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Best practice guideline for the subcutaneous administration of insulin in adults with type 2 diabetes

Description of Methods Used to Formulate the Recommendations

June 2004 Guideline
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.

2009 Supplement
The Registered Nurses' Association of Ontario (RNAO) has made a commitment to ensure that this practice guideline is based on the best available evidence. In order to meet this commitment, a monitoring and revision process has been established for each guideline every three years.
A panel of nurses and allied health professionals was assembled for this review, comprised of members from the original development panel as well as other recommended individuals with particular expertise in this practice area. A structured evidence review based on the scope of the original guidelines was conducted to capture the relevant literature and other guidelines published. Initial findings regarding the impact of the current evidence based on the original guideline were summarized and circulated to the review panel. The revision panel members were given a mandate to review the original guideline in light of the new evidence, specifically to ensure the validity, appropriateness and safety of the guideline recommendations as published in 2004.
A review of the most recent studies and relevant guidelines published since the original guideline did not support dramatic changes to the recommendations, but rather suggested some refinements and stronger evidence for the approach.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

The guideline developers reviewed published cost analyses.

Method of Guideline Validation

External Peer Review
Internal Peer Review

Description of Method of Guideline Validation

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.


Major Recommendations

Note from the National Guideline Clearinghouse (NGC) and the Registered Nurses' Association of Ontario (RNAO): In June 2009, the RNAO guideline development panel was convened to achieve consensus on the need to revise the existing set of recommendations. A review of the most recent studies and relevant guidelines published since the original guideline does not support dramatic changes to the recommendations, but rather suggest some refinements and stronger evidence for the approach.
The levels of evidence supporting the recommendations (Ia, Ib, IIa, IIb, III, IV) are defined at the end of the "Major Recommendations" field. See the original guideline document for additional information provided in the "Discussion of Evidence."
Practice Recommendations
Recommendation 1
Nurses should assess psychosocial factors that may affect the individual’s ability to successfully initiate insulin therapy. Assessment strategies that include the use of open-ended questions to assess barriers, stressors, self-efficacy, and beliefs about insulin initiation should be used.
(Level of Evidence = III)
Recommendation 2
Education for administering insulin should be tailored in collaboration with the individual to address current knowledge, abilities, and needs.
(Level of Evidence = Ia)
Recommendation 3
Nurses should provide and/or reinforce appropriate teaching regarding insulin preparation and administration. Topics to include are:
  • Insulin: type, action, stability, storage, and compatibility
  • Preparation and administration of insulin
  • Sharps disposal
  • Follow-up for medical and self-care support
(Level of Evidence = IV)
Recommendation 4
Nurses should encourage blood glucose self-monitoring as an integral part of daily diabetes management for individuals taking insulin. The recommended frequency of testing will vary according to diabetes treatment and the individual's need and ability.
(Level of Evidence = III)
Recommendation 5
Individuals who self-monitor blood glucose should receive initial instruction and periodic re-education regarding self-testing technique, meter maintenance, and verification of accuracy of self-testing results.
(Level of Evidence = III)
Recommendation 6
Nurses should ensure clients taking insulin receive appropriate basic nutrition information.
(Level of Evidence = IV)
Recommendation 7
Clients treated with insulin, and their caregivers, should be taught how to prevent, recognize and treat hypoglycemia.
(Level of Evidence = IV)
Recommendation 8
Nurses must be aware of the effects of acute illness, surgery, and diagnostic procedures on blood glucose levels.
(Level of Evidence = IV)
Recommendation 9
Nurses should provide basic education on blood glucose monitoring, dietary, and medication adjustments for periods of illness. This information should be given initially and reviewed periodically with the client.
(Level of Evidence = IV)
Education Recommendations
Recommendation 10
Nursing curriculum should include education about the care and management of diabetes.
(Level of Evidence = IV)
Organization & Policy Recommendations
Recommendation 11
Health care organizations should facilitate ongoing diabetes education of nursing staff about diabetes care and management.
(Level of Evidence = IV)
Recommendation 12
Organizations must ensure that individuals receiving insulin have ready access to an appropriate form of glucose at all times.
(Level of Evidence = IV)
Recommendation 13
Organizations should develop and communicate appropriate policies and procedures to reduce the potential for medication errors related to insulin therapy.
(Level of Evidence = IV)
Recommendation 14
Organizations should have a process for documentation to support nursing practice related to insulin therapy.
(Level of Evidence = IV)
Recommendation 15
Nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational, and administrative support. Organizations may wish to develop a plan for implementation that includes:
  • An assessment of organizational readiness and barriers to implementation
  • Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process
  • Dedication of a qualified individual to provide the support needed for the implementation and implementation process
  • Ongoing opportunities for discussion and education to reinforce the importance of best practices
  • Opportunities for reflection on personal and organizational experience in implementing guidelines
In this regard, the 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 RNAO strongly recommends the use of this Toolkit for guiding the implementation of the best practice guideline on Best Practice Guideline for the Subcutaneous Administration of Insulin in Adults with Type 2 Diabetes.

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