Medicines Optimisation Team Standard Operating Procedure Insulin Quantities Audit

Transcription

1 Medicines Optimisation Team Standard Operating Procedure Insulin Quantities Audit Aim Review and rationalise the insulin quantities based on dosage instructions for diabetic patients in order to align quantities prescribed and reduce waste. Rationale The appropriate use of prescribed insulin is paramount since it has both patient safety and health economic implications. Incorrect or ambiguous dosage instructions can lead to adverse outcomes. Over ordering of insulin can cause unnecessary stock piling of medication in patient s homes that poses a risk to the individual and waste to the health economy. Inclusion criteria: All patients prescribed any insulin preparations as pens or insulin vials. Audit criteria Patient ID Patient surname Patient Forename Patient Age Registered or usual or prescribing GP [as per practice] Institutionalised or housebound status documented Current insulin, directions and quantity prescribed over the last 3 months Insulin initiated by Problem history of hypoglycaemia or hyperglycaemia Concurrent medication for hypoglycaemia, eg. Hypostop Gel and/or glucagon (GlucaGen Version I. August 2016 Page 1

2 HypoKit ) Diabetes Type documented (i.e. type 1 or 2, gestational, insulin pump) Pharmacist comments Proposed action GP agreement Exclusion Criteria Exclude patients who have had recent medication review and had prescribed quantities adjusted. Method Medicines Optimisation Lead for CCG will inform all GP practices within CCGs about the insulin quantities audit prior to its implementation Run the insulin search for your allocated surgery using the audit criteria above (Pre-built insulin search is available on EMIS enterprise to be copied where applicable) Export the results to EXCEL spread sheet Practice prescribing lead or equivalent to confirm all patients at the practice level on current insulin prescription and agrees to the audit Confirm the current insulin dose (from patients consultation notes, secondary care letters or by telephoning patient, this source should be documented in the consultation history with the date)/ On EMIS-web the READ code 66Aw (Insulin Dose) should be used to document the dosage. Calculate the required quantities using the current dose and insulin calculator provided, ensure there are enough for air shots Review the ordering frequency of the patient to ascertain whether over ordering is occurring Adjust the quantities on patient prescription and round it up to nearest whole pen. If the patient quantity needed per month when rounded up is very close to a full pen i.e. 0.8 or above it would be sensible to allow an extra pen in case of loss or malfunction. In addition set two pens as a minimum per month per patient, as one pen would be a risk for the reason stated above. Record the potential cost saving based on the previous 12 months issues of insulin. Inform the patient of any adjustments made via letter or verbally Note: Repeat dispensing patients should not be switched until the next authorised batch of prescriptions is due. However, if the GP practice has a robust recall process in place and the remaining batch prescription(s) are returned successfully, these patients may be switched. Identify the patient(s) on the data collection sheet with your recommendation(s) and discuss with the practice their preferred method of proceeding further. Version I. August 2016 Page 2

3 Worked example Method 1 calculation table (appendix 1) Patient is on 58 - Round up to 60 on the table. This would mean that 2016 would be needed per month which would be 6.72 pens and round up to 7 pens. As we have already rounded up the dose this quantity should be appropriate for this patient, but be cautious if rounding down e.g. if patient had been on 54 and we had gone to 50 you may want to give an additional pen. Method 2 Calculation from diabetes guidelines As a rule of thumb to calculate the quantity of insulin to prescribe the following formula can be used: (Total daily ) daily =58/10 = = 6.8 pens rounded up to 7 pens 54 daily =54/10= =6.4 pens rounded up to 7 pens (note if using table would come out as 6 pens) When all the above has been completed: Add a consultation to the patients notes to state the action taken Add the dose and the date this was confirmed in brackets to each of the insulin prescriptions if this is agreed with the practice, especially if currently only prescribed as directed. Mail merge and send patient letter if previously agreed. QIPP interventions captured and reported on QIPP record sheet. Adjusting insulin quantities: Once the above has been completed change the insulin quantities on the patients repeat prescription. If insulin quantities have been altered in consultation mode then add quantities altered with a brief explanation of changes carried out in the free text. Amend the medication duration on the prescription to coincide with how long this quantity of pens will last for the patient in-line with other prescription items. Informing the Patient: Informing the patient will depend on individual practice policies and the nature of the change. This may be done during the telephone conversation with the patient or by letter. Version I. August 2016 Page 3

4 Safety: If the person carrying out the changes has any concerns e.g. any alerts (such as do not change the quantity ) refer the query to the GP, practice pharmacist or Medicines Optimisation Team. Version I. August 2016 Page 4

5 APPENDIX 1 Quantity Calculation Chart Calculation Chart for the monthly amount of insulin to be prescribed in relation to daily dose taken Daily dose With air shots used when changing pen needles. Daily Number of used per month with airshots (Pens and cartridges) Number of 3ml cartridges or pens needed per monthly prescription (contain 300 ) Number of required per month with no airshot (Syringes) Number of10ml vials needed per monthly prescription (1,000 ). No airshot required. 1 will last 3 months Insulin calculation will be needed for each type of insulin being used At times of sickness, infection, pregnancy, steroid treatment more insulin will be required for that period. People with type 1 and type 2 diabetes who vary insulin dose with meals will need enough to cover the average amount taken each month Gluco RX needles are suitable for all devices. Lengths longer than 8 mm should not be used. Skin lifts are important to inject into the subcutaneous layer of skin. Version I. August 2016 Page 5

6 APPENDIX 2 Template patient letter Dear (Patient name) Date: Re: (Name of prescribed item, strength and form) Patients may have excessive quantities of prescription items that are ordered but are not always used before it is ordered again. This can lead to a build-up of unused prescribed items in your home, presenting a potential safety risk. Risks could include: Accidentally taking/using prescription items which are out of date. Accidentally taking/using the wrong prescription items. Increasing the chance of young children finding them. To reduce this risk, prevent medicines waste and to make best use of NHS resources, we have been reviewing the prescribing of some prescription items. We have reviewed the prescriptions of all patients who are prescribed (name of prescribed item, strength and form). The quantity of your (name of prescribed item, strength and form) has been changed from: Original quantity: (specify ORIGINAL quantity) to: New quantity: (specify NEW quantity) The maximum number of prescription issues before your next review date has been limited. Please note the reason for this alteration is NOT that your condition has changed. If you have any further queries, please discuss with your community pharmacist or GP. Yours sincerely, On behalf of Name of GP practice Version I. August 2016 Page 6

7 Version Date of review: Author: Approved by: Lilliana Alani, Specialist Clinical Audit Facilitator in MM, Cannock Chase CCG GP Lead South East Staffs & Seisdon CCG Head of Medicines Optimisation South East Staffs & Seisdon CCG Date of approval: 1/11/2016 Version I. August 2016 Page 7