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BBIT is a clinical and teaching tool for patients and clinicians alike. Developed by Dr. K. Helmle and Dr. A. Edwards at the University of Calgary, the BBIT protocol in conjunction with the website, electronic order set, in-services, clinical worksheets and reference cards aims to improving the quality of care for diabetic patients during their hospital stay. BBIT is a safe and physiologic means of replacing insulin, and results in improved glycemic control and shorter length of stay in hospital. IMPORTANT: Though BBIT relies on a safe algorithm to establish insulin doses, it does not replace clinical judgment. Please, only use BBIT if you feel comfortable with the nuances of insulin administration.
Diabetes in hospital is COMMON
Diabetes is a very common condition, affecting an estimated 1 in 20 Canadians. In fact, one in four inpatients has diabetes, and local
data in Calgary suggests the prevalence reaches 40% for patients admitted to the Internal Medicine Service. It is estimated that the
health care budget contributes $13 billion dollars per year to the care of 2 million Canadians with Diabetes.
Poor Glycemic Control in hospital results in POOR OUTCOMES
If clinicians fail to recognize and treat hyperglycemia appropriately, diabetic patients are at risk for multi-organ complications,
infection, prolonged hospitalization, and increased mortality. As well, hyperglycemia in hospital has been associated with poorer
prognosis in patients with stroke, COPD exacerbations, community acquired pneumonia, trauma, acute coronary syndrome, stem cell
transplantation, and following surgery.
Improving Glycemic Control can IMPROVE OUTCOMES and REDUCE COST OF CARE
Improving glycemic control in hospital has been associated with shorter length of stay in hospital and decreased rates of readmission,
which in one study resulted in substantial cost-savings of $1500 per patient. Moreover, in a second study, implementing programs
focused on treating hyperglycemia led to as much as a 450% return on investment. The Canadian Diabetes Association recognizes
that diabetic patients have complex needs while in hospital, and that their acuity of illness, intake and activity are difficult
to predict and treat appropriately. It is for these reasons that the CDA has recommended blood glucose targets of 5 to 11 for patients
who are admitted to hospital. These targets are higher and more flexible than the typical targets for diabetic patients who are well at home.
The Canadian Diabetes Association (CDA) recognizes that diabetic patients have complex needs while in hospital. Their illness, intake and activity are difficult to predict and treat appropriately; therefore, the CDA has recommended blood glucose targets of 5 to 11 mmol/L for patients who are admitted to hospital. These targets are higher and more flexible than the typical targets for diabetic patients who are well at home.
Basal bolus insulin therapy (BBIT), which integrates the pharmacology of different insulin analogs to replicate physiologic insulin profiles, aims to anticipate patient's insulin needs and prevent hyperglycemia from developing. BBIT is a common method of treating diabetes outside of the hospital setting, and therefore may be more familiar to patients. BBIT is a mneumonic meant to remind clinicians of the essential steps involved in ordering insulin:
Bolus Insulin Dosing
Bolus not required! Patient is NPO.
Try AgainInsulin doses should be adjusted every 2 to 3 days by 10& to 20& according to the patients blood glucose values to achieve effective in-target blood glucose control (5-11 mmol/L). If the patient's fasting glucose in the morning is consistently high (above 8 mmol/L), the qhs basal dose should be increased by 10 to 20&. If a recurrent correction dose is needed at a given meal due to a consistently elevated blood glucose, then the correction dose amount should be added to the PREVIOUS meal's bolus dose! If a patient develops hypoglycemia (blood glucose < 4 mmol/L), use AHS hypoglycemia pathway, treat with 15g of carbohydrate (4 dextrose tabs or 1/2 a small juice) and recheck the chemstrip in 15 minutes. Discuss the situation surrounding the hypoglycemic event with the patient. Were there diet or activity discrepancies to account for the low blood glucose? Was there a medication dose or administration error? If so, work to correct these issues. If there is no identifiable cause of hypoglycemia, reduce the preceding meal's bolus dose by 10-20&. If hypoglycemia occured overnight, reduce the bedtime basal dose by 10-20%. |
The management of diabetes in hospital is complicated!
It is complicated...
Currently, when patients present with complex disease and poorly controlled diabetes, the typical response by any given care team is to utilize a "sliding scale" insulin regimen to combat the patients' changing medical status, irregular diet routine and schedule, and to avoid issues with drug-drug interactions.
Change requires motivation and enthusiasm! Once the will to change is present, education, incentives and tools to achieve that change are all beneficial. In the sections below, and throughout this website, you will find the tools necessary to implement the change to Basal Bolus Insulin Therapy.
An educational seminar explaining the rationale and theory behind BBIT in the form of an adobe breeze presentation, can be viewed here. A full screen version is also available here.
An educational seminar focusing on appropriate ordering or BBIT by using example cases. The presentation is in the form of an adobe breeze presentation, can be viewed here. A full screen version is also available here.
A set of pocket cards demonstrating the BBIT protocol for both insulin dependent and non-insulin dependent diabetics is also available. To view these pocket cards online, please click the buttons to the right.
A downloadable copy of the individual pocket cards in .pdf format is available here. You will need Adobe Acrobat Reader.
If you would like to view the cards directly on a mobile device, such as an iphone, please click here and save the page as a link to your mobile's desktop. Note that you will be able to use the cards even when offline!
A set of BBIT protocol worksheets is available for offline use for clinical and teaching purposes. These can be kept on the patient's chart in settings where no computerized order entry system exists in order to faciliate the use of the BBIT protocol.
A downloadable copy of the worksheets in .pdf format is available here. You will need Adobe Acrobat Reader.
An educational seminar in the form of an adobe breeze presentation and geared towards the multidisciplinary health care team can be viewed here. A full screen version is also available here.
An educational seminar focusing on appropriate ordering or BBIT by using example cases. The presentation is in the form of an adobe breeze presentation, can be viewed here. A full screen version is also available here.
A set of pocket cards outlining the BBIT protocol tailored to nursing specific needs is also available. These pocket cards provide important information about BBIT with regard to appropriate nursing care, as well as various tips and suggestions to implement BBIT effectively. To view these pocket cards online, please click the buttons to the right.
A downloadable copy of the individual pocket cards in .pdf format is available here. You will need Adobe Acrobat Reader.
If you would like to view the cards directly on a mobile device, such as an iphone, please click here and save the page as a link to your mobile's desktop. Note that you will be able to use the cards even when offline!
For more information about training opportunities, please contact us.
BBIT applications for mobile devices including iPhone, Android and BlackBerry will be available soon!
In the interim, if you would like to view the pocket cards directly on a mobile device, please click here and save the page as a link to your mobile's desktop. Note that you will be able to use the cards even when offline!