Guidance for the Self Administration & Self-Management of Diabetes, Including Blood Glucose Monitoring, by Adults in Leeds Teaching Hospitals Trust

1. Introduction
2. Definitions
3. Key roles and responsibilities
4. Assessment
5. Blood Glucose Monitoring
6. Patients self blood glucose testing process
7. Reassessment

1. Introduction

1.1. This guidance should be read in conjunction with The Leeds Teaching Hospitals NHS Trust Procedure for the Self administration of medicine by patient/carers policy. (http://thehub.leedsth.nhs.uk/Documents/PoliciesandProcedure/Self Administration of Medicines by Patients or Carers Procedure.pdf)

1.2. This guidance has been developed to provide a framework which allows patients with diabetes to safely manage their condition whilst they are in hospital. This includes the administration and/or dosing of their insulin and monitoring of blood glucose levels. Self-management of diabetes and insulin is advocated as a gold standard within documentation from Diabetes UK ( A good Inpatient Diabetes Service (July 2019)), NPSA (2010, 2011) NICE (2011) and NHS Diabetes (2011, 2012) ^(1-6). Evidence is available to suggest that promoting and encouraging patient self-administration of subcutaneous insulin reduces the risk of medication errors and improves patient and staff satisfaction.

1.3. There is also evidence that many patient meters do not meet the required international standards (7-10). ISO 15197 In vitro diagnostic test systems – requirements for blood glucose monitoring systems for self- testing in managing diabetes mellitus.
The proposed update to this standard in 2012 stated that blood glucose monitors should achieve 95% of results:
Within ± 0.83 mmol/L of laboratory results at concentrations of under 5.6 mmol/L
Within ± 15% of laboratory results at concentrations of 5.6 mmol/L or more.

1.4. Leeds Teaching Hospitals Trust wishes to encourage patients to self manage their diabetes, as recommended by national guidelines, and has a responsibility to ensure that patients within our care are supported to do so safely.

1.5. This purpose of this guidance is to ensure that:

• appropriate patients are recruited on to the self-management of insulin scheme, where this is judged clinically safe
• these patients are fully informed about the scheme, assessed as competent to safely administer their insulin, record blood glucose levels if appropriate, and safely access/store insulin on the ward area
• appropriate monitoring arrangements are in place
• correct documentation is completed and filed in the medical record
• patients under the age of 19 should be referred to the ‘transition team’ for assessment before undertaking self-management
• any patient admitted with diabetic ketoacidosis (DKA) should be referred to the diabetes team before supporting a self-management decision

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2. Definitions

Self-management of diabetes in hospital is the independent, proactive use of insulin to maintain stable and near-normal capillary blood glucose levels while taking into account the effects of illness and changes in diet and activity.
Self-administration is the taking of medication (injected or oral) as prescribed by a doctor or non-medical prescriber.

Level 1 – Blood glucose monitoring will be done with the hospital system and insulin administered by the nurse in conjunction with the patient, providing a full explanation. There is no patient self-monitoring or self-administration. The registered nurse will record insulin dose given. Nurse/Clinical support worker (CSW) will record blood glucose results

Level 2 – The patient may or may not monitor his/her own blood glucose. The patient will administer their own insulin under nurse supervision as prescribed by Doctor or non-medical prescriber. The nurse will record the dose administered, record ‘self’ and sign in the nurse section of the administration record on the insulin chart. Insulin will be stored in a self-administration insulin box that can be kept in / on the bedside locker.

Level 3 – The patient may or may not monitor his/her own blood glucose. They will independently decide on their insulin dose and administer their own insulin . They will record the dose given and sign the patient section on the administration record of the insulin prescription chart. The nurse will check that the dose has been given, record 'self' and sign in the nurse section on the prescription chart. Insulin will be stored in a self-administration insulin box that can be kept in / on the bedside locker.

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3. Key roles and responsibilities

3.1. All LTHT Staff

• At no point must a member of Leeds Teaching Hospitals staff use a patients own blood glucose meter. If a member of LTHT staff is to administer insulin or the patient is assessed at Level 1 the glucose reading must be from a ward glucose meter.
• The diabetes transition would like to assess young people under the age of 19 prior to self-management being agreed, so please refer to them Ex 64996

3.2. Nursing staff

• assess the clinical condition of the patient to determine whether this may impair the patient’s ability to self-manage using the ‘Diabetes Self-Management Care Plan’ (WUN 1022) as their assessment tool
• encourage patient involvement and respect the patient’s wishes in decisions about all aspects of their diabetes care
• where there is disagreement about a patient’s ability to self-manage their diabetes, to involve the specialist Diabetes Team
• determine the level to which patient can self-manage

3.3. Medical staff

• prescribe insulin on the insulin prescription chart in accordance with the Safe Use of Insulin guidance and ensure that it is ordered promptly
  https://www.nice.org.uk/advice/ktt20/chapter/evidence-context#insulin-prescribing-and-administration-reducing-errors
• know which patients are self-managing their diabetes or administering their own insulin, in liaison with nursing staff
• ensure the appropriate level of self administration/management is indicated on the front of the Insulin prescription chart i.e. nurse administration, or self-administration (level 2 or 3) and is updated if the patient’s condition changes (in liaison with nursing staff)
• ensure that the insulin prescription chart is updated when an insulin prescription is changed and that the patient and the nursing staff are informed accordingly.

3.4. Nursing staff

• sign the level 3 box in the self-administration/management section of the prescription chart for patients who they agree may self-adjust their insulin
• if level 1 administer insulin, or level 2 oversee self-administration of insulin, in accordance with the Nursing and Midwifery Council Standards for medicines management (11)
• encourage patients to bring into hospital their own supply of insulin, insulin pen needles, hypo treatment and blood glucose monitoring equipment
• ensure that patients have an adequate supply of the correct insulin and the correct administration device
• ensure that all insulin pens are clearly labeled with the patient’s addressograph and disposed of after use
• ensure that insulin pens are never be used by more than one patient (because of the risk of cross infection)
• ensure patients are shown how and where to record blood glucose levels (subject to them having a suitable blood glucose meter)
• ensure patients are shown where to record insulin doses (level 3), and are aware that nurses will help with this where necessary
• must sign the insulin prescription chart daily to confirm that patients who self- administer/manage their insulin (level 3) remain competent to do so.
• Will seek advice from medical colleagues or diabetes team where there are concerns re a person’s ability to self-administer/manage accurately

3.5. Pharmacy

• when requested to prioritise dispensing requests for insulins do so as to avoid missed or delayed doses
• ward pharmacists and pharmacy technicians check medication history for possible discrepancies between the prescription, the ID card, the dose and the supply of insulin brought from home as appropriate

3.6. Diabetes Team

• support the introduction of self-management of diabetes and self- administration of insulin across LTHT
• provide ongoing general support for staff
• provide specific advice to patients new to self-management of their diabetes or self-administration of insulin
• advise where there is disagreement about a patient’s suitability to self-manage their diabetes or self-administer insulin
• advise what actions to take where a patient’s blood glucose readings are persistently out of the range 4 mmol/litre - 12 mmol/litre.
• will see patients who have been admitted with DKA for supporting self management /administration
• the ‘Transition Team’ will review all patients under the age of 19 before they undertake self management

3.7. The patient - If level 2 or 3

• must inform nursing staff when blood glucose levels read under 
4 mmol/litre and above 12 mmol/litre if monitoring their own blood glucose
• let nursing staff know if they are unable to continue to self-manage their diabetes or self-administer insulin
• safely dispose of sharps and clinical waste.
• store insulin as agreed with ward staff and return any keys on discharge.
• inform nursing or pharmacy staff if they require more insulin or equipment, with sufficient notice for this to be addressed before supplies run out
• will get blood glucose monitoring supplies brought in from home

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4. Assessment

4.1. nursing staff will have the responsibility for assessing the patient’s suitability for self administration/self-management of the diabetes or self-administration of insulin according to the criteria set out in the Self-management Care Plan (WUN1022) but may seek help from medical colleagues as necessary

4.2. It is not appropriate for patients to self-manage their diabetes or self-administer insulin when they are acutely unwell, including

• during periods of diabetic ketoacidosis
• when in a hyperosmolar hyperglycaemic state
• when experiencing severe infection
• immediately post-general anaesthetic or sedation
• when severely dehydrated or in shock
• whilst they require intravenous insulin.

4.3. Discussion about self management of their diabetes and self-administration of insulin should be undertaken with all patients whose condition is relatively stable and who normally self-administer/dose their insulin at home. The Assessment Checklist must be completed (WUN1022)

4.4. If the answer to all the questions on the assessment checklist is “yes”, the patient is suitable to self-manage their diabetes at level 3 at this time.

4.5. If the answer to all the questions on the assessment document is “no”, the patient is not suitable to self-administer at this time and should be assessed as level 1.

4.6. If the patient wishes to self-manage or self-administer but the answer to one or more of the questions on the assessment document is “no”, the patient may be assessed as level 1 or 2 following careful consideration of the individual’s circumstances. The Diabetes Team should be contacted for advice if necessary.

4.7. Patients for whom insulin is initiated in hospital or patients who wish to develop self- management skills should be assessed at level 2.

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5. Blood glucose monitoring

5.1. Patients who are self-managing their diabetes should be given the opportunity to test their blood glucose whilst in hospital, using their own blood glucose monitoring equipment ( this includes continuous glucose monitoring (CGM) and flash glucose monitoring) and supplies.

5.2. Minimum recommended testing as per self-management care plan. However the frequency of CBG testing may vary according to individual circumstances or in those who are self-managing

5.3. Patients undertaking self-management of their diabetes must agree with their clinical team the minimum frequency of blood glucose tests to be done and record the result on their insulin prescription chart or blood glucose chart. They may need encouragement and support to do this. In some cases it may be necessary for nursing staff to record blood glucose levels where the patient is unable.

5.4. Minimum recommended testing plan the frequency of CBG testing may vary according to individual circumstances or in those who are self-managing’

5.5. Patients must agree to notify staff if their blood glucose is under 4 mmol/litre or above 12 mmol/litre. (a patient information leaflet detailing their responsibilities will be given to them Print unit number WNA1424)

5.6. All blood glucose results under 4 mmol/litre must be confirmed with a ward blood glucose meter.

5.7. If there are concerns about the accuracy of a patient’s blood glucose meter this can be checked using the ward meter, using the same sample of blood. If blood glucose levels on the patient’s meter are within 1 mmol/litre of the result from the ward meter, this can be classed as acceptable. This rule is only applicable for results ≥4 mmol/litre, as any result less than 4 mmol/litre obtained on the patient’s meter must be confirmed by repeat on a ward glucose meter. If the patient’s meter is not performing adequately the ward meter must be used until the patient’s meter is repaired or replaced.

5.8. If there are problems with a patient’s own blood glucose meter, encourage the patient or carer to contact the meter company’s helpline for advice or replacement. Alternatively you can contact the Diabetes Team who will also be able to provide a replacement meter.

5.9. Please note:

• it is not appropriate to contact Point of Care about
patients’ own meters
• Point of Care/ Pharmacy cannot provide patients with blood glucose meters, lancets or test strips.

5.10. Where two consecutive blood glucose readings are above 12 mmol/litre, blood glucose should be rechecked using the ward meter. If blood glucose levels are persistently out of this range, consider reviewing diabetes medication/insulin. Referral can be made to inpatient diabetes team if required.

5.11. Under no circumstances should a patient’s own blood glucose meter be used by nursing staff in the hospital setting.

5.12. For patients on real time and intermittently scanned continuous glucose monitoring (rtCGM and isCGM), ensure any hypoglycaemia suspected is confirmed with capillary blood glucose reading. Similarly, treatment post hypoglycaemia should be confirmed using capillary blood glucose reading.

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6. Patients’ self blood glucose testing process

6.1. Before patients undertake blood glucose testing on their own meter

• A comparison blood glucose test with a Trust meter should be undertaken. The results must be within 1 mmol/litre of the Trust meter reading. This rule is only applicable for results ≥4 mmol/litre, as any result less than 4 mmol/litre obtained on the patient’s meter must be confirmed by repeat on a ward glucose meter.
• This comparison check should be recorded on the insulin prescription chart and repeated at least weekly.
• If the patient’s meter is not reading accurately the ward meter must be used until it is repaired or replaced. It is NOT adequate to just repeat the comparison process. The patient must be assessed as level 1 or 2.

6.2. Once a patient and their meter has been assessed as suitable for self-management, the patient, if s/he is agreeable:

• must be asked to sign the ‘patient declaration agreement’ which is on their self- management care plan and the appropriate box ticked to indicate the elements of care they are undertaking
• is provided with a patient information leaflet “Information for those with diabetes during your stay in hospital’ which can be ordered from Print Unit WNA1424.
• must be provided with a secure lockable storage place for their supplies
  -Requests for safe storage can be made to Medicines Management Nursing Team on Ex 65301/65701 or 67399

6.3. The patient must be informed of:

• the importance of recording blood glucose (if at level 2/3 and insulin doses if level 3) and how to do this and be assured that nurses will help with this where necessary
• the requirement to inform nursing staff when blood glucose levels read under 4 mmol/litre and above 12 mmol/litre
• the need to let nursing staff know if they are unable to continue to self-manage their diabetes or self-administer insulin
• their responsibilities for the safe disposal of sharps (in the sharps container provided by the ward) and clinical waste (eg used tissues and strips), safe storage of insulin and the need to return the key on discharge
• the need to inform nursing or pharmacy staff if they require more insulin with sufficient notice for this to be addressed before supplies run out. Blood glucose monitoring strips/lancets must be supplied from home

6.4. The nurse must sign the insulin prescription chart daily to confirm that patients who self- administer/dose their insulin (level 3) remain competent to do so.

6.5. Staff must be alert to identify gaps in patient knowledge, self-management and self- administration skills. These must be addressed in a timely manner, involving the Diabetes Team as necessary.

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7. Reassessment

7.1. In addition to daily checks, patients’ suitability for self-management of diabetes or self-administration of insulin should be formally reassessed, and documented on the assessment checklist, at least weekly. Circumstances which prompt an earlier reassessment include:

• the patient becoming confused, more unwell or increasingly dependent
• the patient being given general anaesthesia or sedation
• an improvement in the patient’s condition
• the occurrence of an incident related to self-management of diabetes or self- administration of insulin, eg the patient inappropriately misses a dose of insulin.

7.2. Following reassessment the insulin chart must be updated and any changes communicated at nursing handover and to medical staff.

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