insulin pen versus standard needles in the prevention of occupational blood exposure. Presentation at the 40th Symposium on Clinical Pharmacy of the European Society of Clinical Pharmacy. Dublin, Ireland. 18- 21 October 2011.

49 Armadans Gil L, Fernandez Cano MI, Albero Andres I, Angles Mellado ML, Sanchez Garcia JM, Campins Marti M, et al. Safety-engineered devices to prevent percutaneous injuries: cost-effectiveness analysis on prevention of high-risk exposure Gac Sanit 2006;5:374- 81.

50 Glenngard AH, Persson U, Costs associated with sharps injuries in the Swedish health care setting and potential cost savings from needle-stick prevention devices with needle and syringe Scand J Infect Dis 2009;41:96- 302.

51 Workman RGN. Safe injection techniques. Prim Hlth C 2000;10:43- 50.

52 Bain A, Graham A. How do patients dispose of syringes? Pract Diab Int 1998;15:19- 21

53 http://www.hse.gov.uk/healthservices/needlesticks/resources.htm)

54 Strauss K. WISE (Workshop on Injection Safety in Endocrinology) New Injection Recommendations. Diabetes & Metabolism. January 2012 Vol. 38, S2-S8.

55 Adams D, Elliott T.S.J., Impact of safety needle devices on occupationally acquired needle stick injuries: a four-year prospective study. J Hosp Infect 2006;64:50-55.

56 Cullen BL, Genasi F, Symington I, Bagg J, McCreaddie M, Taylor A, Henry M, Hutchinson SJ, Goldberg D. Potential for reported needle stick injury prevention among healthcare workers in NHS Scotland through safety device usage and improvement of guideline adherence: an expert panel assessment. J Hosp Infect 2006;63: 445-451.

57 Meryl H. Mendelson, Bao Ying Lin-Chen, Lori Finkelstein-Blond, Eileen Bailey, Gene Kogan. Evaluation of a Safety IV Catheter (IVC) (Becton Dickinson, INSYTE™ AUTOGUARD™) : Final Report Eleventh Annual Scientifi c Meeting Society for Healthcare Epidemiology of America, 2001 SHEA, Toronto, Canada.

58 Jagger J et al. The impact of U.S. policies to protect healthcare workers from bloodborne pathogens: The critical role of safety-engineered devices, Journal of Infection and Public Health (2008) 1, 62—71.

59 Le Floch JP, Herbreteau C, Lange F, Perlemuter L. Biologic material in needles and cartridges after insulin injection with a pen in diabetic patients. Diabetes Care 1998;21:1502-1504.

60 Sonoki K.,Yoshinari M.,Iwase M.,Tashiro K., Iino K., Wakisaka M., Fujishima M. Regurgitation of Blood into Insulin Cartridges in the Pen-like Injectors. Diabetes Care 2001; 24: 603-604.

61 Kiss P, De Meester M, Braeckman L. Needle stick injuries in nursing homes: The prominent role of insulin pens, Infect Control Hosp Epidemiol 2008; 29:1192-1194.

62 Risks of Dried Blood, Center for Disease Control, Atlanta, USA, 1995.

63 Prüss-Üstün A, Rapiti E, Hutin Y. Global burden of disease from sharps injuries to health-care workers; Environmental Burden of Disease Series, No. 3; World Health Organization Protection of the Human Environment Geneva 2003. Table 9, Hepatitis B vaccine coverage among health-care workers

64 Strauss K; WISE Consensus Group. WISE recommendations to ensure the safety of injections in diabetes. Diabetes Metab. 2012 Jan;38 Suppl 1:S2-8.

65 Armadans Gil L, Fernandez Cano MI, Albero Andres I, Angles Mellado ML, Sanchez Garcia JM, Campins Marti M, Vaque Rafart J. [Safety-engineered devices to prevent percutaneous injuries: cost-effectiveness analysis on prevention of high-risk exposure] Gac Sanit 2006 Sep-Oct;20(5):374-81. http://www.ncbi.nlm.nih.gov/pubmed/17040646

66 Anna H. Glenngard ;Ulf Persson, Costs associated with sharps injuries in the Swedish health care setting and potential cost savings from needle-stick prevention devices with needle and syringe Scandinavian Journal of Infectious Diseases, Volume 41, Issue 4 2009, pages 296 – 302. http://informahealthcare.com/doi/abs/10.1080/00365540902780232

67 NHS Scotland, Needlestick Injuries; Sharpen your Awareness, Annex 3, Safer Devices Cost Benefi t Assessment. http://www.sehd.scot.nhs.uk/publications/nisa/nisa-13.htm

Further Reading1 Bloodborne viruses in the workplace:

Guidance for employers and employees Leafl et INDG342 HSE Books 2001 (single copy free or priced packs of 10 ISBN 978 0 7176 2062 3) www.hse.gov.uk/pubns/indg342.pdf

2 HSE’s risk assessment web pages: www.hse.gov.uk/risk, and

3 Five steps to risk assessment Leafl et INDG163(rev2) HSE Books 2006 (single copy free or priced packs of 10 ISBN 978 0 7176 6189 3) Web version: www.hse.gov.uk/pubns/indg163.pdf 4 www.hse.gov.uk/forms/heath/emasoffi ces.htm

4 BS 7320: 1990 Specifi cation for sharps containers British Standards Institution

5 EN 388: 2003 Protective gloves against mechanical risks British Standards Institution

6 www.hse.gov.uk/riddor 7 Sharps safety. RCN guidance to support

implementation of the EU. Directive 2010/32/EU on the prevention of sharps injuries in the health care sector. www.rcn.org.uk/__data/assets/pdf_fi le/0008/418490/004135.pdf

8 A step by step guide to COSHH assessment HSG97 (Second edition) HSE Books

9 2004 ISBN 978 0 7176 2785 1 Tackling drug related litter. Guidance and good practice Defra October 2005 www.defra .gov.uk


References References

9.0 9.0


The following members of the FIT4Safety Consensus Group scrutinized this document, amended copy and approved its content and format on the 27th April 2012. The FIT Board retains full editorship rights over this document and associated materials.

Joan AllwinkleDiabetes Specialist Nurse, Edinburgh

Sian BodmanLead Nurse Diabetes, Aneurin Bevan Health Board, Wales

Beverley BrittonCommunity Diabetes Specialist Nurse, Bristol Community Health

Katrina DeasClinical Practice Development Offi cer, NHS Fife

Carrie FelgateHead of Infection Control, Staffordshire

Philip FrenchRepresenting People with Diabetes, Edmonton London

Rose GallagherRCN Infection Prevention & Control Advisor, London

Will HarperRepresenting People with Diabetes, Oxford

Allison HeseltineHead of Infection Prevention & Control, Staffordshire

Jane HodsonLead IV Practitioner, Guy & St Thomas’ NHS Foundation Trust, London

Jill HolmesInfection Prevention and Control Nurse Specialist, Leeds

Debra HutchingsDiabetes Specialist Nurse, Sutton & Merton Community Services

Liz KampsConsultant Nurse Diabetes, UCLH, London

Dr David Millar-JonesGPwsi Diabetes, Associate Specialist Diabetes, South Wales

Leslie MillsSenior Diabetes Nurse Specialist, Warrington and Halton Hospitals NHS Foundation Trust

Cathy MoultonClinical Advisor Diabetes UK, London

Frances MurrayLead Nurse, Royal Blind School, Edinburgh

Des PorterStreet Scene Team Leader, Oxfordshire City Council

Anna ReidNurse Consultant Diabetes, Guys & St Thomas’ NHS Foundation Trust, London

Brett SeamerSupply Chain and Logistics Manager, Epsom & St Helier University Hospitals NHS Trust

Nicki SkillenCommunity Diabetes NurseBucks Healthcare NHS Trust

Rebecca StretchInfection Control Lead Nurse, Camden provider Services, London

Doris ThomsonSenior Infection Control Nurse, Camden & Islington Foundation Trust London

Perdy Van Den BergClinical Lead, Oxfordshire Community Diabetes Service

Pinky VirhiaLecturer Practitioner, Glasgow Royal Infi rmary

Daniel WarneTeam Leader, Direct Services, Oxfordshire City Council

Christopher WilgerSenior Community Childrens Nurse and Diabetes Lead, North Hampshire Hospital NHS Foundation Trust, Basingstoke

Contact Details

Debbie Hicks debbie.hicks@enfi eld.nhs.uk

Su [email protected]

Dr Debra [email protected]

Expert Consensus Group

10

Optimising Diabetes Care

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