Basal Bolus Insulin Therapy

Alberta Health Services (AHS) Diabetes Obesity and Nutrition Strategic Clinical Network (DON SCN) is leading a multifaceted quality improvement initiative to standardize and improve diabetes management in hospital. Basal Bolus Insulin Therapy is an initial priority.

Why is Diabetes in Hospital Important?

Diabetes in hospital is COMMON
Diabetes is a very common condition, affecting an estimated 1 in 20 Canadians. Local data suggests that 1 in 5 adult patients admitted to hospital in Alberta has diabetes. It is estimated that the health care budget contributes 13 billion dollars per year to the care of 2 million Canadians with Diabetes. In Alberta, patients with diabetes stay in hospital 40% longer than their non-diabetic counterparts (3 days versus 5 days in the 2014/15 fiscal year).

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 mortality1, 2. 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 surgery3, 4, 5, 6, 7, 8, 9, 10.

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 patient11. Moreover, in a second study, implementing programs focused on treating hyperglycemia led to as much as a 450% return on investment12. The Canadian Diabetes Association (CDA) 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 10 mmol/L for most patients who are admitted to hospital. These targets are higher and more flexible than the typical targets for patients with diabetes who are well at home.

Basal Bolus Insulin Therapy

Basal Bolus Insulin Therapy (BBIT) is a way of ordering multiple daily injections of subcutaneous (sc) insulin that better replicates how our body naturally produces insulin. Basal Bolus Insulin therapy allows clinicians to customize insulin regimens based on the unique needs of each patient. It is proactive, and aims to anticipate the patient's insulin needs. Individualizing BBIT better enables providers to keep the hospitalized patient’s blood sugars within the target range of 5-10 mmol/L.

It prevents blood sugar highs and lows, allowing the patient to feel better. This is in contrast to the commonly used “sliding scale”, which, although still common, treats high blood sugar after it has occurred. Traditional sliding scale insulin treatment is not individualized, and can result in greater blood sugar fluctuation throughout the day.

IMPORTANT: Though BBIT relies on a safe calculation to establish insulin doses, it does not replace clinical judgment.

Objective

Basal bolus insulin therapy (BBIT), which integrates the pharmacology of different insulin analogs to replicate physiologic insulin profiles, aims to anticipate patients' insulin needs and decreases both hyperglycemic and hypoglycemic events. 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:

  • Basal - Long acting insulin to reproduce endogenous insulin that is normally produced by the pancreas 24 hours per day in those without diabetes. This insulin is produced in response to the liver’s continuous production of glucose (gluconeogenesis).
  • Bolus - Short acting insulin to balance the carbohydrate intake with meals.
  • Insulin Correction - Additional short acting insulin used to make small corrections and bring blood glucose back to target, if needed.
  • Titrate - Ensure that blood glucose is monitored 4 times daily and that insulin doses are adjusted to meet CDA targets of 5-10 mmol/L.
Our ultimate objective is to promote safe and effective diabetes management in hospital by focusing on clinical education, quality improvement and knowledge translation.

Patient Information

 

Basal Insulin Dosing

Bolus Insulin Dosing

Bolus not required! Patient is NPO.

Insulin Correction

Titrate

Insulin doses should be adjusted every 1 to 3 days by 10% to 20% according to the patients blood glucose values to achieve effective in-target blood glucose control (5-10 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 hypoglycemia protocol, treat with 15g of carbohydrate (4 dextrose tabs or 1/2 of a cup of juice or pop) 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% to 20%. If hypoglycemia occured overnight, reduce the bedtime basal dose by 10% to 20%.

Key Messages Summary


Supporting Education

Key Messages

Overview

Ordering - Paper

Ordering - SCM

Educational Resource


Pocket Cards

Prescriber Cards

Nursing Cards


Contact

Implementation

What's the Issue?

The management of diabetes in hospital is complicated!

It is complicated...

  • by the patients' presenting illness, and medication interactions
  • by changes to the patients' routine, such as dietary status, their level of activity
  • by issues involving the healthcare team and the clinical environment, such as poor coordination of blood glucose testing and administration of insulin
  • by the adjustments to the patients' glycemic mangement that is required, as health status changes, to achieve targets
  • by competing priorities - clinical, environmental and administrative

Currently, when patients present with complex disease and poorly controlled diabetes, the typical response by most care teams is to use a "sliding scale" insulin regimen, given the patients' changing medical status, irregular diet routine and schedule, and to avoid issues with drug-drug interactions. This results in costly, and most importantly, unsafe, blood glucose control for the patient, despite clinical evidence supporting the use of BBIT as a safer and more clinically versatile alternative. In spite of this evidence, the use of SSI in hospital has persisted, leading to the question of how do we change?

How do we Change?

Knowledge translation (KT) is a term describing how we integrate research into our every day work - a simple definition is 'doing better with what we know' (Mrklas, 2015). Research shows us that knowledge is necessary for practice change, but is usually insufficient on its own to get us to change what we do (Straus et al, 2009; Straus 2012). This change problem is not unique to diabetes, or health care - attempts to increase the use of research evidence to inform decision-making and behavior change are a challenge in many clinical areas and other industries (Straus et al, 2013).

The Knowledge to Action Framework (Graham, et.al., 2013)Knowledge is only one of the reasons why a shift to new practice may not be happening (Michie et al, 2011). There are many things that can get in the way. To change practice, it is important to think about what might get in the way of change - before we try it out. This helps us anticipate and plan around potential barriers, and gives us an opportunity to undertake work to move them out of the way (Michie et al, 2014). Research also shows us that if we think through these barriers, make a plan together (and a back up plan just in case), we are more likely to achieve our change goals (Sales et al, 2006; Verbiest et al, 2014; Presseau et al, 2014 & 2015).

The field of knowledge translation emerged as a way to help close gaps between what we know and what we do (Straus et al, 2013). KT is a rapidly expanding area of research and practice, spurred on by the reality that we measurably put evidence into practice about 50% of the time (Cabana et al, 1999; Grol & Wensing, 2004; Kerr et al, 2004; McGlynn et al, 2003; Rhodes & Maier, 2001; Mangione-Smith et al, 2007).

train and platformThese gaps between what we know and do are called “knowledge to action” or K2A gaps (Straus et al, 2013) and when we find them, it is important to dedicate time and effort to understanding and bridging them in order to make sure evidence based practice doesn’t stay in guidelines, but becomes what we do everyday. Finding knowledge-to-practice gaps and helping teams to systematically overcome them is a big part of the work undertaken by the Diabetes, Obesity and Nutrition Strategic Clinical Network. It is also core to the field of science and practice we call knowledge translation (also called implementation science in the UK). KT studies tell us that there are important individual, contextual, organizational (and other) factors that can help or hinder us in doing what we know frequently and reliably, particularly in healthcare environments that are in perpetual motion (Damschroder et al, 2009). The reason we are so focused on K2A gaps is because they can be significant sources of practice variation leading to wide discrepancies in patient outcomes, quality and safety of care, efficiency and cost. A deliberate plan to help make change in the practice setting might be able to help us ‘mind the gap’ and do what we know more frequently and reliably.

It is this deliberate, planned approach that we are using to help you and your team adopt BBIT into your daily routine. Strong implementation approaches are made up of two kinds of evidence - the evidence for a clinical intervention (in this case, BBIT) and the evidence that informs its use (Straus et al, 2015). Both parts are important because change is often challenging, expensive, time and resource intense and hard to sustain. If we make change without a systematic approach, it is impossible to learn from the process, estimate impacts (positive and negative), and generate generalizable data that can help others make the same change in other zones or organizations (Mrklas et al, 2015).

In the sections below, and throughout this website, you will find the tools that will help your team to implement the change to Basal Bolus Insulin Therapy.

For Physicians

Key Messages: Diabetes Management in Alberta Hospitals

  • 1-page summary
  • Presentation - An educational seminar explaining the key messages in the form of an Adobe Connect presentation, can be viewed here. A full screen version is also available here.

BBIT Overview Presentation

An educational seminar explaining the rationale and theory behind BBIT in the form of an Adobe Connect presentation, can be viewed here. A full screen version is also available here.

BBIT Ordering - paper-based

An educational seminar focusing on appropriate ordering of BBIT by using example cases. The presentation is in the form of an Adobe Connect presentation, can be viewed here. A full screen version is also available here.

BBIT Ordering - SCM

An educational seminar focusing on appropriate ordering of BBIT by using example cases. The presentation is in the form of an Adobe Connect presentation, can be viewed here. A full screen version is also available here.

Pocket Cards

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!

BBIT Worksheet

A worksheet for physicians or prescribers to utilize for insulin calculations is available here.

For Nurses

Key Messages: Diabetes Management in Alberta Hospitals

  • 1-page summary
  • Presentation - An educational seminar explaining the key messages in the form of an Adobe Connect presentation, can be viewed here. A full screen version is also available here.

BBIT Overview Presentation

An educational seminar explaining the rationale and theory behind BBIT in the form of an Adobe Connect presentation, can be viewed here. A full screen version is also available here.

BBIT Ordering - paper-based

An educational seminar focusing on appropriate ordering of BBIT by using example cases. The presentation is in the form of an Adobe Connect presentation, can be viewed here. A full screen version is also available here.

BBIT Ordering - SCM

An educational seminar focusing on appropriate ordering of BBIT by using example cases. The presentation is in the form of an Adobe Connect presentation, can be viewed here. A full screen version is also available here.

Nursing Cards

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!

Contact

For more information about BBIT, please contact us.

References

References

Click on the references above to bring them up in Google Scholar!

Mobile BBIT

BBIT applications for mobile devices including iPhone, Android and BlackBerry may be available in the future!

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!