CP04 Insulin and Blood Glucose - Devon Partnership NHS Trust

Prescribing and Administrating Insulin
and
Monitoring Blood Glucose Levels
Clinical Protocol CP04
Protocol Summary
The prescribing of all medicines on inpatient units should be recorded on the Trust
Prescription and Administration chart. Additional specialist charts are to be used for
high risk medication with variable dosing. This protocol provides guidance on how to
complete the Diabetes Chart (F11) that must be used for the prescribing and
administering of insulin and for monitoring blood glucose.
CP04 Prescribing and Administering Insulin and Monitoring Blood Glucose
Approved by Drug and Therapeutics Committee: April 2014
Review Date: April 2016
1 of 9

Document Control
Version Date Issued Author Name / Job Title / Email
1.0 March 2010
2.0 November 2010 Deborah Marriott (Network Lead Clinical Pharmacist)
3.0 September 2012 deborah.marriott@nhs.net
4.0 February 2013
5.0 April 2014 Rosalind Gittins (Lead Clinical Pharmacist (Specialist Services))
rgittins1@nhs.net
Target audience/ staff groups: Clinical staff - all in-patient staff responsible for the prescribing and
administration of insulin and the monitoring of blood glucose
Ratifying Group:
Drug and Therapeutics Committee
Date ratified: April 2014
Implementation date: May 2014
Review date: April 2016
Document History
Version Start date End date Author History
1.0 March 2010 DM First version of Protocol signed off
1.1 June 2010 October 2010 DM Protocol updated in response to NPSA Rapid Response Report
‘Safer Administration of Insulin’.
1.1 October 2010 October 2010 DM Working group set up (invites sent out through Heads of Services
and Clinical Leads for each Directorate)
1.2 November
2010
November
2010
DM
Received comments from C Dixon, V Ford, Debbie Ashton
(MMLP) and RLS. Concluded that more space needed on form
for time and date.
1.2 November
2010
November
2010
DM Included information received from Richard Beaumont (Pathology
Lead for Blood Glucose Monitoring at RD+E
2.0 November
2010
November
2010
DM Document ratified at Medicines Governance Group on 18 th
November 2010
2.1 July 2012 July 2012 DM Updated to include Insulin Passport, reference to Rio, and
comments received regarding last version of the document.
3.0 Sept 2012 KS Document signed off
3.1 Oct12 DM References to use of glucagon removed
4.0 Feb 2013 KS Document signed off
4.1 Feb-14 RG Changes made to SOP and form F11 due to new insulin injection
devices being used.
4.1 May14 DM Checked HBA1C levels to national guidance
5.0 May14 KS Document ratified at DTC and signed off.
Document Working Group
VERSION 4.0 Adult services Older People’s
Services
Directorates
Medicines Management
Other
Specialist
Services inc LD
Secure Services
All Pharmacists and Technicians
Marie Dougal-Johnson Diabetes Specialist Nurse at RD&E , Sam Rosindale Diabetes
Lead Champion Torbay Care Trust, Gayle Richards Lead Diabetes Specialist Nurse,
NDDH- contacted but no response received
CP04 Prescribing and Administering Insulin and Monitoring Blood Glucose
Approved by Drug and Therapeutics Committee: April 2014
Review Date: April 2016
2 of 9

Prescribing and Administering Insulin and Monitoring Blood Glucose
1. Scope, general responsibilities and training requirements
This protocol applies to all staff who are responsible for ordering, storing, handling, prescribing or
administering Insulin. It also applies to staff who monitor blood glucose levels.
Between November 2003 and November 2009, over 16,000 incidents involving insulin were reported
to the National Patient Safety Agency (NPSA), resulting in several deaths and serious harm. An alert
was issued in 2010 that directed that all Healthcare Professionals (HCPs) involved in prescribing,
dispensing or administering insulin should complete the NHS Diabetes e-learning package (see
Online course programme).
In 2011, the NPSA published another alert with the following standards to be implemented in all
health organisations by 31 st August 2012:
1. Adult patients on insulin therapy receive a patient information booklet and an Insulin Passport
to help provide accurate identification of their current insulin products and provide essential
information across healthcare sectors.
2. Healthcare professionals and patients are informed how the Insulin Passport and associated
patient information can be used to improve safety.
3. When an Insulin is prescribed, dispensed or administered, healthcare professionals crossreference
available information to confirm the correct identity of insulin products.
4. Systems are in place to enable hospital inpatients to self-administer insulin where feasible.
The Diabetes National Service Framework (Standard 8) aims to ensure that good quality care
is provided for people with diabetes whenever they are admitted to hospital. It emphasises
that patients should continue to be involved in decisions concerning the management of their
diabetes wherever possible
Contact your local diabetes specialist centre or the prescriber if you are unfamiliar with any
aspect of a person’s diabetes care.
North Devon District Hospital
01271 322726 (349105 if urgent)
Royal Devon & Exeter NHS Foundation Trust 01392 411611 & ask for Specialist
Diabetes Nurse
South Devon Healthcare NHS Foundation Trust 01803 655028
2. Prescribing of Insulin
2.1 Insulin therapy must only be initiated under the direction of specialist diabetes teams.
2.2 When continuing an established prescription, prescribers must satisfy themselves that the
insulin they are prescribing is the correct type and dose. They must also confirm the blood
glucose monitoring requirements and target values with the person or their relative/carer (see
SOP MM25 Medicines Reconciliation).
2.3 People should be encouraged to bring their medicines, their Insulin Passport and their
information booklet into hospital with them on admission.
CP04 Prescribing and Administering Insulin and Monitoring Blood Glucose
Approved by Drug and Therapeutics Committee: April 2014
Review Date: April 2016
3 of 9

Most people will have received their passport / insulin safety card and the patient
information leaflet from either their diabetes specialist nurse or GP. However, Trust
prescribers must check that the person has received this information and provide a
replacement if necessary.
The Medicines Management Team will provide the wards with passports
Information leaflets can be printed from here (or contact Medicines Management
for a copy)
Ensure that you record the check and provision of a leaflet or passport on Rio.
2.4 All Insulins must be prescribed on form F11 Diabetes Chart (see Appendix 1). Care must be
taken to ensure that the insulin type is fully documented including:
Full brand name (e.g. Humulin M3 not just Humulin; Humalog Mix 50 not just Humalog
Mix)
Insulin species where applicable (e.g. human / bovine / porcine)
Device (e.g. vial / cartridge / disposable pen)
Dose (do NOT use the abbreviations IU or U for Units as this is a well documented source
of dosage errors with the I being mistaken for the number one and U for a zero).
A Guide to Insulin Preparations is available from MIMS:
http://www.mims.co.uk/Tables/1096962/Insulin-Preparations/DCMP=ILC-SEARCH
2.5 The Diabetes Chart should be referenced on the front of the Prescription and Administration
Chart in the additional chart section. The Insulin should also be listed in the regular medicines
section of the Prescription and Administration Chart but no dosage instructions should be
provided and the instruction “See Diabetes Chart” should be written in the additional
information (i.e. all dosage and administration records should only be made on the Diabetes
chart).
2.6 Non-insulin injectable products for the management of diabetes must be written on the
inpatient prescription and administration record and not on the insulin chart.
2.7 If someone is admitted with a prescription for an insulin that isn’t included in the local
formulary (click here to access the Devon formularies) every effort should be made to
continue with this product during the inpatient stay. This can be achieved by using the
person’s own supply (providing it has been stored as specified), by requesting a supply via
FP10, or by the acute trust pharmacy making a special order. Contact your acute trust
pharmacy and diabetes specialist centre for advice on an individual basis.
2.8 Some people may be prescribed an insulin dose range rather than a specific dose and they
may be used to adjusting their insulin dose in response to their blood glucose results. Confirm
the person’s’ treatment regime with the GP or specialist diabetes service and document in Rio
notes and on the Diabetes Chart.
2.9 Once the Diabetes chart is complete or the person is discharged then it must be scanned into
the clinical documentation section on Rio.
2.10 Contact your local diabetes specialist centre if you are unfamiliar with any aspect of a person’s
diabetes care.
CP04 Prescribing and Administering Insulin and Monitoring Blood Glucose
Approved by Drug and Therapeutics Committee: April 2014
Review Date: April 2016
4 of 9

3. Glucose Monitoring
3.1. Blood glucose levels are assessed by measuring either glucose or glycosylated haemoglobin
A1c (HbA1c). Blood glucose results provide a snap shot specific to the moment of the test
whereas HBA1c results reflect blood glucose control over the previous 2 to 3 months.
3.2. Urine testing is occasionally used but it does not give information regarding hypoglycaemia
and is unsuitable for use by people who use insulin to control their diabetes.
3.3 Glycosylated Haemoglobin Targets (HbA1c)
When a person with diabetes is admitted to an inpatient unit, the prescriber should check
the following with their GP and record the details in Rio.
Date of the last HbA1c test
Result of the last HbA1c test
HbA1c target for this individual.
3.4 There are three target levels for HbA1c in GPs Quality and Outcomes Framework (QOF); 59,
64 and 75 mmol/mol. The three targets are provided as an incentive to improve glycaemic
control across the distribution of HbA1c values. The lower level may not be achievable or
appropriate for all patients.
3.5 HbA1c should be monitored at 2 to 6 monthly intervals until the level is stable and then at 6
monthly intervals. Blood samples need to be sent to pathology lab for analysis. Results
should be recorded in Rio notes.
3.6 Blood Glucose Targets
Blood glucose monitoring is appropriate for people with:
type 1 or 2 diabetics who use insulin
type 2 diabetics who are taking a sulphonylurea and who are at a greater risk of
hypoglycaemia
type 1 or 2 diabetics when the person has an intercurrent illness including infection, stress,
or trauma that could affect insulin or oral hypoglycaemic drug requirements
type 1 or 2 diabetics when introducing medication that may affect diabetes control (e.g.
addition of an antipsychotic)
3.7 Blood-glucose concentrations vary substantially throughout the day. The usual target is to
maintain a concentration of 4 to 7 mmol/l before meals and less than 9mmol/l after meals.
3.7 Blood glucose targets should be documented by the prescriber on the Diabetes Chart with
actions to be taken if results are outside of the acceptable range.
3.8 For the Management of Hypoglycaemia in Adults with Diabetes Mellitus, see Clinical Protocol
CP21 (available on the Trust website – For Professionals and Prescriber section)
3.9 There are no national guidelines for the frequency of glucose testing. The optimum testing
regime will depend on the diabetes treatment, the degree of glycaemic control desired and the
preferences of each individual.
CP04 Prescribing and Administering Insulin and Monitoring Blood Glucose
Approved by Drug and Therapeutics Committee: April 2014
Review Date: April 2016
5 of 9

3.10 The testing frequency required, and any stipulations (e.g. before meals), should be
documented on the Diabetes Chart.
3.11 Using Blood Glucose Meters
All staff who use blood glucose monitoring equipment should receive local training from the
pathology lab or their local trainer. This should be documented in their local training record
and on ESR where possible.
3.12 Equipment should be maintained and quality control checks performed as directed by the
pathology lab.
3.13 Each blood glucose meter has its own specific testing strips. Some of these testing strips
have limited stability once the container has been opened. Always check the container for
expiry information and record the date that it was opened on the container.
3.14 If the meter is the ward meter, the testing strips will be available through the acute trust
pharmacy. If the meter belongs to an individual, the strips may not be available through the
Trust and the patient’s own supply (or FP10 prescription) may be needed.
3.15 Blood glucose results must be recorded on the Diabetes Chart and in Rio (Core Assessment,
Physical Monitoring, Blood Glucose Monitoring). The comments section should be used to
indicate any decisions/actions made in response to these results or any other factors that may
affect blood glucose results.
4. Administering Insulin / Supervising Insulin administration
4.1 Any individual prescribed insulin, or requiring blood glucose monitoring, must have a care plan
covering these actions documented in Rio.
4.2 If the individual prefers to retain responsibility for certain aspects of their diabetes care,
including self-administration of insulin, then this should be documented using the
administration agreement on the Diabetes Chart.
4.3 For self-administration of insulin the individual should use the needle device that they are
familiar with. The BD Duo Autoshield® safety insulin needle MUST be used if staff are
administering the insulin or changing needle (a video showing how to use this device is
available on the Medicines Management pages of the Trust intranet – Support for Nurses
section)
4.4 When receiving Insulin on to the ward the nurse must check the individual storage instructions
for each Insulin. Usual instructions for storage are:
Storage before opening, 2-8ºC (in the fridge)
Storage after opening, room temperature for up to 28 days (storage in a fridge after
opening can cause increased pain at the injection site and affect the release
characteristics in the body). Ensure that a label detailing the date of opening is
attached to the device on opening.
CP04 Prescribing and Administering Insulin and Monitoring Blood Glucose
Approved by Drug and Therapeutics Committee: April 2014
Review Date: April 2016
6 of 9

4.5 Nurses must be familiar with the insulin device that is to be used and the licensed sites of
administrations (see www.medicines.org.uk/emc/). Contact your specialist diabetes centre for
guidance if required.
4.6 Nurses administering, or observing the self-administration of insulin, must satisfy themselves
that the dose of insulin prescribed is reasonable. They must check the insulin product and
dose with the individual whenever the individual has the capacity to do so.
4.7 All insulin doses must be measured and administered using a single use insulin syringe or a
commercial insulin device. Intravenous syringes must NEVER be used for insulin
administration.
4.8 If insulin is administered using a pen or device, the needle must be removed after each
administration. People who are self-administering should be observed to place the needle
securely into a sharps bin. The Autoshield safety needle must also be placed securely into a
sharps bin.
4.9 Once the Diabetes Chart is complete or the person is discharged then it must be scanned into
the clinical documentation section on Rio.
CP04 Prescribing and Administering Insulin and Monitoring Blood Glucose
Approved by Drug and Therapeutics Committee: April 2014
Review Date: April 2016
7 of 9

Appendix 1
DIABETES CHART
For the Prescribing, Administration and Monitoring of Insulin
Name NHS No Date of Birth
Ward Consultant Sex M / F
PRESCRIBED INSULIN TREATMENT REGIME
Insulin Insulin Dose/Dose Range (units)* Doctor
Full Product Name Device B’fast Lunch Dinner Bed signature
Date
Pharm
signature
A
B
C
*state number only, do not use abbreviations U or IU
PLEASE ENSURE THAT MONITORING REQUIREMENTS ARE COMPLETED OVERLEAF AT TIME OF
PRESCRIBING
Date of
test
RECORD OF BLOOD GLUCOSE (BG) RESULTS
Time
of test
BG
result
Mmol/l
Staff
Initials
Response / Comments
(eg: Hypoglycaemic
Events, UTI, post meal)
RECORD OF INSULIN ADMINISTRATION
Date
of
admin
Time
of
admin
Insulin
A/B/C
Actual
Dose
Units
Nurses
Initials
THIS FORM (ID F11) IS INCLUDED IN THIS CLINICAL PROTOCOL FOR
INFORMATION ONLY
TO OBTAIN A COPY OF THIS FORM PLEASE CONTACT MEDICINES
MANAGEMENT ON 01392 675674 OR EMAIL
Dpn-tr.pharmacyteam@nhs.net
CP04 Prescribing and Administering Insulin and Monitoring Blood Glucose
Approved by Drug and Therapeutics Committee: April 2014
Review Date: April 2016
8 of 9

Name NHS No Date of Birth
Ward Consultant Sex M / F
BLOOD GLUCOSE MONITORING REQUIREMENTS
Date
Frequency of
testing
Time in relation to meals,
doses, and other instructions
Meter and strips
(Ward/Patient Own)
Doctor
Signature
Pharm
Signature
ACTIONS TO BE TAKEN BY NURSING STAFF IN RESPONSE TO THE FOLLOWING OBSERVATIONS
Observation Required Response to Observation Doctor Signature
Blood
level >9
Blood
level