• Registered Nurses Association of Ontario (RNAO). Best practice guideline for the subcutaneous administration of insulin in adults with type 2 diabetes. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2004 Jun. 91 p. [121 references]

This is the current release of the guideline.

Type 2 diabetes

Counseling
Evaluation
Management

Nursing

Advanced Practice Nurses
Nurses

• To present nursing best practice guidelines for the subcutaneous administration of insulin in adults with type 2 diabetes
• To assist nurses who do not specialize in diabetes education and care to administer insulin safely and to teach basic self-management skills to clients who require insulin therapy

Individuals 18 years and older with type 2 diabetes requiring subcutaneous insulin therapy

Evaluation

Assessment of patient psychosocial factors

Management/Treatment/Counseling

1. Provide appropriate teaching for patients and their caregivers to include:
   • Insulin preparation and administration
   • Self-testing technique, meter maintenance and accuracy verification
   • Prevention, recognition, and treatment of hypoglycemia
   • Management adjustments during periods of illness
2. Evaluate understanding of previous teaching and reeducate or reinforce as needed
3. Nursing education recommendations and strategies directed at the competencies required for practice
4. Organization and policy recommendations and strategies directed at practice settings and the environment in order to facilitate nurses’ practice.

• Morbidity
• Glycemic control
• Safety of subcutaneous administration of insulin

Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases
Searches of Unpublished Data

A database search for existing guidelines was conducted by a university health sciences library. An initial search of the MEDLINE, Embase, and CINAHL databases for guidelines and articles published from January 1, 1995, to December 2002, was conducted using the following search terms: "type 2 diabetes", "diabetes self-care education", "insulin initiation", "self-care", "self management", "systematic reviews", "practice guideline(s)", "clinical practice guideline(s)", "standards", "consensus statement(s)", "consensus", "evidence-based guidelines" and "best practice guidelines".

One individual searched an established list of Web sites for content related to the topic area. This list of sites, reviewed and updated in October 2002, was compiled based on existing knowledge of evidence-based practice Web sites, known guideline developers, and recommendations from the literature. Presence or absence of guidelines was noted for each site searched as well as date searched. The Web sites at times did not house a guideline but directed to another Web site or source for guideline retrieval. Guidelines were either downloaded if full versions were available or were ordered by phone/e-mail.

A Web site search for existing diabetes guidelines was conducted via the search engine "Google", using the search terms identified above. One individual conducted this search, noting the search term results, the Web sites reviewed, date and a summary of the findings. The search results were further critiqued by a second individual who identified guidelines and literature not previously retrieved.

Additionally, panel members were already in possession of a few of the identified guidelines. Is some instances, a guideline was identified by panel members and not found through the previous search strategies. These were guidelines that were developed by local groups or specific professional associations.

The final step in determining whether the clinical practice guideline would be critically appraised was to have two individuals screen the guidelines based on the following criteria. These criteria were determined by panel consensus:

• Guideline was in English, international in scope.
• Guideline dated no earlier than 1998.
• Guideline was strictly about the topic area.
• Guideline was evidence-based (e.g. contained references, description of evidence, sources of evidence).
• Guideline was available and accessible for retrieval.

Four guidelines were deemed suitable for critical review using the Appraisal of Guidelines for Research and Evaluation instrument.

Following the appraisal process, the guideline development panel identified four guidelines to develop the recommendations cited in the guideline.

Weighting According to a Rating Scheme (Scheme Given)

Level of Evidence

Ia - Evidence obtained from meta-analysis or systematic review of randomized controlled trials

Ib - Evidence obtained from at least one randomized controlled trial

IIa - Evidence obtained from at least one well-designed controlled study without randomization

IIb - Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization

III - Evidence obtained from well-designed nonexperimental descriptive studies, such as comparative studies, correlation studies, and case studies

IV - Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities

Review of Published Meta-Analyses
Systematic Review

Not stated

Expert Consensus

In January of 2003, a panel of nurses with expertise in practice and education related to diabetes, from institutional and community settings, was established by the Registered Nurses Association of Ontario (RNAO). At the onset, the panel discussed and came to consensus on the scope of the best practice guideline.

The panel members divided into subgroups to undergo specific activities using the short-listed guidelines, other literature, and additional resources for the purpose of drafting recommendations for nursing interventions. This process yielded a draft set of recommendations. The panel members as a whole reviewed the recommendations, discussed gaps and available evidence, and came to consensus on a draft guideline.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

External Peer Review
Internal Peer Review

The development process yielded an initial set of recommendations. The panel members as a whole reviewed the recommendations, discussed gaps and available evidence, and came to a consensus on a draft guideline.

This draft was submitted to a set of external stakeholders for review and feedback. Stakeholders represented various health care disciplines, as well as professional associations. External stakeholders were provided with specific questions for comment, as well as the opportunity to give overall feedback and general impressions. The results were compiled and reviewed by the development panel. Discussion and consensus resulted in revisions to the draft document prior to publication and evaluation.

The levels of evidence supporting the recommendations (Ia, Ib, IIa, IIb, III, IV) are defined at the end of the "Major Recommendations" field

Definitions:

Level of Evidence

Ia - Evidence obtained from meta-analysis or systematic review of randomized controlled trials

Ib - Evidence obtained from at least one randomized controlled trial

IIa - Evidence obtained from at least one well-designed controlled study without randomization

IIb - Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization

III - Evidence obtained from well-designed nonexperimental descriptive studies, such as comparative studies, correlation studies, and case studies

IV - Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities

None provided

The type of evidence is provided for each recommendation (see "Major recommendations").

• This guideline will assist nurses who are not specialists in diabetes care to safely initiate and administer insulin, a "high-alert" medication.
• This guideline will provide answers to the question: What are the essential client self-care components to be addressed by nurses when caring for an adult with type 2 diabetes who requires subcutaneous insulin.
• Patients who receive support in achieving optimal glycemic control significantly reduce the risk of microvascular damage; the major cause of blindness and kidney disease and non-traumatic amputations.

Not stated

• The document needs to be reviewed and applied, based on the specific needs of the organization or practice setting/environment, as well as the needs and wishes of the client. Guidelines should not be applied in a "cookbook" fashion but used as a tool to assist in decision making for individualized client care, as well as ensuring that appropriate structures and supports are in place to provide the best possible care.
• These best practice guidelines are related only to nursing practice and not intended to take into account fiscal efficiencies. These guidelines are not binding for nurses and their use should be flexible to accommodate client/family wishes and local circumstances. They neither constitute a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses Association of Ontario (RNAO) give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work. Any reference throughout the document to specific pharmaceutical products as examples does not imply endorsement of any of these products.
• It is acknowledged that the individual competencies of nurses varies between nurses and across categories of nursing professionals (registered practical nurses [RPNs] and registered nurses [RNs]) and are based on knowledge, skills, attitudes, and judgement enhanced over time by experience and education. It is expected that individual nurses will perform only those aspects of care for which they have obtained appropriate education and experience. Both RNs and RPNs should seek consultation in instances where the client’s care needs surpass the individual nurse’s ability to act independently.

Best practice guidelines can only be successfully implemented if there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. Registered Nurses Association of Ontario (RNAO), through a panel of nurses, researchers, and administrators has developed the Toolkit: Implementation of Clinical Practice Guidelines based on available evidence, theoretical perspectives, and consensus. The Toolkit is recommended for guiding the implementation of any clinical practice guideline in a health care organization.

The Toolkit provides step-by-step directions to individuals and groups involved in planning, coordinating, and facilitating guideline implementation. Specifically, the Toolkit addresses the following key steps:

1. Identifying a well-developed, evidence-based clinical practice guideline
2. Identification, assessment, and engagement of stakeholders
3. Assessment of environmental readiness for guideline implementation
4. Identifying and planning evidence-based implementation strategies
5. Planning and implementing evaluation
6. Identifying and securing required resources for implementation

Implementing practice guidelines that result in successful practice changes and positive clinical impact is a complex undertaking. The Toolkit is one key resource for managing this process.

Evaluation and Monitoring

Organizations implementing the recommendations in this nursing best practice guideline are advised to consider how the implementation and its impact will be monitored and evaluated. A table found in the original guideline document, based on the framework outlined in the RNAO Toolkit: Implementation of clinical practice guidelines (2002b), illustrates some suggested indicators for monitoring and evaluation.

Living with Illness

Effectiveness
Patient-centeredness
Safety

• Registered Nurses Association of Ontario (RNAO). Best practice guideline for the subcutaneous administration of insulin in adults with type 2 diabetes. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2004 Jun. 91 p. [121 references]

2004 Jun

Registered Nurses Association of Ontario - Professional Association

Funding was provided by the Ontario Ministry of Health and Long Term Care.

Not stated

Guideline Development Panel Members

Anna Brundage, RN, BHSc(N), CDE
Team Leader
Manager
TRIDEC
Sunnybrook and Women’s College
Health Sciences Centre
Toronto, Ontario

Ceilia Ayotte, RN, CDE
Diabetes Educator
Peterborough Regional Health Centre
Peterborough, Ontario

Marianne Beckstead, RN, MN, CDE
Clinical Nurse Specialist – Diabetes
University Health Network
Toronto, Ontario

Sharon Brez, RN, BScN, MA(Ed), CDE
Advanced Practice Nurse
Endocrinology and Metabolism
The Ottawa Hospital
Ottawa, Ontario

Linda Fraser, RN, BScN, CDE
Diabetes Educator
Victorian Order of Nurses – Peel
Mississauga, Ontario

Karen Gorecki, RN, MN
Clinical Nurse Specialist – Diabetes
Leadership Sinai Centre for Diabetes
Mount Sinai Hospital
Toronto, Ontario

Robin Hokstad, RN, CDE
Diabetes Nurse Educator
Diabetes Centre – Nipissing District
North Bay, Ontario

Nancy Muller, RN, CDE
Diabetes Nurse Educator
Red Lake District Diabetes Program
Red Lake, Ontario

Mary Beth Neibert, RN, MS, CDE, ACNP
Clinical Nurse Specialist – Diabetes
St. Joseph’s Hospital
Hamilton, Ontario

Josephine Santos, RN, MN
Facilitator, Project Coordinator
Nursing Best Practice Guidelines Project
Registered Nurses Association of Ontario
Toronto, Ontario

Susan Stinson, RN, CDE
Diabetes Education Centre
Grand River Hospital
Type 2 Health Management Clinic
St. Mary’s Hospital
Kitchener, Ontario

Declarations of interest and confidentiality were made by all members of the guideline development panel. Further details are available from the Registered Nurses Association of Ontario (RNAO).

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI on November 3, 2004. The information was verified by the guideline developer on November 23, 2004.

This document is in the public domain and may be used and reprinted without special permission, except for those copyrighted materials noted for which further reproduction is prohibited without the specific permission of copyright holders. The Registered Nurses Association of Ontario (RNAO) will appreciate citation as to source. The suggested format for citation is indicated below:

Registered Nurses Association of Ontario (2004). Best practice guideline for the subcutaneous administration of insulin in adults with type 2 diabetes. Toronto, Canada: Registered Nurses Association of Ontario.