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How to Find Your Way Around 1. You can play the PowerPoint, and find the Test here How to Find Your Way Around 2. You can minimise this column and make the main page bigger by clicking this icon. Click it again to bring it back. How to Find Your Way Around 3. Always click this ‘Home’ icon to save your progress and log off. This is very important! 22nd April 2009 Using Insulin Safely e-Learning Introduction and Course Objective Objective: • By the end of this course you, as a healthcare practitioner, will be able to safely prescribe and/or administer insulin Walkthrough of the course: • Understanding insulin • The range of insulin and injection devices • The different ways to administer insulin • The identification and possible side effects of insulin therapy • Take home message and Test • (please note that some of the answers in the test are from the links in this Powerpoint presentation to external sites, as well as the Powerpoint presentation itself) What is Insulin? • • • Insulin is a hormone, which lowers the level of glucose in the blood It is made in the pancreas, and is released into the bloodstream when glucose levels increase, such as after eating The release of insulin into the system helps glucose to enter the body’s cells, where it is either used immediately for energy, or stored for future use Hyperglycaemia • • • People who have diabetes have an ineffective pancreas which either, does not produce enough insulin, or which cannot deal effectively with insulin This causes glucose levels in their blood to increase (termed ‘hyperglycaemia’), and insulin is needed to lower these levels Most people who have diabetes test their blood to measure their glucose levels, and this allows them to manage their glucose levels Some Statistics… • • • • 4-5% of the UK population have diabetes, and 2030% of these people are treated with insulin Insulin is a life saving drug, used in both hospital settings and in the community, however, the risks of insulin usage in hospital settings will be significantly higher, as surgery and acute illnesses can lead to hyperglycaemia Correct use of insulin is the most effective treatment of hyperglycaemia when used correctly, but incorrect use can cause harm to patients Errors in insulin prescribing and administration are twice as likely to cause patient harm than any other medication Errors • • • • Insulin is in the top 5 high alert medications! In the USA, insulin is responsible for 33% of medical errors leading to death within 48 hours of the error The National Patient Safety Agency (NPSA) report in 2010 reported that 62% of insulin errors were around administration, with prescribing being the most common error The NPSA also noted over 15000 incidents, including 6 deaths, in England and Wales during 2003-2009 Real Life Incidents • Click the link below to read some real life stories about insulin errors • http://www.diabetes.nhs.uk/safe_use_of_insulin/safe _use_of_insulin_elearning_module/true_stories/ • It is worth noting that any errors you make will cause problems for your patient, for you as a healthcare professional, and also for the Trust Individualised Care • Patients will have their own routine for managing their diabetes • Ask them about how they manage their treatment • Ask them when they normally measure their blood glucose levels • Ask them when they normally take their medication • Ask them when they normally eat • Try to maintain their normal routine as much as possible This may involve observed self-medication • The Right Insulin • • • • When prescribing or administering insulin, always be sure of the 4 considerations: • The right INSULIN • The right DOSE • The right TIME • The right WAY There are over 20 types of commercial insulin – it is imperative you choose and use the right type! Most insulin is genetically engineered to be more like the insulin that the body produces naturally, and some of these have different absorption properties (insulin analogues) There are 2 different names for each type of insulin…a proprietary name and an approved name, e.g. Apidra®, and Insulin Glulisine The Right Insulin • • There are 4 types of insulin, classified according to how they act on the body Some of these are combined to make insulin mixes: • Rapid Acting – Usually begins working within 5-15 minutes, should be taken just before eating, peaks between 30-90 minutes, and it ends usually between 3-5 hours • Short Acting – Begins working in 30-60 minutes, peaks between 2-3 hours, usually ends around 5-8 hours • Intermediate Acting – Usually starts working in 2-4 hours, peaks between 12-14 hours, and ends after around 16 hours • Long Acting – Starts working within 6 hours, and lasts for up to 36 hours Insulins Available: Short-Acting and Rapid-acting Full information on each at www.medicines.org.uk PRESCRIBE BY FULL TRADE NAME. SPECIFY DEVICE. 100units/ml. Vials are 10ml. Cartridges are 3ml. Prefilled “pens” Insulin (neutral insulin, soluble insulin) Hypurin Bovine Neutral W Hypurin Porcine Neutral W Actrapid (10ml vial only) N Humulin S L Insuman Rapid (cartridges only) S Insulin Aspart Novorapid N Insulin Glulisine Apidra S Insulin Lispro Humalog L Insulins Available: Intermediate-Acting Isophane Insulin Hypurin Bovine Isophane Hypurin Porcine Isophane Insulatard Humulin I Insuman basal Wockhardt UK Wockhardt UK Novo Nordisk Lilly Sanofi Aventis Insulins Available: Long-Acting Insulin Detemir Levemir Novo Nordisk Insulin Glargine Lantus Sanofi Aventis Insulin Zinc Suspension Hypurin Bovine Lente (10ml vial only) W Protamine Zinc Insulin Hypurin Bovine Protamine Zinc (10 ml vial only) Wockhardt UK Insulins Available – Biphasic Insulins Biphasic insulin aspart NovoMix 30 Biphasic insulin lispro Humalog Mix25 Humalog Mix50 Biphasic isophane Insulin Hypurin Porcine 30/70 Mix Humulin M3 Insuman Comb 15 Insuman Comb 25 Insuman Comb 50 Novo Nordisk Lilly Lilly Wockhardt Lilly Sanofi Aventis Sanofi Aventis Sanofi Aventis Injection Devices Autopen 24 (for Sanofi-aventis 3ml cartridges, EITHER 1-unit dosage adjustment (DA) or 2 unit DA) Autopen Classic (for Lilly and Wokhardt 3ml cartridges, EITHER 1 unit DA or 2 unit DA) (Owen Mumford) ClikSTAR (for Lantus, Apidra, Insuman 3ml cartridges 1-unit DA) (Sanofi Aventis) HumaPen Luxura (for humulin, humalog 3ml cartridges 1 unit DA) (Lilly) Huma Pen Luxura HD (for humulin, humalog 3ml cartridges 0.5ml DA) (Lilly) NovoPen (for penfill cartridges) NovoPen Junior (for 3ml cartridges 0.5unit DA) NovoPen 3 demi (for 3 ml cartridges 0.5unit DA) NovoPen 4 (for 3 ml cartridges 1unit DA) OptiClik (for Lantus optiClik or Apidra OptiClik cartridges) OptiPen Pro 1 (for insuman cartridges) How complex can it be? An example Insulin aspart is the generic name Novorapid is the trade name The presentations available of it are Novorapid 10ml vial Novorapid penfill Novorapid Flexpen Novorapid Flextouch (this is the new one) Other Devices Pharmacy supplies the following: Lancets – Unistik 3 comfort Contour blood glucose test strips Contour normal control solution (for daily calibration) Contour log record book (for calibration) Bayer blood glucose kit Insulin needles and syringes (for actrapid) Insulin passports If patients are using their own devices to measure blood glucose they MUST be clearly marked with patient name and date of arrival, NOT USED FOR ANY OTHER PATIENT, and sent home with the patient. Prescribing 1 • • • • • • • • Crosscheck with a number of sources to verify correct insulin and equipment (e.g. patient, carer, PODs, “insulin passport”, GP, BNF, diabetic nurse) Prescribe by TRADE NAME including device(s) Write UNITS in full, not U or IU and never in ml State time, and relation to meals, food, bedtime, and route Prescribe different preparations separately If to be self-administered, write this on the PMAC and the care plan If administered, state review date for self-administration Patients who have been using fast-acting insulins or insulin pumps MUST be able to self-administer – nurse administration would be unsafe. Look at temporary alternatives if they cannot Administration Encourage and support self-administration Use equipment/devices designed for insulin (not IV or oral dose syringes) Insulin is usually injected subcutaneously. Check route. Infusions are not used at NEPFT Check contact numbers for local diabetic team and pharmacy support Check carefully – right insulin, right dose strength and volume, right time in relation to meals/sleep If in doubt CHECK before administering, but do not just leave! Make sure the patient has an insulin passport, up to date and completed with the details. Supply one if not. The Insulin Passport Can be obtained from pharmacy if patient does not have one already Supply All wards should stock insulin needles and syringes, and glucogel Soluble insulin (actrapid) in fridges at each location for emergencies Insulins (usually with devices) must be prescribed and ordered specifically for individual patients, and used for discharge supply Patient’s own can be used on ward after checking Store in fridge on ward. Can be stored up to 1 month at room temperature, so write date when taking out of fridge for discharge or leave Other Common Errors Oral hypoglycaemics not prescribed at mealtimes (e.g. metformin, gliclazide) Hypoglycaemics prescribed at night Insulin prescribed PRN with little or no further information/detail Glucagon PRN with no further information Patient fasting or vomiting, insulin or hypoglycaemics not reviewed to take account of this Patient too unwell to self-administer, no revised/detailed care plan or prescription Monitoring Calibrate Contour kit at beginning of each day it is used Patients (NOT STAFF) may use their own blood glucose monitoring kits, but store separately and mark clearly Write frequency of monitoring in care plan What is a Normal Blood Sugar Level? Fasting plasma glucose (2 hours after a meal or 2 hours after 75g Glucose) 3.8 – 5.5 mmol/l Maximum 7.8 mmol/l Emergency Treatment of Low Blood Sugars See emergency protocol Sweet drink, biscuits if conscious Glucogel (protocol, does not need to be prescribed) Refer to doctor for review Continue to monitor until blood sugars are normal Look at diet, exercise, timings etc Refer to local diabetic service if necessary Emergency Treatment of High Blood Sugar Contact a Doctor ASAP Actrapid insulin prescribed at suitable dose (not usually more than 4 units for levels 10mmol and above) Be prepared to transfer the patient to acute care if blood sugars are very high Care plan for monitoring short-term after the event, and fluids Review and develop strategy with the patient/carer to avoid it happening again Contacts for Support Local diabetic team (write the number clearly on the PMAC) Consultant nurse for physical healthcare: 01206 228 692 Pharmacy 01245 315 500 or ward-based staff www.diabetes.nhs.uk British National Formulary www.bnf.org i-connect/policies/medicines management/ policies & Procedures/ tab17 high risk medicines and tab 18/ emergency medication Local Diabetic Teams Chelmsford 01245 516371 (switchboard 443673) Colchester 01206 742076 (switchboard 747474) Harlow 01279 698675 (switchboard 444455) Take-Home Message Insulin is complicated and potentially very dangerous Take care to prescribe correctly and with all the details Check carefully before administering or observing selfadministration – you are a professional too! Talk to your patient and/or carer – use their expertise You Have Now Finished the Learning Please click the ‘Test’ icon in the left column. You may need to maximise the column by clicking the top left icon. Remember to click the ‘Home’ icon when you finish the Test to save your results