Insulin Injection and Injection Site Rotation Best Practices for LTC Pharmacy Services

Long-term care pharmacy services aren’t limited to the dispensing of oral medications—vaccines and insulin injectables are also among the items dispensed. Staying up-to-date on the latest findings related to injections is key for LTC pharmacy services providers. Blood glucose control can be a challenge in our geriatric resident population for a variety of reasons. As we age, a number of factors can affect blood glucose management, ranging from physiological changes and erratic nutritional intake to impaired renal or hepatic function to variable physical activity and even polypharmacy. Trying to pinpoint the culprit of blood glucose swings can be a daunting task. In addition to these common potential sources of blood glucose variability, there are several often-overlooked factors—a person’s skin, insulin injection technique, and injection site rotation practices. Let’s take a look at some important considerations and best practices associated with insulin injection technique and injection site rotation recommend by post-acute care pharmacy providers.

LTC Pharmacy Services Best Practice: Why Injection Site Rotation Is important

Repeated injection into the same site can cause lipohypertrophy and lipodystrophy.   Lipohypertrophy is the buildup of fat under the skin. Subsequent injection into areas of lipohypertrophy can lead to lipodystrophy, which is scarring of the fat. Subsequent injection into areas with lipohypertrophy or lipodystrophy can significantly slow the absorption of insulin.  The altered insulin absorption may lead to elevated glucose levels, which may be attributed to insufficient disease management instead of poor insulin administration technique.   [Tweet “DOs and DONT’s related to insulin injection in the #longtermcare setting”]

LTC Pharmacy Services Best Practice: Insulin Injection and Injection Site Rotation

Insulin is best absorbed from the abdomen, hips, upper buttocks, outer thighs, and the backs of the upper arms. Insulin is absorbed at different speeds depending on the injection site location. The abdomen is generally the fastest, followed by the upper arms, upper thighs, and buttocks. Because of the variability in absorption, it is suggested to use the same area of the body for different administration times to maintain as much consistency as possible. For example, if a resident has an order for insulin injections three times daily with meals and at bedtime, you may want to consider the following insulin administration plan:

• For the breakfast and lunch doses, inject in different areas of the abdomen because of faster absorption from this area and the inherent need for insulin sooner because of carbohydrate intake during meals.
• For the supper dose, inject in the upper arms, again because of the relative speed of absorption and the need of the insulin secondary to impending carbohydrate ingestion.  
• For the bedtime dose, inject in the upper legs or buttocks because these doses are normally longer-acting insulin that will be providing insulin coverage throughout the night.

For someone that is just getting meal doses, it is generally not recommended to give in the abdomen one day and the buttocks the following day due to the absorption variability and the need for these therapies to be faster-acting. To avoid lipohypertrophy and lipodystrophy, injections should be rotated within the general area of the body by switching sides, spacing injections by at least 2 inches from the previous injections, or by using the face-of-the-clock technique to keep track of injection location. Clear and consistent documentation on the medical administration record is important in the long-term care setting due to the variability in nurses who are providing the injections based on shifts or days of the week. The table below highlights some additional important considerations to administering insulin injections. While good insulin injection practices and injection site rotation are not the magic bullet for optimal blood glucose control in our resident population, it is a solid practice standard that should be utilized on a daily basis. If you have a resident that has poorly controlled blood sugars that cannot be attributed to other common areas of concern, injection techniques and site rotations may be areas of special consideration to try to find the root cause of the issue. Our Grane Rx team works with your team to help ensure optimal care for residents. Learn more about our long-term care pharmacy services and how we can partner by calling (866) 824-MEDS (6337).]]>