DIABETES CARE IN THE UK
FIT UK Forum
for Injection
Technique UK
The UK Injection
Technique
Recommendations
3rd Edition
Optimising
Diabetes Care
DR
AF
T
THE INJECTION TECHNIQUE RECOMMENDATIONS
Preface
Forum for Injection Technique (FIT) UK provides evidencebased best practice recommendations for people with
diabetes who are using injectable therapies and for
clinicians who care for people with diabetes using
injectable therapies. Through these recommendations,
people with diabetes can achieve the best possible
health outcomes by ensuring that the correct dose
of medication is delivered to the correct injection site,
using the correct technique. FIT UK understands that
written guidelines alone will not change clinical
practice unless appropriately implemented. FIT UK
is committed to engaging in a range of initiatives
including research, education and support for
healthcare professionals, carers and people with
diabetes.
Our Objectives
• To review the injection techniques currently being used by
people with diabetes.
• To identify, and to provide information on ‘Best Practice’
and eduction programmes used in the UK
• To raise awareness of the impact that existing and emerging
research regarding injection technique may have on health
outcomes and wellbeing for those with diabetes that
require subcutaneous injection therapy
• To facilitate opportunities in which best practice can be
discussed, developed, implemented and evaluated across
the UK
3
THE INJECTION TECHNIQUE RECOMMENDATIONS
Introduction
Over 15 years ago a small pioneering group
of medical and nursing staff gathered for the
first time to explore the evidence for optimal
injection technique.
FIT UK was established following the 3rd International Injection
Technique meeting in Athens 2009. Informed by the results of the
International Injection Technique Survey(159) and contemporaneous
injection technique evidence from around the world, the founders of
FIT UK determined to share their findings and their passion for optimal
injection technique not only in the UK but around the world.
FIT UK has grown from a single entity based in the UK and is now
represented in countries including:
•
•
•
•
•
•
•
Canada
Dominican Republic
India
Ireland
Philippines
South Africa
Switzerland
Diabetes UK estimates that more than one in 16 people in
the UK has diabetes (diagnosed or undiagnosed) and that there are 3.9
million people living with diabetes in
the UK’. This is projected to rise to 5 million people by 2025. (192)
Diabetes diagnosis rates are equivalent to:
• more than 400 people every day
• over 17 people every hour
• around three people every ten minutes (192)
4 DATE PUBLISHED: September 2015
* data on file
FIT UK
Everyone with type 1 diabetes (T1DM) will need insulin from diagnosis.
Currently there are are around 465,000 people over the age of 16 with
T1DM using insulin. A Further 26,500 children and young people use
insulin in the UK. It is estimated that 28.3% of all people with diabetes
are prescribed insulin injections in the UK(160). Therefore more than
3.9 million people estimated to have diabetes, almost 1 million of
these will need to inject insulin. (195)
FIT UK’s overarching mission is:
‘To support people with diabetes using injectable
therapies to achieve the best possible health outcomes
that are influenced by correct injection technique’.
To date FIT UK has delivered many education programmes and
produced the First UK Injection Technique recommendations (2010)
and Safety Recommendations (2012) which have been distributed and
accessed online by many thousands of health care professionals. FIT
UK has also produced a range of educational support materials and
e-learning modules.
FIT UK is committed to supporting the implementation of the
recommendations and developing them further as new evidence
emerges. We welcome any comments, suggestions and active
participation in ensuring that the updated recommendations remain
relevant and useful for now and in the future.
web: www.fit4diabetes.com
email: infouk@fit4diabetes.com
Meet the team.
Debbie Hicks
Nurse Consultant –
Diabetes (Chair)
Barnet, Enfield &
Haringey Mental
Health Trust
Dr Debra Adams
Head of Infection
Prevention and
Control (Midlands
and East). NHS
Trust Development
Authority
Jane Diggle
Specialist
Practitioner, Practice
Nurse. Church View
HC South Kirkby, West
Yorkshire
Carole Gelder
Childrens nurse
specialist and
lecturer, Leeds
Childrens Hospital and
University of York
5
THE INJECTION TECHNIQUE RECOMMENDATIONS
New and emerging evidence shows that optimal injection technique
is critical to improving health outcomes. A pioneering study by
Blanco (189) demonstrated that almost two thirds of patients have
lipohypertrophy due primarily to incorrect or no rotation of injection
sites. Of the patients with lipohypertrophy 39.1% had unexplained
hypoglycaemia and 49.1% had glycaemic variation. Patients with
lipohypertrophy were found to be using much more insulin than those
without, estimated to cost the Spanish Healthcare system €122million
per year in excess insulin usage.
A study by Grassi (190) demonstrated that a multimodal approach
to injection technique education and support could reduce HbA1c by
6mmol/moL (0.58%) in patients treated with insulin. Interestingly this
was achieved using less insulin and without any weight gain. The
development of FIT UK and the subsequent UK recommendations for
injection technique have been supported by BD Europe. They have
also been endorsed by Diabetes UK along with the pharmaceutical
companies whose therapies include subcutaneous injections of insulin
and GLP-1 agonists.
6 DATE PUBLISHED: September 2015
* data on file
DR
AF
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Contents
Preface and Objectives
Introduction
FIT UK
Endorsements
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
11.0
12.0
13.0
14.0
15.0
16.0
17.0
3
4
5
8
Psychological Challenges of Injections
Therapeutic Education
Injection Sites
Injection Site Care
Insulin Storage and Suspension
Reduction of Injection Pain
The Correct Use of Pen Devices
The Correct Use of Syringes
Absorption Rates
Needle Length
Lifted Skin Folds
Rotation of Injecting Sites
Lipohypertrophy
Bleeding and Bruising
Pregnancy
Safety Issues
Disposal of injecting material
11
12
13
14
15
15
16
17
18
21
23
24
24
25
26
27
31
References
Contributors
32
39
7
THE INJECTION TECHNIQUE RECOMMENDATIONS
Endorsements.
“Diabetes UK both welcomes and supports the FIT initiative.
Good injection technique leads to good blood glucose control which
is vital in preventing the long term complications of diabetes. As so many people with diabetes
are now being prescribed injectable medication, this is a timely and important enterprise which
will bring great benefit to them. ”
Simon O’Neill, Director of Health Intelligence. DIABETES UK
“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 GLP1s. The Forum for Injectable Therapy (FIT) provides comprehensive evidenced
basedguidelines 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 believe 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.
8 DATE PUBLISHED: September 2015
* data on file
BD Medical – Diabetes Care
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.”
Nicky Barry, Divisional Director Diabetes, Sanofi
“ 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 are extremely proud of the heritage they share with the
Forum for Injection Technique, and fully support the continued work of the
FIT Board and FIT associates who continue to expand the boundaries of best
practice within the fields of insulin injection and medication management.
The first and second editions of the FIT recommendations have been shared with over 30,000
healthcare professionals, and the welcome third edition will surely continue to bring the many
positive clinical benefits to patients and healthcare professionals alike. BD would like to
personally congratulate the FIT board on this magnificent achievement, and look forward to
supporting FIT for many years to come.”
Loïc Herve, Business Unit Director Diabetes Care BD
Supported by medical technology company Becton, Dickinson U.K. Limited. (www.bddiabetes.co.uk) BD and
BD Logo are trademarks of Becton, Dickinson and Company. ©2015 BD
9
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
B
C
STRONGLY RECOMMENDED
RECOMMENDED
UNRESOLVED ISSUE
For the scientific support the following
scale was used.
1
2
3
At least one randomised controlled study
At least one non-randomised (or non-controlled
or epidemiologic) study
Consensus expert opinion based on extensive
patient experience.
A number of significant studies have published evidence in the
intervening years since 2009. Therefore FIT UK has conducted a further
review of critical evidence and included this within the 3rd edition of
the Injection Technique Recommendations. The new evidence has also
been subjected to the rigour of the strength scale of recommendations
as above.
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 Injection Recommendations for Patients with Diabetes:
Diabetes & Metabolism 2010. Vol 36. informed these recommendations
and we thank the editors of Diabetes & Metabolism for permission to
use material from this article.
10 DATE PUBLISHED: September 2015
* data on file
STRONGLY RECOMMENDED
RECOMMENDED
UNRESOLVED ISSUE
At least one randomised controlled study
At least one non-randomised
(or non-controlled or epidemiologic) study
Consensus expert opinion based on
extensive patient experience.
1.0
Psychological Challenges
of Injections
1.1 Children
1.2 Adults
1 Children have a lower threshold
for pain than adults and
sometimes find injecting
uncomfortable. The healthcare
professional (HCP) should ask
about pain, since many young
people with diabetes will not
bring it up spontaneously.
(18, 20)
1 The HCP should prepare all
people with type 2 diabetes
for likely future injectable
therapy early in the disease
pathway, by explaining the
natural, progressive nature
of the disease, stating that it
includes injectable therapy and
making clear that injectable
therapy treatment is not a sign
of patient failure. (30)
2 Younger children may be helped
by distraction techniques (as
long as they do not involve
deception) or play therapy (e.g.
practicing injections on a soft
toy) while older children may
respond better to Cognitive
Behavioural Therapies (CBT)
where available. (19)
3 CBT includes relaxation
training, guided imagery,
graded exposure, active
behavioural rehearsal,
modelling and reinforcement as
well as incentive scheduling.
(19)
4 HCPs should reflect on their
own perceptions of injectable
therapy and avoid using any
terms which imply that such
therapy is a sign of failure, a
form of punishment or a threat.
(33,34)
5 Pen devices may have
psychological advantages over
syringes and therefore maybe
more acceptable. (31,35-37)
2 Both the short-term and
long-term advantages of good
glucose management should
be emphasised. Finding the
right combination of therapies
including injectables leading to
optimal glucose management
should be the goal. (31,32)
3 Through culturally-appropriate
pictures and stories, HCPs
should show how injectable
therapy could enhance both the
duration and quality of life. (31)
11
THE INJECTION TECHNIQUE RECOMMENDATIONS
2.0
Therapeutic Education
1 The HCP should spend time
exploring the individual’s
anxieties about the injecting
process and the injectable
therapy itself. (33,40)
2 At the beginning of injection
therapy (and at least every
year thereafter) the HCP
should discuss:
• Injecting regimen
• Choice and management
of the devices used
• Choice, care and self-
examination of injection sites
• Correct injection techniques
(including site rotation,
injection angle and possible
use of skin folds)
• Injection complications and
how to avoid them
• Optimal needle length
• Safe disposal of used sharps
(32-35, 38-41)
12 DATE PUBLISHED: September 2015
* data on file
Ensure that each of these
topics have been fully
understood. (34)
3 Injection technique education
should be put in place and
regularly reviewed and recorded
in the individuals care plan.
4 Current injection practice
should be discussed and if
possible observed. Injection
sites should be examined and
palpated, if possible at each
visit but at least once a year.
(38,40,41)
STRONGLY RECOMMENDED
RECOMMENDED
UNRESOLVED ISSUE
At least one randomised controlled study
At least one non-randomised
(or non-controlled or epidemiologic) study
Consensus expert opinion based on
extensive patient experience.
3.0
Injection Sites
The diagram shows the current
recommended injection sites for
injectable therapy
Figure 1:
Recommended injection sites.
13
THE INJECTION TECHNIQUE RECOMMENDATIONS
4.0
Injection Site Care
1 The site should be inspected
and palpated by the individual
prior to injection. (5,6)
2 Avoid using a site showing
signs of lipohypertrophy,
inflammation, oedema or
infection until the problem has
been resolved. (15,49,50-55)
3 Injections should be given
into a clean site using clean
hands. (56)
4 The site should be cleansed
with soap and water when
found to be unclean. (56)
5 Disinfection of the site is
usually not required; however,
alcohol swabs may be used
prior to injections given in the
hospital or care home setting.
(6, 57-60)
14 DATE PUBLISHED: September 2015
* data on file
Keeping injection sites healthy:
A simple six step programme
that patients should be
supported to follow for each
injection
1. The site should always
be inspected prior to the
injection
2. Avoid injecting into sites
with lipohypertrophy,
oedema,inflammation or
signs of infection
3. Inject only into a clean site
with clean hands
4. Cleanse the site with
domestic soap and water if
required
5. Always rotate sites, try to
spread the time between
a single injection site as
much as possible (Refer to
section 13)
6. Never reuse needles
STRONGLY RECOMMENDED
RECOMMENDED
UNRESOLVED ISSUE
At least one randomised controlled study
At least one non-randomised
(or non-controlled or epidemiologic) study
Consensus expert opinion based on
extensive patient experience.
5.0
6.0
Insulin Storage
and Suspension
Reduction of
Injection Pain
1 Store injectable medication
in current use at room
temperature (according to
manufacturers instructions).
Avoid direct sunlight and areas
of temperature extremes. Store
unopened injectable medication
in an area of the refrigerator
where freezing is unlikely
to occur. (66,67)
2 Cloudy insulin (e.g. NPH and
pre-mixed insulin) must be
gently rolled ten times and
inverted ten times (not shaken)
until the crystals go back into
suspension and the solution
becomes milky white.
(61-65)
Tips for making injections less
painful include:
• Keeping injectable therapy
in use, at room temperature.
(66,67)
• Using needles of shorter length
and smaller diameter. (157)
• Using a new needle at each
injection. (5,6,17,36,68)
• Insert the needle in a quick
smooth movement through
the skin. (69)
• Inject slowly and ensure that
the plunger (syringe) or thumb
button (pen) has been fully
depressed. (69)
• Remove at same angle and
keep hand steady.
Suspension of NPH insulin before and after
electronic tipping to 180° (one cycle)
A: Before (after 24 sedimentation).
B: After 7 cycles.
C: After 20 cycles.
15
THE INJECTION TECHNIQUE RECOMMENDATIONS
7.0
The Correct Use of
Insulin Pen Devices
1 Pen devices should be primed
(observing at least a drop at
the needle tip) according to
the manufacturer’s instructions
before each injection. Once
flow is verified, the desired
dose should be dialled and the
injection administered. (36,68)
2 Pen devices and cartridges are
for single person use only and
should never be shared due to
the risk of cross contamination.
(37,57)
3 Pen needles should be used
only once. (3,5,6,17,59,76,77)
4 Using a new needle each time
may reduce the risk of needle
breakage in the skin, ‘clogging’
of the needle, inaccurate dosing
and indirect costs (e.g Abscess).
(77)
5 First the needle is inserted
into the skin. After pushing
the dose button in completely,
the individual should count
slowly for 10 seconds before
withdrawing
the needle in order to deliver
the full dose and prevent
the leakage of medication.
Counting past 10 seconds may
be necessary for higher doses.
(61,69,71,74,78,79)
6 Needles should be safely
disposed of immediately after
use and not left attached to the
pen. This prevents the entry
of air (or other contaminants)
into the cartridge as well as the
leakage of medication out of
the cartridge, which can affect
subsequent dose accuracy.
(71-75)
1: Make sure you have a clean site and clean
hands and check the injection site.
2: Place a new needle onto your pen device
and screw firmly into place, but do not over
tighten.
7 Injecting through clothing
should be discouraged. As
needle lengths are becoming
shorter there is increased risk
of intradermal injection.
3: Remove outer and inner cap.
16 DATE PUBLISHED: September 2015
* data on file
STRONGLY RECOMMENDED
RECOMMENDED
UNRESOLVED ISSUE
At least one randomised controlled study
At least one non-randomised
(or non-controlled or epidemiologic) study
Consensus expert opinion based on
extensive patient experience.
7.0
8.0
The Correct Use of
Insulin Pen Devices
The Correct
Use of Syringes
1 A syringe should be used only
once and disposed of safely.
(3,5,6,17,59,76,77)
4: If the insulin is cloudy type, gently invert
10 times and roll between palms of hands 10
times to fully mix it.
7: Hold the pen in your fist; keep your thumb
away from the dose button. With the pen at 90
degrees to the skin surface, gently push the
needle through the skin into the injection site.
2 When drawing up insulin, the
air equivalent to the dose
should be drawn up first
and injected into the vial to
facilitate easier withdrawal.
3 If air bubbles are seen in the
syringe, hold syringe with
needle uppermost, tap the
barrel to bring them to the top
and then remove the bubbles
by pushing the plunger to expel
the air.
5: Test dose, set the dial to 2 units and with
the needle tip pointing upwards and away from
you bu still visable press the dose button.
You should see a bead of insulin appear at the
needle tip. repeat if no insulin appears.
8: Push down the dose button with your
thumb. Hold the needle in the injection site
for a full ten seconds after you have finished
pushing the dose button. Then gently remove
the needle from the skin.
6: Set your dose.
9: Remove the used pen needle and place in
sharps box ready for safe disposal.
4 Never withdraw insulin from pen
cartridges or prefilled pens with
a syringe.
17
THE INJECTION TECHNIQUE RECOMMENDATIONS
9.0
Absorption Rates
All insulin and GLP1 injections should be
administered subcutaneously.
9.1 Human Insulin
1 Intramuscular (IM) injection of
all human insulin should be
avoided since rapid absorption
and serious hypoglycaemia can
result. ( 95,96)
2 The thigh and buttocks are
the preferred injection sites
when using NPH (intermediate
acting) as the basal insulin,
since absorption is slowest
from these sites. (43,97)
3 The abdomen is the preferred
site for soluble human insulin,
since absorption is fastest
there. (16,44,46,98-100)
4 The absorption of soluble
(short acting) human insulin
in the elderly can be slow and
this insulin should not be used
when a rapid effect is needed.
(14,101)
(Note: Insulin
actions may overlap)
18 DATE PUBLISHED: September 2015
* data on file
5 For insulin in strengths other
than 100units/ml (U100)
please refer to manufacturers
instructions for use.
For those people who require
very large doses of insulin
U-500 insulin maybe an option
instead of U-100. U-500 is
only available as soluble
insulin. However it has a
pharmacokinetic profile more
closely simulating NPH human
intermediary insulin than
soluble short acting human.
U-100. (5,6,158)
This can be short, intermediate
or long acting and will absorb at
different rates depending where
on the body you inject.
Bolus (fast acting) insulin.
The abdomen is preferred for this soluble
insulin since absorbtion is fastest here.
It will deal quickly with a rise in blood
glucose after eating
6 Massaging the site before or
after injection may speed up
absorption and is not generally
recommended. (5,6,70)
Basal (intermediate acting) insulin.
The thigh and buttocks are the best sites for
this insulin as absorbtion is slowest here.
Will reduce the risk of hypo overnight.
STRONGLY RECOMMENDED
RECOMMENDED
UNRESOLVED ISSUE
At least one randomised controlled study
At least one non-randomised
(or non-controlled or epidemiologic) study
Consensus expert opinion based on
extensive patient experience.
9.0
Absorption Rates
Continued
9.2 Premixed Insulin
1 Intramuscular (IM) injection of
all human insulin should be
avoided since rapid absorption
and serious hypoglycaemia can
result. (95,96)
2 Premixed insulin (human or
analogue) should be given in
the abdomen in the morning
to increase the speed of
absorption of the short-acting
insulin in order to cover postbreakfast glycaemic excursions.
(12)
Pre-mixed human and pre-mixed
analogue insulin will absorb at
different rates depending where
on the body you inject.
Morning
When injected in the morning or during the
day this insulin will quickly reduce blood
glucose levels after meals. Acts fastest when
injected into the abdomen.
3 Premixed insulin should be
given in the thigh or buttock
before evening meal as this
leads to slower absorption and
decreases the risk of nocturnal
hypoglycaemia. (93,97)
4 Massaging the site before or
after injection may speed up
absorption and is not generally
recommended. (5,6,70)
Evening
Injecting into the thigh or buttocks in the
evening or before bed will slow the insulin
absorption and help reduce risk of hypo at
night.
19
THE INJECTION TECHNIQUE RECOMMENDATIONS
9.0
Absorption Rates
Continued
9.3 Insulin Analogues
1 Rapid-acting insulin analogues
may be given at any of the
injection sites, as absorption
rates do not appear to be
site-specific. (81-85)
2 Long-acting insulin analogues
may be given at any of the
injection sites, as absorption
rates do not appear to be
site-specific. (87,88)
3 IM injections of long-acting
analogues must be avoided
due to the risk of severe
hypoglycaemia or erratic
control. (89,90)
20 DATE PUBLISHED: September 2015
* data on file
9.4 GLP-1 Agonists
5 Do not inject a rapid and a long
acting analogue insulin in the
same site within a 24hr period.
6 Larger doses may cause a delay
in the peak and increase the
duration of action. (5,6)
7 Massaging the site before or
after injection may speed up
absorption and is not generally
recommended. (5,6,70)
1 Pending further studies, people
with diabetes who inject GLP1 agents should follow the
manufacturers instructions. (72)
STRONGLY RECOMMENDED
RECOMMENDED
UNRESOLVED ISSUE
At least one randomised controlled study
At least one non-randomised
(or non-controlled or epidemiologic) study
Consensus expert opinion based on
extensive patient experience.
10.0
Needle Length
10.1 Children and
Adolescents
1 Insulin must always be
delivered into subcutaneous tissue to help ensure
predictable absorption
(163-167)
2 There is no clinical reason for
recommending needles longer
than 4mm for children and
adolescents. (118,162)
3 Children and adolescents using
a 5 or 6mm needles must lift
a skin fold with each injection.
(9,83,86,110,112-117,156,157,162)
4 In the majority of cases a 4mm
needle may be inserted at 90
degrees without a lifted skin
fold. However, considerable
care must be taken to
ensure there is sufficient
combined subcutaneous fat
and skin thickness to avoid
intramuscular deposition
(9,162)
10.2 Adults
5 If children have only an 8 mm
needle available (as is currently
the case with syringe users), it
is essential to use a lifted skin
fold and give injections into
the buttocks to minimise the
risk of intramuscular injection.
(111,118,119,162)
6 Arms should only be used for
injections if administered by a
third party and using a lifted
skin fold.
7 Avoid pushing the pen device in
to the skin thus indenting the
skin during the injection, as the
needle may penetrate deeper
than intended and enter the
muscle.
1 Insulin must always be
delivered into subcutaneous
tissue to help ensure
predictable absorption
(163-167)
2 There is no clinical reason for
recommending needles longer
than 6mm for the
administration of insulin.
(105,119,132,161)
3 4, 5 and 6 mm needles are
suitable for all people with
diabetes regardless of BMI
for insulin injections; they
may not require a lifted skin
fold; particularly if using 4
mm needles. (9,74,104,106 –
108,156,157,161)
4 injections of insulin with
shorter needles (4, 5, 6 mm)
should be given in adults at
90 degrees to the skin surface.
(9,74,106 – 108,130,161)
21
THE INJECTION TECHNIQUE RECOMMENDATIONS
10.0
Needle Length
Continued
Adults
Intramuscular injection (IM)
6 Individuals using ≥8mm needles
should ensure they are using
a lifted skin fold to avoid IM
injections. (105,131,161)
Skin layer - don't inject here
Subcutaneous layer - inject here
Muscle layer - dont inject here
Intramuscular injection (IM)
22 DATE PUBLISHED: September 2015
* data on file
01
2
Any insulin injected into muscle
will be absorbed too quickly
into the bloodstream, which may
result in high variability of blood
glucose levels and increased risk
of hypoglycaemia.
To avoid injecting into the muscle
layer it is important to use a
short pen needle and if necessary
use a lifted skin fold.
01
2
01
2
5 To prevent possible IM
injections when injecting into
slim limbs and abdomens, even
short needles (4,5 and 6mm)
may warrant use of a lifted skin
fold. (9,105,106,131,161)
Injecting into muscle is also
known to be more painful
and might cause bleeding and
bruising.
Longer pen needles increase
the chance of injecting
into the muscle, therefore
it is crucial to perfect the
technique for the needle you
are using or switch to short
pen needles.
STRONGLY RECOMMENDED
RECOMMENDED
UNRESOLVED ISSUE
At least one randomised controlled study
At least one non-randomised
(or non-controlled or epidemiologic) study
Consensus expert opinion based on
extensive patient experience.
11.0
Lifted Skin Folds
The skin fold technique
1 All people with diabetes/carers
should be taught the correct
technique for lifting a skin fold
from the onset of injectable
therapy. (see Fig 2.)
2 The lifted skin fold should not
be squeezed so tightly that it
causes skin blanching or pain.
3 The optimal sequence should be:
1) Make a lifted skin fold
2) Insert needle into skin at 90˚
angle
3) Administer therapy
4) Leave the needle in the skin for
at least 10 seconds after the
thumb button plunger is fully
depressed
5) Withdraw needle from the skin
6) Release lifted skin fold
7) Dispose of used needle safely
(see section 17)
This technique can reduce the risk
of intramuscular injection BUT
MUST be carried out properly as
directed by your nurse or doctor.
Only the thumb, index finger and
middle finger should be used, and
the skin fold should be held until
after the pen needle is removed
from the skin.
BEWARE: this technique should
take up skin and subcutaneous
tissue only, leaving muscle behind.
Figure 2: Correct (left) and incorrect (right)
ways of performing the skin fold.
23
THE INJECTION TECHNIQUE RECOMMENDATIONS
12.0
13.0
Rotation of
Injecting Sites
Lipohypertrophy
1 Individuals should be taught an
easy-to-follow rotation scheme
from the onset of injection
therapy. (146,147)
2 One scheme with proven
effectiveness involves
dividing the injection site into
quadrants (or halves when
using the thighs or buttocks);
using one quadrant per week
and moving always in the same
direction, either clockwise or
anti-clockwise (see Figures 3
and 4). (148)
Figure 3: Injections within any quadrant
should be spaced at least 1cm from each
other
24 DATE PUBLISHED: September 2015
* data on file
3 Injections within any quadrant
or half should be spaced at
least 1cm from each other in
order to avoid repeat tissue
trauma.
4 HCP should verify that the
rotation scheme is being
followed at each visit and
should provide advice where
needed.
5 Use a variation of educational
approaches and available tools
to inform how to detect for
lipohypertrophy.
Figure 4: Sample structured rotation plan
for abdomen and thighs. Divide the injection
area into quadrants or zones. Use 1 zone per
week and move clockwise4
1 Individuals should be taught
to examine their own injection
sites and how to detect
lipohypertrophy. (41,138)
2 Sites should be inspected and
any abnormalities documented
by the HCP within the
individual’s care plan. For
more information please refer
to the FIT SDP booklet. At a
minimum, each site should be
examined visually as well as
a tactile inspection annually
(preferably at each visit). It
is recommended that the FIT
UK Unexplained Hypoglycemia
assessment tool is used. If
lipohypertrophy is already
present the sites should be
monitored at every review.
(41,138,189).
3 Using various available tools
such as making two ink marks
at opposite edges of the
lipohypertrophy allows the lipo to
be measured and its size
recorded for long-term follow
up. If visible the area of
lipohypertrophy could
also be photographed for the
same purpose (189).
STRONGLY RECOMMENDED
RECOMMENDED
UNRESOLVED ISSUE
At least one randomised controlled study
At least one non-randomised
(or non-controlled or epidemiologic) study
Consensus expert opinion based on
extensive patient experience.
14.0
Bleeding
and Bruising
4 Individuals should be advised
(and rationale explained)
not to inject into areas of
lipohypertrophy until abnormal
tissue returns to normal (which
can take months to years).
(139,140,189).
6 Caution is needed; too great
a reduction in dose could lead
to an increased risk of Diabetic
Ketoacidosis in people with
Type 1 Diabetes. However, too
small a reduction could result
in hypoglycaemia.
1 Individuals should be reassured
that bleeding and bruising
do not appear to have adverse
clinical consequences for
the absorption or action
of injectable therapies.
(149,150)
5 Switching injections from
areas of lipohypertrophy to
normal tissue often requires a
decrease of the dose of insulin
injected. The amount of change
varies from one individual to
another and should be guided
by frequent blood glucose
measurements. (50,140,189)
7 The best current preventative
and therapeutic strategies
for lipohypertrophy include
rotation of injection sites with
each injection, and non-reuse
of needles. (136,137,139,141143,189)
2 If persistent bruising occurs
review injection technique.
Do not reuse.
Figure 5: Examples of lipohypertrophy
Lipoatrophy, although very rare,
is a wasting of the subcutaneous
tissue at injection sites. Injecting
into these sites should be avoided.
Figure 6: Cluster of injection punctures.
25
THE INJECTION TECHNIQUE RECOMMENDATIONS
15.0
Pregnancy
1 Due to the paucity of evidence
regarding insulin injection
technique during pregnancy,
the following recommendations
are based upon available
research and clinical
experience.(168,169) During
pregnancy, questions often
arise from women regarding
why, where and how insulin is
used. The initial concerns of the
mother regarding the effect of
insulin injections or infusion on
the foetus must be explored, to
facilitate medication adherence.
Ease of use and safety issues
(e.g. hypoglycaemia) should
also be discussed.(170)
26 DATE PUBLISHED: September 2015
* data on file
15.1 Recommendations
1 Education regarding insulin use
during pregnancy is essential
for all pre-gestational women,
and women with gestational
diabetes who require insulin.
This education should include
discussion of the psychological
adjustment to insulin use,
changes to insulin requirements
during pregnancy, appropriate
injection sites and their
rotation, and prevention of
hypoglycaemia.
2 Shorter needles (4 mm or
5 mm) should be used to
decrease the potential for
intramuscular injection.
(171-174)
STRONGLY RECOMMENDED
RECOMMENDED
UNRESOLVED ISSUE
At least one randomised controlled study
At least one non-randomised
(or non-controlled or epidemiologic) study
Consensus expert opinion based on
extensive patient experience.
16.0
Safety Issues
1 Sharp devices represent a risk
for the transmission of bloodborne pathogens to the user
in the event of a needle stick
injury (NSI) or muco-cutaneous
blood exposure.(175)
2 The priority for employers must
be to secure the safest possible
workplace. The Management
of Health and Safety at Work
Regulations 1999 make it a
legal requirement for employers
to carry out risk assessment
of their activities. This should
identify the measures they
need to have in place to comply
with their duties under health
and safety. This should be
achieved through a combination
of awareness raising,
information, risk assessment,
preventing or controlling the
risk, safe disposal of sharps
and reporting incidents.
See figures 1 & 2 page 29.
(176)
3 In accordance with a new EU
Directive and its transpositions
into member-state legislation,
use of sharps (Clause 3:
definition 4) must be carried
out using safety engineered
devices where available.
(177) This obligation covers
all sharps used in diabetes
management in the hospital
and healthcare sector e.g.
settings both private and public
where healthcare takes place
and might include; hospital,
primary care, ambulances,
care homes, schools, prisons,
nurseries, caregivers in home
settings, etc. (178-191)
4 The use of safety engineered
devices where available should
be considered for people with
diabetes who self care, e.g.
those known to be positive for
HIV, HBV and HCV. Where there
are vulnerable people within
the household of someone
with diabetes, safety
engineered devices should
be made available.
This also includes those who
have limited access to safe
sharps disposal.
27
THE INJECTION TECHNIQUE RECOMMENDATIONS
16.0
Safety Issues
Continued
5 When introduced into
healthcare settings where a
culture of safety has been
fostered and appropriate
training given, safetyengineered devices can
significantly and sustainably
decrease the incidence of NSI.
(180-185)
6 Any health care setting which
uses insulin pens must follow
a strict one-patient/one-pen
policy. (178,186)
7 When syringes are used, only
safety-engineered ones must
be accepted and the protective
mechanism must be integral to
the device.(187)
Click here to read
FIT4Safety
28 DATE PUBLISHED: September 2015
* data on file
8 All persons at risk must receive
appropriate education and
training on ways to minimize
risk, including the importance
of following optimal injection
or lancing techniques, using
available safety engineered
devices and using Personal
Protective Equipment (e.g.
gloves).(188)
9 Healthcare providers must
encourage reporting of NSI,
near misses and incorrect
technique within a ‘no blame’
culture. Central review of
these reports must take place
regularly to facilitate policy
change and assess educational
needs.
10 Procedures for what to do in
the event of a NSI must be
clearly communicated. Formal
protocols with named clinical
care contacts must be available
in all areas where sharps are
used.
STRONGLY RECOMMENDED
RECOMMENDED
UNRESOLVED ISSUE
At least one randomised controlled study
At least one non-randomised
(or non-controlled or epidemiologic) study
Consensus expert opinion based on
extensive patient experience.
16.0
Safety Issues
FIGURE 1
Always Events and Safety
Compliance Bundle
This assessment tool is
designed for all clinicians to
use in their workplace. If you
answer ‘No’ to any statement
in the tool then there is a risk
which needs to be addressed in
your workplace
ALWAYS EVENTS – THE PREVENTION OF SHARPS
INJURIES Y/N. It is expected that;
Y/N
All healthcare providers in whatever setting will comply with the EU Council
Directive 2010/32/EU by May 2013.
All healthcare providers will risk assess the need for safety engineered
devices (SED) when utilizing sharps in all scenarios.
All users of sharps should be trained and instructed not to re-cap any
sharps devices.
All healthcare establishments will have in place sharps safety reporting
through local governance systems (e.g. Infection Prevention and Control,
Occupational Health and Safety, Risk Management et al) to monitor sharps
injuries, evaluate potential trends associated with sharps injuries, audit
practice, and co-ordinate the trialling and introduction of SED.
Users of sharps will be involved in trialling and choosing the SED to be
used.
Users of SED will be trained how to optimally use and dispose of the
device.
All users of sharps/SED will be provided with appropriate sharps disposal
containers for use at the point of care.
All sharps will be disposed of in a safe and appropriate manner.
All sharps disposal containers will be collected appropriately and disposed
of according to National guidance.
All sharps injuries will be reported appropriately through the local reporting
system.
Reproduced with kind permission of Dr. Debra Adams, January 2012.
29
THE INJECTION TECHNIQUE RECOMMENDATIONS
16.0
Safety Issues
FIGURE 2
COMPLIANCE SAFETY STANDARD
ALWAYS EVENTS
The prevention of sharps
injuries score.
Alternatively Safety Bundle
Approach might be as follows.
Healthcare providers are aware of the deadline (May 2013) and the
implications associated with EU2010/32.
Healthcare providers have risk assessed the need for safety engineered
devices (SED) when utilizing sharps in all scenarios e.g. diabetic syringes,
vaccinations, needle/syringe, cannulas, suture, lancets, blades etc.
Users of sharps are trained to, and do not re-cap any sharps device.
SAFETY COMPLIANCE SCORE
Scores <100% require an action
plan to be developed and
implemented.
This assessment tool is designed
for all clinicians to use in their
workplace. If you answer ‘No’ to
any statement in the tool then
there is a risk which needs to be
addressed in your workplace
Healthcare providers have developed an Inoculation Injury Review Group
(e.g. Infection Prevention and Control, Occupational Health and Safety, Risk
Management et al) to monitor NSI, evaluate potential trends associated with
NSI, audit practice, and co-ordinate the trialling and introduction of SED.
Users of sharps are involvedin trialling and choosing the SED to be used
(see Appendix 1 of WISE). Users of “sharps” have been trained in how to
optimally operate/activate, and use the SED.
Users of sharps/SED have been provided with appropriate sharps disposal
containers for use at the point of care.
Sharps are disposed of in a safe and appropriate manner.
Management policies have been determined to ensure that sharps disposal
containers are collected promptly and are disposed of according to National
guidance.
Home users are informed of how sharps disposal containers should be
stored in the home and how disposal of the boxes may be actioned.
All sharps injuries will be reported appropriately through the local reporting
system.
30 DATE PUBLISHED: September 2015
* data on file
Y/N
STRONGLY RECOMMENDED
RECOMMENDED
UNRESOLVED ISSUE
At least one randomised controlled study
At least one non-randomised
(or non-controlled or epidemiologic) study
Consensus expert opinion based on
extensive patient experience.
17.0
Disposal of
injecting material
1 All HCPs and individuals/
carers should be aware of local
regulations regarding sharps
disposal. HCPs and individuals/
carers should be made aware
of the consequences of
inappropriate disposal of sharps
(e.g. needle stick injuries to
others such as refuse workers).
(154)
5 Under no circumstance should
sharps material be disposed
of into the public rubbish or
household refuse system.
6 Empty pen devices can be
disposed of in the normal
house hold refuse when the
needle is removed.
2 Correct disposal should be
taught to people with diabetes
from the beginning of injection
therapy and reinforced
throughout.
3 Where available, a needle
clipping device could be used.
It can be carried in the
injection kit.
4 Sharps guard (sharps box) is
available on FP10. However,
disposal is according to local
policy.
Figure 9. All needles should be disposed of
in an approved sharps container after use
31
THE INJECTION TECHNIQUE RECOMMENDATIONS
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150 Kreugel G, Beter HJM, Kerstens MN,
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139 Hambridge K. The management of
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140 Jansà M, Colungo C, Vidal M.
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144 Bantle JP, Weber MS, Rao SM,
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145 Davis ED, Chesnaky P. Site rotation...
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146 Lumber T. Tips for site rotation. When it
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147 Thatcher G. Injectable therapy injections.
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148 Diagrams courtesy of Lourdes Saez-de
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151 Engström L, Jinnerot H, Jonasson E.
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152 Smith DR, Leggat PA. Needlestick and
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153 Adams D, Elliott TS. Impact of safety
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154 Workman RGN. Safe injection techniques.
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155 Bain A, Graham A. How do people with
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156 Gibney MA, Arce CH, Byron KJ, Hirsch
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157 Hirsch L, Klaff L, Bailey T, Gibney M,
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158 Cochran E, Musso C & Gorden P. The use
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159 De Coninck C., Frid A., Gaspar R., Hicks
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160 Kostev Insulin Therapy in Type 2
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161 Hirsch 2014., Laurence Hirsch, MD, Karen
Byron, MS, and Michael Gibney, RN, MA.
Intramuscular Risk at Insulin Injection
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162 Lo Presti D, Ingegnosi C, Strauss K. Skin
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163 Thow JC, Johnson AB, Fulcher G, et
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164 Karges B, Boehm BO, Karges W:
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165 Vaag A, Handberg A, Lauritzen M, et al.:
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166 Vaag A, Damgaard Pedersen K,
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167 Frid A, Ostman J, Linde B: Hypoglycemia
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168 Kreugel G, Beijer HJM, Kerstein MN, et al.
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169 Kahara T, Kawara S, Shimizu A, et al.
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170 de Valk H, Visser GH. Insulin during
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171 Gibney MA, Aarce CH, Byron KJet al.
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172 Laurent A, Mistretta F, Dottigioli D, et
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173 Tan CY, Statham B, Marks R, et al.
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174 Vora JP, Peters JR, Burch A, et al.
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175 EU Commission for Employment, Social
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176 http://www.hse.gov.uk/healthservices/
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177 EU Commission for Employment, Social
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workers in Europe, 8th March 2010.
178 Article 3.2 says that where risk cannot
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“eliminating the unnecessary use of
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practice and on the basis of the results
of the risk assessment, providing medical
devices incorporating safety-engineered
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2010/32/EU, Official Journal of the
European Union, L134/71 and Council
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179 Adams D, Elliott TSJ. Impact of safety
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180 arantola A, Golliot F, Astagneau P,
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181 Cullen BL, Genasi F, Symington I et al.
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182 Mendelson MH, Lin- Chen BY, FinkelsteinBlond L, Bailey E, Kogan G. Evaluation
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183 Louis N, Vela G, Groupe Projet. Évaluation
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184 Lamontagne F, Abiteboul D, Lolom I,
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185 Tuma SJ, Sepkowitz KA. Efficacy of Safetyengineered device implementation in the
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186 Sonoki K, Yoshinari M, Iwase M, Tashiro
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187 Adams D, Elliott TSJ. A comparative user
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188 Jagger J, Perry J, Gomaa A, Phillips EK.
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189 Blanco M,. Hernández M.T., Strauss K,.
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190 Giorgio Grassi, MD, Paola Scuntero,
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191 Council Directive 2010/32/EU, Official
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38 DATE PUBLISHED: September 2015
* data on file
Contributors
NURSE CONSULTANT DIABETES, RETIRED FIT BOARD MEMBER
ELAINE ADAMS
CERYS AKARCA
JO BAKER
ISABELLE BANE
RHONDA BLEAKLY SIAN BODMAN
DEBBY BREWER
DEBBIE CALLAND
HILARY CASKEY
HELEN CARTER LYNN CARTWRIGHT
LINDA CLAPHAM
ALISON CLARKE
HEIDI CLARKE
PENNY CLARKE
PATRICIA CLAWSON
LOUISE COLLINS
MICHELE COLLOBY
REBECCA COOK
JANE COOK
RUTH COOK PETER DAVIES
CLAIRE DRAKE
LESLEY DRUMMOND
SIAN FITZGERALD
ANNA FOLLETT
MARY GLASS
FIONA JAMISON
SUE JONES
LIZ KAMPS KIM KEAR
LISA KING
LESLEY LAMEN
SARAH LEA JILL LITTLE
BREID MCGIRR
OONAGH MCGLONE
DAMIEN MCHUGH
HELENA MCKEEVER
MARGARET MCNEILL
DR. D. MILLAR JONES
JANICE MOSES
CAROL NAYLOR DEB NOLAN
SUSAN NYIKA
GEORGINA PARISI
HEATHER REED
SUE ROBSON SAM ROSINDALE
GWENDOLINE SEWELL
TERRI SHARP
KATE SLOWEY
ANGELA STUBBS SIMONA TULUC
LOUISE TYLER
CLAIRE VICK
JENNI WALLACE
MARINA WALSON
SUE WALTERS
SIAN WARD
JACKIE WEBB ADELE WEST SHARON WILSON
LYNDI WILTSHIRE
ANDREW WOODBURN - DRAYTON
LYNN WOOLWAY
HILARY YULE
COMMUNITY DIABETIC SPECIALIST NURSE
COMMUNITY DIABETES SPECIALIST NURSE
CHILDREN’S DIABETES SPECIALIST NURSE
COMMUNITY DIABETES SPECIALIST NURSE
DIABETES NURSE SPECIALIST
LEAD NURSE DIABETES, COMMUNITY DIVISION
DIABETES SPECIALIST NURSE
PATHWAY LEAD DIABETES SPECIALIST NURSE
DIABETES NURSE SPECIALIST
DIABETES SPECIALIST NURSE
PRACTICE NURSE
DIABETES NURSE SPECIALIST/CENTRE MANAGER
DIABETES SPECIALIST NURSE
COMMUNITY DIABETIC SPECIALIST NURSE
DIABETES SPECIALIST NURSE
DIABETES SPECIALIST NURSE
PAEDIATRIC DIABETES SPECIALIST NURSE
DIABETES SPECIALIST NURSE
LEAD DIABETES INPATIENT SPECIALIST NURSE
LEAD DIABETES NURSE
DIABETES SPECIALIST NURSE
CONSULTANT IN DIABETES & ENDOCRINOLOGY
CHILDREN’S DIABETES SPECIALIST NURSE
LEAD DIABETES CLINICAL NURSE SPECIALIST
DIABETES SPECIALIST NURSE
COMMUNITY DIABETIC SPECIALIST NURSE
DIABETES SPECIALIST NURSE
DIABETES SPECIALIST NURSE
LEAD NURSE FOR DIABETES
DIABETES SPECIALIST NURSE
CHILDREN’S DIABETES SPECIALIST NURSE
DIABETES SPECIALIST NURSE
DIABETES INPATIENT SPECIALIST NURSE & DIABETES SPECIALIST NURSE
DIABETES SPECIALIST NURSE
DIABETES SPECIALIST NURSE
DIABETES SPECIALIST NURSE
DIABETES SPECIALIST NURSE
PAEDIATRIC DIABETES SPECIALIST NURSE
DIABETES SPECIALIST NURSE
DIABETES SPECIALIST NURSE
DOCTOR/GP
DIABETES SPECIALIST NURSE
NURSE PRACTITIONER
DIABETIC INPATIENT SPECIALIST NURSE
DIABETES SPECIALIST NURSE
COMMUNITY DIABETES SPECIALIST NURSE
DIABETES SPECIALIST NURSE
DIABETES NURSE SPECIALIST
DIABETES LEAD CHAMPION FOR TORBAY & SOUTHERN DEVON
TEAM LEADER/ CHILDREN’S DIABETES NURSE SPECIALIST
DIABETES NURSE PRACTITIONER
DIABETES SPECIALIST NURSE
COMMUNITY DIABETES SPECIALIST NURSE
DIABETES SPECIALIST NURSE
DIABETES SPECIALIST NURSE
LEAD DIABETES SPECIALIST NURSE
DIABETES SPECIALIST NURSE
CHILDREN’S DIABETES SPECIALIST NURSE
CHILDREN’S DIABETES SPECIALIST NURSE
DIABETES SPECIALIST NURSE
LEAD DIABETES SPECIALIST NURSE
DIABETES IN-PATIENT SPECIALIST NURSE
DIABETES SPECIALIST NURSE
HEAD OF DIABETES CARE
ACUTE MEDICINE UNIT CHARGE NURSE
DIABETES SPECIALIST NURSE
DIABETES SPECIALIST NURSE
DR
AF
T
All contributors who reviewed
this document were professional
clinicians or people with a special
interest in diabetes in the UK
SU DOWN Optimising
Diabetes Care
www.fit4diabetes.com