Insulin administration - Yeovil District Hospital NHS Foundation Trust

PROTOCOL ON THE SAFE
ADMINISTRATION OF INSULIN IN
HOSPITAL
Version number 1 Version date: December 2010
Author Diabetes Nurse Specialist
First approval date 19 January 2011
Forum approved Diabetes Team Meeting (adult care)
Approved by Diabetes Team
Next review date January 2013

Contents
1. Purpose 2
2. Introduction 2
3. Prescribing of insulin 2
4. Administration of insulin 2
5. Self administering 3
6. Mixing insulin 3
7. Insulin delivery devices 3
8. Timing of insulin injections 4
9. Injection sites and injection technique 4
10. Storage of insulin 5
Annex A Substitutions if a patients usual insulin is unavailable 6
Appendix 1 Insulin delivery devices 7
1. Purpose
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1.1 The purpose of this protocol is to ensure that all insulin is administered safely and
in accordance with best practice guidelines.
2. Introduction
2.1 As a result of significant numbers of patient safety incidents involving insulin the
National Patient Safety Agency (NPSA) issued a Rapid Response Report in June
2010 regarding the safer administration of insulin (NPSA/2010./RRR013).
2.2 The two most common errors identified were:
the inappropriate use of non-insulin (IV) syringes, which were marked in ml
and not insulin units; and
the use of abbreviations such as “U” or “IU” for units.
2.3 This protocol aims to reduce the risk of harm to inpatients which may be caused by
the improper use of insulin.
2.4 A mandatory e-learning programme is also available to provide further training for
those involved in the prescribing, preparation and administering of insulin from:
www.diabetes.nhs.uk/safeuseofinsulin
3. Prescribing of insulin
3.1 The insulin prescription must be checked before each dose of insulin is given; it
must be dated and signed.
3.2 The name of each insulin must be written out in full, followed by the word “Insulin”
with the dose prescribed with the words “units” spelt in full and not abbreviated as
“U” or “IU”.
3.3 Any abbreviation is unacceptable as it may be interpreted as a zero, with the
consequence of an insulin overdose.
3.4 If a patients’ usual insulin is not available see Annex A for a suitable substitution
which may be used until the patients own insulin can be obtained.
4. Administration of insulin
4.1 The Yeovil District Hospital NHS Foundation Trust Medicines Management Policy,
available on the intranet, should be adhered to at all times with regard to the
administration of all medicines.
4.2 All patients with diabetes who usually administer their own insulin should be
enabled to continue doing so, if their condition permits this – see below.
5. Self administering
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5.1 The section on self medication within the Trust’s Medicines Management Policy
must be adhered to; this includes appropriate, documented assessment of the
patient for suitability for self medication. The patients ability to self medicate may
alter several times during one admission and this should be documented on the
assessment.
5.2 Any proposed changes made to patients’ insulin doses should be communicated to
the patient immediately.
5.3 Some patients may give variable doses of quick acting insulin and adjust doses of
longer acting insulin. The Insulin prescription chart should reflect this practice.
5.4 Illness and admission to hospital are stressful events and blood glucose levels may
rise as a result. Patients who are used to adjusting their own insulin doses should
be encouraged to continue to do so as necessary.
5.5 If patients are not mobile enough to access a ward sharps container they should be
provided with a 1 litre sharps container at the bedside, in order to minimise the risk
of sharps accident.
6. Mixing insulin
6.1 Many of the commonly used insulins are premixed e.g. Novo Mix 30. Some older
insulin regimens involve the mixing of two different insulins in a syringe prior to
administration. Soluble, or short acting insulins, such as Humulin S or Actrapid,
and rapid acting insulins, such as Humalog or NovoRapid, must only be mixed
with an isophane insulin, such as Humulin I or Insulatard.
6.2 Under no circumstances should soluble insulins be mixed with Levemir or
Lantus, or insulin zinc suspensions e.g. Hypurin Bovine Protamine Zinc.
6.3 Insulin suspensions (cloudy insulins) must be mixed thoroughly by gently rolling -
not vigorously as this will destroy the insulin molecule before drawing up. Contact
the Diabetes Department on ext 4517 should you need further advice before
mixing or giving insulins.
7. Insulin delivery devices
7.1 Subcutaneous insulin must be delivered via insulin syringes or with a commercial
Insulin pen. Under no circumstances must intravenous syringes be used to
measure and administer insulin doses.
7.2 The standard insulin syringe used by the Trust is the BD 0.5 ml insulin syringe with
an integrated 8mm needle. The ‘twin bin’ service will ensure that each clinical area
has a sufficient supply of insulin syringes. (These must be stored separately from
the 1ml IV syringes). Insulin pen needles can be obtained from pharmacy.
7.3 Commercial insulin pens are available on prescription for people with diabetes
using insulin therapy. If a patient starts insulin treatment whilst in hospital the
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Diabetes Specialist Nurses will supply appropriate pens (if using a disposable pen
these will be dispensed from pharmacy). If the patient is already using insulin pens,
they will need to bring their own into hospital.
7.4 A chart showing currently available insulin delivery devices can be found in
Appendix 2.
8. Timing of insulin injections
8.1 Refer to the chart below for specific timings for different insulins.
8.2 Levemir and Lantus insulins should be given within ½ an hour of the same time(s)
each day.
TIMING OF DIFFERENT TYPES OF INSULIN IN RELATION TO FOOD
To be given just before or
immediately after food
intake
Rapid acting insulin
analogue
NovoRapid
Humalog
Apidra
Mixed insulin using a rapid
acting insulin analogue
Humalog Mix25
Humalog Mix50
NovoMix 30
To be given 20 - 30
minutes before food
intake
Short acting soluble insulin
Actrapid
Humulin S
Hypurin Porcine Neutral
Mixed insulin using short
acting soluble insulin
Humulin M3
Hypurin Porcine 30/70 Mix
9. Injection sites and injection technique
Administration unrelated
to food intake
Medium acting insulin
Insulatard
Humulin I
Hypurin Porcine Isophane
Long acting insulin
Hypurin Bovine Protamine Zinc
Long acting insulin analogue
Lantus
Levemir
9.1 Insulin must be injected into the subcutaneous fat of the abdomen, thighs or
buttocks. These are the best sites for injection as they have a layer of fat to absorb
the insulin just under the skin.
9.2 Ideally, insulin should be injected into the same general area at the same time
each day. For example, an individual using a twice daily regimen of Novomix 30
may inject into the abdomen in the morning and the thighs before the evening
meal. If the patient is not self administering insulin, a record should be made of the
injection site used.
9.3 To avoid lipohypertrophy (fatty lumps at insulin injections sites), which cause
erratic insulin absorption, the same square inch of flesh should not be used again
for a week. If you suspect a patient has lipohypertrophy please ask the Diabetes
Nurse Specialist to review the patient as this may often be a cause of erratic
control.
9.4 Always inject at an angle of 90
using either an 8mm insulin syringe or the patients
own pen needles – the length of these may vary depending on patient size.
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9.5 Always ensure the injection is given into a “pinch up” skin fold (If the patient is
using 5 or 6mm needles this is not necessary).
9.6 A new syringe or pen needle must be used for each injection.
9.7 If using an insulin pen the needle should be removed after each injection.
10. Storage of insulin
10.1 For those patients who are self administering their insulin, the insulin and device
must be clearly labelled with the patient’s name and hospital number. On discharge
they should be taken home by the patient or returned to pharmacy.
10.2 Stock insulin must be stored in a locked refrigerator. Patients spare insulin
cartridges or disposable pens should be stored as above with the patients name
recorded on the box.
10.3 Disposable and reusable insulin pens in use must not be stored in the refrigerator.
10.4 Insulin may be kept for 28 days not above 25 C and away from direct heat and light.
The date from which it is first used should be noted, after 28 days it must be
discarded.
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Substitutions if a patients usual insulin is unavailable
Insulins within the same colour band are interchangeable. Please ensure on discharge that the patient has their usual insulin
with the correct pen.
Insulin Type Insulin Name
Rapid Analogue a) Humalog (Lispro)
b) NovoRapid (Aspart)
c) Apidra (Glulisine)
Short Soluble a) Humulin S
b) Actrapid
c) Insuman Rapid
Mixed Analogue
(rapid and
protamine
suspension)
Mixed Soluble &
Isophane
Intermediate
Isophane
Long-acting
Analogue
a) Humalog Mix 25
b) Novomix 30
c) non available
a) Humulin M3
b) Mixtard 30
c) Insuman Comb 25
a) Humulin I
b) Insulatard
c) Insuman basal
a) non available
b) Levemir (Detemir)
c) Lantus (Glargine)
Pharmaceutical
Company
a) Eli Lilly
b) Novo Nordisk
c) Aventis
a) Eli Lilly
b) Novo Nordisk
c) Aventis
a) Eli Lilly
b) Novo Nordisk
c) Aventis
a) Eli Lilly
b) Novo Nordisk
c) Aventis
a) Eli Lilly
b) Novo Nordisk
c) Aventis
a) Eli Lilly
b) Novo Nordisk
c) Aventis
Administration Action
Up to 15 mins before, during
or just after meals
Action onset 15 mins
Peak 2 hours
Duration up to 5 hours
15 - 30 mins prior to meals Action onset 30 - 60 mins
Peak 2 - 4 hours
Duration up to 8 hours
Up to 15 mins before, during
or just after breakfast and
evening meal
15 - 30 mins prior to
breakfast and evening meal
Early morning and/or late
evening
May be administered without
food
Usually – early morning or
late evening at a set time.
May be administered without
food
As rapid analogue and
protamine
suspension similar to action of
intermediate isophane
(mixed together)
As short soluble and
intermediate isophane
mixed together
Action onset 60 - 90 mins
Peak 4 - 12 hours
Duration up to 24 hours
Action onset 3 - 4 hours
Peak up to 14 hours
Duration up to 24 hours
If a patient is admitted on an insulin not listed above, please contact the Department of Diabetes on ext. 4517 for advice
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Appendix 2
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