POLICY AND PROCEDURE FOR THE PRELOADING OF INSULIN Prepared by:
Karen Armitage
Approval Information:
Patient Care and Professions Directorate Date Approved: COMMITTEE:
Lead Director:
Sheila Dilks
Responsible Area:
12th September 2007 PEC
Version No. Approved:
One
Review Date:
June 2009 (sooner if change in guidance or in response to any incident report)
Reference to Standards for Better Health Domain
First domain – Safety Fourth domain – Patient Focused Fifth domain – Accessible and Respnsive Care
Core/Development standard
C1; C16; C17; D9; D10;
Performance indicators
1. A reduction in the percentage of diabetics whose care incorporates the pre-loading of insulin.
History of Document
Originally Huddersfield South and Central Primary Care Trust 2006 Written by:- Elizabeth Jobes Diabetes Specialist Nurse Karen Armitage Professional Development Facilitator Kirklees Primary Care Trust Issue 1 Adapted from above, following further consultation
CONTENTS
Section No.
Page No’s
POLICY FOR THE PRE-LOADING OF INSULIN 1.
Acknowledgements
3
2.
Associated Policies
3
3.
Introduction and Overview
3
4.
Scope
4
5.
Responsibilities
4
PROCEDURE FOR THE PRE-LOADING OF INSULIN 1.
Principles of practice
5
2.
Contra-indications
5
3.
Practical process of pre-loading insulin
6
4.
References
7
5.
Bibliography
7
6.
Appendices 8 Flow chart for the pre-loading of insulin 9 Assessing risk – the pre-loading of insulin
NICE Guidance Once NICE guidance is published, health professionals are expected to take it fully into account when exercising their clinical judgement. However, NICE Guidance does not override the individual responsibility of health professionals to make appropriate decisions according to the circumstances of the individual patient in consultation with the patient and/or their guardian or carer.
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Policy for the pre-loading of insulin 1.
Acknowledgements South Western Staffordshire Primary Care Trust - Clinical Guidelines District Nurse Practice Development Group:- Rosemary Robinson, Sonia Stephenson, Deborah Roberts, Annabelle Favell-Potter, Joanne Keeling, Margaret Farmer, Melanie Wimpenny, Beverley Greenbank
2.
Associated Policies Infection Control Policy Royal Marsden Clinical Procedures Consent Policy Medicines Code
3.
Introduction/Overview The need to promote patient independence and choice as well as ensuring safe, effective and appropriate use of resources is recognised by the Primary Care Trust (PCTs). This policy is supported by a procedure for the preloading of insulin for patients to selfadminister later. It stresses the necessary principles of practice including patient assessment and review, ensures other methods of insulin administration have been considered, together with contra-indications, and details appropriate insulin storage requirements and record keeping. Diabetes Mellitus is a chronic condition. Patients require long-term medication to control blood glucose levels and reduce the risk of associated complications. For some patients the prescribed treatment is regular insulin injections. There are various devices, which facilitate the self-administration of insulin. However, for a small number of patients difficulty is experienced in the correct drawing up (or dialling up) of the appropriate insulin dose although the patient will be competent with the technique of injecting. For these patients the pre-loading of insulin, for the individual to self-administer later, at the appropriate time, can preserve independence and facilitate choice. The Royal College of Nursing (RCN) (2006) purport that whilst the pre-loading of insulin is not recommended for all types of insulin e.g. short-acting (soluble) insulin and long acting analogue – Glargine, other insulin types can be pre-loaded into syringes for a maximum of 7 days. However, in the interest of patient safety, Kirklees PCT recommends a maximum of 4 days.
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4.
Scope This policy covers all registered nursing employees of the Primary Care Trust who are required to treat patients with diabetes mellitus. It relates specifically to the patient who is able to safely self-administer the correct dose of insulin at the correct time, but is unable to draw up insulin.
5.
Responsibilities 5.1 It is the responsibility of every Trust employed registered nurse who is required to treat patients with diabetes mellitus to be familiar with this policy and procedure. 5.2 Registered nurses involved in the administration of insulin, as in all other areas of their practice, will be responsible for maintaining and updating their knowledge and practice. 5.3 Registered nurses in administering any medicines, in assisting with administration or overseeing any self-administration of medicines must exercise professional judgement, apply knowledge and recognise their professional accountability as per Nursing and Midwifery Council (NMC) Guidelines for the Administration of Medicines 2002. 5.4 Registered nurses are responsible for recognising any limitations in their knowledge and competence and declining any duties they do not feel able to perform in a skilled and safe manner (NMC 2004).
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Procedure for the pre-loading of insulin 1.
Principles of practice 1.1 Pre loading of insulin should only be recommended when alternative methods of delivery are not possible. 1.2 Registered Nurses should be aware of the alternative injection devices available and discuss the patient’s needs and preferred options with the Diabetes Specialist Nurse or General Practitioner. 1.3 Pre loading of insulin should only begin following a full written risk assessment and the ruling out of alternative methods of administration. A thorough assessment of the patient’s understanding of the insulin regime, their ability to manage it, and the support available to the patient between community nurse visits, must be undertaken. (see appendices) 1.4 A patient should always be consulted about their insulin administration and informed consent obtained regarding the care to be provided. 1.5 1.5 Insulin should be pre-loaded twice weekly i.e. not drawn up for more than 4 days; the patient must be advised of the correct storage recommendations. 1.6 Correct storage - pre-filled syringes should be stored, with needle end slightly elevated, in a labelled protective container in the main body of the fridge (away from the freezer section or the back of the fridge) between 2 – 8 degrees centigrade. (RCN 2006) 1.7 Where insulin is to be administered at different times of the day (unless same dose and insulin type) then separate containers, which are easily distinguishable, must be used. 1.8 Arrangements must be made to ensure the monitoring of diabetes control is undertaken. Diabetes monitoring may be undertaken by the patient themselves, a family member/friend or by an interim visit by a member of the community nursing team. Arrangements for this being based on a full written risk assessment. 1.9
Regular re-assessment of the patient and plan of care must be undertaken and documented. (3 monthly or sooner if patient’s circumstances change)
1.10 The pre-loading of insulin should only be undertaken by nurses who have the appropriate knowledge and competence. 2.
Contra – indications 2.1 Insulin which is not suitable for pre loading: • Short Acting (Soluble) insulin • Long acting Analogues e.g.Glargine 2.2 Unstable diabetic condition
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2.3 Lack of satisfactory storage facilities in the patient’s home
3.
2.4
Unpredictable mental state or declining cognitive ability
2.5
Patient is in a care home without his or her own, individual, private storage facilities.
Practical process of pre-loading insulin Equipment required: • • • •
Plan of care Gloves Sharps Box Insulin Syringes 30, 50 or 100 unit syringes (depending which is most appropriate for the dose), needle length should be no more than 8 millimetre (mm). • Relevant prescribed Insulin Vial • Labelled Container(s) provided by patient for storage of pre filled syringes • Mediswab 3.1 Read and check plan of care. Check for allergies/contra-indications. Check all previous pre loaded syringes have been administered and safely disposed of. 3.2 Explain procedure to patient, ensuring consent obtained. 3.3 Prepare clean working surface and collect equipment required; check insulin for expiry date and against instructions of care plan. 3.4 Wash Hands. 3.5 Prepare equipment and re-suspend insulin at least 10 times if using cloudy insulin. 3.6 Draw up insulin in presence of patient as follows for each syringe using a clean procedure to prevent contamination:3.6.1
Swab insulin vial with a mediswab and allow to dry.
3.6.2
Remove needle cover and pull back plunger to measure an amount of air equivalent to the amount of insulin prescribed.
3.6.3
With insulin vial standing upright, insert the needle through the centre of the rubber cap and push down plunger.
3.6.4
Invert the insulin vial
3.6.5
Pull back plunger until slightly more than correct dose is drawn up.
3.6.6
Expel any air bubbles back into vial.
3.6.7
Recheck correct prescribed dose has been drawn up and remove needle from vial.
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3.6.8
Carefully re-sheath needle (there is no risk of contaminated needle stick injury as needle is sterile – in the event of a needle stick injury the syringe must be safely discarded).
3.7 Store pre-filled syringes with needle end slightly elevated, within a labelled protective container in main body of the fridge (away from freezer section or the back of the fridge). For twice-daily injections, with different doses, a method of identification for the containers must be negotiated with the patient and recorded in the care plan, taking into account the patient’s preferences and capabilities. 3.8 Dispose of clinical waste and wash hands. 3.9 Complete nursing notes ensuring date, time, insulin type/dose and number of insulin syringes drawn up are recorded. 3.10 Advise patient re:3.10.1 3.10.2 3.10.3
Timing of their injections. Re-suspending all pre-loaded insulin at least 10 times prior to injection, if using cloudy insulin. Correct disposal of sharps.
3.11 Ensure arrangements are in place, based on the risk assessment, for patient support and monitoring. Ensure patient is aware of Community Nursing Team contact number. 3.12 Ensure plan of care meets patient’s needs, and ability, by regular review and
reassessment (3 monthly or sooner if patient’s circumstances change). Liaise with Diabetes Specialist Nurse as required. References RCN Diabetes Forum (2006) Pre-mixing and pre-loading of insulin for patients at home. RCN Guide for Community Nurses Final Draft RCN: London NMC (2002) Guidelines for the administration of medicines. NMC, London. NMC (2004) Code of Professional Conduct: Standards for conduct, performance and ethics NMC: London 4.
Bibliography DoH (2001) NSF for Diabetes Standards. DoH London
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Appendix 1
Flow chart for the pre-loading of insulin Has the patient, through education and support, shown that he/she: 1 2. 3
Understands the insulin regime. Is able to administer insulin correctly and independently at the appropriate time and dispose of used syringes safely. Is unable to draw up accurately and independently the prescribed insulin dose. YES
NO
Consider alternative methods of insulin administration which facilitates accurate dialling/drawing up - refer to diabetes specialist nurse for advice/support
Continue to provide daily/twice daily nursing visits to manage diabetes control / consider education of carers/family
Are alternative methods of administration appropriate? NO
YES Provide support/education to patient until independent with insulin regime/monitoring.
Are there contra-indications to the pre-loading of insulin? (see box a)
YES
NO Can patient: 1. Provide correct storage requirements – Fridge, protective container to store pre-filled syringes. 2. Monitor diabetes control independently or arrangements are in place for monitoring to be undertaken. 3. Distinguish between the a.m. and p.m. dose containers if on twice daily insulin regime. Is patient aware of support available between nurses’ visit including nurse contact details? YES
NO
Would pre-loading of insulin promote patient independence and meet patient need?
NO
YES Commence pre-loading of insulin. Arrange with patient when to undertake twice weekly visits to monitor diabetes control and draw up insulin Ensure arrangements are in place (and documented) for regular re-assessment of the plan of care and patient’s ability. (Re- assessment should be undertaken 3 monthly or sooner if patient’s circumstances change).
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Contra-indications BOX A Insulin which is not suitable for pre-loading: short-acting (soluble) insulin long-acting Analogues e.g. Glargine Unstable diabetic condition Lack of satisfactory storage facilities: 1. Fridge in working order 2. Protective container/s to store syringes Patient suffers from an unpredictable mental state or declining cognitive ability. Patient is in a care home without 8 of his 9 or her own, individual, private storage facilities.
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Appendix 2
Assessing risk - The pre-loading of insulin The pre-loading of insulin should be considered as a last resort and only following a risk assessment. Its aim is to promote patient independence not as a means of saving nursing time. Contra-indications Insulin which is not suitable for pre-loading: short-acting (soluble) insulin long-acting Analogues e.g. Glargine Unstable diabetic condition Lack of satisfactory storage facilities: 3. Fridge in working order 4. Protective container/s to store syringes Patient suffers from an unpredictable mental state or declining cognitive ability. Patient is in a care home without his or her own, individual, private storage facilities. No contra-indications then a positive response to all of the following is required before the pre-loading of insulin can commence: YES
1)
Has the patient shown that he/she understands their insulin regime?
2)
Has the patient been provided with education and support regarding the drawing up of insulin but remains unable to do this accurately and independently?
3)
Has the patient shown that he/she is able to administer insulin correctly and independently at the appropriate time?
4)
Does the patient know how to dispose of the used syringes safely?
5)
Has advice been sought from the Diabetes Specialist Nurse Team?
6)
Have alternative methods of insulin administration been considered/tried without success?
7)
Can the patient monitor diabetes control independently or are arrangements in place for monitoring to be undertaken?
8)
Is the patient aware of the nursing team’s contact details and available support between nurse’s visits?
9)
If on twice daily insulin dose will the patient be able to distinguish between a.m. and p.m. dose?
10)
Does clinical judgement support the use of preloading of insulin for the patient?
11)
Would pre-loading of insulin promote patient independence and meet patient need?
12)
Will arrangements be put in place (and documented) for the regular reassessment of the plan of care (3 monthly or sooner if patient’s circumstances change)?
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or N/A