headline picture of project

Home-Based Insulin Management

SAID ABDULLAHI

Approval

A
B
Ba
G
P

What

A training service to help educate Type 1 diabetes patients in how to manage their condition and a DIY cooling container to help store insulin at home without electricity.

Where

Dagahaley refugee camp, Kenya

Materials

  • For the charcoal cooler “Qaboojie”
  • Jerry can
  • Blanket
  • Charcoal
  • Wire mesh
  • Scissors
  • Stapler
  • Marker

For the testing:

  • HbA1c Analyzer
  • Glucometers
  • Diabetes test strips
  • Insulin syringes with needles
  • Sharps disposal containers
  • Lancets or needles for finger pricks
  • Patient booklet to record blood sugars
  • Creatinine test

Team

  • Nurses
  • Doctors
  • Community health workers

In 2015, MSF was providing care to 24 patients with Type 1 diabetes living in the Dagahaley refugee camp, on the Kenyan side of the border with Somalia. Product information for the insulin that they needed stated that it should be kept below the temperatures found in the camp. Patients who lacked access to refrigeration were forced to walk across the high-security camp to reach the hospital emergency room twice a day to receive their doses. , so often missed doses, and particularly in the evening. Without the regular insulin patients were unable to control their glycaemic levels and frequently had to be admitted to the hospital due to acute complications.

MSF teamed up with University of Geneva (UNIGE) to study the stability of insulin at the high temperatures found in the camp and found that it was stable. With this new knowledge, our team began training Type 1 diabetic patients living in the camp how to manage their condition, including administering their own insulin injections and measuring their blood-sugar levels. We provided each patient with a small locally-made cooling container to store their insulin.

Part 1: Researching insulin heat-stability

In 2014, we collaborated with UNIGE to undertake a heat-stability study of insulin under temperature conditions mimicking those of Dagahaley camp. The camp temperature, monitored over seven days during the hottest part of the year, oscillated between 25 and 37°C in 12-hour cycles. We found that various formulations of insulin remained viable at these temperatures, even when not refrigerated. This opened up the possibility for patients to store doses of insulin at home, as an alternative to twice daily hospital visits.

Part 2: Designing a home insulin management programme

Our challenge was to train patients of varying ages, some with low levels of literacy, to manage their diabetes at home. Based on staff and space availability, we decided that a five-day residential induction programme, where groups of four or five patients (and their carers) stayed in the hospital, would work best. By the end of the training, patients and carers would need to have learned the following:

  • the symptoms of hypo/hyperglycaemia
  • how to react to these symptoms
  • how to store insulin
  • good hygiene and infection prevention practises
  • the correct injection and dosing techniques
  • how to check and record their blood sugars
  • how to care for themselves on sick days
  • how to manage their food intake to help with their diabetes management

Designing for the user and the context

Part 3: What should be in a discharge kit

As follow-up to the training, we put together a self-care discharge kit for patients, which included enough doses and monitoring equipment (glucometers and blood glucose test strips (sugar strips)) to last one month.

We also realised that we would need to make a simple, temperature-controlled container where patients could safely and hygienically store insulin at home.

In many places, local solutions exist for keeping water cool, such as a claypot. This can be used rather than making this container.

Part 4: Crafting the charcoal insulin cooler

Traditional charcoal-based evaporative coolers, known as qaboojie, are used by the local population to keep vegetables fresh. We applied the same principle to build a small cooler unit out of a jerry can, which could be used to store insulin vials.

To make a charcoal cooler:

Cut a jerry can in half, leaving 3-4” of plastic connected at the back to keep the two halves together.

Place the jerry can on an appropriately sized blanket and trace the outline on the fabric. This will be the covering for the jerry can so it needs to cover it completely.

Add an appropriate amount of margin on all sides to ensure complete coverage of the can and then cut the pattern out.

Staple the blanket to the jerry can.

Fill the bottom half of the can with charcoal and cover this with a wire mesh basket.

Place the insulin vials in the mesh basket. Moisten the charcoal and the blanket, then close up the jerry can. Wet the blanket at least twice a day.

Part 5: Inviting patients

With everything prepared, we started to invite patients to the induction programme. We searched for patients who met the following criteria: willing to inject insulin and check their own blood sugar levels; willing to be admitted to the hospital to determine their insulin needs and for education, and to come back for follow-up appointments; able to read, write and understand numbers; and have good motor skills (for the injections and testing) or have a carer to help them. Our youngest patient was four years old and our oldest was 65.

Part 6: Small Batch Training of Patients

During the induction programme, patients and carers received health education and a patient/carer competency assessment. The team also carried out baseline checks on the patients. Upon discharge, patients were given the discharge kits. Twenty-four patients were enrolled in the home-based insulin management programme and all successfully completed the induction course.

The education of patients and carers and practicising the skills of self-injection and blood sugar testing are a key part of the patient induction. It’s important to follow up with refresher sessions and discussion of the key points at patient visits. The competency assessment checklist used in Dagahaley is available for sharing.

Using data to evaluate

Part 7: Reduction in hospital admissions

We conducted follow-up consultations at patients’ homes and in the clinic. All 24 patients agreed to home management since it allowed them to return to their daily activities. A HbA1c blood test to determine how well their diabetes was being managed, was conducted at enrolment, and again at three months and six months. We set a target for the programme that patients should reach an HbA1c level of 8.5%. During follow-up, there were no admissions due to diabetic ketoacidosis, and diabetes-related hospital admissions dropped from 93 in June-November 2015 (on average 15.5 a month) to 15 in June-November 2016 (2.7 a month). One patient in the test group died of an unrelated injury (burns) and five were repatriated to Somalia.

Part 8: Challenges

The biggest challenge we faced was that food insecurity in the camp made it difficult for patients to manage their condition.

Food insecurity makes it difficult to manage insulin-requiring diabetes. It’s important to make sure that insulin dosing and timing is reflective of realistic food intake, and that patients are advised about how to manage their food accordingly (for example dividing the food that is available into multiple intakes per day).

Part 9: Temperature monitoring

We sent 32 vials of residual insulin after patient use to UNIGE for testing. These samples had remained in patients’ home between 12 and 31 days. The jerry cans had protected them well and all were found to be safe for patients to use.

Scaling up

Part 10: Going Forward

Based on the success of the test group, home-based insulin management programme was set up at the hospital, to improve patient care and reduce admissions due to diabetes-related complications.

We should be trying to move towards home-based insulin management as the standard of care in MSF settings. However, there are different challenges to implementation in different contexts. There exist standard operating procedures from Dagahaley that can be adapted to other contexts.

How many patients are affected by insulin-requiring diabetes in your hospital?

How is care currently provided to them?

What benefits could home-based insulin management bring to patients and their diabetes management?

Implementing this design requires review and coordination with HQ. Note that, at the time of going to print, OCG (Philippa Boulle, Non-Communicable Diseases Advisor; Chronic Disease Team Leader) has validated the contents of this feature. If you have any technical questions, please get in touch with your NCD Advisor.