Insulin Competency Development

Toronto Diabetes Care Connect released the following report in January 2018: Insulin Competency Development: A Report of the Insulin Standards Working Group (Toronto Central LHIN Region). This report includes a comprehensive summary of the work of the Insulin Standards Working Group (2013 – 2017) and a number of recommendations regarding insulin competency development.

Authorizing Mechanisms

The following authorizing mechanisms are routinely used by insulin prescribers (e.g. physicians or nurse practitioners) to authorize diabetes educators to support people with starting and adjusting insulin:

1. Medical Directives
   • A medical directive can be developed with a specific diabetes education program to authorize the support of insulin start and/or dose adjustment by the specific program’s competent diabetes educators for all of your patients of a particular type (e.g. adults with type 2 diabetes) .
   • If you wish to explore this option please contact the specific diabetes program directly and review the information and tools to support this on the Federation of Health Regulatory Colleges of Ontario’s website.
2. Direct Orders
   • A direct order (e.g. Toronto Diabetes Care Connects’s (TDCC) Insulin Order & Prescription) can be used to authorize the support of insulin start and/or dose adjustment by any competent diabetes educator of any diabetes education program to support the specific patient whom the order is for with insulin starts and/or dose adjustment.

 About TDCC’s Insulin Order & Prescription Form

This direct order was adapted from the Ontario College of Family Physician’s Insulin Prescription Tool in 2014 by the Toronto Central Region’s Insulin Standards Working Group (facilitated by Toronto Diabetes Care Connect). A number of key stakeholders were involved in the creation of this order including diabetes educators, physicians, pharmacists, and practice advisers from the College of Nurses of Ontario and College of Dietitians of Ontario. More information about this tool can be obtained by contacting Toronto Diabetes Care Connect.

Instructions on How to Use the Insulin Order & Prescription

1. Fill in person’s name & date of birth
2. Select the following:
   a) type of insulin
   b) starting dose (with timing of dose)
   c) adjustment/titration amount
   d) glycemic target
3. Note any changes to existing antihyperglycemic agents
4. Complete prescription information (if using as a prescription)
5. Sign & date the order/prescription
6. Fax the order/prescription (if using as both an order and a prescription please ensure the form is sent to both the diabetes education program and the pharmacy).
   a) For new referrals, fax this as an attachment/addendum to the referral
   b) For ongoing care/medication changes, fax this to the specific diabetes education program that is supporting the individual

Prescribers will save time and support timely support by filling in the form completely according to the instructions below.

Other ways to authorize insulin starts & dose adjustments

Physicians and nurse practitioners can use other methods of authorizing diabetes educators to support insulin starts and dose adjustments such as:

1. Using other insulin order sets
2. Embedding your insulin order into your referral letter or EMR in some way (see below)

If you choose to use any of these options please ensure that your medical order for insulin initiation and dose adjustment includes all required elements (see below).

Required information to include in a medical order for insulin start and dose adjustment

1. Client information: Name & Date of Birth (e.g. Jane Doe, DOB: [month/day/year])
2. Medication information: Name; Dose; Frequency/timing; & Route of administration (e.g. Lantus 10 units via subcutaneous injection qhs)
3. Parameters around titration/dose adjustment delegation: Amount of dose adjustment; Frequency & timing of dose adjustment; Target for dose adjustment (e.g. Adjust Lantus dose by 2 units every 3 or more days until fasting CBG is between 5-7 mmol/L)
4. Specific instructions around existing antihyperglycemic agents (AHAs) (e.g. No changes to be made to existing AHAs) This element is not a requirement of the College of Nurses of Ontario however we recommend that it be included to support the safety of the individual using insulin.
5. Health Care Provider’s Information
   • Name – printed (e.g. Dr. Joe Smith)
   • Signature & Date signed (e.g. Dr. Joe Smith, CPSO #: month/day/year) The CPSO# is required if order is to be used as a prescription

Unless otherwise specified the elements above are required elements of a medication order as per the College of Nurses of Ontario (Practice Standards Medication 2008).

Prescribing Tips for Starting and Adjusting Insulin

Instructions and examples for insulin starts and dose adjustments can be found on Diabetes Canada’s Website and/or on the back of the TDCC Insulin Order & Prescription Form (included with permission from the Ontario College of Family Physicians’ Insulin Prescription).