Review of insulin therapy and pen use in hospitalized patients

The experiences of insulin use among older people with Type 2 diabetes mellitus: A thematic synthesis

BACKGROUND

Type 2 diabetes mellitus is common in older people. Managing diabetes in older people can be challenging due to comorbidities and age-related disabilities, particularly in the context of insulin therapy. The purpose of this review is to explore older people's experiences of insulin use and to consider how these experiences might inform healthcare delivery.

REVIEW METHODS

A systematic review with thematic synthesis was conducted and reported in accordance with the PRISMA and ENTREQ statements. MEDLINE, Embase, PsycInfo, CINAHL and Web of Science were searched from 1985 to September 2019 with subsequent updates in December 2019 and June 2022. Included studies were quality appraised, findings tabulated, and results used to inform an integrated thematic synthesis.

RESULTS

Fourteen studies that reported insulin experiences with 274 patients aged 60 years and over were included; nine of the studies were qualitative and five used questionnaires surveys. Seven themes emerged that were grouped into treatment-related factors (physical impact of insulin, physical capacity to administer insulin, insulin self-management behaviours) and person-centred factors (emotional factors, social factors, daily living, and personal knowledge/beliefs). Three analytical themes to guide clinical practice were derived from the data: addressing physical capacity and ability, supporting social and emotional issues and improving interactions with healthcare professionals.

CONCLUSION

The review indicates issues surrounding the technical aspects of insulin administration, side effects of treatment and reactions to insulin administration are common amongst older people. However, research evidence is limited, and there is an urgent need for empirical, participatory research with older insulin dependent adults with type 2 diabetes.

IMPLICATIONS FOR PRACTICE

Healthcare professionals need to ensure that older type 2 diabetes people on insulin are actively involved in their own care, to allow their insulin regimens to be personalised and aligned with their goals and expectations. Tailored educational interventions to reduce treatment hazards and promote physical and psychological wellbeing are also needed for this population.

EADSG Guidelines: Insulin Storage and Optimisation of Injection Technique in Diabetes Management

To date, insulin therapy remains the cornerstone of diabetes management; but the art of injecting insulin is still poorly understood in many health facilities. To address this gap, the Forum for Injection Technique and Therapy Expert Recommendations (FITTER) published recommendations on injection technique after a workshop held in Rome, Italy in 2015. These recommendations are generally applicable to the majority of patients on insulin therapy, athough they do not explore alternative details that may be suitable for low- and middle-income countries. The East Africa Diabetes Study Group sought to address this gap, and furthermore to seek consensus on some of the contextual issues pertaining to insulin therapy within the East African region, specifically focusing on scarcity of resources and its adverse effect on the quality of care. A meeting of health care professionals, experts in diabetes management and patients using insulin, was convened in Kigali, Rwanda on 11 March 2018, and the following recommendations were made: (1) insulin should be transported safely, without undue shaking and exposure to high (> 32 °C) temperature environments. (2) Insulin should not be transported below 0 °C. (3) If insulin is to be stored at home for over 2 months, it should be stored at the recommended temperature of 2-8 °C. (4) Appropriate instructions should be given to patients while dispensing insulin. (5) Insulin in use should be kept at room temperature and should never be kept immersed under water. Immersing insulin under water after the vial has been pierced carries a high risk of contamination, leading to loss of potency and likelihood of causing injection abscesses. (6) The shortest available needles (4 mm for pen and 6 mm for insulin syringe) should be preferred for all patients. (7) In routine care, intramuscular injections should be avoided, especially with long-acting insulins, as it may result in severe hypoglycaemia. (8) The practice of slanting the needle excessively should be avoided as it results in sub-epidermal injection of insulin which leads to poor absorption and may cause "tattooing" of the skin and scarring. (9) In patients presenting in a wasted state, with "paper-like skin", injections should, if possible, be initiated with pen injection devices, so as to utilise the 4-mm needle without lifting a skin fold (pinching the skin); otherwise lifting of a skin fold is required, if longer needles are utilised. (10) Reuse of needles and syringes is not recommended. However, as the reuse of syringes and needles is practiced for various reasons, and by many patients, individuals should not be given alarming messages; and usage should be limited to discarding when injections become more painful; but at any rate not to exceed reusing a needle more than 5 times.

Economic outcomes with the conversion of insulin delivery methods in hospitals

PURPOSE

To evaluate the insulin wastage and associated acquisition costs when switching from individual patient supply (IPS) of 3-mL pens of rapid-acting insulin (RAI) aspart to floor stock (FS) dispensing of 3-mL vials of RAI lispro, and with conversion from IPS of 3-mL pens to centralized unit dose (CUD) of 10-mL vials of basal insulin detemir.

METHODS

Data from September 2010 to December 2012 from three hospitals in the Roper St. Francis Healthcare (RSFH) were used: Roper Hospital (368 beds), Bon Secours St. Francis Hospital (204 beds), and Roper St. Francis Mt. Pleasant Hospital (85 beds). Insulin wastage and associated acquisition costs were estimated using regression models.

RESULTS

The conversion from IPS of 3-mL pens of insulin aspart to FS of 3-mL vials of lispro was associated with a significant decrease in insulin wastage (204,042 IUs; p < .001) and equated to an average savings of $106.40 per patient at all three hospitals combined (p < .001). For basal insulin, conversion from IPS of 3-mL pens of insulin detemir to CUD of 10-mL vials was associated with a significant decrease in insulin wastage at Roper and St. Francis Hospitals (p < .001). For Mt. Pleasant Hospital, the decrease was not statistically significant. The predicted average reduction in insulin wastage per month was 52,542.9 IUs (p < .001) at all three hospitals combined.

CONCLUSIONS

Switching RAI from IPS of 3-mL pens of insulin aspart to one-time unit dose insulin lispro dispensed from FS 3-mL vials as needed significantly reduced insulin wastage and associated acquisition costs at the three combined hospitals. Conversion of basal insulin from IPS of 3-mL pens of insulin detemir to CUD of 10-mL vials of insulin detemir was associated with a significant reduction in insulin wastage and associated acquisition costs at three hospitals combined.

Comparison of Insulin Detemir and Insulin Glargine for Hospitalized Patients on a Basal-Bolus Protocol

BACKGROUND: The primary purpose of this study is to determine whether insulin detemir is equivalent to insulin glargine in controlling hyperglycemia for the adult hospitalized patient on a basal-bolus treatment regimen. METHODS: A retrospective study was conducted at two acute care hospitals within the same health system. Patients from both facilities who were initiated on a basal-bolus subcutaneous insulin regimen were included in the study. The basal-bolus regimen consisted of three components: basal, bolus, and corrective insulin with only the data from the first seven days analyzed. Once the basal-bolus protocol was initiated, all previous glycemic agents were discontinued. The target glycemic goal of the study was 100–180 mg/dL. RESULTS: In both groups, 50% of the patients had achieved the target glycemic control goal (100–180 mg/dL) by day 2 (p = 0.3). However, on the seventh or last day of basal-bolus treatment, whichever came first, 36.36% of patients receiving insulin detemir (n = 88) achieved the blood glucose reading goal compared to 52.00% in patients receiving insulin glargine (n = 100) (p = 0.03). This corresponded to an adjusted odds ratio of 2.12 (1.08 to 4.15), p = 0.03. The adjusting variables were provider type, whether the patient was hospitalized within 30 days prior and diagnosis of stroke. The mean blood glucose readings for the insulin glargine and the insulin detemir groups while on basal-bolus therapy were 200 mg/dL and 215 mg/dL, respectively (p = 0.05). The total number of blood glucose readings less than 70 mg/dL and less than 45 mg/dL was very low and there were no differences in number of episodes with hypoglycemia between the two groups. CONCLUSION: There was not a statistical difference between the two groups at 2 days, however there was on the seventh day or the last day of basal-bolus treatment. There were nonsignificant hypoglycemia events between basal insulin groups and the results for the last or seventh day of treatment may not be clinically significant in practice.

Facilitating the safe use of insulin pens in hospitals through a mentored quality-improvement program

PURPOSE

Results of the MENTORED QUALITY IMPROVEMENT IMPACT PROGRAM℠ (MQIIP) on Ensuring Insulin Pen Safety in Hospitals, which was part of an ASHP educational initiative aimed at ensuring the safe use of insulin pens in hospitals, are described.

METHODS

During this ASHP initiative, which also included continuing-education activities and Web-based resources, distance mentoring by pharmacists with expertise in the safe use of insulin pens was provided to interprofessional teams at 14 hospitals between September 2014 and May 2015. The results of baseline assessments of nursing staff knowledge of insulin pen use, insulin pen storage and labeling audits, and insulin pen injection observations conducted in September and October 2014 were the basis for insulin pen quality-improvement plans. Postintervention data were collected in April and May 2015.

RESULTS

Compared with the baseline period, significant improvements in nurses' knowledge of insulin pen use, insulin pen labeling and storage, and insulin pen administration were observed in the postintervention period despite the relatively short time frame for implementation of quality-improvement plans. Program participants are committed to sustaining and building on improvements achieved during the program. The outcome measures described in this report could be adapted by other health systems to identify opportunities to improve the safety of insulin pen use.

CONCLUSION

Focused attention on insulin pen safety through an interprofessional team approach during the MQIIP enabled participating sites to detect potential safety issues based on collected data, develop targeted process changes, document improvements, and identify areas requiring further intervention. A sustained organizational commitment is required to ensure the safe use of insulin pen devices in hospitals.

Examining Factors That Impact Inpatient Management of Diabetes and the Role of Insulin Pen Devices

Insulin administration in the acute care setting is an integral component of inpatient diabetes management. Although some institutions have moved to insulin pen devices, many acute care settings continue to employ the vial and syringe method of insulin administration. The aim of this study was to evaluate the impact of insulin pen implementation in the acute care setting on patients, healthcare workers and health resource utilization. A review of published literature, including guidelines, was conducted to identify how insulin pen devices in the acute care setting may impact inpatient diabetes management. Previously published studies have revealed that insulin pen devices have the potential to improve inpatient management through better glycemic control, increased adherence and improved self-management education. Furthermore, insulin pen devices may result in cost savings and improved safety for healthcare workers. There are benefits to the use of insulin pen devices in acute care and, as such, their implementation should be considered.

Determinants of nurse satisfaction using insulin pen devices with safety needles: an exploratory factor analysis

Background

A paucity of data exists to examine nurses’ satisfaction with the use of insulin pens with safety needles in hospitalized patients with diabetes. We investigated major determinants of nurses’ preference of the method of insulin administration in the context of a General Hospital in Northern Italy.

Methods

Consecutive patients admitted to three hospital units of different care intensity requiring insulin received insulin therapy through either the vial/syringe method (October to December 2012) or pen/safety needles with dual-ended protection method (January to March 2013). Before the implementation of insulin pens, floor nurses received a specific training program for proper insulin pen injection technique including individual testing of the devices (pen/safety needles). At the end of the study, nurses completed the Nursing Satisfaction Survey Questionnaire. Cronbach’s alpha was used to determine the internal consistency and reliability of the questionnaire. Major determinants of satisfaction were investigated through an exploratory factor analysis. The association between each retained factor and time spent to teach patients how to self-inject insulin with pen devices was also investigated.

Results

Fifty-three out of 60 nurses (mean age ± SD 36.2 ± 8.5 years, 85 % women, 57 % with 10+ years of working experience) returned the questionnaire. Internal consistency of the questionnaire was satisfactory (Cronbach’s alpha > 0.9). Three months after their introduction, about 92 % of nurses considered pen devices an “improvement” over the vial/syringe method. Two factors explained 85 % of nurses’ satisfaction, one related to convenience and ease of use, and the other to satisfaction/time spent for dose preparation and administration. The latter factor was inversely correlated with time spent on patients’ training tasks.

Conclusions

Nurses’ satisfaction with pen devices was higher than previously reported, possibly reinforced by safety needles with dual-ended protection. Perceived workload was a major determinant of nurse satisfaction using pen devices with safety needles. To facilitate the introduction of insulin pens in the hospital setting, it should be specifically addressed during training programs in the switch-over period.