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DEVELOPMENTS IN THE DIABETES SPECIALIST NURSING SERVICE

DEVELOPMENTS IN THE DIABETES SPECIALIST NURSING SERVICE . Community Diabetes Specialist Nursing Team- 2012 Barnsley Business Delivery Unit. Prevalence of Diabetes in Barnsley. There are 11,989 people aged 17 and over on the Diabetes QOF register in Barnsley (2011)

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DEVELOPMENTS IN THE DIABETES SPECIALIST NURSING SERVICE

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  1. DEVELOPMENTS IN THE DIABETES SPECIALIST NURSING SERVICE Community Diabetes Specialist Nursing Team- 2012 Barnsley Business Delivery Unit

  2. Prevalence of Diabetes in Barnsley There are 11,989 people aged 17 and over on the Diabetes QOF register in Barnsley (2011) This is 6.2% compared with 5.4% nationally (QOF 09/10) By 2030, in Barnsley, it is forecast that 20,738 people (expected prevalence 9.8%) will have diabetes

  3. Specialist Diabetes Nursing Services In Barnsley • The community specialist diabetes nursing service strives to meet the needs of the increasing population with diabetes • Many new challenges being faced • Looking at new ways of working/ Service redesign • Working in partnership with the local acute trust

  4. Referral Criteria • Newly diagnosed Type 1 Diabetes • Type 1 diabetes who have a problem with their diabetes control or psychosocial issue • Type 2 diabetes requiring assessment and initiation of GLP and/or Insulin therapy • Patients on insulin with acute problems with glycaemic control • Patients who are acutely unwell e.g. with diarrhoea/vomiting which is affecting their diabetes control • Newly diagnosed Type 2 diabetes or those with established Type 2 diabetes for structured group education

  5. Referral Criteria • Type 1 diabetes requiring structured education programmes • Type 1 diabetes requiring carbohydrate counting skills to improve glycaemic control • Specialist support and education for patients with Type 1 diabetes on insulin pump therapy • Pregnant women with Type 1, Type 2 and Gestational diabetes • Specialist support for patients with diabetic foot problems • Patients requiring advice for fasting for hospital investigations • Those requiring insulin/medication review and/or change of insulin regime

  6. Referral Process • Crisis- refer via telephone to the diabetes specialist nurses (01226 209884 or 07500100530) AND fax referral (01226 209888) • Other referrals- use the diabetes nurse specialist referral form

  7. PATIENT SAFETY ALERT NPSA/2011/PSA003: SAFER USE OF INSULIN

  8. NPSA/2011/PSA003- The Adult Patients Passport to Safer use of Insulin • Insulin is a potent, live-saving medication…. but if prescribed or administered inappropriately or inaccurately has the potential to cause harm (Fowler and Rayman, 2010) • Insulin appears regularly in the top 10 high-alert medicines worldwide (NPSA, 2009) • Fatal patient safety incidents involving patients with diabetes have been reported by the media • Safety is a priority for every healthcare professional and a concern for patients

  9. National Patient Safety Agency • 2010- 16600 patient safety incidents involving insulin (over a 6 year period) • Six deaths reported, 12 incidents involving severe harm due to insulin error • 26% of the incidents due to wrong insulin dose, strength or frequency e.g. Novomix 30 given instead of Novorapid • 20% due to omitted medicines eg whilst an inpatient • 14% patients prescribed or dispensed the wrong insulin e.g. many similar sounding insulin's such as Humulin M3, Humulin I

  10. National Patient Safety Agency Alerts • 2010- recommending all healthcare professionals involved in prescribing/ dispensing or giving insulin complete the NHS Diabetes e-learning package on safe use of insulin http://www.diabetes.nhs.uk/safe_use_of_insulin/ • 2011- asking all NHS trusts in England and Wales to issue a passport to all adult patients requiring insulin therapy • Aim to provide essential information across healthcare sectors • No avoidable harm- No avoidable death

  11. Common mistakes and errors involving insulin • Do NOT use abbreviations such as ‘U’ or ‘IU’ for units • The dose may be misread • The use of abbreviations may result in the dose of insulin to be misread • For example- 10U may be read as 100

  12. Common mistakes and errors involving insulin • There are around 20 different types of insulin and have different profiles of action • The names and packaging of insulin is often very similar- for example Humalog/ Humalog Mix 50 or Humalog mix 25

  13. Common mistakes and errors involving insulin • Patients can get the wrong insulin type Patient given the wrong type of insulin (Novorapid instead of Novomix 30) resulting in significant hypoglycaemia associated with a fall and confusion. Fortunately the patient was found by her daughter and brought to hospital

  14. Common mistakes and errors involving insulin • Patients can get the wrong insulin presentation or device A patient discharged from hospital with the wrong insulin pen, so was unable to administer the insulin dose as prescribed. The patient was given a Humapen Luxura rather than a Novopen and the cartridges are not interchangeable (patient unable to give insulin)

  15. Types of Insulin • Rapid acting analogues (Novorapid, Apidra, Humalog)- Lasts 4-5 hours, peak action at 2 hours- usually given at meal times • Short acting soluble insulin (Humulin S, Actrapid)- 8 hours action • Isophanes- Medium acting Human insulin (Humulin I, Insulatard, insuman basal) 8-12 Hours duration, peak action 4-5 hour) • Long acting analogues (Levemir/Detemir- up to 18 hour duration, Lantus/ Glargine- up to 24 hour duration, No peak action • Bi phasic insulin (Humulin M3, Humalog mix 25, Insuman comb 25, Novomix 30)- Short and medium acting insulin

  16. Types of Insulin

  17. Insulin Regimes • Once daily insulin regimes- a medium or long acting insulin at bedtime, often used with oral hypoglycaemic agents in Type 2 diabetes • Twice daily regimes- twice daily injections usually using mixtures and alongside Metformin in Type 2 diabetes • Multiple insulin injections/ Basal bolus regime- involves giving quick acting insulin with meals and one or two injections of medium or long acting insulin

  18. Insulin regimes Twice daily insulin regimes using biphasic insulin

  19. Insulin regimes • Commonly used insulin mixtures are: PREMIXED INSULINS- For example, Humulin M3, Insuman comb 25 (given 30-40 minutes prior to a meal) BIPHASIC ANALOGUE MIXTURES- For example Humalog mix 25, Novomix 30 (given up to 10 minutes prior to a meal or immediately before a meal) • Cloudy in appearance, never given at bed time, snack at supper time may be required

  20. Insulin Regimes • Multi dose/Basal Bolus injection regimes • Uses one or two injections of long acting insulin and injections of rapid/ short acting insulin with meals

  21. Insulin regimes • Commonly used rapid acting insulins are NOVORAPID/ HUMALOG/ APIDRA (clear in appearance, can be injected immediately before food, peak effect is 1-2 hours after injection) • Commonly used short acting insulins are HUMULIN S/ ACTRAPID (injected 30-40 minutes prior to food, lasts 6-8 hours)

  22. Insulin regimes • Commonly used long acting analogue insulins are LEVEMIR (lasts up to 18 hours) LANTUS (lasts up to 24 hours, no peak action) • Commonly used intermediate acting (isophane) insulins are INSULATARD/ HUMULIN I/ INSUMAN BASAL

  23. Safe prescription and administration- The right insulin • It is very important that the correct insulin is prescribed, dispensed and administered • Many insulins have similar looking and sounding names and similar packaging is a potentially hazardous and a major cause of insulin errors For example • Humulin S- is a short acting human insulin • Humulin I- is an intermediate acting insulin • Humulin M3- is an insulin mixture (30% short and 70% intermediate acting)

  24. Safe prescription and administration- The right insulin • Similar names is confusing for patients as well as for professionals- your patient may describe their insulin incorrectly For example • Apidra- rapid acting insulin • Insuman Basal- intermediate acting human insulin • Insuman comb 25- insulin mixture • Lantus- long acting basal insulin • Prescription errors can be avoided by checking the name and packaging of patients insulin

  25. Safe prescription and administration- The right time • Another common error is the prescription/administration of insulin at the wrong time • Incorrect timing of insulin will risk hypoglycaemia at some times and hyperglycaemia at other times • For example- if Humalog mix 25 is prescribed at bedtime instead of teatime, blood glucose levels may be high after tea and low during the night • Similarly is teatime insulin is administered 30-60 minutes after instead of with the meal blood glucose levels will be high after the meal and low several hours later

  26. Patient Safety To ensure the safety of patients with diabetes, checks need to be in place at every stage to ensure patients inject the right insulin: Prescribe right Dispense right Inject right

  27. Prescribe right For the prescriber (general): For the specialist referring the patient back to their GP: • Ensure the patient notes down the exact name and correct type of insulin e.g. in one of the patient guides available and knows how to take the insulin correctly • Advise the patient to check that the insulin received from the pharmacist is identical to the one listed in their notes taken during their consultation • Ensure the patient notes down the exact name and correct type of insulin e.g. in one of the patient guides available • Advise the patient to check that their GP prescribes the correct insulin as agreed with the specialist and to refer back to the specialist in case of any doubts

  28. Dispense right Examples of problems that may occur at the pharmacy level The following procedure is recommended to ensure patient safety when insulin is dispensed: • The prescription may be unclear • The patient states that a repeat prescription looks different to their previous prescriptions (e.g. their insulin is usually cloudy, but the one just received is a clear solution) • The patient says they have been prescribed a new insulin, but the one just received looks identical to the one they used previously For the retail/hospital pharmacist: • Ensure the correct insulin is dispensed by double-checking against the prescription (and with the patient in a retail pharmacy setting) • Refer back to the prescriber in case of any doubts The patient shall be advised to: • Check that the correct insulin has been dispensed by the pharmacist (by double-checking against the prescription and/or the notes taken during the specialist/GP consultation) • Refer back to the specialist/GP in case of any doubts

  29. Inject right Prior to injecting the insulin, the following precautions are recommended: For hospital personnel: • Prior to injecting, always cross-check that: • the insulin intended for administration is identical with the one prescribed • follow the outlined insulin therapy instructions closely (especially with regards to the recommended dose and injection device to be used) • If in any doubt at any stage, please refer back to the prescriber The patient shall be advised to: • Always cross-check that the insulin he/she is injecting is identical with the one mentioned in the notes from the consultation with their GP/specialist prior to injection, and that they are taking it correctly • If in any doubt at any stage, he/she shall always refer back to the prescriber HCPs and patients must always have a pre-agreed plan of action to follow in case the wrong insulin has been injected.

  30. Simple rules to remember when prescribing, dispensing and injecting insulin Prescribers (specialists, GPs) Dispensers (pharmacists) Advice for the patient prior to injection • Be familiar with the insulin you prescribe • Ensure the patient knows what has been prescribed and how to take it correctly • Ensure others can easily identify what has been prescribed • Ensure you understand what has been prescribed • Ensure hospital personnel receive what has been prescribed and understand how to administer it correctly • Ensure the patient receives what has been prescribed and understands how to take it correctly • Ensure your patients know what they have been prescribed • Ensure your patients check that they receive what they have been prescribed • Ensure your patients know how to inject what they have been prescribed in the right way

  31. The insulin passport The NPSA recommend • That all adults with diabetes requiring insulin therapy be provided with an information leaflet outlining potential errors that can occur with insulin • And the correct insulin safety ID card

  32. The patient information leaflet Provided to empower patients and support safety in insulin treatment Provides information to the patient surrounding the possible errors that can occur during the prescribing, dispensing and injection of their insulin It provides information for emergencies and safe use of insulin as patients transfer across healthcare providers The leaflet available is- Diabetes: Insulin, use it safely and has been developed by NHS Diabetes

  33. How to use the leaflet Give the leaflet to the patient and encourage them to read it Explain that several insulin preparations have similar names and this leaflet is highlighting this Record that the patient information leaflet has been given

  34. The insulin safety card Contains accurate and up to date details of the patients insulin product(s) Provided by the pharmaceutical company Provides information and picture of insulin type and delivery device (Recommended by NHS Diabetes)

  35. How to use the insulin safety card Select the appropriate safety card for the correct insulin and device Give to the patient and ask them to carry with them at all times Advice them to use it to check they have the right insulin when receiving a prescription, when insulin is dispensed and when insulin is being given to them by another person

  36. Professional Responsibility THE NPSA RECOMMEND Healthcare professionals who prescribe insulin are responsible for issuing patients with the information booklet and insulin passport Replacements should be provided when insulin is changed, the card is lost or it has become unreadable

  37. Obtaining the leaflets and insulin safety cards/ insulin passports • The patient information leaflet can be accessed at: http://www.diabetes.nhs.uk/safe_use_of_insulin/implementation_of_the_insulin_passport/patient_information_booklet_and_insulin_safety_cards/ • Insulin cards can be obtained from the Community diabetes specialist nursing team if required • Further supplies can be obtained from the pharmaceutical companies if required

  38. In Summary The NPSA recommend That all adults with diabetes requiring insulin therapy be provided with an information leaflet outlining potential errors that can occur with insulin And a patient and held record- the insulin passport The contact details for the Community Diabetes Nursing team are: Sue Jones (Lead): 07909930604 Glen Nicholson: 07971795712 Helena Healey: 07971034694 Judith Marples: 07788564670 Jo Bissell: 07971795711 Amanda Leishman: 07733313402

  39. The X-PERT Programme:taking control The X-PERT Programme is a 6 week group education programme for people with diabetes helping them to learn to self-manage their condition and reduce the need for medication. • Structured patient education programme that meets the key criteria identified by the DOH and Diabetes UK to implement the NICE guidelines. • Delivered by trained Xpert educators (diabetes specialist nurses and dieticians) • Based on principles of empowerment, discovery learning and patient centred care

  40. The X-PERT Programme:taking control It has proven to be: • clinically effective - participants demonstrate improved diabetes control, increased self-management skills and improved lifestyle and quality of life and have a reduced need for medication • cost effective -per patient it costs less than the annual average prescription for diabetes medication • empowering - improves the health and well-being of participants

  41. The X-PERT Programme:taking control • Week 1 –, explanation of aetiology of type 1 and type 2 diabetes, the role of obesity and physical inactivity on insulin resistance, patients encouraged to obtain weight, BP, blood lipids and HbA1c at beginning of the course (taken if required) • Week 2- Focuses on weight management, introduces the concept of the balance of good health, explores carbohydrate digestion and effect on blood glucose • Week 3 – Carbohydrate awareness exploring the carbohydrate content of various foods utilising food models and other visual aids

  42. The X-PERT Programme:taking control • Week 4 – Understanding food labels, a virtual supermarket tour • Week 5 – Possible complications of diabetes • Week 6 –Interactive session reinforcing and summarising course content and exploring participant understanding • Patients will be invited to attend a follow up session where subsequent biochemical parameters will be discussed

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