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Adjustable Dosing Insulin Prescribing Chart

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Context

Insulin Prescription Charts in use were originally developed for fixed dose insulin regimens. Quality improvement work by the Paediatric Diabetes Team over the last 3 years resulted in 92% of our paediatric patients using variable dosing, i.e. each dose is calculated to match their carbohydrates plus a correction for any hyperglycaemia. The charts in use were no longer fit for this purpose.  There was also no scope for one off doses (e.g. for sick day management) or for insulin pump users. Insulin errors were a potential risk.

Aims

The aim was to develop a prescription chart which would enable all doctors to understand and safely prescribe variable dose insulin regimens to patients using both subcutaneous injections and insulin pumps. The chart should also include the ability to document management of hypoglycaemia. The record of insulin administered should enable an audit trail of how each dose was calculated, and of blood glucose levels - which would assist in longer term adjustment of prescriptions. Explanatory material should be included within the chart for both prescribers and administers of insulin. Overall aim is to prevent insulin errors.

Description

Explanatory material relating to potential different insulin regimens which are commonly prescribed is presented at the beginning of the chart for doctors not familiar with every method of giving insulin.  A full explanation of carbohydrate counting and calculating corrective insulin is included in this section.  Signposting information for management of hyperglycaemia in the unwell patient, and managment of DKA included as priority. Separate charts developed for: (A) Injected insulin - Multiple daily regimens / alternative injection regimens, (B) Insulin pump therapy, (C) Once only rapid acting insulin doses during sick day management and (D) Hypoglycaemia action.  Scope on charts A and B for recording adjustment of prescription during an in-patient stay without requiring a new chart. Blood glucose and insulin given record chart with sufficient space for a 1 week stay if required. All content in one booklet.

Implementation

The charts were developed using good practice examples from a number of sources. An initial draft version was piloted for a 2 month period.  Each completed chart was reviewed by the diabetes team and real time feedback given from prescribers. Adjustments were made, and an additional chart was included for once only insulin doses calculated for sick day management, as it was clear this would also be helpful. The 2nd pilot was completed in a shorter space of time using simulated cases before the final chart was agreed. An interactive teaching package was used at the point of introduction.

Suggestions for further implementation

The teaching package is to be repeated regularly for rotating and new staff. We are planning to make a laminated 10 minute teaching booklet which staff can use to familiarise themselves with the tool outside of formal teaching sessions.

Challenges and learning

Time to focus on development was a challenge and led to some delays in moving the project forwards. The (necessary) complexity of the chart was a potential barrier to use and the intention is to overcome this with regular teaching and support of juniors/ nursing staff. A useful learning point was that in the second version we chose to limit any potential for variation from best practice, for example pre-writing 'units' wherever possible. The diabetes nursing team, trust pharmacists, and management teams were supportive in terms of ensuring the charts met requirements of all teams and achieved trust safety standards.

Quality assurance/MHRA registration

Approved by local Trust MRAG committee. Pilot of draft forms ironed out technical issues and potential areas of confusion. The tool would be applicable to other hospitals and potentially to the adult service in this trust. The tool will need to be updated by our local team if there are future substantial changes to our insulin adjustment advice to patients.