In early 2014 the Commission completed a pilot of a standardised National Subcutaneous Insulin Chart to evaluate its effect on the safety of insulin prescribing and administration in hospitals. The chart provides a combined record of blood glucose monitoring with insulin prescribing and administration.
Eight public and private hospitals from three states and territories piloted the chart from early 2013 to early 2014.
Prior to introducing the pilot insulin chart, hospitals were required to conduct a baseline audit of their existing medication charts and forms used to prescribe and administer subcutaneous insulin and record blood glucose levels (BGLs). The pilot insulin chart was introduced on all adult wards following extensive education of medical, nursing and pharmacy staff using materials provided by the Commission.
In the pilot, hospitals reported issues, including adverse events resulting from the use of the insulin chart. Post-implementation audit data was collected six months after introducing the chart. Qualitative research, consisting of two implementation experience surveys and focus groups in selected sites, was conducted at the end of the intervention.
Overall the pilot subcutaneous insulin chart improved:
There were fewer instances of hypoglycaemia, and hyperglycaemia above 20 mmol/L. However, there was an increase in BGLs in the upper range (12 – 20mmol/L).
An unexpected consequence of the chart was an increase in the number of missing routine doses of insulin. This was largely attributed to the requirement for medical officers to review and write daily routine insulin orders in response to patient BGLs.
The eight pilot hospitals agreed that the pilot subcutaneous insulin chart was safer than their previous subcutaneous insulin chart. However, they recommended some design changes to improve the chart’s usability.
The National Insulin Form Pilot Advisory Group (the expert group providing oversight of the pilot) recommended modifying the design of the chart followed by further pilot testing.
In October 2014 the Commission contracted the School of Psychology at the University of Queensland to develop a modified chart and conduct further human factors testing against the national pilot chart. This work has now been completed and the new pilot chart developed by the University of Queensland will form the basis for a second phase of piloting in a small number of hospitals from mid-2015. A final version of the subcutaneous insulin chart is expected to be available mid-2016.
Diabetes in hospitalised patients is common and insulin is frequently prescribed. There is a need to ensure the safe and effective prescribing, administering and monitoring of medications for diabetes, particularly insulin.
Diabetes management in acute care is often sub-optimal, with problems such as poor glycaemic control, inadequate glucose monitoring and hypoglycaemia occurring commonly. Poor diabetes management compromises both the resolution of the diabetic patient’s intercurrent illness as well as their ongoing diabetic status.
Prescribing of insulin is complex and not without risk. Insulin is regarded as a high risk drug accounting for around 15% of the highest risk incidents (actual and potential) experienced in acute care.1
The objectives of the National Insulin Subcutaneous Insulin Chart pilot are to:
The hypothesis being tested is that the use of a standardised chart for prescribing and administering subcutaneous insulin and recording BGLs, when combined with planned implementation and education, can:
The Insulin Subcutaneous Order and Blood Glucose Record is designed to:
Contact for the project is Helen Stark on (02) 9126 3521 and firstname.lastname@example.org
1. Kerr M. Inpatient Care for People with Diabletes: The Economic Case for Change: National Health Service, 2011:52.