User Guide to National Insulin Subcutaneous Order and Blood
Contents
1. Food choices are determined from the standard options available at the site Sites are encouraged to ensure that the chosen food choices are in a central location in each ward unit and outpatient facility Each ward unit and outpatient facility should have access to intravenous glucose 50 and glucagon 1mg injection to use in emergency situations Glucose based products are preferred as initial treatment Diet low kilojoule products must not be used to treat hypoglycaemia User Guide to National Insulin Subcutaneous Order and Blood Glucose Record Adult 21 Hypoglycaemia Management in Diabetes BGL Less than 4mmol L Is patient conscious and cooperative If on insulin infusion stop insulin infusion continue glucose infusion AND Position patient on side and maintain airway AND Call a code blue Medical Emergency AND Never give anything orally to a patient who is unconscious or drowsy If no IV access administer OR administer 30mL 50 Img glucose as glucagon IM 1 slow IV push dose only If IV access RN doctor to Stay with patient until they regain consciousness Recheck BGL after 5 mins if still unconscious or after 15 mins if conscious No BGL greater than 47 Yes If unconscious and BGL greater than 4 manage decreased level of consciousness If patient conscious follow up with appropriate oral or IV treatment User Guide to National Insulin Subcutaneous Ord2. agent If not eating normally or markedly labile BGLs consider insulin infusion Are alterations to insulin regimen or initiation of insulin required Consider a Is it likely that insulin will be continued after discharge If not is it necessary to start it currently b What was the pre morbid BGL control like What is current HbA1c c Does the patient want long term insulin treatment If so what is their preferred regimen d Was hyperglycaemia secondary to treated hypoglycaemia Previously taking routine insulin No Consider initiation of basal bolus insulin therapy Suggested starting doses Basal dose units weight kg divided by 4 Mealtime units Currently on basal and mealtime insulin Consider Suggested starting doses are Conversion to Basal units basal bolus total daily dose divided by 2 insulin Mealtime units total daily dose divided by 6 Hyperglycaemia within 4 hours of meal No Increase Increase that basal dose by mealtime 20 dose for the following day by 10 a 4 amp 6 4 4 4 4 4 4 4 4 E 4 weight kg divided by 12 Adjust doses of current insulin regimen If adjusting current insulin regimen increase corresponding dose the following day by 1096 Additional considerations Consider supplemental rapid short acting insulin Table 1 f previously on insulin dose according to total daily dose f not dose according to weig
3. is prescribed for a patient with diabetes this form should be used for BGL monitoring as the alerts and notification prompts will also apply to patients not receiving insulin 6 1 Routine insulin orders There are six spaces to prescribe routine insulin in this section Meal times are pre printed to ensure insulin is given immediately before a patient eats All mealtime insulin doses including those with 15 30 minute delay in onset of action are to be given immediately before the patient eats when their meal is in front of them Rationale In the hospital setting meal delivery times are variable and if delayed after insulin has been administered hypoglycaemia may result Prescribing spaces There are four prescribing spaces with the following Mea time pre printed o Breakfast o Lunch o Dinner oO Pre Bed e Two prescribing spaces without the pre printed Meal time one at the top and one at the bottom of the Routine Insulin Orders section The additional prescribing spaces are to be used when a patient has an additional insulin injection prescribed at a single meal time For example if a patient receives both their basal insulin and their mealtime insulin at breakfast Routine Insulin Orders must be ordered for each day Date 14 7 Mealtime insulin is given at start of meal 10 7 11 7 12 7 13 7 units units units units units z um e e ope es Signature name Meal time Name of insulin i i 8 88 8 Breakfast ealtime insuli
4. orders Document the administration of phone order insulin in the Administration Hecord as outlined previously Also cross reference the order by writing phone in the dose box in the Routine Insulin Orders The phone order must be signed by the authorised prescriber or otherwise confirmed in writing according to facility procedure 7 4 Documenting administration of stat orders If the Medical Officer attends the ward and prescribes a single dose in the Stat Phone Insulin Orders then he she must verbally inform the RN responsible for the patient s care Prepare and administer the insulin and document the administration in the Administration Record as outlined previously User Guide to National Insulin Subcutaneous Order and Blood Glucose Record Adult 15 7 5 Examples 7 5 1 Routine insulin The patient is prescribed 8 units of rapid acting insulin as a routine insulin dose for breakfast on 11 7 12 The BGL is 12mmol L Eight 8 units of insulin are ordered in the Routine Insulin Orders There are no supplemental or stat phone insulin orders so the dose to be administered remains 8 units of routine rapid acting insulin The time of administration 0730 is documented in the Time given row 8 units of rapid acting insulin is administered and documented as 8 the total dose administered in the relevant row of the Administration Record The nurses should initial to document the administration as outlined above Nurses mu
5. patient provide basic and advanced life support 3 If on insulin and eating normally do not withhold if required subsequent mealtime or basal insulin after treating 2 Review diabetes management for causes of hypoglycaemia hypoglycaemia and correct avoidable causes a If reduced oral intake consider reducing mealtime insulin a If the cause is identified and corrected e g missed dose s delayed or reduced intake insulin dose adjustment is 4 If on a sulphonylurea obtain specialist advice on not required unless hypoglycaemia recurs management as hypoglycaemia can be recurrent or If the cause is not identified or cannot be corrected prolonged and a Monitor BGL hourly for 4 hours then 4 hourly for 24 i hypoglycaemia has occurred within 4 hours after hours after last hypoglycaemic episode mealtime insulin reduce the dose of that mealtime If recurrent hypoglycaemia commence IV glucose insulin by 20 the following day titrating rate to BGL greater than 4 mmol L li If hypoglycaemia has occurred outside 4 hours after c Withhold oral hypoglycaemic treatment until recovered mealtime insulin reduce basal insulin dose by 20 and review whether further therapy is required 11 Pharmacy review It has been clearly demonstrated that inpatients benefit from a clinical pharmacist review of their medication regimen Associated activities such as liaison with medical and nursing staff clarification of orders supply and administratio
6. prompt Name of routine insulin The 4 units of supplemental rapid acting insulin are documented in the Administration Record against the row with the Name of supplemental insulin prompt O 12 77 12 m 1 Mrs ka y AMME J8 units units units units Prepared and administered as a single dose of 12 units units units units units units units but documented as i Routine Insulin and units units units units o7api24s R152140 Supplemental insulin AASA APA doses pf NN units units Junits units units units Routine Insulin Orders must be ordered for each day Supplemental Insulin Orders valid until changed or ceased Contact doctor if expected dose not ordered Sliding scale insuNn alone is NOT recommended consider basal insulin needs E Date 40 7 11 7 12 7 13 7 14 7 8 MI insulin is given at start of meal Remember Adjust Xoutine insulin based on supplemental insulin requirements e p a ah aa as DE RE units units units units ess vum ee a sid Name of insulin Usually the same Signature FL Lu as the routine short acting insulin Meal time Name of ane With meals only upplemental insulin name Breakfast ealtime insulin name CAAA ee Deren Supp ESSE lumessummont s SiwoNDS JS Signature James Simmonds Abd IMMOND same insulin as mealtime insulin am IS FAESEX os are SCY YS cases sce Meal time Name of insulin M SCR UN hone is NOT necessary to pr
7. routine J Fay short acting insulin they may be given a E TT together but must be recorded separately ommen wey The nurse also cross references the phone order in the Routine Insulin Orders so that clinicians are aware a phone order has been taken Routine Insulin Orders must be ordered for each day Contact doctor if expected dose not ordered Date 14 7 mdi insulin is given at start of meal 10 7 11 7 12 7 1 Mill RR E E E E ER UE Signature name Breartast Meoltime insulin name N Sad Suu Bas Sus Breakfast ealtime name E E imona AI ar Signature James Simmonds name IMMOND pas JS JS 2G PAGS Lunch Mealtime aaia name 8 Prescriber Print your N Sendus James Simmonds n EPNER S Dinner pa rn ae Dinner Heal insulin name halin name ais d mer i isl ae Signature James Simmonds name rama SIMMONDS JS IJS MG IS PreBed Basal insulin name 244 24 24 28 Pre Bed Basal jails name units units units ppm Prescriber Print your ISa JS MG Signature James Simmonds name SIM MONDS IS JS MG ma m SU aito e units Prescriber Print your Signature name User Guide to National Insulin Subcutaneous Order and Blood Glucose Record Adult 18 This area below the Administration Record is for documenting communication between members of the team caring for the patient regarding insulin therapy and diabetes management Examples of what can be documented here are that o the doctor h
8. 13 7 14 7 Mealtime insulin is given at start of meal o pue d at an units units units units units Signature name Meal time Name of insulin IV Breakfast ealtime insulin name jS M C ORO Prescriber Print your Signature James Simmonds name IMMOND PAE Ea Lunch ___ Mealtime insulin name V Saul Sul SnuP n Lunch Mealtime ail name A asi Prescriber Print your F SB 3 MG Signature James Simmonds tame STMMONDS PAS BE 45 1 MG 6 4 Administration record When prescribing insulin the prescriber should write the full trade name in the Aaministration Record where the rows prompt Name of routine insulin and Name of supplemental insulin f the prescriber has not written the insulin trade name and the patient requires an insulin dose the RN or pharmacist may write the full trade name in these rows Administration Record Name of routine insulin oe Mealtime insulin name untel unis unite 24 Name of routine insulin Basal insulin name aa ul md Name of routine insulin dala units units units Name of supplemental insulin Supplemental insulin name s unite User Guide to National Insulin Subcutaneous Order and Blood Glucose Record Adult 13 7 Documentation of insulin administration See examples of documenting insulin administration throughout this section Administration of all insulin doses is documented in the Administration Record Prepare and administer insulin acc
9. AUSTRALIAN COMMISSION oN SAFETY ano QUALITY in HEALTH CARE TRIM 64694 User Guide to National Insulin Subcutaneous Order and Blood Glucose Record Adult Commonwealth of Australia 2012 This work is copyright It may be reproduced in whole or in part for study or training purposes subject to the inclusion of an acknowledgement of the source Requests and inquiries concerning reproduction and rights for purposes other than those indicated above requires the written permission of the Australian Commission on Safety and Quality in Health Care GPO Box 5480 Sydney NSW 2001 or mail safetyandquality gov au Suggested citation Australian Commission on Safety and Quality in Health Care 2012 User Guide to National Insulin Subcutaneous Order and Blood Glucose Record Adult ACSQHC Sydney Acknowledgment This work was developed by Medication Services Queensland of Queensland Health and is based on the user guide developed to support the State Insulin Subcutaneous Order and Blood Glucose Record for adults This document is available on the Commission web site at www safetyandquality gov au User Guide to National Insulin Subcutaneous Order and Blood Glucose Record Adult 2 Table of contents O esn OOOO Pa EE 4 ERI n 3 Identification and demographics BRUIT RN E jszMwphldemgahs 5 a Cross reference with National Inpatient Medication Chart IMG 6 4 Monitoring notification instructions fareetieweny 0000000000 8 42M
10. National Insulin Subcutaneous Order and Blood Glucose Record Adult 7 Monitoring Record 10 7 12 11 7 12 Change BGLto Standarda 2hrs post meal Standard 2hrs post meal tick all that apply At 02 00am L At 02 00am 7 Other Ful BGL mmotL Write i ied rge k 00 00 30 oo 15 45 00 15 Note The example above uses 24 hour time in the Time spaces e Perform a BGL according to facility procedure e Write the BGL in the coloured row corresponding with the relevant range printed to the left and right of the Monitoring Record Note any instructions in the ALERTS section that aligns with that range If the BGL is less than 4mmol L initiate hypoglycaemia management as per Hypoglycaemia Management in Diabetes BGL less than 4mmol L which is printed on page 4 and notify the treating prescriber or doctor on call Then o Tick the Hypo Intervention box after initiating hypoglycaemia treatment and ensuring patient safety o Perform follow up BGLs according to Hypoglycaemia Management in Diabetes BGL less than 4mmol L which is printed on page 4 and respond accordingly see section 10 o Document the hypoglycaemia treatment and response in the medical record If the BGL is in a high alert range i e greater than 20mmol L or the second consecutive BGL greater than 16mmol L or the third consecutive BGL greater than 12mmol L o Notify the treating prescriber or doctor on call o Perform a urine or blood
11. a routine mealtime or basal insulin dose It may be required if the o Patient s condition dietary intake or a concurrent medication is altering their insulin requirements o Patient has recently commenced subcutaneous insulin and optimal doses have not yet been determined Example Prescription for supplemental doses to be administered with meals Supplemental Insulin Orders valid until changed or ceased Sliding scale insulin alone is NOT recommended consider basal insulin needs Remember Adjust routine insulin based on supplemental insulin requirements If unsure seek advice Frequency Name of insulin Usually the same as the routine short acting insulin lV With meals onl Y Supplemental insulin name Lle hourly same insulin as mealtime insulin L Other GDOGIE Lat It is NOT necessary to prescribe supplemental insulin for all patients Start date ELI If the BGL mmol L is wwWe l3d d tt units rh administer MERRER units non Eee el Prescriber Signature Print your name IS James Simmonds SIMMONDS then Tick the Frequency the supplemental insulin dose is to be administered o With meals only if the patient is tolerating an oral diet o 6 hourly if the patient is receiving continuous parenteral nutrition or tube feeding o Other specify in specific circumstances and specify when it would be required Write the Name of Insulin to be administered in the space provided Usually if the pati
12. and document the date the order was changed then initial Note the acronym D C discontinued should not be used for ceased orders since this can be confused with discharge Always use cease When the insulin regimen is being changed not a dose change which can be facilitated on the chart the prescriber must not overwrite the order The original order must be ceased and a new order written on a new subcutaneous insulin form User Guide to National Insulin Subcutaneous Order and Blood Glucose Record Adult 10 Example Ceased Routine Insulin Orders Routine Insulin Orders must be ordered for each day Contact doctor if expected dose not ordered Date Mealtime insulin is given at start of meal Prescriber Print your Sig nature name Bre e Breakfast Mealtime insulin name Gil ud Coss Presct riber Name of insulin 9 phone Mealtime insulin name ri miu EA Sgrere James Simmondslrane SIMMONDS a UTOR ZI KE sjel Ceased Cha Medline incilin name A S A units uum James Simmonds ama STMMO AAN imixedzmsulin prior to pali AMENE TE new M am onds none SIMffONDS JS operis I Simmonds si 7 Tw mpm units Prescriber Print your Signature name 6 2 Supplemental insulin orders It is not necessary for all patients to have supplemental insulin prescribed It might be considered where glycaemic control has been erratic and strict control is desirable Supplemental insulin may be in addition to
13. as been notified of the BGL o ahypoglycaemic event has been treated o the patient has been changed to intravenous insulin imei rn Hypo treated per protocol Fo Call Dr for Starting routine insulin review Skipned breakfast lunch dose The Guidelines for Managing Hyperglycaemic Alerts on page 1 have been included to assist inexperienced and non frequent prescribers and other clinicians They are not designed to decrease autonomy or specialist input If there are any clinical concerns senior medical officer advice should be obtained The guidelines provide information related to assessment required when called for a Hyperglycaemia Alert Q initiation of basal and mealtime insulin and adjustment of insulin doses suggested stat and supplemental doses based on weight or previous total daily dose Queensland Tom Jones Hospital M Government JOHNSON 223344 IAN M 21 04 1958 Insulin Subcutaneous oo Order and Blood Glucose nc candies six 4444 Record Adult enim 0412 345 e78 MAMMA AMI MC 123456789 IBD 3 Exp 12 2013 Guidelines for Managing Hyperglycaemia Alerts 1 Hydration and dietary status is hyperglycaemia easily explained by dietary indiscretion Ketones if ketone test is positive consider diabetic ketoacidosis DKA Seek expert advice Concurrent medications if on oral corticosteroids or Total Parenteral Nutrition TPN seek expert advice Missed doses of insulin or oral hypoglycaemic
14. be utilised for all inpatients requiring subcutaneous insulin and or BGL monitoring unless ward unit procedures state otherwise e A different insulin chart is required for the prescribing administration and monitoring of intravenous insulin 2 General instructions e All entries are to be written legibly in ink No matter how accurate or complete an order it may be misinterpreted if it cannot be read clearly e Water soluble ink e g fountain pen should not be used e Black ink is preferred e A medication order is valid only if the authorised prescriber enters all the required items e All information should be printed e No erasers or whiteout should be used e The form allows orders to be updated daily for 5 days after which time the order must be rewritten on a new form The patient s current hospital and ward location should be clearly marked on the nsulin Subcutaneous Order and Blood Glucose Record Adult See Section 3 2 User Guide to National Insulin Subcutaneous Order and Blood Glucose Record Adult 4 3 Identification and demographics 3 1 Patient identification Patient identification ID on the nsulin Subcutaneous Order and Blood Glucose Record Adult is consistent with the identification required when using the National Inpatient Medication Chart NIMC A watermark has been included in the patient identification sections on pages 1 and 2 as a reminder that a prescription is not valid unless
15. d BGLs Immediately after prescribing insulin the prescriber should write the full trade name of the insulin to be administered in the row s in the Administration Record section with the prompt Name of routine insulin Trade names are preferred in insulin prescribing to avoid confusion as discussed in Section 6 1 Example Houtine Insulin Orders Routine Insulin Orders must be ordered for each day Contact doctor if expected dose not ordered Date 10 7 11 7 12 7 13 7 14 7 Meaning insulin is given at start of meal m pem eee name Breakfast ealtime aiii name um 8 8 8 Prescriber your Signature James Simmonds name IMMOND ANT 2s JS ce nse aL he L Lunch Mealtime kai name vA units 8 units units in x ALS as we ET ames Simmonds 5 StMMONDS ZA 25 45 ME Dinner Mealtime insulin name wits men toss Cun aas Prescriber nt yo Signature a James Simmonds ne SIMMONDS Scale Se ee Name of insulin Borla nane L 24 28 28 a Basal insulin name mul eid uude Ciis idis ESSE James Simmonds cs amp TuMONDS S 15 MG Signature James Simmonds name SIMMONDS 255 units units units units units Prescriber Print your Signature name If routine insulin is ceased the original order must not be obliterated The prescriber must draw a clear line through the order taking care that the line does not obliterate other orders The prescriber must write the reason for changing the order e g cease change to insulin regimen
16. e diabetes to have their insulin dose withheld completely Siren ESUOR NOD Nurses must write the dose given time ebenso given and initials Mealtime oa S name units If for any reason insulin cannot be Name of routine insulin administered as ordered notify Basal insulin name doctor enter code W for withheld and Name of routine insulin document in clinical record Name of supplemental insulin Supplemental insulin name If supplemental short acting insulin is Time given ordered for the same time as routine short acting insulin they may be given Nurse 1 2 initials together but must be recorded separately Reviewed at1730 Comments Starting routine insulin 7 1 Administration of a routine insulin dose After taking and recording a BGL check if an insulin dose is to be administered Note some patients may be prescribed more than one type of insulin at a time In the Routine Insulin Orders section Meal times i e Breakfast Lunch Dinner Pre Bed are pre printed The dose is prescribed under the current Date column If there is no dose ordered where one would be expected contact the prescriber or doctor on call to determine if a dose is required and to provide a phone order if it is Calculate and prepare total insulin dose Routine Supplemental Stat Phone Confirm the insulin type and dose is correct with another appropriately trained nurse Check local procedure to determine whether different types of i
17. edical Oticer to moy specilinsivcions 7 As viabetesireaimentprortoadmisson i amp Monitoring record for blood glucoselevels 7 SA Blocd Glucose Moning OOOO amp Insulin orders prescribing gt jOtRwmemwinodes O O 29wpemewimumodes MC j 3SmM emodes n SMSmodes 0 Sa2Pwmeode j84Mmmswonem 7 Documentation of insulin administration M rt Adminstration of aroutne nsuindose YC re Administration ofa supplementalinsuindose a Documenting phone orders and administration of phone orders S ra Documenting administration ofstatorders BENE ONE NN fBiRwwemm 0 9 J82Sppememdiwdn Wo 18 um EON EN 9 9 Guidlines tor Managing Hyperaicaemia Alens 1 30 Hypoglycaemia Management in Diabetes Adult SSN um m EN om EN 10 1 Hypoglycaemia Management in Diabetes BGL less than 4mmol L 10 2 Diabetes treatment review following treated hyperglycaemia User Guide to National Insulin Subcutaneous Order and Blood Glucose Record Adult 3 User Guide to National Insulin Subcutaneous Order and Blood Glucose Record Adult Exceptions This form is NOT intended to be used for children 1 Purpose The purpose of this user guide is to explain how clinicians should use the nsulin Subcutaneous Order and Blood Glucose Record Adult to take full advantage of its safety features The safety features of the form promote consistent documentation to assist with accurate interpretatio
18. ent is receiving rapid or short acting routine insulin with meals the same type of insulin is prescribed as supplemental insulin Write the Start date and Start time that the orders are written User Guide to National Insulin Subcutaneous Order and Blood Glucose Record Adult 11 otandardised BGL ranges which are colour coded and match the BGL ranges in the Monitoring Record are pre printed on the form with a starting BGL range for supplemental insulin of 8 1 12mmol L If required alternate BGL ranges may be used Document the insulin doses in the relevant Start date column The doses should be written as a whole number and be written against the BGL ranges at which they are to be administered The word units is pre printed as a watermark The prescriber must sign the order and print their name in the spaces provided The prescriber must also write the full trade name of the supplemental insulin in the Administration Record row with the prompt Name of supplemental insulin The Supplemental Insulin Order remains valid until ceased or changed This is in contrast to routine insulin orders where doses are required for each day Rationale Routine doses should be adjusted daily in response to the BGLs and the amount of supplemental insulin required in the previous 24 hours Therefore the patient s requirement for supplemental insulin should reduce as routine insulin doses are adjusted If necessary review and amend supplemental dose change
19. er and Blood Glucose Record Adult Doctor to revise insulin infusion Is patient nil by mouth or nil by tube Is patient on an insulin infusion Yes Stop insulin infusion continue glucose infusion AND contact doctor urgently Contact doctor urgently AND If IV access RN doctor to If no IV access administer OR administer 30mL 50 glucose as slow IV push Img glucagon IM 1 dose only If the patient If the patient is NBM is not NBM RN doctor to Give one serve administer OR fast acting 30mL 50 glucose as slow IV push carbohydrate Sg Commence or revise from list below IV glucose infusion and review diabetes management Recheck BGL after 15 mins Recheck BGL after 15 mins No BGL v greater than 4 No BGL Yes greater than 4 Yes rate and concurrent glucose Patient is receiving food orally a or by tube Yes Give 1 serve of fast acting carbohydrate from list below Hecheck BGL after 15 mins No BGL greater than 4 Yes Follow up 1 serve of slow acting carbohydrate from list below infusion Recommence insulin infusion and glucose infusion at adjusted rate 15 minutes after hypoglycaemic event has resolved Repeat BGL after 1 hour Document hypoglycaemic event on BGL and insulin chart and document actions taken in patient record Notify doctor to review recent diabetes treatment Beware of recurre
20. escribe suce J Lunch Mealtime insulin name Z TEA T aeo It is NOT necessary to Itis NOT necessary to prescribe supN suptNemental insulin for all patients Prescriber Print your Sanoue James Simmonds rers SIMMONDS ZA ISN TE TET 12 77 lv a anane OC on MES Sun un nu Dinner Mealtime iiaii name unis units Es m pee eret pes Simonds Fw um Signature Sands James Simmonds Simmonds name e SIMMONDS IS AS MG IS 24 28 then Basal insulin name 24 units units pem pes administer ie j Ro m Tmmonnd J5 25 MG sont Col in sists Signature James name SIM MONDS HS J MG pm ee emma S LREN ENIM EM and notify Dr Prescriber Print your units unis units units un 5 Prescriber Signature Print your name IS a qme 0p ine mons SINNKE User Guide to National Insulin Subcutaneous Order and Blood Glucose Record Adult 17 7 5 3 Phone orders On the 14 7 12 there is no insulin ordered for lunchtime As the patient has been receiving routine insulin the nurse notifies the prescriber that the lunchtime BGL is 8mmol L A phone order is made for 9 units of rapid acting insulin to Nurse 1 who initials to confirm receipt of the order Nurse 2 reads the written phone order back to the prescriber to confirm and countersigns receipt of the order Nurse 1 writes phone in the Routine Insulin Orders dose box to indicate that a phone order has been taken Nurse 1 and Nurse 2 then prepare the orde
21. he BGL Insulin box on page 1 of the NIMC MEDICATION CHART of ADDITIONAL CHARTS IV Flug BGL nsum _ Acute Pain Clozapine Palliative Care Chemotherapy IV Heparin _ Other User Guide to National Insulin Subcutaneous Order and Blood Glucose Record Adult 5 Cross reference the insulin order in the NIMC regular medications section to ensure insulin is not omitted during hospital admission and from discharge medications Cross referencing should be done either by a Placing a pre printed sticker stating that Insulin is Ordered for this Patient See Insulin BGL form OR Insulin is ordered for this patient see Insulin BGL form b The authorised prescriber pharmacist or registered nurse RN hand writing on the section If stickers are unavailable Medication Print Generic Marne Frequency amp Enter lines Insolin Indication Ph armiacy Oty ontnus on discharge es Ma Dur gon Frasier Signature Prod Your Name 4 Monitoring notification instructions 4 1 BGL Frequency The prescriber should indicate the BGL Frequency required for the patient Default BGL monitoring for an inpatient is pre meals and at 21 00hours Tick all options that apply More than one box can be ticked Consider if patient requires more frequent BGL monitoring e g at 0200 hours if risk of nocturnal hypoglycaemia or fasting and 2 hours post meal if pregnant If the prescriber does n
22. ht If insulin is started ensure early referral within 24 hours to specialist diabetes nurse educator or equivalent service Ongoing doses require daily review for adjustments according to BGLs and supplemental doses required over the previous days Table 1 Suggested initial stat and supplemental rapid short acting insulin doses Pr eviously vic ES Less than 26 units 26 50 units 51 100 units More than 100 units previous total daily dose EY ee Less than 50 kg 50 1 100 kg 100 1150 kg More than 150 kg use actual weight LINAV d8HO0939 198 ANY 43080 SNOANVLNOENS NIINSNI User Guide to National Insulin Subcutaneous Order and Blood Glucose Record Adult 20 10 Hypoglycaemia Management in Diabetes Adult 10 1 Hypoglycaemia Management in Diabetes BGL Less than 4mmol L This flow diagram on page 4 has been designed to standardise the management of hypoglycaemia in adults treated in the hospital setting emergency department inpatients and outpatients The flow diagram has four treatment pathway options based on the patient s current condition treatment and dietary status These are determined by whether the patient is O O O O conscious and cooperative receiving insulin via an intravenous insulin infusion nil by mouth or nil by tube receiving food orally or by tube Lists of appropriate food choices are supplied for use as initial and follow up treatment according to the diet the patient is receiving O O
23. idered User Guide to National Insulin Subcutaneous Order and Blood Glucose Record Adult 12 6 3 Stat phone insulin orders Document any single stat or phone insulin dose orders in this section Administration of the insulin dose is documented in the Administration Record section along with Routine doses see section 7 3 6 3 1 Stat orders If the doctor is notified of an out of range BGL a stat dose may be ordered The prescriber must inform verbally the RN responsible for the patient s care of any stat orders 6 3 2 Phone orders If a RN takes a phone order for any insulin dose routine or due to an out of range BGL the order is documented here A second nurse must read back the written order to the prescriber to confirm that the order is correct and then countersign the phone order The nurse s receiving the phone order must check if the stat phone order replaces or is in addition to other insulin orders Phone orders should be signed by the prescriber within 24 hours Stat Phone Insulin Orders also complete Administration Record above Check with doctor if order replaces or is in addition to 2e m insulin orders ris Date time Prscber Phone PIG Name of insulin Units fd Order prescribe OF aose Signature Print your name Tec 1 14 7 12 14 7 12 Mealtime insulin mame 9 DR ait etek a Routine Insulin Orders must be ordered for each day Contact doctor if expected dose not ordered Date 10 7 11 7 12 7
24. ketone test document the result in the Ketones box and notify the prescriber of any positive result Tick the Dr Notified box fa urine ketone test is performed the result is documented as neg if no ketones are present or as a or etc as indicated on the urine ketone test strip bottle fa blood ketone test is performed the result is documented as a number e g 0 6 or 1 4 Also document the actions taken in the medical record Further information can be documented in the Comments section below and in the medical record Monitoring Record Standard i 2hrs post meal Py Standard a 2hrs post meal Standard 2hrs post meal _ At 02 00am _ Other At 02 00am Other At 02 00am Other 13 17 121 o2 oz 12 17 21 02 07 12 17 21 T SCR IEEE Ble eere eI Notify if 3 consecutive 45 4 4 amp m Date Change BGL to tick all that apply BGLs greater than 12 gt r m 7 o Les than 4 Treat hypoglycaemia and notify doctor immediately Refer to Hypoglycaemia Management page 4 Hypo intervention Doctor notified User Guide to National Insulin Subcutaneous Order and Blood Glucose Record Adult 8 6 Insulin orders prescribing Insulin orders are divided into three sections Houtine Supplemental and Stat Phone Insulin Orders Patients may require any combination of these orders If no insulin
25. l time the insulin is to be administered under the appropriate date column Units is pre printed as a watermark Do not write U or IU as these abbreviations can cause serious dose administration errors e g if bu is misread as 50 units Each dose is prescribed in a different space according to the meal or time it is to be administered If the patient has been receiving insulin and no dose is ordered for the next meal or time the nurse must call the treating prescriber or the doctor on call for a phone order The previous day s order is not a recurrent dose order In the event of a phone order being required the nurse writes phone in the appropriate insulin dose box of the Routine Insulin Orders section to indicate that a phone order has been taken For additional instruction on phone orders please see the instructions at Section 6 3 Stat Phone Insulin Orders Insulin doses must be ordered for each day When writing up daily doses it is appropriate to prescribe doses for the rest of that day and for the first dose s of the following day The prescriber may order insulin doses for several days when the BGLs have been acceptable and stable in the range of 4 12mmol L The prescriber orders the insulin doses for subsequent days in the additional Date columns The new dose supersedes those written for previous dates A new form must be written by the prescriber after 5 days or when there is no space to order doses or recor
26. me PERNA Lunch Mealtime insulin name vA Se ua Sinmun SIMON ZA Signature James Simmonds name MMONDS mner Mealtime insulin name Pal Sal Baia Sonal unm Mealtime insulin name units Prescriber Print yo ply EET S eee e ee ee Name of insulin Bosal ineulin name 24a 24 28 lon us Basal insulin name incu aed ee C umm i KATAMAN Signature James Simmonds name SIMMOND J JS JS MG 75 Mia c Prescriber Print your Signature name Meal time Dinner Meal time Pre Bed FAROE ANM User Guide to National Insulin Subcutaneous Order and Blood Glucose Record Adult 16 7 5 2 Supplemental insulin At lunchtime on 12 7 12 the patient is prescribed 8 units of rapid acting insulin as a routine insulin dose The BGL is 12 5mmol L By checking the Routine Supplemental and Stat Phone Insulin Orders sections it can be seen that with a BGL of 12 5mmol L the patient is to be administered 8 units of routine rapid acting and 4 additional units of supplemental rapid acting insulin There is no stat phone order The total insulin dose of 12 units of rapid acting mealtime insulin 8 units of routine rapid acting insulin plus 4 units of supplemental rapid acting insulin is prepared and administered as a single injection The time 12 45 is documented in the Time given row The 8 units of routine rapid acting insulin are documented in the Administration Hecord against the correct row with the
27. n information are necessary to ensure safe and effective outcomes for patients Patients not seen by a clinical pharmacist during their stay are at greater risk of an unfavourable medicine related outcome The clinician undertaking pharmacy review should sign the Pharmacy Review section on the bottom right side of page 3 as a record that they have reviewed the insulin form on the corresponding day to ensure that all insulin orders are clear safe and appropriate for that individual patient therefore reducing the risk of an adverse drug event Pharmacy Review User Guide to National Insulin Subcutaneous Order and Blood Glucose Record Adult 23
28. n name 8 8 T Prescriber j Print your P AFAFA MG Signature James Simmonds name STMMOND Ax JIS FS 946 MG 8 Lunch Mealtime insulin name he d m aen I Si suono AA E 45 96 SIMMONDS N TS 4 MG Signature James Simmonds Contact doctor if expected dose not ordered In the prescribing space for the appropriate meal time e g Breakfast write the full trade name of the insulin to be administered in the space marked Name of insulin For premixed insulin specify the insulin type in full e g Mixtard 30 70 Humalog Mix 25 NovoMix 30 Mixtard or Humalog Mix are not complete orders Rationale Trade names are preferred for insulin prescribing to avoid confusion as there are many look alike sound alike generic insulin names which are not interchangeable Additionally wherever possible the patient should receive the brand of insulin they use or will be using at home The prescriber must sign each order and initial in the grey shaded row immediately below the insulin and dose prescribing space where initials is watermarked The prescriber must print their name in full at least once per form User Guide to National Insulin Subcutaneous Order and Blood Glucose Record Adult 9 At the top of the first Date column in the Routine Insulin Orders section write the date the dose is to be administered Write the number of units ordered as a whole number only in the box relevant to the mea
29. n of subcutaneous insulin orders The form is intended to reflect best practice The specific sections of the form assist clinicians to safely prescribe and administer insulin and to monitor blood glucose levels BGLs The Institute for Safe Medication Practices ISMP considers insulin a high risk medication Standardising the communication of medication information between doctors nurses and oharmacists working in hospitals aims to reduce harm to patients from medication errors This has been proven by the introduction of the National Inpatient Medication Chart NIMC Standardisation in addition to reducing patient harm allows for a collaborative approach to the training of medical nursing and pharmacy staff in the use of acommon form Linking all the information required to manage inpatient diabetes requirements is expected to enable clinical staff to more effectively manage patient treatment For patients who are not treated with insulin the form is used for BGL monitoring The following are general requirements regarding use of the nsulin Subcutaneous Order and Blood Glucose Record Adult e All authorised prescribers must order medicines for inpatients in accordance with legislative requirements according to the relevant state and territory drugs and poisons legislation e Orders should be reviewed daily and when notifications of out of range BGLs occur ensuring appropriate diabetes management and dosing of insulin e The form is to
30. nsulin can be mixed in the syringe Administer the insulin Document the time insulin is given in the Time given row of the Aaministration Record to accurately reflect the time of administration which may be slightly different from the time the BGL is recorded Document the administration as outlined above User Guide to National Insulin Subcutaneous Order and Blood Glucose Record Adult 14 7 2 Administration of a supplemental insulin dose Review the Supplemental Insulin Orders and check whether supplemental insulin is required at that Meal time according to the BGL ranges for which it is prescribed Calculate and prepare the dose of insulin to be administered and which may be in addition to a routine mealtime dose Administer the insulin and document the administration in the Administration Record as outlined above Supplemental insulin and routine insulin of the same type e g short acting and due at the same time may be administered together but must be documented separately 7 3 Documenting phone orders and administration of phone orders If a RN takes a phone order for any insulin dose Routine or because BGL requires notification the order is documented here Note A second nurse must read back the order documented by the first RN to the doctor to confirm it is correct and then countersign the phone order The nurse s receiving the phone order must check to see if the Stat Phone order replaces or is in addition to other insulin
31. nt hypoglycaemia risk is greater with oral agents Doctor must review Always give follow up oral carbohydrates or IV glucose after glucagon injection Fast Acting Carbohydrate give one serve 15 grams of one of the following as 100mL Lucozade 1 serve Polyjoule as per directions 150mL lemonade or other softdrink not diet 10 Glucodin tablets 3 teaspoons sachets sugar dissolved in 50mL water f small or 4 large glucose jellybeans Normal Diet 150mL orange juice 30mL cordial not diet 1 tub pre prepared thickened cordial not diet Diet full thick 3 individual serves of jam not diet PEG or 100mL Lucozade Nasogastric 1 serve Polyjoule as per directions Tube Feed wa 150mL orange juice feeding tube 30mL cordial not diet mixed with 150mL water mixed with 150mL water Slow Acting Carbohydrate give one serve 15 grams of one af the following as follow up treatment 250mL milk 1 tub 200g yoghurt 1 slice bread 2 sweet plain biscuits 1 piece fruit Next meal if being served within 30 mins 1 tub pureed fruit 1 serve thickened milk drink 150mL enteral feed 27 10 2 Diabetes treatment review following treated hyperglycaemia Diabetes management must be reviewed in response to a hypoglycaemic event and clinicians should refer to the Diabetes treatment review following treated hypoglycaemia guidelines Diabetes treatment review following treated hypoglycaemia 1 Assess
32. nt prior to admission Nil insulin prior to admission Metformin and gliclazide 5 Monitoring record for blood glucose levels 5 1 Blood glucose monitoring Generally the BGL target range for most inpatients on general wards receiving subcutaneous insulin and or oral treatments is 4 10mmol L with up to 12mmol L considered reasonable In the Monitoring Record there are two rows that do not have any shading 4 8mmol L and 8 1 12mmol L If BGLs fall within this monitoring range a doctor is not required to be notified unless requested in the Special Instructions or if there are specific concerns Certain situations e g pregnancy require tighter control The Special Instructions area can be used to define specific BGL targets and notifications A doctor must be notified when the BGL is e less than 4 mmol L e greater than 20 mmol L e the second consecutive BGL greater than 16 mmol L e the third consecutive BGL greater than 12 mmol L To document a BGL e The date should be documented on the top of the current Date column e The nurse or prescriber should document the Diet the patient is to receive for the day e g Nil By Mouth NBM Total Parenteral Nutrition TPN clear fluids full diet This prompts re assessment of insulin requirements should the patient be fasting for a procedure or have altered dietary requirements e Document the time the BGL is measured in the Time space at the top of the BGL column User Guide to
33. ording to facility procedure Document the dose administered against the corresponding Name of routine insulin or Name of supplemental insulin row in the Administration Record Document the time insulin is given Initial in the Nurse 1 initials box to acknowledge administration of the dose The second nurse checking the insulin dose should initial in the Nurse 2 initials box The 2 sets of initials confirm the administration of each insulin dose A BGL should be performed within the 30 minutes before an insulin dose as it may change significantly prior to insulin administration if left longer Insulin doses administered at mealtimes should be given immediately before a patient eats when their meal is in front of them Rationale In the hospital setting meal delivery times are variable and if delayed after insulin has been administered hypoglycaemia may result Routine Supplemental and Stat Phone insulin orders may be ordered for the same time If so insulin orders that are the same type of insulin e g short acting may be administered together but must be documented separately If clinical judgement indicates that a prescribed dose should not be administered e g the patient is fasting or vomiting notify the prescriber to review the dose If for any reason an insulin dose cannot be administered as ordered notify the prescriber enter code W for withheld and document in the clinical record Note It would be unusual for a patient with type on
34. ot indicate the BGL frequency BGLs should be recorded according to the Standard monitoring frequency pre meals and at 21 00 hrs BGL Frequency tick all that apply 4 Standard Pre meals and at 21 00hrs At 02 00am _ 2 hours post meal If not instructed default is Standard The BGL frequency should be reviewed and updated regularly in the appropriate date columns of the Monitoring Record M 7 12 W Standard VW 2hrs post meal At02 00am Other n User Guide to National Insulin Subcutaneous Order and Blood Glucose Record Adult 6 4 2 Medical Officer to notify special Instructions The prescriber should document who to notify of any BGL that is out of range or other concerns regarding diabetes management If the name space on the left side of page 2 is left blank the resident medical officer for the treating team will be notified The doctor on call will be notified after hours Clinicians may document any Special Instructions related to the patient s diabetes management in the space provided on the left side of page 2 Medical Officer to notify 4 3 Diabetes treatment prior to admission Clinicians should write the Diabetes treatment prior to admission in the space provided in the bottom right hand corner of page 3 This may include oral hypoglycaemic agents and or insulin names and doses Optional additional information may include the insulin device that the patient uses Diabetes treatme
35. red insulin dose Nurse 1 and Nurse 2 then administer the insulin and write the time as 12 45 in the Time given row They write 9 as the units administered and initial under the dose The prescriber signs the phone order within 24 hours Stat Phone Insulin Orders also complete Administration Record above Check with doctor if order replaces or is in addition to other insulin orders Date Date time Prescriber Paang Name of insulin Units I prescribed of dose ira Dos Signature Reetyescnama 9 Tper phone Dr J Simmonds TR P M me er one i 14 7 12 Mealtime insulin name 2 UD Simmonds LC ee 1 Yn Y B Nurses must write the dose given tme LL Mame of routine insulm i AN 9 e nina eis ps 7 I RC 24 fani IE T atataj TT TE If for any reason insulin cannot be i Name of routine ins administered as ordered notity Basal nsum name atl wi X see documentincinicalrecora P i mmm P S document in clinical record p Name cf supplemental insulin ge PUIP supplementa insulin name s c gt A a 173q215d WI 7p BR er Ee f r r d k J J PE kA m p Revi iewed at1730 Hype treated per protecel Fe al or N Starting routing insulin review Skipped breakfast lunch dose If supplemental short acting insulin is Time g ordered for the same time as
36. s as required in the corresponding date columns Changes are validated by the prescriber initialling at the bottom of the corresponding start date column The Supplemental Insulin Order does not continue past the last usable day on the form After completion of a previous form Supplemental Insulin Orders must be either o Ordered on the new form if supplemental insulin is to be continued or o ceased on the expiring form to communicate the intention that the patient is no longer to receive supplemental insulin Administration of the insulin dose is documented in the Administration Record section see section 6 4 Example ceasing the supplemental order Supplemental Insulin Orders valid until changed or ceased Sliding scale insulin alone is NOT recommended consider basal insulin needs Remember Adjust routine insulin based on supplemental insulin requirements If unsure seek advice Frequency Name of insulin Usually the same as the routine short acting insulin v With meals only Supplemental insulin name L 6 hourly same insulin as mealtime insulin C ON r GDOCIVE suu ets It is NOT necessary to prescribe supplemental insulin for all patients then administer additional Greater than 20 and notify Dr Prescriber Signature Print your names ac James Simmonds SIMMOND Special Note SUBCUTANEOUS SLIDING SCALE insulin is NOT RECOMMENDED as sole insulin therapy BASAL insulin requirements should be cons
37. st write the dose given time given and initials If for any reason insulin cannot be administered as ordered notify doctor enter code W for withheld and document in clinical record If supplemental short acting insulin is ordered for the same time as routine short acting insulin they may be given together but must be recorded separately Routine Insulin Orders d Administration Record m Name of routine insulin NENNEN Mealtime insulin name unital unis a Name of routine insulin aap d Basal insulin name units units units units units Name of routine insulin NENNEN units units units units units MEME Name of supplemental insulin Supplemental insulin name 7406145 NW A use 1 2intias PETZ A urse 1 2 initials f L2 Reviewed atl730 Comments i REGN Startipe routine insulin 8 units FN units 24 gt Ni pp EE s 4E HN unit 73G1800 1715 2130 ak Cols M 4 o Time given SA DRENE 2R i must be ordered for each day Contact doctor if expected dose not ordered Date Mealtime insulin is given at start of meal 10 7 11 7 12 7 13 7 Iw Meal time Signature name Meal time Breakfast mm a ul a ual units Pd me uc iium kia Mealtime insulin rame WA S 8 8 9 ealtime insulin name i unita Prescriber Print your Signatute_ James SimmondsinameSTMMONDS Z ISA IS MS Lunch Mealti
38. the patient s identifiers are present This can be done in one of 2 ways 1 The current patient ID label placed on pages 1 and 2 2 Asa minimum written in legible print the patient o UR number o Name family and given o Address o Date of birth o Gender M Male F Female Indeterminate The first prescriber must print the patient s name under the label to verify that both the ID label and the insulin orders relate to the correct patient This will reduce the risk of the wrong ID label being placed on the form which could lead to the wrong patient receiving insulin Insulin should not be administered if the prescriber has not completed the patient identification details In these situations o Contact the prescriber urgently as insulin should not be withheld o dfthe original prescriber is not available contact the doctor on call Tom Jones Hospital JOHNSON 223344 IAN M 27 04 1958 12 Nearby Street Somewhere Close 4444 Ph h 07 1234 5678 ena 0412 345 e78 MAMMA AI MC 123456789 IDtj EXp 12 2013 First Prescriber to Print Patient Name and Check Label Correct GN Johnson 3 2 Hospital demographics Complete facility ward unit and year in this section at the top right side of page 3 Insulin Subcutaneous Order and Facility Your Hospital Blood Glucose Record Adult Ward Unit Your Ward Year 20 12 3 3 Cross reference with National Inpatient Medication Chart NIMC Tick t
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