Forum for Injection Technique 2.0 Addendum 1: Insulin use in indoor settings.

Insulin is a frequently used drug in the indoor setting. Comprehensive recommendations for best practice in insulin injection technique have been published by the forum for injection technique (FIT), India. This addendum focuses on insulin use in indoor settings, and complements the FIT 2.0 recommendations. It discusses insulin use and disposal in critical care and noncritical care settings. It also highlights the need to ensure continuing nursing and medical education, and frame insulin policies for such use.

INTRODUCTION

The Forum for Injection Technique (FIT), India, released the second edition of its Recommendations for best practice in insulin injection technique in 2015.[1] While the need to focus on insulin injection techniques in perioperative and intensive care settings has been highlighted earlier,[2] the FIT2.0 has focused more on insulin usage in the outdoor setting. The FIT 2.0 recommendations do describe insulin use in indoor patients, but in brief. Keeping in view the high incidence of needlestick injuries, and inaccurate insulin technique, in nurses who inject insulin,[3] there is a need to highlight insulin technique in indoor settings.

This addendum suggests best practices to be followed in hospitalized patients in detail. It discusses practices for safe insulin use and disposal in the Intensive Care Units (ICU) and noncritical care settings, and underlines the need to create insulin policies or insulin stewardship programs, similar to existing antibiotic policy guidelines and programs, in each ICU and ward.

While drafting this addendum, covering guidance on insulin use in indoor settings, inputs from infection control and nursing experts were taken at an expert meeting held on May 10, 2016 in Mumbai, India. This was done to ensure practicality and pragmatism in execution of these recommendations in an indoor setting or hospital setup. For a clinical consensus, the addendum was shared with members of the FIT India board for their views before it was finalized.

Critical care settings

Each ICU should frame and follow an insulin policy, with equal emphasis on patient and health-care provider safety

The policy should focus on appropriate insulin technique, including prevention and management of needlestick injury

The ICU insulin policy should state the insulin preparation, strength, and delivery device to be used.

Compatibility of insulin strengths and their delivery devices should be ensured.

As far as possible, a single strength of insulin should be used in all patients in a hospital to minimize errors.

In India, presently, it is recommended that only vials and syringes be used. Use of insulin pens eliminates the need for matching strength of insulin and delivery device.

Insulin syringes should be stored away from other syringes

At times, insulin syringes may be used for other purposes such as antibiotic sensitivity tests. Such syringes should be marked and stored separately

Records of glucose monitoring, insulin dosage, time, and site of insulin must be maintained in indoor settings

Such records may be on dedicated sheets, or may be part of the overall bedside medical charts

Each patient should have his or her own insulin vial or pen, preferably kept at the bedside

Each vial or pen should be labeled with the patient's name and bed number/registration number

Certain ICUs use a common insulin vial for all patients. A fresh syringe should be used to draw each insulin dose

Emphasis should be laid on avoidance of syringe reuse, correct sharps disposal, and avoidance of needlestick injuries

Needlestick injuries must be reported to higher authorities in real time, using standard reporting forms

Intravenous insulin is the drug of choice for glycemic control in critical care settings.[45]

Noncritical care settings

Insulin policy

Each ward should frame and follow an insulin policy, with equal emphasis on patient and health-care provider safety

The policy should focus on appropriate insulin technique, including prevention and management of needlestick injury

The ward insulin policy should state the responsibilities of nursing and medical staff with respect to insulin prescription, counseling, storage, dose titration, administration, and disposal

Insulin syringes should be stored away from other syringes

At times, insulin syringes may be used for other purposes such as antibiotic sensitivity tests. Such syringes should be marked and stored separately

Each patient should have his or her own insulin vial(s), kept at the bedside or in a common refrigerator

Each vial or pen should be labeled with the patient's name and bed number/registration number

Subcutaneous insulin is the drug of choice for glycemic control in noncritical care settings [5]

As far as possible, a single strength of insulin should be used to minimize errors

Use of insulin pens reduces the chances of error.

Injection responsibility

Nursing and medical staff should assist in glucose monitoring, dose titration, and insulin injection when required

Patients who are capable of self-injecting should be encouraged to administer their insulin doses themselves

Patients who are unable to inject on their own should be administered insulin by nursing staff

Records of glucose monitoring, insulin dosage, time, and site of insulin must be maintained in indoor settings

Such records may be on dedicated sheets, or may be part of the overall bedside medical charts.

Injection technique

Compatibility of insulin strengths and their delivery devices should be ensured

Nursing staff must make every attempt to inject insulin over the abdomen or thigh

Nursing staff must make every attempt to follow a proper rotation policy

Rotation can be followed by marking sites of insulin injections with ink, after taking patient consent, and avoiding those sites for future injections

Rotation can also be followed by recording the site of every insulin injection on a paper grid attached to the insulin dose chart

Emphasis should be laid on avoidance of syringe reuse, correct sharps disposal, and avoidance of needlestick injuries

Needlestick injuries must be reported to higher authorities in real time, using standard reporting forms.

Patient education

Nursing staff should be aware that the insulin injection technique they practice will be followed by patients at home, after discharge

Medical and nursing staff should ensure that patients and/or their caregivers are adequately trained in insulin technique and disposal before discharge from hospital.

Safe disposal

Hospital staff are at high risk of needlestick injuries, and this predisposes them to blood-borne diseases.[6] Safe disposal practices help minimize this risk. It is recommended that:

Insulin syringes and pen needles should not be reused in indoor settings

Insulin syringe and pen needles should not be recapped

Insulin syringes and pen needles should be disposed of in dedicated sharps containers

Sharps containers should be available in every ICU, ward patient room, and at every nursing station

Insulin sharps should be disposed of in accordance with biomedical waste regulations [7]

At discharge, patients and their care givers should be counseled about safe and environment-friendly disposal methods.

Audit and appraisal

The ICU and ward insulin policy should be audited regularly by senior nursing and medical staff

Continuing nursing and medical education should be carried out to ensure proper insulin use and disposal in indoor settings

Such continuing education should factor the frequent turnover of nursing and resident staff in hospital settings.

SUMMARY

These simple, yet succinct, suggestions add value to the FIT 2.0 guidelines and should be useful for both nursing and medical staff. These suggestions should encourage creation of insulin policies, similar to antibiotic policies followed in the ICUs, in indoor settings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.