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For inpatients with diabetes, creative strategies needed for insulin pen education
BALTIMORE — The use of insulin pens varies widely from hospital to hospital, and teaching strategies for patients newly diagnosed with diabetes must be tailored based on what is available in a specific inpatient setting, according to a speaker here.
“Insulin pens can be used safely in hospitals by following the most recent Institute of Safe Medication Practices [ISMP] guidelines,” Jane Jeffrie Seley, DNP, MSN, MPH, GNP, CDE, BC-ADM, CDTC, FAADE, FAAN, program manager of the glycemic control program at New York-Presbyterian Hospital/Weill Cornell Medical Center, told Endocrine Today. “If your hospital does not use pens, creative teaching strategies are needed for patients to learn how to use pens at home.”
In February 2013, the ISMP warned that hospitals must reexamine the safe use of insulin pens and transition from their routine use, following several incidents in which patients were possibly exposed HIV, hepatitis B and hepatitis C due to the reuse of insulin pens on multiple patients after changing the disposable needle, Seley said during a presentation at the American Association of Diabetes Educators annual meeting.
In 2014, the ISMP again warned of more problems with inpatient insulin pen use — errors with wrong-patient pen use were still occurring, despite the use of high-level strategies, including one-on-one staff education, the implementation of pen and patient barcode scanning and an electronic medication administration record (eMAR) at the bedside, Seley said. Based on the risks and the warnings, some hospitals have never transitioned to insulin pens or reverted to using insulin vials, Seley said.
“A lot of people were against the idea of pens in the hospital, but I pointed out some important facts,” said Seley, who attended the national ISMP summit meeting held in 2015 to discuss safety challenges of insulin pens and helped craft their latest pen-use guideline. “What are new insulins coming out as? Pens. A lot of them aren’t even coming out in vials. It’s only a matter of time before we would be forced to move to pens anyway.”
The use of vial-and-syringe insulin in the hospital, Seley said, does not reflect the reality of patients once they transition to home.
“When patients go home from the hospital, what are they going home using — pens or vials?” Seley said. “Pens. Do you think it’s difficult to teach someone how to go home on a pen if you don’t have a pen to use with them? The real problem is you’re not simulating life for them. They’re in the hospital injecting into a practice pillow.”
New insulin pen guidelines
Today, the ISMP 2017 guidelines for optimizing safe, subcutaneous insulin use in adults outlines several safety standards for insulin pen use in the hospital, Seley said, including the following:
- Insulin pens should be dispensed with patient-specific barcode labels confirming the correct pen type;
- Patient-specific labels should be scanned at the bedside;
- Patient-specific labels should be affixed to the body of the insulin pen, not the cap, without obscuring the dose window or manufacturer label; and
- Each pen should be returned to a patient-specific bin after each use.
In addition to those guidelines, Seley said nurses should have only one insulin pen in their possession at a time. Carrying multiple pens, Seley said, increases the risk for patient errors.
“I’ve seen nurses who were inclined to have two or three pens in their pockets, and that is how most of those mistakes happen, by carrying multiple patient pens at the same time,” Seley said. “If you remember one thing that I said here today, it’s this: If you want pens back in your hospital, you must make the nurses promise — they have to promise —one insulin pen at a time, and then [put it] back in a patient-specific bin in your institution.”
Teaching strategies
For hospitals that do not use insulin pens, teaching protocol typically includes a practice pen and pillow, Seley said, along with informational handouts for the patient. While helpful, the teaching strategy is not the most effective for the patient, Seley said.
“It’s very nice to do a practice pillow, but it’s very different from doing it on yourself,” Seley said.
For hospitals that do not use insulin pens, the “workaround,” Seley said, is for nurses to use the vial-and-syringe system to teach patients how to safely inject themselves with insulin pens at home.
“The patient doesn’t need to draw [the insulin] up from the vial — the nurse can do that for them — but every single time the nurse comes in to give an injection, instead of giving it to the patient, it’s an opportunity for the patient to do the injection,” Seley said. “It’s the exact same steps as a pen: Choose a site, needle in, plunger down, count to 10, remove it.”
Seley said her institution also offers patients a generic handout, available in multiple languages, that teaches the basic injection methods for various types of insulin pens. – by Regina Schaffer
References:
Macmaster H and Seley JJ. Sending individuals home on insulin and keeping the home. Presented at: American Association of Diabetes Educators; Aug. 17-20, 2018; Baltimore.
Guidelines for optimizing safe subcutaneous insulin use in adults. Available at: https://www.ismp.org/guidelines/subcutaneous-insulin.
Disclosure: Seley reports she serves on advisory boards for Boehringer Ingelheim/Lilly Alliance and Sanofi.