Diabetes - General Information 

The guidance below covers:

• Key safety information for insulin.
• Hospital admission checklist for patients with diabetes.
• Hospital discharge checklist for patients with diabetes.
• Referral to the diabetic team.

Top Insulin Safety Tips

• Always check the type of insulin, dose and frequency of administration from two sources (e.g. patient and carer), particularly when importing information from ECS to Clinical Portal.
• If a patient uses pen insulin, prescribe pen insulin and administer using a pen. 
• Never draw insulin from a pen with a syringe. 
• Use pen safety needles. 
• Always prescribe on an Insulin Prescription Chart with 'units' pre-typed.  Never write 'U' or 'IU'. 
• Always continue basal / long-acting insulin in a type 1 diabetic patient (even if fasting or nil-by-mouth, dose may need adjustment).
• Twice daily mixed insulins e.g. Humulin® M3 are typically prescribed before breakfast and before evening meal, not at bedtime. 
• Ensure basal insulin has been administered before stopping variable rate intravenous insulin infusion (VRIII). 
• If patients on insulin pumps are admitted and unable to self-manage, remove pump and commence VRIII.
• Be aware of concentrated pen insulins (Tresiba® 200units/mL, Toujeo® 300units/mL, Humalog® 200units/mL).
• Xultophy® = Tresiba® 100units/mL + liraglutide 3.6mg/mL.  Can switch to Tresiba® only as an inpatient if Xultophy® is unavailable or due to GI upset (Xultophy® 'dose steps' = Tresiba® insulin units). 

Hospital admission checklist for patients with diabetes 

• Clarify type of diabetes.
• Check HbA1c (if no result in last 3 months). 
• Consider checking blood ketones / venous blood glucose (VBG) if hyperglycaemic. 
• Check at least 2 sources for diabetes drugs, especially insulin - clarify type, frequency, doses. 
• Prescribe insulin by brand name (e.g. Novorapid®), not generic name (e.g. Insulin aspart). 
• Prescribe / document insulin delivery method on insulin chart (if self-administers) i.e. penfill cartridges or type of disposable pen (e.g. Novomix® 30 FlexPen). 
• Be aware of concentrated insulin and combination pens (e.g. Toujeo®, Xultophy®).
• Always prescribe on both HEPMA and Insulin Prescription Chart with 'units' pre-typed.  Never write 'U' or 'IU' after the number. 
• Consider holding non-insulin therapy depending on presentation (see section on managing non-insulin therapy in an acutely unwell patient with type 2 diabetes). 
• Consider proactively altering insulin doses depending on the acute presentation and initial capillary blood glucose (CBG) measurements. 
• Never stop intermediate / long-acting insulin in type 1 or pancreatic diabetes. 
• If the patient is on an insulin pump, seek early senior / specialist advice, especially if drowsy or confused. 

Hospital discharge checklist for patients with diabetes 

• Review any withheld diabetes drugs and consider restarting if appropriate.
• Review any inpatient dose titrations (especially insulin and gliclazide) and communicate with patient / carer and GP about any ongoing titration advice (e.g. proactive down titration if reducing course of steroids).
• Include insulin doses on the immediate discharge letter (IDL) and use brand names, not generic. 
• If patient is unable to self-manage new insulin regime, ensure that the Community Nursing Team and Community Diabetes Specialist Nurse (DSN) Team are aware (ward nurses can refer). 
• If the community nurse is to administer insulin, vials and syringes must be prescribed on the IDL.
• Ensure patient has follow up with local diabetes outpatient team or DSN, and copy to relevant consultant. 
• If DSN follow-up is arranged prior to discharge, check that the patient knows where and when.

Referral to the diabetes specialist team 

Indications for referral to diabetes inpatient team: 

• New diagnosis of type 1 diabetes. 
• Diabetic Ketoacidosis (DKA)
• Recurrent or severe hypoglycaemia, where attempts at insulin or gliclazide titration are unsuccessful. 
• Hyperglycaemia (when recent HbA1c <70mmol/mol), where attempts at insulin or gliclazide titration are unsuccessful. 
• Hyperglycaemic Hyperosmolar States (HHS)
• Patients who require insulin initiation. 
• Intravenous insulin (VRIII) >48 hours. 
• Patients using continuous subcutaneous insulin infusion (CSII) pumps. 
• Active foot ulceration (also refer to Podiatrist via Trakcare).
• Diabetes in pregnancy. 
• Nil-by-mouth (NBM) or parenteral or enteral feeding, with problematic glycaemic control. 
• Problematic glycaemic control in the context of changing renal function. 
• Patient education - sick day rules, hypoglycaemia, driving advice, insulin administration, glucose testing. 

Refer via Trakcare: Select patient -> New request -> Other -> Diabetes inpatient referral.