National Subcutaneous Insulin Form Pilot Project Audit Tool User
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1. ID complete on the Yes No NIMC insulin form chart Patient identification ID on the National Insulin Subcutaneous Form should be consistent with the identification required when using the National Inpatient Medication Chart NIMC In the pre audit for hospitals using specific forms for insulin patient ID should be as per the NIMC EITHER the current patient identification label OR as a minimum the patient name UR number date of birth and gender written in legible print The first prescriber must print the patient s name under the label Patient ID must be complete on all active forms to record Yes For further information see National Inpatient Medication Chart User Guide including Paediatric versions at www safetyandquality gov au publications national inpatient medication chart user quide including paediatric versions Is the insulin form cross referenced Yes No or Not Applicable in pre audit only if using specific in the regular medications section of insulin form and or applicable cross referencing must be the NIMC on all active forms For further details see page 5 of the User Guide to National Insulin Subcutaneous Form Yes No Review tests results and or medical records for in hospital HbA1C test result or a recent HbA1C test done within the last three months Yes No Record Yes if BGLs are recorded on the same form as insulin is prescribed Record No if separate forms used for BGL monitoring2. and they are unable to enter any data If this is the case go to the Tools menu and choose Protection then Unprotect Sheet see screenshot below ae ee UL inam semine Pay ea S E eee A HERE I ibcutaneous insulin Form Pilot AUDIT TOOL hepece Verte Final Pare wirio HER T _ Audit Result 5 Audit Result Demographics and 1 Protection E Urgrotect Sheet Orne Colmar a y Humber Duraban of cures form s use patient must be admitted for at least 24 hours Yes No Requirements are the same es for patient inthe NIMC audit Patent must be complete om wi active forme Options You No or Not Applicable m pre auda only f esing spectic insule foem and or applicable cross references must be on all active foemas National Subcutaneous Insulin Form Pilot Audit Tool User Guide 6 4 Enter the audit results into the Audit Result column see screenshot below There is a separate data entry record created for each patient each time the file is saved The column titled Audit Result and the Comments field are the only cells in the pre implementation and post implementation audit files that can be used to enter data There are four cell types in both spreadsheets e Cells which accept only numeric values only eg Number of days of insulin therapy audited e Cells with only Yes No options or Yes No Not applicable options e Cells with single option selection eg Is the insuli
3. sites participating in the National Subcutaneous Insulin Form Pilot The audit tool is an automated Microsoft Excel spreadsheet that will be distributed to hospitals involved in the pilot Staff at pilot sites will use the automated excel spreadsheet to record their answers to the audit questions for each patient s data The questions include data elements related to e Documentation of insulin prescription and administration e Accurate recording of BGLs and other test results where available e Notification of out of range BGLs to medical officers and documentation of action taken When the audit is complete project coordinators will save the file and email a copy of it to the senior Project Officer managing data on behalf of the Commission National Subcutaneous Insulin Form Pilot Audit Tool User Guide 5 3 Installation and use of the Audit Tool There are two automated excel files used for data entry which will be distributed by email to hospitals involved in the pilot One will be used for data collection for the pre implementation baseline audit and the other for the post implementation audit that will be undertaken six months after introducing the pilot subcutaneous insulin form The two files are named 1 ID national insulin pilot project 3 4 3 pre audit xls 2 ID t national insulin pilot project 3 4 3 post audit xls The files will be emailed to hospitals separately The post implementation audit file will be sent a
4. AUSTRALIAN COMMISSION on SAFETY ano QUALITY in HEALTH CARE National Subcutaneous Insulin Form Pilot Project Audit Tool User Guide 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 National Subcutaneous Insulin Form Pilot Project Audit Tool User Guide ACSQHC Sydney Acknowledgment Many individuals and organisations have freely given their time and expertise to develop the National Subcutaneous Insulin Form Pilot Project Audit Tool User Guide In particular the Commission acknowledges all health professionals and other experts who have contributed to the user guide The involvement and willingness of all concerned to share their experience and expertise is greatly appreciated National Subcutaneous Insulin Form Pilot Audit Tool User Guide 1 1 Table of contents Osam O RR o 0 B 4 nveducton to Natonal insulin Form Plot quaitave sty 3 aras OOO 3 jasSawwsseon OOOO 3 jasPeedswddp jR4Adid OOOO 8 a instalsion anduse ort
5. Therefore the number of doses prescribed is 5 as the 6 dose is not yet due Supplemental order Count the number of times a dose would be required according to the BGL parameters for the National Subcutaneous Insulin Form Pilot Audit Tool User Guide 14 Number of insulin doses prescribed which are clear Number of insulin doses prescribed which use unapproved abbreviations Number of insulin dose prescriptions that are missing Number of doses that are required to be administered Number of doses initialled as having been administered Number of doses with administration time documented supplemental doses Sliding scale as above Phone Number of stat phone order doses prescribed Count the number of insulin doses which are clear number of units written legibly eg you can read it is a 6 Will require auditor to only count doses required up until the time the audit takes place even if additional doses are ordered Count the number of insulin doses which use unapproved abbreviations e g units abbreviated to u U u s IU Count the number of missing orders for insulin doses Missing not prescribed For scheduled doses this refers to when a dose has not been prescribed For sites that use the NIMC for the pre audit this would be an unusual occurrence and would only apply if an entire order was not written Therefore if using NIMC leave this field blank Count the number of insulin doses required to
6. al doses are required at the particular BGL range If a code is used for not administering insulin as per NIMC it will be counted as an administration Number of doses initialled as having been 37 s administered Count Count number of doses administered with time given documented Number of doses with administration time documented Write not applicable for a form that does not require the nurse to document the actual administration time of the insulin dose pre audit Add Another Ins ulin Order for this Patient Reset Form Next Patient Add another insulin order for this patient button National Subcutaneous Insulin Form Pilot Audit Tool User Guide 7 6 Click on the Next Patient button see screenshot below when all values are entered for this patient This will copy the data into a separate sheet within the excel file and will also reset the Audit Result column for the next patient Count Count only doses required up until the time of auditing Will require auditor to determine if supplemental doses are required at the particular BGL range If a code is used for not administering insulin as per NIMC it will be counted as an administration Number of doses initialled as having been Count Count number of insulin doses administered so that dose administered omissions can be calculated Count Count number of doses administered with time given documented Number of doses with administration time documente
7. and insulin prescribing Are BGLs recorded on the same form as insulin is prescribed National Subcutaneous Insulin Form Pilot Audit Tool User Guide 11 Is the requested frequency of BGL Yes No monitoring documented on the BGL Record Yes if the frequency of BGL monitoring is recorded monitoring form chart on all active BGL monitoring forms at the time of the audit Record No if the frequency of BGL monitoring is not recorded on all active BGL monitoring forms at the time of the audit Number of days BGLs are recorded Count the number of days in which the number of BGLs as requested recorded match as a minimum the frequency requested For example the patient s requested BGL frequency is 4 times daily before meals and before bed The patient was admitted at 10 00 hours on day 1 and the audit is undertaken at 14 00 hours on the day 3 of the admission Therefore the expected minimum number of recorded BGLs is three on day 1 four on day 2 and two on day 3 up to the time the audit is undertaken How many BGLs are recorded Count the number of BGLs recorded denominator for Question 11 How many BGLs are recorded Count the number of BGLs recorded correctly correctly Is the documentation legible If a graph does the dot position and the written number match If the BGLs are written in a shaded range as in the Pilot subcutaneous insulin form are the numbers written in the correct range NEN lc M94 Numb
8. be administered up to the point of the audit denominator for next question If a code is used for not administering insulin as per NIMC this is counted as an administration For supplemental doses this refers to the number of times the parameters were met for administration of the supplemental dose Will require auditor to determine if supplemental doses that were required at the particular BGL range were administered Count the number of insulin doses initialled as having been administered If a code is used for not administering insulin as per NIMC count as an administration Count the number of doses administered with time given documented Record not applicable for a form that does not require the nurse to document the actual administration time of the insulin dose pre audit only National Subcutaneous Insulin Form Pilot Audit Tool User Guide 15
9. by two form s that have been initialled as being received by two nurses nurses Record zero if there are no phone orders that are initialled as being received by two nurses Leave blank if there are no applicable phone orders or where zero is recorded in item 24 above National Subcutaneous Insulin Form Pilot Audit Tool User Guide 13 Insulin orders Complete items 26 to 38 for each type of insulin order e g one for routine and another for supplemental Specify type of insulin order Select either Routine Scheduled Supplemental Stat Phone sliding scale insulin stand alone sliding scale insulin is intermittent short acting insulin given in response to BGLs without any background basal or mixed insulin Audit each complete order that has been prescribed for the patient even if order has been ceased Is the insulin name clear Options Select either clear unclear missing Clear Name of insulin spelled correctly legible includes suffixes e g NovoMix 30 Humalog Mix 25 Unclear any of the above not fulfilled Missing name of insulin not documented Is route of administration clearly Options Select either clear unclear missing specified Clear intended route of admin complete or approved abbreviation used Acceptable terminology subcutaneous sub cut Unclear use of unapproved abbreviations s c s q Missing route of admin not documented pre audit only Is frequency of administration Optio
10. d s Write not applicable for a form that does not require the nurse to document the actual administration time of the insulin dose pre audit Add Another Ins ulin Order for this Patient Reset Form Next Patient Next Patient Button 7 n the data sheet that is automatically created the column headed Test Case ID allows auditors to see how many patients audits have been entered Each Test Case ID represents one patient see screenshot below Do not change any data once it is in the data sheet If you need to revise any data that has been copied across to the data sheet please contact the Commission Senior Project Officer first Hide Unhi R Data is automatically entered into a separate data sheet when the file is saved Each row of data represents one chart audit 2 audit LTaT audit Ge audit_ e_THT audit OX THT audit Cd opti audit Od opit audit Gd npki audi Gd THT audit O5 audit Gb TAT 8 Auditors should regularly save the file using the usual File Save option Once the audit is complete ensure you have saved the final version of the file The file should be emailed as a normal attachment to the senior project officer managing data on behalf of the Commission Hospitals should retain a copy of the pre implementation audit data for their records National Subcutaneous Insulin Form Pilot Audit Tool User Guide 8 Add Another Insulin Order for this Patient ls This button is used wh
11. e nito 8 31Subcitanenus Insuin FarmPinPreimpemenalonAudtTon 6 jS amp Cmmios 0 9 ssPwkmpemmawnAt SS t pasanan penes 8 4 1 Audit parameters National Subcutaneous Insulin Form Pilot Audit Tool User Guide 2 2 Introduction to National Insulin Form Pilot Project quantitative study The primary aim of the National Subcutaneous Insulin Form Pilot Project is to improve the safety of insulin prescribing and administering for adults in acute care without compromising glycaemic control A secondary outcome of improvement in in hospital glycaemic control will be explored Project objective The objective of the project is to test the following hypothesis e That the use of a standard form for subcutaneous administration of insulin when combined with planned implementation and education can e Reduce the opportunities for error in subcutaneous insulin prescribing and administration documentation and e Not result in inferior blood glucose level control e The standard subcutaneous insulin form must e Link the prescribing of insulin with administration and recorded blood glucose levels e Provide forcing functions to reduce the use of non standard abbreviations and non standard dosing regimens e Provide guidelines for action to be taken in the event of BGLs reaching levels that indicate that the medical officer should be alerted and action taken and e Prompt daily review and adjustment of insulin doses in respons
12. e to BGLs The quantitative study will comprise a baseline data collection education of staff introduction of the pilot subcutaneous insulin form followed by a post implementation data collection See figure below Each hospital will conduct two audits 1 A pre implementation baseline audit using the NIMC or local hospital insulin form This must be completed before education of staff has commenced and 2 Postimplementation audit at 6 months using the pilot subcutaneous insulin form Sample selection is a random sample of inpatients or all inpatients prescribed subcutaneous insulin Patients must have been admitted for at least 24 hours prior to auditing Paediatric patients are excluded The sample should be taken from patients that meet eligibility criteria i e the patient has been admitted to the hospital for at least 24 hours prescribed subcutaneous insulin and using a form for the prescription and administration of subcutaneous insulin Co National Subcutaneous Insulin Form Pilot Audit Tool User Guide In the pre implementation baseline audit the form s to be audited include e National Inpatient Medication Chart NIMC and specific hospital form for recording BGLs or e Hospital specific form for recording BGLs and for prescribing and administering insulin In the post implementation audit the pilot subcutaneous insulin form will be audited The audit requires a review of the end of bed charts forms and to
13. en an additional insulin order is required for the same patient It also resets the position of the audit back to Question 26 which is the start of the insulin order questions Reset Form 2 This button is utlised to reset the form to blank The position is then reset to Question 1 This function should only be used if the auditor is half way through an audit and realises the patient is ineligible to be included or otherwise wishes to delete information for this patient Next Patient 3 This button will reset the form for the next patient The position is reset to Question 1 The post implementation audit parameters are identical to the pre implementation baseline audit The method for conducting the audit should be the same as for the baseline audit A post implementation audit excel tool will be emailed to hospitals towards the end of the six month pilot period for hospitals to use to enter their post implementation audit results National Subcutaneous Insulin Form Pilot Audit Tool User Guide 9 4 Data analysis and audit parameters Data will be analysed for effectiveness of the pilot subcutaneous insulin form s safety features in reducing opportunities for error in the prescribing and administration of insulin Audit parameters 1 Parameters to measure opportunities for and actual errors in prescribing and administration of insulin including e Clarity of order e Dose frequency route of administration unclear inco
14. er of BGLs less than 4mmol L Count the number of readings where BGL is less than 4 mmol L denominator for following two questions Record zero if there are no BGLs less than 4mmol L Number of times treatment for Count the number of times treatment for hypoglycaemia hypoglycaemia less than 4 mmol L is documented on BGL monitoring form insulin ordering is documented on BGL monitoring form or in medical record can be a tick on the insulin form form insulin ordering form or indicating treatment initiated or documentation in the medical record medical record In pre audit specify location of documentation using the free text field Leave field blank if there are no occurrences ie where zero is recorded in item 12 above Number of times there is Count the number of times there is documentation that a documentation that a medical medical officer has been notified of hypoglycaemia can officer has been notified regarding be a comment or a tick on the BGL or insulin form hypoglycaemia on the BGL indicating that the medical officer has been notified or monitoring form insulin ordering documentation in the medical record In pre audit specify form or medical record location of documentation using the free text field Leave field blank if there are no occurrences ie where zero is recorded in item 12 above Number of BGLs greater than 20 Count the number of BGLs that fall into the hyperglycaemia mmol L range denominator for next
15. fter the pre implementation baseline audit has been completed and sent to the Commission 3 1 Subcutaneous Insulin Form Pilot Pre implementation Audit Tool On receipt of the IDz national insulin pilot project 3 4 3 pre audit xls file project coordinators are instructed to 1 Create a project folder on the computer C drive or desktop called C National Subcutaneous Insulin Form Pilot Save the IDZ national insulin pilot project 3 4 3 pre audit xls file into this folder Instruct the staff members conducting the audit to use the file ID _ national insulin pilot project 3 4 3 pre audit xls to enter and submit data for the pre implementation audit Open the excel file when ready to commence entering data for the pre implementation audit Make sure the enable macro security settings are set to Enable all Macros Search for Enable security Macros for further instructions If there is more than one staff member conducting the audit it is recommended that only one version of the pre implementation audit file is used One person should be responsible for keeping a record or log of how many audits have been completed for each stage of the project Note that data can be collected manually using printed versions of the spreadsheet and then entered into the pre implementation audit file or the data can be entered directly into the file using a computer laptop NOTE Some users may find that on opening the spreadsheet it is protected
16. it period Smaller hospitals with less than 40 inpatients prescribed subcutaneous insulin per month should audit all patients Who should conduct the audits It is recommended that a clinician skilled in diabetes management with some experience in conducting safety and quality audits undertake the audits where possible Ideally the same person should do all the auditing although it is recognised that this may not be possible Referral to an endocrinologist or general physician for clinical queries when undertaking the audits is recommended 2 3 Project schedule The pre implementation audit should be completed before education is provided Data collection for both the pre implementation audit and post implementation audit should be completed within a 4 week period The post implementation audit should take place six months after introducing the pilot subcutaneous insulin form An indicative project schedule is provided below although it is recognised that timelines may vary by hospital However it is expected that post implementation auditing will be concluded by mid August 2013 National Subcutaneous Insulin Form Pilot Audit Tool User Guide 4 Project milestones Date completed Baseline Audit completed By 30 December 2012 Hospitals send baseline audit data to Commission By 15 January 2013 otaff education By 15 February 2013 Subcutaneous Insulin Chart introduced By mid February 2013 e Teo An audit tool has been developed to assist
17. n name clear Select either clear unclear missing e The Comments sections which are free text fields word limit of 250 characters i Free text Enter audit results in the Audit flaldsfor Result column entering comments National S neous Insulin Form Pilot AU KFXxern 2 hit Audit Item Question ED Demographics and Patient Identification unt Count the number of current active forms per patient used to record insulin For pre audit use local processes e g hospital insulin Form BGL forms andlor MIMIC Number af insulin Forms used to record BGLs insulin orders and insulin administered Number of days oF insulin therapy audited Co Humber Duration of current Forms in use patient must be admitted For at least 24 hours ves I No YesiMo Requirements are the same as for patient ID in the MIMIC audit Is patient ID complete on the MIC insulin Formrehart m P P Comments Patient ID must be complete on all active Farms 5 The audit requires Questions 26 to 38 to be answered for each type of insulin order e g answer these questions for a routine insulin and then again for supplemental insulin Click on the Add another insulin order for this patient button to answer the questions for each type of insulin ordered for the patient see screenshot below om qmm i Count Count only doses required up until the time of auditing Will require auditor to determine if supplement
18. ns Select either clear unclear missing incorrect clearly specified not applicable Clear order to be administered with breakfast lunch dinner or for basal insulin at a specific time Unclear for mixed or short acting insulin doses to be administered at a specific time the order does not specify to be administered with food at mealtime Missing no frequency documented Incorrect frequency documented is incorrect Not Applicable applies to stat phone orders Has the order been signed by the Yes No Not Applicable prescriber Record Yes if there is evidence of prescriber signature Record No if no evidence of prescriber signature Record Not Applicable if your hospital does not have a policy for Doctor s signature required on phone orders Is the prescriber name clear Yes No Record yes if prescriber name is clearly legible at least once on the form Record No if the prescriber name is NOT clearly legible on the form Number of insulin doses prescribed Count the number of doses for each order up to the point of auditing denominator for next three questions Will require auditor to only count doses required up until the time the audit takes place even if additional doses are ordered For example Routine Scheduled order A scheduled order is written for basal insulin to be administered at 21 00 hours on the NIMC The patient has been admitted for 6 days and the audit is undertaken at 16 00hrs on the 6 day
19. ols for blood glucose monitoring insulin prescribing and administration Some audit parameters will require the auditor to review the patient s medical record and or laboratory tests in addition to the insulin form The audit parameter on medication history recording will require review of forms used to record the patient s medication history The six month post implementation audit sample should be drawn from patients treated in the final month of the trial Forms from only the final month of the pilot should be used to provide data on the appropriateness of the use of the form after it has been in use for several months The method for auditing to be used by hospitals will be based on availability of resources and access to patient medical records insulin forms The audits can be undertaken prospectively or retrospectively however hospitals should employ the same method for the pre and post implementation audits The post implementation audits should be similar to the pre implementation in the number of forms charts and wards audited Where hospitals are auditing retrospectively or where there is more than one form chart available at the end of the bed for prospective audits a maximum of seven days of insulin therapy should be audited Sample Size The sample size for each hospital will be negotiated and agreed with individual hospitals as it will depend on the expected number of eligible patients available for the audit in a one month aud
20. on Medical Officer notification Record zero if there are no BGLs that fall outside the specified parameters for this patient s BGL parameters for Medical Officer notification Number of BGLs that are outside Count the number of BGLs that fall outside the specified the specified parameters for BGL parameters for Medical Officer notification where a Medical Officer notification where a Medical Officer was notified MO was notified Leave field blank if there are no occurrences ie where zero is recorded in item 19 above Where is insulin ordered Select either NIMC Hospital specific insulin form Pilot subcutaneous insulin form post audit only Other please specify if other free text field required to be completed Is there evidence of pharmacist Yes No review Have a pharmacist initials been documented in the pharmacy review section or otherwise annotated at least once at the point of insulin prescription Is the diabetes treatment prior to Select either NIMC National Medication Management admission documented Plan Medication reconciliation form insulin prescribing form not documented anywhere Other please specify using free text field saaa Total number of phone orders Count the number of subcutaneous insulin phone orders on current active insulin form s Record zero if there are no phone orders How many phone orders are Count the number of phone orders on current active initialled as being received
21. question Record zero if there are no BGLs greater than 20mmol L National Subcutaneous Insulin Form Pilot Audit Tool User Guide 12 Number of times there is Count the number of times there is documentation that a documentation that a medical medical officer has been notified of hyperglycaemia officer has been notified regarding can be a comment or a tick on the BGL or insulin form severe hyperglycaemia greater indicating that the medical officer has been notified or than 20 mmol L is documented on documentation in the medical record In pre audit specify the BGL monitoring form insulin location of documentation using the free text field supplied ordering form or medical record Leave field blank if there are no occurrences ie where zero is recorded in item 15 above Number of BGLs in the range of 12 Count the number of BGLs that fall into the hyperglycaemia B 000 mmol L range of 12 20 mmol L What are the EM BGL Enter the BGL notification range for this patient eg less parameters for medical officer than 4 and greater than 13 notification documented on the form eg Notify medical officer if BGL is 4 and gt 13 for each patient s chart being audited Number of BGLs that are outside Count the number of BGLs that fall outside the specified the specified parameters for this parameters for this patient s BGL parameters for Medical patient s BGL parameters for Officer notification denominator for next questi
22. rrect or missing e Use of unapproved abbreviations e Completeness of administration documentation e Incorrect insulin doses administered e Scheduled doses not administered e Evidence that hypoglycaemia is treated and hyperglycaemia is managed and e Type of insulin regimen prescribed 2 Agreed Glucometrics e Percentage of patient days with BGLs in acceptable range 4 0 to 12 0 mmol L e Percentage of patient days with at least one BGL lt 4 0 mmol L e Percentage of patient days with at least one BGL gt 20 0 Inclusion criteria for audits e Patients must be admitted for at least 24 hours and must be prescribed subcutaneous insulin e Audit up to the most recent seven days of insulin therapy e Six month post implementation audit sample should be drawn from patients treated in the final month of the trial e Paediatric patients are excluded National Subcutaneous Insulin Form Pilot Audit Tool User Guide 10 fuser Number of insulin forms used to Count the number of current active forms per patient used prescribe and administer insulin to prescribe and administer insulin for pre audit use local processes Number of days where audit data Auditors should audit the same days for BGL is collected number of days where monitoring recording and insulin ordering BGLs are recorded and Patient must be admitted for at least 24 hours subcutaneous insulin is prescribed un A maximum of up to 7 days should be audited Is patient
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