Introduction
Recommended topics for diabetes educators Education about injection technique for delivery of insulin, including a review of hypoglycaemia (causes, detection, treatment and prevention) as well as when to check blood glucose and individualised pre- and post-meal targets Periodic review of injection technique and sites, especially when blood glucose control is suboptimal Use, care and action of the medications(s) to be administered Choice of injection devices, considering ease of use and patient limitations including cost, manual dexterity, hearing and visual impairment For pre-filled devices, considering opened expiration date, total number of units/mg in device and daily dose when choosing devices, when applicable Injection site selection and rotation, including teaching patient to examine sites for lipohypertrophy Choice of needle: length and gauge to maximise comfort and efficiency Technique Timing of injection, related to the effect of the medication, meals, activity and stressors Targets for dosing adjustments related to monitoring, activity stressors, and meals Injection discomfort and complications Safe disposal of used sharps Quality control including medication storage considerations, opened and unopened expiration dates Inspection of the injectable medication before each use |
Methodology
Insulin Transportation and Storage
Manufacturer to Country’s Main Storage Facility
Distribution to Health Care Facility
Storage of Insulin at Community Health Care Facility
Transfer of Insulin from Pharmacy to Home
Storage of Insulin at Home
Barriers to Insulin Injections
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Insulin is started after all other therapies fail.
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Once on insulin treatment, it is always insulin treatment.
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Patients on insulin must eat before the insulin is injected, or else they pass out.
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Patients must always have a refrigerator at home to keep the insulin in.
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Insulin injections are always very painful.
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Injections are a social stigma.
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Starting insulin therapy means that the diabetes is severe and the patient has reached the end-stage (death is near).
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Injection sites will soon become raw and exhausted.
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Insulin induces hypoglycaemia, a condition synonymous with death; and that this is almost always occurs in patients on insulin therapy.
Psychological Insulin Resistance
Overcoming Barriers for Insulin Injection
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Referring patients for diabetes self-management education and medical nutrition therapy.
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Providing ongoing self-management support, and
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Addressing emotional issues.
Therapeutic Education
The First Injection
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The patient should be counselled and be informed that most people are afraid of the needle prick, until they do it and see how relatively pain-free it actually is.
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The sizes of the needles available should be demonstrated to reassure the patient that the needles are thin and short.
Injection Recommendations
Site of Injection
Care of Injection Site
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To always visually inspect the injection sites before injecting insulin.
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To palpate the injection sites before injecting insulin. Patients should be instructed on how this is done.
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To avoid injecting into sites with lipohypertrophy, oedema, inflammation or signs of infection.
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To bathe with soap and water daily.
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To rotate sites of injection every day.
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Not to reuse the needle if possible; otherwise limit the reuse when injections become more painful; but should not reuse needles more than 5 times.
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There is no need to swab the area, if clean. If the injection site is not clean, clean with plain water. Swabbing with spirit-swabs is not recommended as it leaves the skin dry.
Rotation of Sites
Physical Aspects of Insulin
Travelling with Insulin
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Carrying insulin while travelling in hot climates can be a challenge. Insulin may be packed in a tight polythene bag and kept inside a small thermos flask [14].
Precautions
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Do not keep insulin in a locked car or in the glove compartment. Temperature in closed vehicles may reach very high levels (above 32 °C), with loss of potency of insulin [14].
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When travelling by air, carry insulin supplies, along with a prescription, in cabin baggage or handbag. Luggage which is checked-in is stored in the aircraft’s hold and may freeze: any insulin in this luggage may lose its potency [14].
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Do not store insulin near extreme heat (above 32 °C) or extreme cold sources (below 2 °C) [14].
Insulin in School
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Identify an appropriate location for insulin storage and follow the guidelines for insulin storage.
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Train one person from the school about insulin administration, doses/injection times prescribed for specific blood glucose values and for carbohydrate intake. The person should liaise with parent/guardian on insulin supplies and other essentials for diabetes care.
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Identify a location in the school to provide privacy during insulin administration, if desired by the student and family.
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The school authority should permit the student to check his or her blood glucose level and take appropriate action to treat hypoglycaemia or hyperglycaemia, when need arises.
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A school authority and preferably peers of the student to recognise symptoms of hypoglycaemia and hyperglycaemia and their immediate management.
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A school authority and preferably peers of the student to understand how participation in physical activity can be safely done.
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A school authority to receive instructions for handling diabetes emergencies.
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A school authority to have a plan for the disposal of sharps and other health waste.
Insulin and Work
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Insulin should be carried in a container to prevent exposure to extreme temperature and sunlight. If the work is in the field, the insulin should be placed in the shade where the temperatures are not high.
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The employer should provide a convenient place to store insulin and other supplies, if work conditions are not suitable for the temporary storage of insulin while at work, especially if the work place is not private enough to administer insulin.
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The employer should give permission to the employee to take short breaks to administer insulin as required. The employee should be permitted to consume food or beverages as needed at their desk or workstation, but this should conform to the social and cultural norms of the society, otherwise a convenient place should be identified for the patient to use [28, 35].
Absorption of Insulin
Factor | Effect on insulin absorption |
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Exercise of injected area | Strenuous exercise of a limb within 1 h of injection increases insulin absorption. For example, injecting on the thigh and immediately riding a bicycle. This is clinically significant for regular insulin and insulin analogues |
Local massage | Vigorously rubbing or massaging the injection site increases absorption |
Temperature | Heat can increase absorption rate, including use of a sauna, shower, or hot bath soon after injection. Exposure to a cold environment has the opposite effect |
Site of injection | Insulin is absorbed faster from the abdomen. Less clinically relevant with long and intermediate-acting insulins (NPH, insulin glargine and insulin detemir) |
Lipohypertrophy | Injection into hypertrophied areas delays insulin absorption |
Jet injectors | Increase absorption rate |
Insulin mixtures | Absorption rates are unpredictable when suspension insulins are not mixed adequately (i.e., they need to be re-suspended) |
Insulin dose | Larger doses delay insulin action and prolong duration |
Physical status (regular versus insulin suspension) | Suspension insulins must be sufficiently re-suspended prior to injection to reduce variability |
Insulin type | Insulin aspart, glulisine and lispro appear to have less day-to-day variation in absorption rates and also less absorption variation from the different body regions. Insulin glargine’s pharmacokinetic profile is similar after abdominal, deltoid or thigh subcutaneous administration. More concentrated insulin has less variability (see U200 and U500 insulins) |
Administration
Preparation of Skin for Injection
Injection Devices
Syringes and Vials
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0.3-ml insulin syringes are graduated in 1-unit intervals and are ideal for doses under 30 units because of their discrete size and easy 1-unit adjustment.
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0.5-ml insulin syringes are graduated in 1-unit intervals and are ideal for doses between 30 units and 50 units.
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1-ml insulin syringes are graduated in 2-unit intervals and are ideal for doses over 50 units.
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Inconvenience of carrying several materials.
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Preparing the syringe.
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Adverse psychological and social impact of using a syringe (syringes are associated with sickness and drug abuse).
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Use of an incorrect insulin product.
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Failure to administer accurate doses.
Insulin Pen Devices
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Disposable or prefilled insulin pens: these devices come with insulin.
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Reusable insulin pens.
Pen Needles
Needle Reuse
Disposal of Syringes
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Lack of information about how and where to dispose.
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Lack of proper advice by doctors and nurses.
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Wrong perception that sharps disposal information is meant only for illegal drug users,
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Some patients feel that using community sharps disposal services may result in revelation of their diabetes status, which may have been kept confidential.
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The perception that disposal of sharps into pit latrines or burning them in cooking fire stoves is a correct way of disposing of sharp hazardous waste, and cheaper.
Step | Guidelines |
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Collection of used needles and syringes (sharp waste) | Puncture-proof box with lid at the top to be used and labelled as “BIOHAZARD” with a biohazard sign and yellow marked Box should be filled up to 75% of its capacity only Recapping the needle, bending/cutting etc., and transfer of sharps using hands should be avoided It is recommended that if possible, a needle cutter is used to cut needles off syringes; and the needles then discarded into the sharp waste, while the plastic part of the syringe is disposed of into a thick plastic bag (non-hazardous waste). Should a needle cutter not be available and therefore the needle cannot be safely removed, the whole syringe should be disposed of into the sharps box (hazardous waste) For picking up of needles or syringes, the syringe end should be preferred; if lying on the ground, a long-handled tong should be used |
Storage and disinfection in DICs (hazardous -waste) | Immersing the sharps in 1% sodium hypochlorite solution for 30 min and then storing in a translucent white or blue coloured bin till final disposal from DIC |
Final disposal from DIC (hazardous waste) | Link up with waste management agencies whenever possible; in case of non-availability, an option of linking with a health facility having an incinerator should be encouraged In the absence of the above possibilities, improvised local mechanisms of disposing the hazardous waste in pits that are at least one metre in depth |
General health-care waste (non-hazardous) | Colour of container usually black Use a plastic bag inside a container which is disinfected after use The bag should be filled to 75% only and collected at least once a day |
Injection Technique Recommendations
Lifting Skin Folds (Pinching)
The Proper Use of Syringes
Injection Technique for Syringe and Vials
Injecting Insulin
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Choose where to give the injection. It may help to keep a chart of places used, so that insulin is not injected in the same place more than once in a day.
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Keep the injection 2.5 cm (one finger breadth) away from scars and 5 cm (two finger breadths) away from the umbilicus.
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Insulin should not be injected into skin that is bruised, swollen, or tender.
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The site chosen for the injection should be clean and dry. If the skin is visibly dirty, the area should be cleaned with plain water. Swabs containing spirit should not be used on injection sites; if used, the area should be left to dry prior to giving an injection of insulin. Patients are encouraged to bathe after work, and daily with soap and water to maintain good hygiene.
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If required lift (pinch) a skin fold and aim the needle perpendicularly at an angle of 90°. The procedure is the same whether a pen device or syringe is used to administer the insulin.
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Push the needle into the skin. Let go of the pinched skin. Inject the insulin slowly and steadily until it is all in.
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Leave the syringe in place for 5–30 s after injecting; ensured by counting from 0 to 5 or up to 30. In East Africa we prefer to tell patients to count from zero to thirty as this is easily remembered.
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Pull the needle out at the same angle it went in. Put the syringe down.
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If insulin tends to leak from the injection site, put some pressure on the injection site with a piece of cotton swab for a few seconds: DO NOT RUB.
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If bleeding occurs, apply a cotton swab with some little pressure for 30 s. This is usually sufficient. DO NOT RUB.
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Place the needle and syringe in a safe hard container. Close the container, and keep it safely away from children. This is the sharps waste container and the needles will be disposed of later appropriately. If the syringe and needle are to be reused, the needle should be carefully recapped, stored away in a clean container and reused later, but not more than 5 times.
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If more than 50 units of insulin is to be injected, it is advisable to split the doses and administer the divided doses either at different times or using different sites for the same injection. The health worker should be the one to determine the splitting of the doses. Large volumes of insulin are associated with more insulin absorption variability, which should be avoided.
Special Situations
Very Thin and Wasted Individuals
Very Obese Individuals
Lipohypertrophy
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Examine the sites for lipohypertrophy at least every 3 months, or more frequently. Injection sites should be gently palpated in order to feel the lipohypertrophy.
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Patients should be instructed on how to palpate the injection sites routinely; and on how to inspect their own sites. Patients should be given training in site rotation and proper injection technique.
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The size of the lipohypertrophy should be estimated by feeling its extreme edge and measuring its longitudinal and transverse diameters using a point 5-cm (two finger breadth) away from the extreme edge of the lipohypertrophy. The site and the size of the lipohypertrophy should be documented in the patient's notes and referred to in future assessment of the lipohypertrophy.
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Patients should be requested to avoid injecting into areas of lipohypertrophy until the next examination. Recommend use of larger injection zones, correct injection site rotation, and non-reuse of needles.
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A reduced dose of insulin may be required after switching injections away from the lipohypertrophy, to avoid hypoglycaemia, as absorption of insulin will be better. Measure the blood glucose and adjust insulin dose.
Pain
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Inject insulin that has a temperature of the surrounding room (20–30 °C).
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Avoid the use topical alcohol for swabbing.
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Relax the muscles at the site during the process of injection.
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Quickly penetrate the skin.
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Do not change direction of the needle during insertion or withdrawal.
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Do not reuse needles, if possible.
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Do not use an injection device that puts pressure on the skin around the injection site.
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Apply a little pressure for 5 to 8 s after the injection, without rubbing: this is advised if an injection seems especially painful.
Paediatrics
Thickness of Subcutaneous Fat
Sites of Injection
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Outer arm.
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Abdomen.
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Hip.
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Thigh area.
Self-Injection
Needle Anxiety and Pain
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Parents themselves have to be calm and composed before any injection. This is comforting for the child.
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Identify the past experiences with injections.
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Select appropriate syringes with needles attached or pens and 4-mm needles.
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Compare the needles used for other injections and insulin.
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Discuss how needles have been designed to improve patient comfort.
Insulin Underdosing and Overdosing
Pregnancy
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The abdomen is generally a safe site for insulin administration during pregnancy. However, as thinning of abdominal fat from uterine expansion is common, pregnant women with diabetes (of any type) should use a 4-mm pen needle when injecting on the abdomen. Other areas follow similar recommendations as in non-pregnant state.
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First trimester: hypoglycaemic events are most common during the 1st trimester. Close monitoring and dose adjustments are important. No change in insulin site or technique is needed.
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Second trimester: insulin can be injected over the entire abdomen as long as properly raised skin folds are used. Lateral aspects of the abdomen can be used to inject insulin when no skin fold is raised.
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Third trimester: injections can be given into the lateral abdomen with properly raised skin folds. Apprehensive patients may use the thigh, upper arm, or buttock instead of the abdomen. Areas around the umbilicus should be avoided during the last trimester [32].
Elderly
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Counsel elderly diabetes patients about the course of diabetes and proper injection technique.
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The elderly should be assisted by a care giver.
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Prevention and treatment of hypoglycaemia should be emphasised.
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Insulin pens are beneficial in the elderly due to their discreetness, simplicity, convenience of use and dosage accuracy.
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For visually impaired patients, the use of acoustic devices for glucose measurement is recommended.
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In patients with both visual and dexterity impairment, pre-filled syringes may be helpful.
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For patients with impaired hearing and those who use hearing aids, conduct education in a noise-free environment.
Health Care Recommendations
Institutional Care
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The use of insulin pens instead of vial and syringes can provide several advantages for hospitalised patients, including greater satisfaction among them and health care providers, improved safety and reduced costs.
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Nurses need to follow the same principles of injection.
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Note that when insulin has to be injected intramuscularly, a needle for intramuscular injection fitted to a syringe that can adequately measure insulin dosage should be used. The usual 6-mm needles or syringes will not deliver insulin intramuscularly [50].
The Community
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A community nurse needs to learn how to administer insulin using both an insulin syringe and a pen device.
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Supplies of insulin syringes should always be available to community nurse teams.
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Review patients requiring insulin administration more than once a day to change to a once-daily regime wherever possible to reduce demand on the community team whilst maintaining appropriate glucose control and quality of life.
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It is recommended that a standard in-house protocol for community nursing teams to administer insulin be developed.
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It is recommended that such protocols should include the full name of the insulin, the dose to be given (with no abbreviation for the word ‘units’) and be signed and dated by the prescriber.