Beruflich Dokumente
Kultur Dokumente
FIT UK Forum
for Injection
Technique UK
The UK Injection
and Infusion
Technique
Recommendations
4th Edition
Optimising
Diabetes Care
UK Injection and Infusion Technique Recommendations
Preface
Our Objectives
To review the injection and infusion techniques currently
being used by people with diabetes
3
THE UK INJECTION AND INFUSION TECHNIQUE RECOMMENDATIONS
Africa
Canada
India
Europe
Latin America
Middle East
Pacific Rim including
--Australia and New Zealand
--China
--Japan
--Korea
--Malaysia
--Philippines
--Singapore
Everyone with Type1 Diabetes Mellitus (T1DM) will need insulin from
diagnosis (3). Currently there are 400,000 people in the UK with T1DM
and over 29,000 of them are children. The number of people diagnosed is
increasing by 4 percent every year and most commonly in children under
five years old. (4)
5
THE UK INJECTION AND INFUSION TECHNIQUE RECOMMENDATIONS
web: www.fit4diabetes.com
email: infouk@fit4diabetes.com
References 39
Contributors 46
Abbreviations 47
THE UK INJECTION AND INFUSION TECHNIQUE RECOMMENDATIONS
Endorsements
Advances in the treatment of diabetes have led to an increase in the number of injectable therapies
available. Correct technique is of paramount importance in order to ensure the benefits of injectable
therapies such as insulin and GLP-1s. The Forum for Injectable Therapy (FIT) provides comprehensive
evidenced based guidelines to improve the process and education of self-injection technique for
people with diabetes. As a company committed to improving the care of patients with diabetes, Lilly
UK welcomes the FIT initiative as an important step in supporting diabetes care in the
United Kingdom.
Ian Dane, Senior Director, Eli Lilly & Company
Novo Nordisk fully endorse the FIT initiative. The benefits of modern injectable medications for the
treatment of diabetes can only be fully realised through the use of correct injection technique. Novo
Nordisk believes it is imperative that Healthcare Professionals understand the importance of good
injection technique and convey this to people with diabetes under their care. FIT
is a superb initiative, from leading professionals in the diabetes care, which will
make a big difference in this area.
Kirsty Tait, Diabetes Marketing Director, Novo Nordisk Ltd.
Sanofi are a company who strive to improve the care for people with diabetes who are using insulin
and GLP-1 therapy by providing a range of injectables. We are proud to support the FIT (Forum for
Injection Technique) initiative which is aiming to improve current practice through demonstration
of best practice and the sharing of scientific evidence. We, too, appreciate the importance of good
injection technique in ensuring people with diabetes who are using injectable therapy
achieve the most benefit from their medication and wish FIT every success. We look
forward to working with FIT in the future.
Sanofi Nicky Barry, Divisional Director Diabetes,
AstraZeneca are pleased to support the FIT initiative. We are striving to provide medicines which can
provide better outcomes for people with Type 2 Diabetes but this can only be achieved when they are
used correctly. Adoption of the FIT guidelines in clinical practice will
help ensure that the best outcome is obtained from all injectable
medicines.
Jay Ark, Head of Injectable at Diabetes Marketing, AstraZeneca
Becton Dickinson has been supporting the ground breaking and inspirational work of the Forum for
Injection Technique for over 8 years. The new 4th Edition of The UK Injection and Infusion Technique
Recommendations follows the Worldwide FITTER Congress held recently in Rome 2015. During this
worldwide event which included 183 participants from 54 countries, delegates reviewed results data
from a worldwide injection technique survey, and this wealth of new data provided the evidence to
help formulate the best practice recommendations you will find in this UK 4th Edition.
Our BD mission; Improving the quality of daily life for people with diabetes, through access to
innovative solutions is incredibly important to all who work at BD, and BD is proud to endorse the
dedicated expert work that FIT UK undertakes. BD welcomes the publication of the 4th Edition of The
UK Injection and Infusion Technique Recommendations and commends the FIT Board
and all the dedicated clinicians from all over the UK for their great achievement.
Loc Herve, Business Unit Director Diabetes Care BD
9
THE UK INJECTION AND INFUSION TECHNIQUE RECOMMENDATIONS
KEY
A Scientific Advisory Board (SAB) (Athens 2009) led the review of available
evidence and decided that for the strength of a recommendation the
following scale would be used:
A STRONGLY RECOMMENDED
B RECOMMENDED
C UNRESOLVED ISSUE
Consensus
3 expert opinion based on extensive patient experience.
A number of significant studies have been published in the intervening years since 2009. Therefore FITTER has
conducted a further review of critical evidence and included this within the 4th Edition of the New Injection
and Infusion Recommendations. The body of evidence has been subjected to the rigour of the strength scale of
recommendations as above however with a slightly modified KEY for the scientific support:
For the scientific support the following modified scale was used.
1 At least one rigorously performed study, peer-reviewed and published.
2 At least one observational, epidemiologic or population-based study.
3 Consensus expert opinion based on extensive patient experience.
Thus each recommendation is followed by both a letter and number (i.e. A2). The letter indicates the weight a
recommendation should have in daily practice and the number, its degree of support in the medical literature. The
most relevant publications bearing on a recommendation are also cited. There are few randomised clinical trials
in the field of injection technique (compared, for example, with blood pressure control) so judgements such as
strongly recommended versus recommended are based on a combination of the weight of clinical evidence, the
implications for patient therapy and the judgement of the group of experts.
These recommendations apply to the majority of people with diabetes using injectable therapy, but there will
inevitably be individual exceptions for which these recommendations must be adjusted.
Acknowledgment
The New Insulin Injection and Infusion Recommendations for Patients with Diabetes: Frid AH, Kreugel G, Grassi
G, et al. New insulin delivery recommendations. Mayo Clin Proc. September 2016;91(9):1231-1255. informed these
recommendations and we thank the editors of the Mayo Clinic for permission to use material from this article.
1.0
Psychological Challenges
of Injections
11
THE UK INJECTION AND INFUSION TECHNIQUE RECOMMENDATIONS
1.0
Psychological Challenges
of Injections
1.2 Strategies for Reducing 7 If bleeding or bruising occur, 10 Fear and anxiety can be
Fear, Pain, and Anxiety assess and reassure the significantly reduced by having
patient that these do not affect the person (parent and child)
1 Include caregivers and family the absorption of insulin or give themselves a dry injection.
members in the planning and overall blood glucose control.
education of the person who is If bruising continues or 11 Most are surprised at how
injecting where appropriate and haematomas develop, observe relatively painless the injection
agreed by the individual. the injection technique and is.
suggest improvements (e.g.
2 Tailor the therapeutic regimen correct rotation of injection 12 On rare occasions the use
to the individual needs of the sites). of injection ports may help
patient. reduce fear of injections and
8 Children have a lower threshold associated pain. Fig 1
3 Have a compassionate and clear for pain. The HCP should ask (24) (25) (11) (26) (27)
approach when teaching correct about pain. (9) (22) For young
injection technique. children consider distraction
techniques or play therapy (e.g.
4 Demonstrate the correct injecting the childs own soft toy
injection technique to the or doll). Older children respond
individual and assess their better to cognitive behavioural
ability to self-inject. therapies (CBT). (7) (10) (23)
With kind permission. i-Port Advance injection port is a registered trademark. 2016
Medtronic MiniMed, Inc. All Rights Reserved. Figure 1: Medtronic Port in situ.
1.0
Psychological Challenges
of Injections
13 Insulin pens with very 1.3 Tips for Injection 5 Insert the needle through the
short needles may be more Education skin in a smooth but not jabbing
acceptable to patients than the movement. Pain fibres are in
syringe and vial. This should be 1 Demonstrate the correct the skin and going through the
discussed with the person (and injection technique to the skin too slowly or too forcefully
family) when teaching injection person (and family.) Then may increase the pain. (31)
technique. The 4 mm pen ask the patient (and family)
needle is reported by patients to demonstrate the correct
to be less painful than longer technique. 6 Inject the insulin slowly
needles. (8,28,29,30) ensuring that the plunger
2 Advise that insulin in use is (syringe) or thumb button (pen)
14 If patients occasionally kept at room temperature to has been fully depressed and
experience sharp pain on make for a more comfortable all insulin has been injected.
injection they should be injection. Cold insulin often With pens the patient should
reassured that the needle may produces more pain. count to 10 after the button has
have touched a nerve ending been fully depressed before
which happens randomly and 3 Advise that the skin should be withdrawing the needle.
will not cause any damage. clean and dry before injecting.
Patients do not need to use 7 Use a sterile, new needle for
a disinfectant (e.g. alcohol each injection. (5,32,33,34,35,
15 If pain persists the HCP should swab) on the skin, but if they 36,37,38,39,40,41,42,43)
see the patient and evaluate do, they should allow it to dry
their injection technique. completely before injecting. 8 HCPs should teach the
importance of rotation and
agree a rotation pattern with
4 Use needles of the shortest the patient when initiating
length (4mm), smallest injection therapy. (5)
diameter (highest gauge
number), and the tip with the 9 Insulin will not be well-
lowest penetration force to absorbed if it is always injected
minimize pain. (31) into the same area. (5) (44)
13
THE UK INJECTION AND INFUSION TECHNIQUE RECOMMENDATIONS
1.0
Psychological Challenges
of Injections
10 It is important to move 14 Insulin pens, pen cartridges
injections at least 1 cm (half an and vials should not be
inch) away from the previous shared in order to prevent the
injection. (5) transmission of infectious
diseases. (32,33,47,34,35,36,
11 Use all injection sites 37,38,39,40,41,42,43)
appropriate to the patients
preference on the body
including the back of the arms,
buttocks, thighs and abdomen.
(5)
2.0
Therapeutic
Education
2.1 Educational Content optimal needle lengths 2.2 Role of the Health Care
Safe disposal of used sharps Professional
1 The HCP should spend time
hypoglycaemia,
exploring patient (and other 1 Teach patients (and other
where appropriate
care-givers) anxieties and care-givers) how to inject
(19,20,21,28,48,49,50,51)
barriers to the injecting process correctly and addressing the
and insulin itself. (48,19) many psychological hurdles the
4 Instructions should be given in patient may face when injecting
2 At the beginning of injection or infusing, especially at the
both verbal and written form,
therapy the HCP should discuss initiation of treatment. (50,48)
individually tailored to the
each of the essential topics and
needs of the person.
ensure this information has
been fully understood, and this 2 Is to understand the anatomy
5 Level of knowledge should
should be assessed at least of insulin delivery sites in
be assessed and observed,
every year thereafter. (12) order to help patients avoid
and all aspects of injection
technique including injection intramuscular (IM) injections
3 The essential injection or infusions and ensure that
sites inspected and palpated,
technique topics include: injections and infusions are
if possible at each visit but at
the injectable therapy consistently given into the
least every year. This should
regimen subcutaneous (SC) tissue,
be documented in the patients
the choice and management without leakage/backflow
records. (48,49,51)
of the devices including or other complications.
safety devices (52,53,54,55,56)
the choice, care and self-
examination of injection 3 Is to have knowledge of the
sites time action profile of the
correct injection techniques different types of insulin
(including site rotation, and GLP-1 receptor agonists
injection angle and possible and the absorption profiles
use of lifted skin folds) from different injection sites.
Resuspension of insulin (57,58,59,60)
where appropriate
injection complications and
how to avoid them
15
THE UK INJECTION AND INFUSION TECHNIQUE RECOMMENDATIONS
3.0
Injecting Process
3.0
Injecting Process
17
THE UK INJECTION AND INFUSION TECHNIQUE RECOMMENDATIONS
3.0
Injecting Process
3.3 Needle Length 2 The 4 mm pen needle may be Others may inject using the 4
used safely and effectively in mm needle without lifting a skin
1 The 4mm pen needle inserted
all obese patients. Although fold. (58,100,105,103)
perpendicularly (at ninety
it is the needle of choice
degrees) is long enough to
for these patients, a 5mm 5 When any syringe needle is
penetrate the skin and enter
needle may be acceptable. used in children, adolescents
01
3.0
Injecting Process
7 Children still using the 5mm 3.4 Lifting a Skin Fold 3 The optimal sequence should
pen needle should inject using be:
1 Each injection site should
a lifted skin fold. But children Lift a skin fold;
be examined individually
using pen needles 5mm Inject insulin slowly at ninety
and a decision made as to
should be changed to 4 mm pen degrees to the surface of the
whether lifting a skin fold is
needles if possible; and if not, skin fold;
required, taking into account
should always use a lifted skin Leave the needle in the skin
the needle length used. The
fold. (58,100,105,103) for a count of 10 after the
recommendation should be
plunger is fully depressed
provided to the patient in
8 If arms are used for injections (when injecting with a pen);
writing and documented in their
with needles 6mm long, a Withdraw needle from the
care plan.
skinfold must be lifted, which skin at the same angle it was
requires injection by a third inserted;
2 The lifted skin fold should not
party. (103) Release skin fold;
be squeezed so tightly that it
Dispose of used needle
causes skin blanching or pain.
9 Avoid indenting the skin by safely.
Fig 7
excessive pressure during
injection, as the needle may
penetrate deeper than intended
and enter the muscle.
Figure 7: Correct (left) and incorrect (right) ways of performing the skin fold.
19
THE UK INJECTION AND INFUSION TECHNIQUE RECOMMENDATIONS
3.0
Injecting Process
3.5 Needle Reuse 3.6 Rotation of Injecting Sites 3 Patients should be taught an
easy-to-follow rotation scheme
1 Syringe or pen needles should 1 Injections should be
from the onset of injection
only be used once. Reusing systematically rotated in such
therapy. This may be adjusted
insulin needles is not optimal a way that they are spaced at
as needed while therapy
injection practice and patients least 1cm from each other in
progresses. The HCP should
should be discouraged from order to avoid repeat tissue
review the site rotation scheme
doing so. trauma. Fig 9 (90,136,47,137)
with the patient at least once a
Fig 8 (1,68,78,132,133,134)
year. (139,140,141,44,142,143,
144,145)
2 One scheme with proven
2 There is an association between effectiveness involves dividing
needle reuse and the presence the injection site into quadrants
of lipohypertrophy, although using one per week and
a causal relationship has moving quadrant to quadrant
not been proven. Patients in a consistent direction (e.g.
should be made aware of clockwise). Fig 10 (138)
this association (and also the
association between reuse and
pain or bleeding). (68,70,135)
BEFORE AFTER
Figure 8: Damage to needle if reused. Figure 9: Injections within any quadrant should Figure 10: Sample structured rotation plan for
x370 magnification. be spaced at least 1cm from each other. abdomen and thighs. Divide the injection area
into quadrants or zones. Use 1 zone per week
and move clockwise.
3.0
Injecting Process
3.7 Correct Use of Pens 4 Pen needles should 3.8 Correct Use of Syringes
be used only once.
1 Pens should be primed 1 When drawing up insulin from
(62,63,68,106,151,152,153,154)
(observing at least a drop at an insulin vial, the air equivalent
the needle tip) according to the to the dose (or slightly greater)
manufacturers instructions should be drawn up first and
5 The thumb button should only
before the injection in order to injected into the vial to facilitate
be touched once the pen needle
ensure there is unobstructed insulin withdrawal. Ensure that
is fully inserted. After that the
flow and to clear needle dead the syringe to be used is an
button should be pressed along
space. Once flow is verified, the INSULIN syringe. Use of any
the axis of the pen, not at an
desired dose should be dialled other type of syringe can cause
angle. (155)
and the injection administered. serious harm. All regular and
(29,146) single insulin (bolus) doses are
6 After pushing the thumb button
measured and administered
completely in, patients should
2 Pens and cartridges are for a using an insulin syringe or
count slowly to 10 before
single patient and should never commercial insulin pen device.
withdrawing the needle in order
be shared between patients due Intravenous syringes must
to get the full dose and prevent
to the risk of biological material never be used for insulin
the leakage of medication.
from one patient being drawn administrationRRR 2010.
(79,33,147,149,156,157)
into the cartridge and then (253)
injected into another person.
7 Pressure should be maintained
(30,32) 2 If air bubbles are seen in the
on the thumb button until
syringe, patients should tap
the needle is withdrawn from
3 Needles should be safely the barrel to bring them to the
the skin in order to prevent
disposed of immediately after surface and then remove the
aspiration of patient tissue into
use and not left attached to the bubbles by pushing up the
the cartridge. (158,159)
pen. This prevents the entry plunger.
of air (or other contaminants)
into the cartridge as well as the
leakage of medication, either of
which can affect dose accuracy.
(30,33,147,148,149,150)
21
THE UK INJECTION AND INFUSION TECHNIQUE RECOMMENDATIONS
3.0
Injecting 4.0
Process Injectable therapies
3 Unlike pens, it is not necessary 4.1 Human Insulins 4.2 Insulin Analogues and
to hold the syringe needle GLP-1 agents
under the skin for a count of
10 after the plunger has been 1 Intramuscular (IM) injections 1 Rapid-acting insulin analogues
depressed.(33,147,157) of Neutral pH suspension may be given at any of the
of crystalline insulin, injection sites, as absorption
4 Syringes must be protamine and zinc (NPH) rates do not appear to be site-
used only once. Fig 11 and long acting insulin must specific. (171,172,173,174,175)
(62,63,68,106,151,152,153,154) be strictly avoided due to
the risk of hypoglycaemia.
(160,161,162,163)
2 Rapid-acting analogues should
be given subcutaneous and not
2 The abdomen is the preferred
IM. (172,173,176)
site for soluble human
insulin since absorption of
3 Patients may inject long-acting
this insulin is fastest there.
insulin analogues in any of
(164,165,166,55,167,95)
the usual injecting sites as
absorption rates do not appear
3 Soluble human insulin /NPH mix
to be site specific. (107)
should be given in the abdomen
to increase the speed of
4 Patients using non-insulin
absorption of these short-acting
injectable therapies should
insulins, in order to cover post-
follow the recommendations
prandial glycaemic changes (56)
already established for insulin
injections with regards to
needle length, site selection
4 If there is risk of nocturnal
and site rotation. (148,177)
hypoglycaemia, NPH and
soluble human insulin mixes
given in the evening should
be injected into the thigh or
buttock as these sites have
slower absorption of NPH.
Figure 11: Syringes must be used only once (168,169,170)
5.0
Lipohypertrophy (LH)
23
THE UK INJECTION AND INFUSION TECHNIQUE RECOMMENDATIONS
5.0
Lipohypertrophy
5.4 Technique for Visual 5.5 Technique of Palpation 5.6 Measuring and
Examination Documenting the
1 Inspect site with lamp first, 1 After hands are warmed by Lipohypertrophy
adjusting its angle to be able rubbing them together or 1 With the patients consent and
to detect any subtle risings or washing in warm water, apply using skin safe marker pen,
depressions across the surface gel (ultrasound gel or another mark the exact position of the
of the skin. water-soluble lubricant for lesion on the patients skin so
clinical use) to the injecting that the patient can clearly see
2 Lipohypertrophy (LH) is usually area and palpate with the tips of the extent of the lesion and
manifested as a raised or the fingers, working in towards avoid injecting into it.
mound-like, convex pattern with the injecting area with light
no change in skin colour or hair massage-like motions (forward 2 Measure the distance along its
distribution; occasionally it can thrusts or circular sweeps). largest dimension (usually the
be manifested as only a shiny longest diameter) in mm and
or hyper-pigmented (especially 2 Lipohypertrophy is manifest by record in patients chart.
in dark-skinned persons) area a change in the subcutaneous
and/or an area of hair loss. (SC) tissue, which is replaced by 3 Photograph the lesion from
a harder, and more rubbery or a distance of 1 meter without
3 If detected, gain consent and less bouncy tissue. flash, using the light from an
mark centre point with pen so oblique source so as to reveal
that area can be palpated later. 3 Often the edges of this surface contours once consent
abnormal area are clearly has been given.
demarcated and it is easy to
feel the transitional zone, which 4 Use the measurements and
appears as a step-up from the photograph to follow progression
of the lesion long-term.
surrounding soft tissue.
5.0
Lipohypertrophy
25
THE UK INJECTION AND INFUSION TECHNIQUE RECOMMENDATIONS
6.0
Injection Issues
6.1 Bleeding and Bruising 6.2 Leakage at Cartridge and 6.3 Skin Leakage
Pen Needle (PN) Connection
1 Patients should be reassured 1 Ensure that the pen needle(PN) 1 Use needles with thin-wall or
that local bleeding and is International Organization for extra thin-wall technology.
bruising do not have adverse Standardization (ISO) certified (199,200)
clinical consequences for the compatible with the insulin pen.
absorption of insulin or for 2 Count to 10 after the plunger
overall diabetes management. is fully depressed before
Fig 13 (198) 2 Position the PN along the axis removing the needle from the
of the pen before screwing or skin. This allows enough time
2 If bleeding and/or bruising are snapping it on. for the injected medication to
frequent or excessive, injection spread out through the tissue
technique should be carefully 3 Pierce straight through the planes and/or to cause the
assessed but this may be due to septum of the cartridge. tissue to expand and stretch.
the presence of a coagulopathy (157,199,200)
or the use of an anticoagulant
or antiplatelet agent. 3 A small amount of skin leakage
(little pearl of liquid at injection
site) can be ignored. It is almost
always clinically insignificant.
(157,199,200)
6.0 7.0
Injection Issues Pregnancy
27
THE UK INJECTION AND INFUSION TECHNIQUE RECOMMENDATIONS
8.0
Technology
8.1 Needle Inner Diameter 8.2 Insulin Infusion Sets 4 All CSII patients should have
(IIS) for Continuous their infusion sites checked
1 High flow rate needles (extra-
frequently or at least annually
thin wall) needles have been Subcutaneous Insulin
for lipohypertrophy by an HCP.
shown to be appropriate for Infusion (CSII)
(205,208)
all injecting patients. Their 1 Population studies suggest
obstruction, bending and that CSII cannulae should be 5 If lipohypertrophy is suspected,
breakage rates are the same as changed every 4872 hours in the patient should be instructed
for conventional quality needles order to minimise infusion site to stop infusing into these
(extremely low), and they offer adverse events and potential lesions and to insert the
distinct flow advantages. Fig 15 metabolic deterioration. cannula into healthy tissue.
(203,204,20,206) (71,145,186,194,195,196,197)
8.0
Technology
9 The smallest diameter needle/ 12 All CSII patients who are lean,
cannula should be considered muscular or active and have a
in CSII patients to reduce pain high probability of the cannula
and the occurrence of insertion or tubing being dislodged may
failure. (212) benefit from an angled infusion
set (30-45 degree). (213)
10 Angled insertion sets should
be considered in CSII patients 13 All CSII patients who have
who experience infusion difficulty inserting their infusion
site complications with set manually for any reason
perpendicular (ninety degree) should insert their infusion
infusion sets. sets with the assistance of a
mechanical insertion device.
11 All CSII patients who experience (213)
a hypersensitivity reaction to
cannula material or adhesive 14 All CSII patients who become
should be considered for pregnant may require
alternative options (alternative adjustments to their infusion
sets, tapes or skin barriers). sets, site locations and
frequency of site changes.
29
THE UK INJECTION AND INFUSION TECHNIQUE RECOMMENDATIONS
9.0
Safety
9.1 Needlestick Injuries/ 3 The use of safety-engineered 6 Health care settings where
Blood-borne Infection Risk devices should be considered insulin pens are used must
for certain autonomous follow a strict one-patient /
1 Safety-engineered devices home-injecting patients with one-pen policy. (230)
play a critical role in protecting diabetes (e.g. those known
injectors, pump users and to be seropositive for Human 7 The optimal safety-engineered
downstream workers, for Immunodeficiency Virus (HIV), device should provide
example refuse workers, Hepatitis B Virus (HBV) and protection for patients, care-
cleaners and porters. Nurses Hepatitis C Virus (HCV), children givers and all others who may
and other HCPs must receive injecting at school, care homes come in contact with the sharp
appropriate education and and prisons). (216,225,226,227) device. (215,216,217,218,219,22
training in how to minimize 0,221,222,223,
risk, by following optimal 224)
techniques, using available 4 Patients with small children
safety devices and wearing at home and/or sub-optimal 8 Manufacturers must investigate
protective clothing (e.g., sharps disposal options all reported needlestick injuries
gloves). (214) should also consider using (NSI) to determine if they are
safety-engineered devices. related to a device failure.
2 Safety-engineered devices (215,217,218,220,221,228)
should be considered first-line
choice if injections are given by
a third party. Pen and syringes 5 HCPs should be involved in
with needles used in these the selection, trial and choice
settings should have protective of devices used in their health
mechanisms for all needles care setting. Evaluation prior
and sharp ends of the delivery to adoption should include key
device. (215,216,217,218,219, specialists (e.g. experienced
220,221,222,223,224) end users, infection prevention
and control and occupational
health). (229,215)
9.0
Safety
9 The use of shorter needles (e.g. 12 Needle recapping should not be 14 Review and evaluation of the
4 mm pen needles) without done and manufacturers should effectiveness of education and
a skin fold is recommended design safety-engineered training and of compliance to
to minimize the the risk of devices which make recaping guidelines must be performed
needlestick injury (NSI) through impossible. Fig16 and Fig 17 at regular intervals. A reporting
a skin-fold. (93,102,130,231) (215,217,218,220,221) system for non-compliance
must be put in place. (215,216,2
13 Hospitals must encourage 17,218,219,220,221,222,223,
10 If a lifted skin fold is used, reporting of NSI and near 224)
the patient should ensure misses and establish a no
that finger and thumb are blame culture. Central 15 Attention must be paid to
approximately 2.5cm (1 inch) review of all NSI/near misses the use of safety-engineered
apart and should make the must take place regularly to devices. If they are used
injection in the centre of the allow for policy change and incorrectly or not activated,
fold thus minimizing through- assess educational needs. they provide no additional risk
skinfold NSI risk. (231) (215,217,218,220,221) reduction over conventional
(non-safety) devices (may
11 NSI awareness campaigns lead to dosing errors).
should be carried out (215,216,217,218,219,
regularly and should include 220,221,222,223,224)
all persons in potential
contact with medical sharps.
(217,218,219,220,232,233)
31
THE UK INJECTION AND INFUSION TECHNIQUE RECOMMENDATIONS
9.0
Safety
10.0
Golden Rules
33
THE UK INJECTION AND INFUSION TECHNIQUE RECOMMENDATIONS
10.0
Golden Rules
4 Inspect site before injecting and 10.3 Injection Technique in 3 Consideration should be given
avoid areas of lipohypertrophy. Children and Young People to the type of insulin and the
time of day when selecting
5 Rotation of injection sites within 1 Insulin must be injected injection sites.
an area is recommended: into healthy subcutanous
Spacing injections (SC) tissue, avoiding 4 Correct rotation of injection
approximately 1 cm breadth the intradermal(ID) and sites must be followed
apart intramuscular (IM) tissue at all times to prevent
Using a single injection as well as lipohypertrophy, lipohypertrophy.
site no more frequently lipoatrophy and scar tissue.
than every 4 weeks when 5 4mm pen needles should be
feasible. 2 Injections should avoid bony used for all children and young
Avoid mixing injection areas prominences by one to two people regardless of age,
and insulin type centimetres. Sites, in order of gender or BMI.
preference are:
Upper outer quadrant of the 6 Children and young people
upper buttocks are at risk of accidental IM
Abdomen, two centimetres injection particularly in the
away from umbilicus thigh; therefore, always use a
Middle 3rd of the back of the lifted skinfold especially if using
upper arm a pen or syringe with a safety
Upper outer 3rd of both needle attached.
thighs
10.0
Golden Rules
10.4 Treating and Preventing Clinicians must document 5 Patients with lipohypertrophy
Lipohypertrophy lipohypertrophy and other who have been instructed to
site complications in patient stop injecting/infusing into
1 All HCPs in diabetes must be records affected tissue must be:
trained in correct injection Patients should
technique and to correctly ducated about the
E
be encouraged to
screen for lipohypertrophy and improved/changed
avoid injecting into
other site complications. absorption when injecting
lipohypertrophy or
into normal tissue instead of
unhealthy sites
2 All patients, caregivers, and lipohypertrophy
Clinicians must monitor
family members must be taught and record any area of Advised that pain may be
the techniques of correct lipohypertrophy to map experienced when injecting
injection or infusion at the change, possibly using the into normal tissue
initiation of therapy and at following tools: ncouraged by a HCP to
E
subsequent reviews, at least on -- Photography monitor glucose levels
an annual basis. -- Body maps with frequently due to the risk of
descriptors for size, unexpected hypoglycaemia
3 Injection sites should be shape, texture
checked by a HCP on a regular -- Transparent graduated
Supported to reduce their
basis, at least annually or more recording sheets. insulin doses in line with
often if LH has been detected. glucose results, knowing
ith patient consent,
W that reductions often exceed
4 All persons who self-inject/ clinicians should mark the 20% of their original dose
infuse insulin or other border of all lipohypertrophy Changed to 4mm pen
injectables must be taught to and other site complications needles/8mm insulin
self-inspect sites and be able with skin-safe single- syringes or the shortest
to distinguish healthy from use markers and instruct needle length available
unhealthy tissue. patients to avoid using to minimise accidental
marked areas until intramuscular risk due to
instructed otherwise using larger areas
35
THE UK INJECTION AND INFUSION TECHNIQUE RECOMMENDATIONS
10.0
Golden Rules
6 All patients must be encouraged 10.5 Insulin Infusion 4 Infusion cannulae sites
to correctly rotate injection/ Technique should be rotated to avoid
infusion sites and educated lipohypertrophy. This involves
of the risks of reusing needles 1 Insulin infusion cannulae full rotation within each site.
in order to minimise risk of must be inserted into healthy
injection site complications: subcutaneous tissue, avoiding 5 Infusion cannulae should be
underlying muscle as well changed within 72 hours.
rinciples of correct rotation
P as areas of skin irritation,
technique must be taught scarring, lipohypertrophy and 6 If kinking occurs consider a
to patients and rotation lipoatrophy. shorter cannula or an angled or
technique assessed at steel infusion set.
least every year and more 2 If bleeding or significant pain
frequently if required occurs upon insertion, the 7 If silent occlusion, interuption
Correct rotation ensures set should be removed and in flow or unexplained
that injections are spaced replaced. hyperglycaemia occur, consider
out approximately 1 cm (a using a cannula with a side port.
finger breadth) from each 3 Preferred sites for infusion
other and that a single cannulae should be
injection site is used no individualised and include:
more frequently than every 4
weeks when feasible. Abdomen, avoiding bony
prominences and umbilicus
Upper outer quadrant of the
upper buttocks and flanks
Middle 3rd of the back of the
upper arm
Upper outer 3rd of both
thighs
10.0
Golden Rules
10.6 Needlestick Injuries and 3 Safety-engineered devices must 7 Insulin delivery by 3rd party
Sharps Disposal be used by all HCPs and by all carers or family member must
3rd party carers using sharps be carried out using correct
1 All HCP, employers and (e.g. injections, blood testing, injection or infusion techniques
employees must comply with infusion) in situations where a and with safety-engineered
relevant international, national risk for disease transmission devices which shield/guard the
and local legislation for the use (i.e. Human Immunodeficiency patient end of the needle at a
of sharps. Virus [HIV] and hepatitis) minimum. Best practice for pen
may be present, and in risky needles requires that both ends
2 Sharp medical devices environments such as care of the needle be protected.
present a potential risk for homes, schools, and prisons.
injury and transmission of
disease. All HCPs, employers 4 Frequent and regular sharps
and employees must ensure awareness campaigns must be
the safest possible working conducted by all employers for
environment by: personnel at risk of contact with
medical sharps.
Conducting regular risk
assessment in all situations 5 Recapping of needles is strictly
where there is potential for prohibited (except by the self-
exposure to sharps injury injector).
Preventing and controlling
risk by means of continuing 6 Where possible safety-
education and training engineered devices with
Providing and using a means passive activation should be
of safe disposal of used used.
sharps conforming with
National standards
Encouraging reporting of
incidents
37
THE UK INJECTION AND INFUSION TECHNIQUE RECOMMENDATIONS
10.0
Golden Rules
Correct disposal
procedures and personal
responsibility be taught to
patients and care givers
by the dispensing clinician
(including pharmacists) and
be regularly reinforced
Safe sharps disposal
systems and processes be
present and known to all
persons at risk of sharps
contact (conforming to
National standards)
Environments where others
are at risk of exposure to
sharps (e.g. care homes,
schools and prisons or
around refuse workers and
cleaners) be highlighted to
the patient
Patients diagnosed with
blood bourne diseases such
as Human Immunodeficiency
Virus (HIV) or Hepatitis be
supported to use safety-
engineered devices and
dispose of them safely
Sharps should never be
placed directly in public or
household rubbish
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