We’re helping hospital patients administer their own insulin
How a diabetes specialist nurse’s project is giving patients control and reducing waste
How diabetes specialist nurse Paula Johnston’s project is giving patients control and reducing waste
Before the start of the insulin self-administration project [at University Hospital Southampton NHS Foundation Trust], 80% of our patients had expressed a wish to be able to inject their insulin themselves while in hospital. A number of wards were letting some patients give themselves insulin but there was no formal process or documentation.
I knew that keeping insulin at a patient’s bedside would save nursing time and, importantly, allow patients to access their insulin themselves at the appropriate time. It was also important to reduce errors relating to insulin administration. I wanted to devise a process to enable safe self-administration.
The keys to our project’s success
Getting key people involved early on A steering group covering all areas included the consultant pharmacist, lead pharmacy technician and director of nursing for quality.
Building relationships I established good relationships with the IT department, which had to build an extra dummy drug into the electronic prescribing system, and with procurement, as they had to buy the plastic boxes to store insulin by patients’ bedsides.
Communication The most important thing has been to keep the right people informed about what we were doing.
Protected time Other trusts have tried to do this as part of the day job, but it was only possible because I had dedicated time for it.
Initially, we thought we could do it within our team, alongside our day jobs. But it quickly became apparent that it would take dedicated time to achieve.
I was seconded to work on the project three days a week, funded by pharmacy. It took 18-24 months to implement at our trust and we are rolling it out to the remaining final areas.
Other trusts have tried it, and we reviewed their approaches. It became clear where they were struggling. One problem was that nursing staff were carrying out the assessment and judging a patient’s suitability to self-administer.
Trusts said this was hampered by high staff turnover, which in turn meant increased training time. Another key issue was documenting the assessment on a paper form – it was not well-completed, and added to the nurses’ workload.
Initial patient assessment
Too much is expected of our nurses, and I knew I did not want the initial assessment to be a nursing job.
I felt it could be carried out by our medicines management technicians, and that they were ideally placed to have this discussion with patients. They were already spending time talking to them about their medications, so they would know which patients might be willing and able to self-administer, and I felt adding insulin self-assessment at this stage would work well.
On a practical level, there are 40-60 technicians at our trust, so it would be possible to get them together for training, whereas it is difficult to get nurses into extra training as they cannot take protected time from ward duties.
Link to electronic prescribing
To make the new process easy and not take up more nursing time, I wanted to link it to the electronic prescribing already introduced at the trust, putting the assessment into the system. All insulin is prescribed, so if we were going to introduce insulin self-administration it had to be part of the electronic prescribing, meaning everything was in the same place.
As project manager, I needed to collaborate with the hospital pharmacy and IT teams. I set up a steering group early on to secure support from key people. This included the deputy director of nursing, consultant pharmacist in diabetes, medication safety team and medicines management technician lead.
Next I developed a tool to assess whether it is safe for a patient to self-administer their insulin in hospital. It includes 'yes' or 'no' questions, the answers to which indicate an outcome. This was discussed at the group’s meetings, as was a visual, easy-to-follow flow chart I developed to illustrate the pathway.
‘When I initially spoke to the technicians there was a lot of negativity, as they thought it would increase their workload. This attitude changed after a series of training sessions’
First we got the whole group together and showed them how to follow the chart. When we rolled it out to different areas we went through it with them in more detail. We gave training on insulin and blood glucose levels and diabetes, giving them the knowledge they needed.
Now this role has developed and the technicians are assuming an extended role by taking a health promotion approach, asking patients how much alcohol they drink, looking at the person holistically, not just the medications they take.
After the initial assessment is prescribed on the electronic system, nursing staff take over and they can see the assessment outcome. They can press a button to agree, or if they are not certain the patient has been assessed correctly they can flag it up with the pharmacy.
Access at the bedside
Before we started self-administration, insulin was kept in fridges that patients did not have access to, so the next issue was finding an appropriate storage container to be placed at patients’ bedsides. We looked at special bedside medicine cabinets, but they are expensive, plus patients move wards or go home and we want medicines to go with them.
‘I came up with a simple and cheap solution – a plastic container costing just 15 pence to be kept at a patient’s bedside’
We contacted the Care Quality Commission, which informed us that as long as we completed a risk assessment the insulin did not have to be locked away. We looked carefully at our records and could not find any incidents of a patient harming themselves or others with an insulin pen.
I came up with a simple and cheap solution – a plastic container costing just 15 pence to be kept at a patient’s bedside. If a patient is unable to administer their own insulin it is stored in the existing cabinet by their bed.
We piloted the project on a cross-section of wards. First was a cystic fibrosis ward, where there were a lot of patients with insulin, followed by one of the vascular wards that had a high incidence of diabetes. Next was a medical ward.
Then we tried a surgical ward. This was more difficult to manage, and because patients were nil by mouth the ward team were understandably apprehensive.
We planned a phased rollout so we could see if any aspects needed changing. We found that some nurses were unfamiliar with the safety needles used, so we provided more training in injections so the nurses knew the correct needles to use. This is an issue we are still addressing in certain areas.
Once the project is standardised on our general wards, we will begin looking at high-care areas such as the emergency department and intensive care.
Early audits show savings. Before this, people were going home and their insulin was not going with them, or the pharmacy team was sending boxes of insulin that were not needed. A lot of insulin was accumulating in walled fridges.
We have reduced the amount of insulin wastage by 58% this year. Last year we reduced our wastage by 54%, which shows the practice is succeeding.
It is also improving patient safety. We have not had any incidents where medications have been mixed up and a patient has been given the wrong insulin.
We are about to look at insulin timing through electronic prescribing, as we now have one year of data. Prior to the self-administration project about 60% of patients on rapid insulin had their administration charted over an hour late. We are hoping to have improved that.
Improved diabetes awareness
In general terms, nurses are now more aware of their patients who are taking insulin and it has raised awareness of diabetes on the wards.
The assessment document pops up at each drug round, showing a particular patient is on insulin, which reminds nurses at multiple points of the day to consider patients’ diabetes, test their glucose levels and so on.
Patient feedback is good. Sometimes it is quite surprising who wants to take control of their insulin. One man in his 80s, who I expected would not want to self-administer completely surpsied me. He had been diagnosed for 30 years, would have done it at home and wanted to keep on doing it. And that was the aim of this project – giving back control to our patients.
Paula Johnston is a diabetes specialist nurse at University Hospital Southampton NHS Foundation Trust