Checklists for Assessing Skills of Children With Type 1 Diabetes on Insulin Injection Technique.
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ABSTRACT: Background
School-aged children often participate in type 1 diabetes (T1D) self-care tasks. Despite widespread discussion about the importance of developing self-care skills in childhood, few explain how the health care team should assess the skills of children with T1D when performing insulin injections.Objective
We sought to assess content validity evidence in two checklists regarding injection technique performed by children.Methods
Two checklists were designed based on a systematic review of the insulin injection technique. Experts in pediatric diabetes, health literacy, and diabetes education assessed the checklists regarding their clarity, objectivity, and relevance. Content validity was assessed using the content validity ratio (CVR).Results
Eleven providers (72% nurses or physicians, professional experience 19.4 ± 10.1 years, 45% of specialists in endocrinology, and 18% in pediatrics) participated in the assessment. Experts considered items containing the word homogeneity inappropriate. Items related to the needle insertion angle and the skin fold did not reach the CVR critical value. The final version of the checklist for syringe injection comprised 22 items with CVR = 0.91, and the checklist for pen injection comprised 18 items with CVR = 0.87.Conclusions
The checklists presented clear, objective, and relevant content that assesses the skills of children with T1D for insulin injection. The checklists formally present the order of the technique and all the steps for insulin injection and allow a quantitative assessment of the operational skills of children. The developed instruments offer providers the possibility of continuous assessment of the progress of the pediatric clientele until they reach independence in diabetes self-care.
SUBMITTER: Ortiz La Banca R
PROVIDER: S-EPMC9294572 | biostudies-literature | 2022 May
REPOSITORIES: biostudies-literature
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Checklists for Assessing Skills of Children With Type 1 Diabetes on Insulin Injection Technique.
Ortiz La Banca Rebecca R Rebustini Flávio F Alvarenga Willyane A WA de Carvalho Emilia C EC Lopes Mayara M Milaszewski Kerry K Nascimento Lucila C LC
Journal of diabetes science and technology 20210109 3
<h4>Background</h4>School-aged children often participate in type 1 diabetes (T1D) self-care tasks. Despite widespread discussion about the importance of developing self-care skills in childhood, few explain how the health care team should assess the skills of children with T1D when performing insulin injections.<h4>Objective</h4>We sought to assess content validity evidence in two checklists regarding injection technique performed by children.<h4>Methods</h4>Two checklists were designed based o ...[more]
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Project description:IntroductionPatients with type 2 diabetes (T2D) receiving premixed insulin often fail to achieve optimal glycemic control. The insulin injection technique (IT) itself may be one of the factors affecting glycemic variability (GV). The aim of this study was to assess the relationship between GV and IT in patients with T2D using premixed insulin.MethodsThis was a single center, cross-sectional, and self-controlled trial. Patients with T2D using premixed insulin were enrolled as inpatients. The 4-day study consisted of a 2-day patient insulin injection period (days 0 and 1) and a 2-day specialist nurse insulin injection period (days 2 and 3). Patient insulin IT were assessed on day 1 by two independent nurses using a skill-related scale consisting of 15 items, with a maximum score for each item of 2 and a total optimum score of 30. All patients underwent 96-h continuous glucose monitoring (CGM) during the 4-day study, and CGM data collected on days 1 and 3 were recorded and analyzed. The primary outcome was the relationship between the insulin IT score and the 24-h mean amplitude glycemic excursion (MAGE) during the patient injection period.ResultsA total of 52 inpatients with T2D who used premixed insulin were recruited and completed the study. The mean total insulin IT score of these patients was considerably lower than the optimum score (17.0 ± 4.4 vs. 30). Our CGM data showed that the MAGE was significantly higher during the patient injection period than during the nurse injection period (P < 0.05). Multiple linear stepwise regression analysis showed that the patient IT score was negatively correlated to the MAGE (P < 0.05). The patient IT score was also negatively correlated to glycated hemoglobin (HbA1c; P < 0.05).ConclusionsA poorer insulin IT may negatively affect GV and HbA1c control in patients with T2D using premixed insulin. Our data indicate that the insulin IT is important for short- and long-term glycemic control.Clinical trial registrationClinicalTrials.gov identification number: NCT03513055.
| S-EPMC6250622 | biostudies-literature
Project description:To date, insulin therapy remains the cornerstone of diabetes management; but the art of injecting insulin is still poorly understood in many health facilities. To address this gap, the Forum for Injection Technique and Therapy Expert Recommendations (FITTER) published recommendations on injection technique after a workshop held in Rome, Italy in 2015. These recommendations are generally applicable to the majority of patients on insulin therapy, athough they do not explore alternative details that may be suitable for low- and middle-income countries. The East Africa Diabetes Study Group sought to address this gap, and furthermore to seek consensus on some of the contextual issues pertaining to insulin therapy within the East African region, specifically focusing on scarcity of resources and its adverse effect on the quality of care. A meeting of health care professionals, experts in diabetes management and patients using insulin, was convened in Kigali, Rwanda on 11 March 2018, and the following recommendations were made: (1) insulin should be transported safely, without undue shaking and exposure to high (> 32 °C) temperature environments. (2) Insulin should not be transported below 0 °C. (3) If insulin is to be stored at home for over 2 months, it should be stored at the recommended temperature of 2-8 °C. (4) Appropriate instructions should be given to patients while dispensing insulin. (5) Insulin in use should be kept at room temperature and should never be kept immersed under water. Immersing insulin under water after the vial has been pierced carries a high risk of contamination, leading to loss of potency and likelihood of causing injection abscesses. (6) The shortest available needles (4 mm for pen and 6 mm for insulin syringe) should be preferred for all patients. (7) In routine care, intramuscular injections should be avoided, especially with long-acting insulins, as it may result in severe hypoglycaemia. (8) The practice of slanting the needle excessively should be avoided as it results in sub-epidermal injection of insulin which leads to poor absorption and may cause "tattooing" of the skin and scarring. (9) In patients presenting in a wasted state, with "paper-like skin", injections should, if possible, be initiated with pen injection devices, so as to utilise the 4-mm needle without lifting a skin fold (pinching the skin); otherwise lifting of a skin fold is required, if longer needles are utilised. (10) Reuse of needles and syringes is not recommended. However, as the reuse of syringes and needles is practiced for various reasons, and by many patients, individuals should not be given alarming messages; and usage should be limited to discarding when injections become more painful; but at any rate not to exceed reusing a needle more than 5 times.
| S-EPMC6437255 | biostudies-literature
Project description:IntroductionProper insulin injection technique is important for optimal glycaemic control, yet patients with diabetes often inject insulin incorrectly. Previous studies identified common errors in insulin injection in Canada, and this article seeks to evaluate the current insulin injection technique practices among patients and explore the effectiveness of feedback and education in improving their technique.MethodsThe study recruited 147 patients and 16 physicians across Canada to gather insights into current insulin injection practices and education gaps. Eligible patients were people living with diabetes who inject insulin using an insulin pen and pen needles. Eligible physicians, who were unsupported by diabetes educators, completed a practice assessment survey and selected 10 eligible patients to complete a baseline assessment survey. During the patient visit, if an error in the patient's technique was identified, a pop-up knowledge transfer (KT) prompt would appear, providing feedback and information on best practices at the point of care. Follow-up surveys were completed 1-3 months later.ResultsPhysicians reported facing barriers to providing education and feedback, including lack of time and personnel, and lack of effective educational material. Patients demonstrated modest improvements in some injection technique domains at their follow-up visit, including injection force factors, time the needle was held in the skin, pen needle reuse, injection area size, and injection angle. The most common initial mistakes by patients were selecting an area smaller than recommended and not paying attention to the injection force. At the second visit, patients reduced an average of one error in their injection technique.ConclusionResults showed that basic feedback by their physician during one visit could exert moderate improvements on patients' injection technique. Proper injection technique is critical for diabetes management, and incorporating targeted ongoing education and support can significantly enhance physician practices, ultimately reducing risks and improving outcomes.
| S-EPMC10597907 | biostudies-literature
Project description:Type 2 diabetes (T2D) is an emerging health risk in obese children and adolescents. Both environmental (lack of physical activity, excess nutritional intake, sedentary lifestyle) and genetic factors contribute to this global epidemic. The growing prevalence of T2D in youth is also associated with a consistently increased incidence of metabolic and cardiovascular complications. Insulin resistance (IR), i.e., whole-body decreased glucose uptake in response to physiological insulin levels, determines impaired glucose homeostasis and it is recognized as cardinal trigger of T2D and cardiovascular disease in both adults and children. In particular, IR and beta-cell dysfunction lead to the persistent hyperglycemia which characterizes T2D. Indeed, both pathological states influence each other and presumably play a crucial, synergistic role in the pathogenesis of T2D, although the precise mechanisms are not completely understood. However, beta-cell dysfunction and IR induce impaired glucose metabolism, thus leading to the progression to T2D. Therefore, understanding the mechanisms correlated with the decline of beta-cell function and IR is crucial in order to control, prevent, and treat T2D in youth. This review focuses on the current knowledge regarding IR and T2D in children and adolescents and showcases interesting opportunities and stimulating challenges for the development of new preventative approaches and therapeutic strategies for young patients with T2D.
| S-EPMC7788344 | biostudies-literature
Project description:IntroductionThe aim of this randomized controlled trial was to assess the impact of providing intensive injection technique (IT) education to patients routinely injecting insulin into sites of lipohypertrophy (LH).MethodsBetween November 2016 and May 2018, insulin-injecting patients with LH treated at Tianjin Metabolism Hospital (a public tertiary medical institution), Tianjin, China, were included in a 6-month prospective randomized controlled trial and randomized into either the intervention (the IT-education group) or the control (control group) arm. The control and IT-education groups were seen by different groups of trained nurses on different clinic days. IT education emphasized moving injections to normal tissue sites, within-and between-site injection rotation, an initial reduction of insulin total daily dose (TDD), and stopping needle reuse. Needles were provided to the IT group, while controls acquired needles in their usual way. Differences in changes in glycated hemoglobin (HbA1c) and insulin TDD were the primary and main secondary endpoints, respectively.ResultsThe control (n = 104) and IT-education (N = 106) groups had similar demographic parameters (97% with type 2 diabetes) and baseline IT behavior. HbA1c reduction was similar in the IT-education and control group in the intention-to-treat (ITT) analysis (6-month between-group difference 0.16% [1.7 mmol/mol], 95% confidence interval [CI] - 0.11, 0.43 [- 1.2, 4.7]; p = 0.239) but was significant by the per-protocol (PP) analysis (difference 0.31% [3.4 mmol/mol], 95% CI 0.02, 0.60 [0.2, 6.6]; p = 0.038). Changes in TDD insulin in the IT-education group were approximately - 7 and - 8 IU by the ITT and PP analyses, respectively, versus - 1 IU (nonsignificant) in the controls (both between-group differences p ≤ 0.05). Despite the study design, IT education "contamination" (unplanned adoption of IT-intervention behaviors) was documented in 63 control patients. By post hoc analyses, HbA1c in "contaminated" controls decreased by 0.70% (7.7 mmol/mol) vs. 0.20% (2.2 mmol/mol) in "non-contaminated' patients (p = 0.019) at 6 months.ConclusionsProper IT, including learning to not inject into sites of LH, proper within- and between site rotation, needle reuse reduction, and the use of 4-mm, 32-G needles in Chinese patients injecting into sites of LH enables a safe reduction of TDD insulin while maintaining overall glycemic control.Trial registrationTrial registration: ChiCTR-IOR-16009270 in the Chinese Clinical Trials Registry.
| S-EPMC7947164 | biostudies-literature
Project description:ImportanceInsulin pump therapy may improve metabolic control in young patients with type 1 diabetes, but the association with short-term diabetes complications is unclear.ObjectiveTo determine whether rates of severe hypoglycemia and diabetic ketoacidosis are lower with insulin pump therapy compared with insulin injection therapy in children, adolescents, and young adults with type 1 diabetes.Design, setting, and participantsPopulation-based cohort study conducted between January 2011 and December 2015 in 446 diabetes centers participating in the Diabetes Prospective Follow-up Initiative in Germany, Austria, and Luxembourg. Patients with type 1 diabetes younger than 20 years and diabetes duration of more than 1 year were identified. Propensity score matching and inverse probability of treatment weighting analyses with age, sex, diabetes duration, migration background (defined as place of birth outside of Germany or Austria), body mass index, and glycated hemoglobin as covariates were used to account for relevant confounders.ExposuresType 1 diabetes treated with insulin pump therapy or with multiple (≥4) daily insulin injections.Main outcomes and measuresPrimary outcomes were rates of severe hypoglycemia and diabetic ketoacidosis during the most recent treatment year. Secondary outcomes included glycated hemoglobin levels, insulin dose, and body mass index.ResultsOf 30 579 patients (mean age, 14.1 years [SD, 4.0]; 53% male), 14 119 used pump therapy (median duration, 3.7 years) and 16 460 used insulin injections (median duration, 3.6 years). Patients using pump therapy (n = 9814) were matched with 9814 patients using injection therapy. Pump therapy, compared with injection therapy, was associated with lower rates of severe hypoglycemia (9.55 vs 13.97 per 100 patient-years; difference, -4.42 [95% CI, -6.15 to -2.69]; P < .001) and diabetic ketoacidosis (3.64 vs 4.26 per 100 patient-years; difference, -0.63 [95% CI, -1.24 to -0.02]; P = .04). Glycated hemoglobin levels were lower with pump therapy than with injection therapy (8.04% vs 8.22%; difference, -0.18 [95% CI, -0.22 to -0.13], P < .001). Total daily insulin doses were lower for pump therapy compared with injection therapy (0.84 U/kg vs 0.98 U/kg; difference, -0.14 [-0.15 to -0.13], P < .001). There was no significant difference in body mass index between both treatment regimens. Similar results were obtained after propensity score inverse probability of treatment weighting analyses in the entire cohort.Conclusions and relevanceAmong young patients with type 1 diabetes, insulin pump therapy, compared with insulin injection therapy, was associated with lower risks of severe hypoglycemia and diabetic ketoacidosis and with better glycemic control during the most recent year of therapy. These findings provide evidence for improved clinical outcomes associated with insulin pump therapy compared with injection therapy in children, adolescents, and young adults with type 1 diabetes.
| S-EPMC5818842 | biostudies-literature
Project description:A 36-year-old man with type 1 diabetes developed skin inflammation at the site of subcutaneous insulin injection after 10?years of basal bolus subcutaneous insulin therapy. This inflammation led to poor insulin absorption, poorly controlled blood glucose and subsequently to ketoacidosis. The problem persisted despite a trial of continuous subcutaneous insulin infusion. The patient went on to be treated with continuous intraperitoneal insulin infusion. Three months after the procedure, he was achieving good glucose control and was able to resume his normal life, with the only complication being an episode of cellulitis surrounding the port site.
| S-EPMC4154006 | biostudies-other
Project description:BackgroundSystematic reviews of research evidence have become an expected basis for decisions about practice guidelines and policy decisions in the health and welfare sectors. Review authors define inclusion criteria to help them determine which studies to search for and include in their reviews. However, these studies may still vary in the extent to which they reflect the context of interest in the review question. While most review authors would agree that systematic reviews should be relevant and useful for decision makers, there appears to be few well known, if any, established methods for supporting review authors to assess the transferability of review findings to the context of interest in the review. With this systematic mapping and content analysis, we aim to identify whether there exists checklists to support review authors in considering transferability early in the systematic review process. The secondary aim was to develop a comprehensive list of factors that influence transferability as discussed in existing checklists.MethodsWe conducted a systematic mapping of checklists and performed a content analysis of the checklist criteria included in the identified checklists. In June 2016, we conducted a systematic search of eight databases to identify checklists to assess transferability of findings from primary or secondary research, without limitations related to publication type, status, language, or date. We also conducted a gray literature search and searched the EQUATOR repository of checklists for any relevant document. We used search terms such as modified versions of the terms "transferability," "applicability," "generalizability," etc. and "checklist," "guideline," "tool," "criteria," etc. We did not include papers that discussed transferability at a theoretical level or checklists to assess the transferability of guidelines to local contexts.ResultsOur search resulted in 11,752 titles which were screened independently by two review authors. The 101 articles which were considered potentially relevant were subsequently read by two authors, independently in full text and assessed for inclusion. We identified 31 relevant checklists. Six of these examined transferability of economic evaluations, and 25 examined transferability of primary or secondary research findings in health (n = 23) or social welfare (n = 2). The content analysis is based on the 25 health and social welfare checklists. We identified seven themes under which we grouped categories of checklist criteria: population, intervention, implementation context (immediate), comparison intervention, outcomes, environmental context, and researcher conduct.ConclusionsWe identified a variety of checklists intended to support end users (researchers, review authors, practitioners, etc.) to assess transferability or related concepts. While four of these checklists are intended for use in systematic reviews of effectiveness, we found no checklists for qualitative evidence syntheses or for the field of social welfare practice or policy. Furthermore, none of the identified checklists for review authors included guidance to on how to assess transferability, or present assessments in a systematic review. The results of the content analysis can serve as the basis for developing a comprehensive list of factors to be used in an approach to support review authors in systematically and transparently considering transferability from the beginning of the review process.
| S-EPMC6330740 | biostudies-literature
Project description:ImportancePediatric data on inpatient home insulin pumps are absent in the literature. Understanding safety of home insulin pumps, managed by patients or caregivers, during times of illness will help diabetes technology securely move into pediatric hospitals.ObjectiveTo examine whether insulin can be safely and accurately delivered to hospitalized children through home insulin pumps when managed by patients or caregivers.Design, setting, and participantsThis single-center, retrospective, observational cohort study included children with insulin-dependent diabetes admitted to a tertiary children's hospital from January 1, 2016, to December 31, 2021. In all these patients, diabetes was the primary or secondary diagnosis on admission.ExposureInsulin delivery via home insulin pump, hospital insulin pump, or subcutaneous injection.Main outcomes and measuresHyperglycemia (glucose, >250 mg/dL) and hypoglycemia (glucose, <45 mg/dL) rates (quantified as the proportion of total insulin-days), glucose variability, and diabetic ketoacidosis (DKA) recurrences were compared for hospital pumps (manual mode), home pumps (manual mode), and subcutaneous injections using bivariate tests.ResultsThere were 18 096 insulin-days among 2738 patients aged 0.5 to 25 years (median age, 15.8 years [IQR, 12.3-18.3 years]). Overall, 990 (5.5%) of insulin-days involved hospital insulin pumps, and 775 (4.3%) involved home pumps. A total of 155 insulin-days (15.7%) involving hospital pumps were hyperglycemic, compared with 209 (27.0%) involving home pumps and 7374 (45.2%) involving injections (P < .001). Moderate hypoglycemia days comprised 31 insulin-days (3.1%) involving hospital pumps compared with 35 (4.5%) involving home pumps and 830 (5.1%) involving injections (P = .02). Severe hypoglycemia did not differ significantly according to insulin delivery method. Two patients using injections (0.01%) developed DKA; no patients using hospital or home pumps developed DKA.Conclusions and relevanceIn this cohort study, home insulin pump use was found to be safe in a children's hospital regarding hyperglycemia and hypoglycemia. These data support use of home insulin pumps during pediatric admissions in patients who do not require intensive care and without active DKA.
| S-EPMC10851090 | biostudies-literature
Project description:Efforts directed toward restoring normal metabolic levels by mimicking the physiological insulin secretion, thereby ensuring safety, efficacy, minimal invasiveness and conveniences, are of great significance in the management of type 1 diabetes among children and adolescents. Regardless of the various technologies being discovered in addressing invasiveness and enhancing medication adherence in the management of type 1 diabetes, yet limited success had been observed among children and adolescents. The multiple daily subcutaneous insulin injections route using vial and syringe, and occasionally insulin pens, remain the most predictable route for insulin administration among children and adolescents. However, this route has been associated with compromised patient compliance, fear of injections and unacceptability, resulting in poor glycemic control, which promote the demand for alternative routes of insulin administration. Alternative routes for delivering insulin are being investigated in children and adolescents with type 1 diabetes; these include the hybrid closed-loop 'artificial pancreas' system, oral, inhalation, intranasal routes, and others. This review article explores the current advances in insulin-delivery methods that address the needs of children and adolescents in the treatment of type 1 diabetes.
| S-EPMC7466897 | biostudies-literature