Challenges with Insulin administration: How to avoid an IJ!

by Flora Bessey, PharmD, BCGP

Those of us who have been in long-term care for awhile have seen the evolution in the treatment of diabetes, specifically insulin options. From “regular (short-acting)” to “NPH (intermediate-acting”) to “long-acting” to “analog (rapid and long-acting).” Patients with type 2 (or type 1) diabetes, and their health care providers, now have many options when choosing insulin.

Until recently, in our setting the administration of insulin was accomplished exclusively the “old-fashioned” way: with a vial and syringe. In the non-institutional world, however, patients were able to access an administration platform that is less cumbersome, and easier, for a non-clinician to utilize: insulin pens.
The availability of insulin pens has now become common in our setting. For many med-pass nurses, this was a welcome change. The dose can be “dialed” up on the pen (as opposed to having to draw it up with a syringe), there is less chance of a needle stick injury (since the needles used on pens are “safety needles”), and since the volume of insulin within each pen is only 3-ml, there is potentially less waste than with the most-common 10-ml vial bottles. However, the very perceived “ease” of use of insulin pens has led to a rash of “immediate jeopardy” citations in buildings all across California.

There are some vitally important things to remember when using an insulin pen. First of all, a pen (unlike a “floor stock” of insulin in a vial in a hospital, for example) can only be used for ONE patient. This is an infection-control issue; when insulin is administered with a pen, biologic material from the patient often “backs up” into the cartridge. This seems like common sense, but the use of one pen on multiple patients has occurred thousands of times across the country, even in very prestigious hospitals. The perception may exist for some nurses that if you change the needle on the pen, it can now be used for a different patient. It is very important to emphasize that this is NOT the case.

Also, although the reservoir of the pen contains 3-ml of insulin, it is NOT to be used as a “small vial!” If small vials are the preference for your facility, then they can be ordered through your pharmacy (and are much cheaper than pens!). If a syringe needle is inserted into the pen’s reservoir, the pen is now contaminated (and, if state is present, you WILL receive an “IJ”).

Next, it is vitally important that the pen be primed before EVERY use. The pen needles contain air (as does the reservoir of the pen, often times), and the pen/needle combination must be primed using 2 units UNTIL A STEADY STREAM is seen. This can take several attempts (I’ve seen it take as many as 5). If the pen is not properly primed, there is no way to know how much insulin is being administered. And, if the state is following on med pass, you WILL receive an “IJ.”

Finally, when the dose is administered, the nurse must leave the needle in the skin at least 5-10 seconds. This depends upon the pen; KwikPen (Lilly insulins including Basaglar, Humalog and Humulin) is 5 seconds; FlexPen and FlexTouch (Novo insulins including Novolog, Levemir and Tresiba) is 6 seconds; Solostar (Sanofi’s Lantus) is 10 seconds (though Sanofi’s Toujeo is 5 seconds…confused yet?). The bottom line is that the nurse must use a watch (or the clock) OR count “One-one thousand, two-one thousand…” to be assured that the full dose has been administered. Otherwise, again, there is no way to know what dose was received. And, again, if CDPHis watching, this is cause for an “IJ.”

Because of these challenges, and a desire to avoid confusion (and survey challenges), some buildings are choosing to minimize insulin pen use. The reality, however, is that on the custodial side, our buildings often have little choice as to what insulin administration platform the Part D insurance will pay for; for example, many of the Part D plans now prefer Basaglar KwikPen for a long-acting insulin, due to cost considerations. If your facility wants a different insulin (for example, a Lantus or Levemir 10-ml vial), this will necessitate a “Prior Authorization.”

In summary, the use of insulin pens (at least to some extent) is something we have to be prepared for in our facilities. Reach out to your consultant pharmacists, or your long-term care pharmaceutical representatives, for assistance is assuring the staff is administering insulin safely, and that your building will avoid the consequences of an “IJ.”