2. Marketing Strategy

Engagement and commitment to change can be influenced by the sites’ ability to make the initiative “their own”. Site-specific re-branding of the Basal Bolus Insulin Therapy (BBIT) project may help overcome cultural resistance to change.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

3. Reminders

Publish posters and computer screensavers advertising the risk of hyperglycemia and merits of glycemic optimization in high traffic areas. Make messages succinct and easily understood.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

4. Data Audit

Data audits of the desired behavior (ie. BBIT ordering frequency) in the pre-implementation period allows for assessment of current state, promotes engagement and facilitates goal-setting. Post-implementation data allows evaluation of implementation success and clinical impact of the change over time. Some sites benefit from a friendly “competition”. Sharing patient-centered outcomes or “quick wins” helps to promote uptake.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

1. Multidisciplinary Continuing Education

Provide multidisciplinary training to address knowledge gaps. This is ideally delivered peer-to-peer. Education sessions may be multimodal, and may be scheduled or impromptu. Examples include:

• Train the Trainer Sessions
• Evidence-based, standardized diabetes education: Diabetes Canada In-hospital Management of Diabetes
• Sharing of influential research: CADTH scoping review of hyperglycemia-associated harms
• AHS Glycemic Policy suite
• BBIT email pearls/posters
• BBIT Overview Webinar in Adobe Flash or as a PDF
• Nursing self-study module
• Interactive website: Online, centralized, shareable repository of educational and implementation tools for the BBIT intervention at www.bbit.ca

1. Blood glucose and insulin administration record, Diabetes Report Card and Alerts

Use an electronic or paper based record to chart all administered insulin doses and point of care testing results, together on the patient chart. The electronic Diabetes Report Card (available in certain centers only) has added clinical decision support functionality to calculate a “Diabetes Score” indicating the incidence of hypoglycemia (blood glucose < 4.0 mmol/L) or significant hyperglycemia (blood glucose > 18 mmol/L) and “in target status” (blood glucose 5-10mmol/L) over the previous 24 hours.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

2. Multidisciplinary Continuing Education

Provide multidisciplinary training to address knowledge gaps. This is ideally delivered peer-to-peer. Education sessions may be multimodal, and may be scheduled or impromptu. Examples include:

• Train the Trainer Sessions
• Evidence-based, standardized diabetes education: Diabetes Canada In-hospital Management of Diabetes
• Sharing of influential research including:
  • CADTH Review of Basal Bolus Insulin Therapy vs. Sliding Scale Insulin in hospital
  • RABBIT-2 Study: Randomized Control Trial of Basal Bolus Insulin Therapy vs. Sliding Scale Insulin Therapy for Medical Inpatients
  • RABBIT-2 Surgery: Randomized Control Trial of Basal Bolus Insulin Therapy vs. Sliding Scale Insulin Therapy for Surgical Inpatients
• Experiences with the BBIT implementation in Alberta
  • Knowledge Translation to Optimize Adult Inpatient Glycemic Management with Basal Bolus Insulin Therapy and Improve Patient Outcomes
  • Qualitative Evaluation of the Barriers and Facilitators Influencing the Use of an Electronic Basal Bolus Insulin Therapy Protocol to Improve the Care of Adult Inpatients With Diabetes
  • Implementation of a Multidisciplinary Educational Strategy Promoting Basal-Bolus Insulin Therapy Improves Glycemic Control and Reduces Length of Stay for Inpatients With Diabetes
• AHS Glycemic Policy suite
• BBIT email pearls/posters
• BBIT Overview Webinar in Adobe Flash or as a PDF
• Nursing self-study module
• Interactive website: Online, centralized, shareable repository of educational and implementation tools for the BBIT intervention at www.bbit.ca

1. Multidisciplinary Continuing Education

Provide multidisciplinary training to address knowledge gaps. This is ideally delivered peer-to-peer. Education sessions may be multimodal, and may be scheduled or impromptu. Examples include:

• Train the Trainer Sessions
• Evidence-based, standardized diabetes education: Diabetes Canada In-hospital Management of Diabetes
• Sharing of influential research including:
  • CADTH Review of Basal Bolus Insulin Therapy vs. Sliding Scale Insulin in hospital
  • RABBIT-2 Study: Randomized Control Trial of Basal Bolus Insulin Therapy vs. Sliding Scale Insulin Therapy for Medical Inpatients
  • RABBIT-2 Surgery: Randomized Control Trial of Basal Bolus Insulin Therapy vs. Sliding Scale Insulin Therapy for Surgical Inpatients
• Experiences with the BBIT implementation in Alberta showing no increase in hypoglycemia
  • Knowledge Translation to Optimize Adult Inpatient Glycemic Management with Basal Bolus Insulin Therapy and Improve Patient Outcomes
  • Implementation of a Multidisciplinary Educational Strategy Promoting Basal-Bolus Insulin Therapy Improves Glycemic Control and Reduces Length of Stay for Inpatients With Diabetes
• BBIT email pearls/posters
• BBIT Overview Webinar in Adobe Flash or as a PDF
• Nursing self-study module

2. Data Audit

Data audit of the desired outcome of interest (ie. Hypoglycemia frequency) in the pre-implementation period allows for assessment of current state, promotes engagement and facilitates goal-setting. Post-implementation data allows evaluation of implementation success and clinical impact of the change over time. Some sites benefit from a friendly “competition.” Sharing patient-centered outcomes or “quick wins” helps to promote uptake.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

3. Multidisciplinary Champions

Identify, support and mobilize nursing, pharmacy, physician and administrative champions to lead the change locally. It is important, if possible, for these individuals to be “opinion leaders” who can persuade or influence the opinions of their peer group. Having active Multidisciplinary Champions share anecdotes or data can help overcome resistance within groups.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

4. Policy

Adopt high level, systemic policy changes supporting recognition and appropriate treatment of hyperglycemia and hypoglycemia The Alberta Health Services Glycemic Management Policy emphasizes:

• The importance of four times daily blood glucose testing (ac meals and hs)
• Appropriate inpatient glycemic targets of 5-10 mmol/L for most inpatients
• Outlines the necessity to notify ordering providers when the blood glucose is below 4.0 mmol/L AND the patient has altered level of consciousness or unable to swallow, or if blood glucose is above 18 mmol/L.

1. Multidisciplinary Continuing Education

Provide multidisciplinary training to address knowledge gaps. This is ideally delivered peer-to-peer. Education sessions may be multimodal, and may be scheduled or impromptu. Examples include:

• Train the Trainer Sessions
• Evidence-based, standardized diabetes education: Diabetes Canada In-hospital Management of Diabetes
• Sharing of influential research including:
  • CADTH Review of Basal Bolus Insulin Therapy vs. Sliding Scale Insulin in hospital
• Nursing self-study module

2. Data Audit

Data audit of the desired outcome of interest (ie. Hyperglycemia frequency, associated harmful outcomes) in the pre-implementation period allows for assessment of current state, promotes engagement and facilitates goal-setting. Post-implementation data allows evaluation of implementation success and clinical impact of the change over time. Some sites benefit from a friendly “competition.” Sharing patient-centered outcomes or “quick wins” helps to promote uptake.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

3. Multidisciplinary Champions

Identify, support and mobilize nursing, pharmacy, physician and administrative champions to lead the change locally. It is important, if possible, for these individuals to be “opinion leaders” who can persuade or influence the opinions of their peer group. Having active Multidisciplinary Champions share anecdotes or data can help overcome resistance within groups

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

4. Policy

Adopt high level, systemic policy changes supporting recognition and appropriate treatment of hyperglycemia and hypoglycemia The Alberta Health Services Glycemic Management Policy emphasizes:

• The importance of four times daily blood glucose testing (ac meals and hs)
• Appropriate inpatient glycemic targets of 5-10 mmol/L for most inpatients
• Outlines the necessity to notify ordering providers when the blood glucose is below 4.0 mmol/L AND the patient has altered level of consciousness or unable to swallow, or if blood glucose is above 18 mmol/L.

5. Reminders

Develop and implement a system to “flag” abnormal blood glucose values for ordering providers to provide a prompt for insulin titration. Some examples include stickers on charts, electronic patient “Diabetes Scores,” notes written by nursing staff in progress notes, etc.

Publish posters and computer screensavers advertising the risk of hyperglycemia and merits of glycemic optimization in high traffic areas. Make messages succinct and easily understood.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

1. Multidisciplinary Continuing Education

Provide multidisciplinary training to address knowledge gaps. This is ideally delivered peer-to-peer. Education sessions may be multimodal, and may be scheduled or impromptu. To overcome the barrier of providers being more comfortable or familiar with sliding scale insulin, champions must provide recurrent opportunities to practice ordering/delivering BBIT to increase familiarity of the BBIT protocol. Hands-on practice in rounds or with case studies is helpful .

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

2. Provincial Basal Bolus Insulin Therapy Adult In-patient Order Set

Paper-based or electronic, evidence-informed single page order set directing appropriate diabetes care, developed using Diabetes Canada (formerly Canadian Diabetes Association) published insulin delivery algorithms and informed by a nation-wide e-scan. User acceptance testing facilitated an iterative approach to improve the quality and safety of care provided to patients with diabetes. The BBIT order set directs appropriate glucose monitoring, safe insulin dosing, timing and administration, and appropriate treatment of hyperglycemia and hypoglycemia. Samples of the Provincial Basal Bolus Insulin Therapy Forms can be found here and here. For sites within Alberta Health Services, please contact the forms department for Form #20889 and #20115. For sites not within Alberta Health Services, the order set can be found here.

This tool applies to: Ordering Providers, Nursing Providers, and Pharmacy.

3. Multidisciplinary Champions

Identify, support and mobilize nursing, pharmacy, physician and administrative champions to lead the change locally. It is important, if possible, for these individuals to be “opinion leaders” who can persuade or influence the opinions of their peer group. Having active Multidisciplinary Champions share anecdotes or data can help overcome resistance within groups.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy, and Administrators.

1. Provincial Basal Bolus Insulin Therapy Adult In-patient Order Set

Ensure appropriate access to paper and/or electronic forms, in high use areas. Samples of the Provincial Basal Bolus Insulin Therapy Forms can be found here and here. For sites within Alberta Health Services, please contact the forms department for Form #20889 and #20115. For sites not within Alberta Health Services, the order set can be found here.
This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

2. Multidisciplinary Champions

Identify, support and mobilize nursing, pharmacy, physician and administrative champions to lead the change locally. It is important, if possible, for these individuals to be “opinion leaders” who can persuade or influence the opinions of their peer group. Having active Multidisciplinary Champions share anecdotes or data can help overcome resistance within groups and provide opportunities for education and social comparison.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

3. Systemic Supports

Prioritize the implementation of BBIT within your group or organization, including both top-down support and bottom- up support. Highlight patient safety and satisfaction as key central themes.
This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

4. Communication Plan

Develop a communication strategy to distribute information to site multidisciplinary champions, and capitalize on the best means of distributing the information from multidisciplinary site champions to their front line peers. For example, email, posters, computer screen savers, prescriber pocket cards, nursing pocket cards, site meetings, unit rounds, times of handover have been used by different sites to communicate messages successfully.
This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

1. Multidisciplinary Champions

Identify, support and mobilize nursing, pharmacy, physician and administrative champions to lead the change locally. It is important, if possible, for these individuals to be “opinion leaders” who can persuade or influence the opinions of their peer group. Having active Multidisciplinary Champions share anecdotes or data can help overcome resistance within groups.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy, and Administrators.

2. Data Audit

Data audit of the desired outcome of interest (ie. Hyperglycemia frequency, associated harmful outcomes) in the pre-implementation period allows for assessment of current state, promotes engagement and facilitates goal-setting. Post-implementation data allows evaluation of implementation success and clinical impact of the change over time. Some sites benefit from a friendly “competition.” Sharing patient-centered outcomes or “quick wins” helps to promote uptake.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy, and Administrators.

3. Blood glucose and insulin administration record, Diabetes Report Card and Alerts

Use an electronic or paper based record to chart all administered insulin doses and point of care testing results, together on the patient chart. The electronic Diabetes Report Card (available in certain centers only) has added clinical decision support functionality to calculate a “Diabetes Score” indicating the incidence of hypoglycemia (blood glucose < 4.0 mmol/L) or significant hyperglycemia (blood glucose > 18mmol/L) and “in target status” (blood glucose 5-10mmol/L) over the previous 24 hours.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy, and Administrators.

4. Multidisciplinary Continuing Education

Provide multidisciplinary training to address knowledge gaps. This is ideally delivered peer-to-peer. Education sessions may be multimodal, and may be scheduled or impromptu. To overcome the barrier of providers being more comfortable or familiar with sliding scale insulin, champions must provide recurrent opportunities to practice ordering/delivering BBIT to increase familiarity of the BBIT protocol. Hands-on practice in rounds or with case studies is helpful.

**NOTE: If Providers are unsure of benefits of BBIT, see “Ordering providers and/or nursing staff do not believe that Basal Bolus Insulin Therapy (BBIT) is better able to achieve blood glucose within target range than sliding scale insulin” Barrier above.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy, and Administrators.

1. Multidisciplinary Continuing Education

If this is a knowledge barrier, ie. the provider is truly unaware of the ability of BBIT to accommodate complex patient situations, this can be addressed with providing additional education.

Provide multidisciplinary training to address knowledge gaps. This is ideally delivered peer-to-peer. Education sessions may be multimodal, and may be scheduled or impromptu. To overcome the barrier of providers being more comfortable or familiar with sliding scale insulin, champions must provide recurrent opportunities to practice ordering/delivering BBIT to increase familiarity of the BBIT protocol. Hands-on practice in rounds or with case studies is helpful. Examples include:

• How to BBIT Guide addresses very specific patient circumstances, including transition from NPO to eating, continuous or intermittent enteral nutrition, parenteral nutrition, renal impairment, corticosteroid treatment, gastroparesis, peri-operative management, transitioning IV to subcutaneous insulin and pump therapy, and discharge planning.
• Guide to Surgical Management with BBIT

2. Data Audit

If this is a belief barrier, ie. the provider does not believe BBIT can accommodate complex patient situations, this can be addressed by reassurance with concrete data obtained via audit.

Data audit of the desired outcome of interest (ie. hyper/hypoglycemia frequency or adverse outcome frequency for patients with certain comorbid diagnoses) in the pre-implementation period allows for assessment of current state, promotes engagement and facilitates goal-setting. Post-implementation data allows evaluation of implementation success and clinical impact of the change over time. Some sites benefit from a friendly “competition.” Sharing patient-centered outcomes or “quick wins” helps to promote uptake.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy, and Administrators.

3. Multidisciplinary Champions

Identify, support and mobilize nursing, pharmacy, physician and administrative champions to lead the change locally. It is important, if possible, for these individuals to be “opinion leaders” who can persuade or influence the opinions of their peer group. Having active Multidisciplinary Champions share anecdotes or data can help overcome resistance within groups.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy, and Administrators.

4. Blood glucose and insulin administration record, Diabetes Report Card and Alerts

Use an electronic or paper based record to chart all administered insulin doses and point of care testing results, together on the patient chart. The electronic Diabetes Report Card (available in certain centers only) has added clinical decision support functionality to calculate a “Diabetes Score” indicating the incidence of hypoglycemia (blood glucose < 4.0 mmol/L) or significant hyperglycemia (blood glucose > 18 mmol/L) and “in target status” (blood glucose 5-10mmol/L) over the previous 24 hours.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy, and Administrators.

1. Data Audit

Data audit of relevant activities (ie. Time to complete order set vs. writing out traditional Sliding Scale Insulin orders, time to administer basal bolus insulin for a patient vs. a sliding scale order, frequency of pages to Ordering providers before or after intervention) helps to highlight efficiencies in workflows. For example, previous sites have demonstrated that paging frequency for out of control blood glucose have been reduced post-implementation, in part from better glycemic control and in part due to standardized correction dosing.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy, and Administrators.

2. Communication Plan

Development and implementation of a consistent means of documenting insulin doses, blood glucose values, and planned procedures, ideally co-located within the patient chart. Development of consensus amongst the care team regarding when to notify ordering provider of “out-of-range” blood glucose values, changes in nutritional status, and timing of off-unit procedures and appointments.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy, and Administrators.

1. Multidisciplinary Champions

Identify, support and mobilize nursing, pharmacy, physician and administrative champions to lead the change locally. It is important, if possible, for these individuals to be “opinion leaders” who can persuade or influence the opinions of their peer group. Having active Multidisciplinary Champions share anecdotes or data can help overcome resistance within groups and provide opportunities for education and social comparison.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

2. Multidisciplinary Continuing Education

Site champions are made aware of implementation resources at Train the Trainer day. All implementation resources are provided in paper and/or electronic form at that time. A summary of this information is available here.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

3. Communication Plan

Establish a communication plan amongst site champions and core implementation team. Bi-directional communication of qualitative and quantitative feedback and user acceptance data, verbal or written feedback, questionnaires, coaching rounds, implementation feedback meetings and via site champions. Develop a communication strategy to distribute information to site multidisciplinary champions, and capitalize on the best means of distributing the information from multidisciplinary site champions to their front line peers. For example, email, posters, computer screen savers, prescriber pocket cards, nursing pocket cards, site meetings, unit rounds, times of handover have been used by different sites to communicate messages successfully. A centralized repository of education and resources is found at www.bbit.ca.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

4. Systemic Supports

Prioritize the implementation of BBIT within your group or organization, including both top-down support and bottom- up support. Highlight patient safety and satisfaction as key central themes.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

1. Communication Plan

Develop and implement a consistent means of documenting insulin doses, blood glucose values, and planned procedures, ideally co-located within the patient chart. Develop consensus amongst the care team regarding when to notify ordering provider of “out-of-range” blood glucose values, changes in nutritional status, and timing of off-unit procedures and appointments.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy, and Administrators.

1. Communication Plan

Develop and implement a consistent means of documenting insulin doses, blood glucose values, and planned procedures, ideally co-located within the patient chart. Develop consensus amongst the care team regarding when to notify ordering provider of “out-of-range” blood glucose values, changes in nutritional status, and timing of off-unit procedures and appointments.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy, and Administrators.

2. Reminders

Develop and implement a system to “flag” abnormal blood glucose values for ordering providers to provide a prompt for insulin titration. Some examples include stickers on charts, electronic patient “Diabetes Scores,” notes written by nursing staff in progress notes, etc.

This tool applies to: Ordering Providers, Nursing Providers.

3. Policy

Adopt high level, systemic policy changes supporting recognition and appropriate treatment of hyperglycemia and hypoglycemia The Alberta Health Services Glycemic Management Policy emphasizes:

• The importance of four times daily blood glucose testing (ac meals and hs)
• Appropriate inpatient glycemic targets of 5-10 mmol/L for most inpatients
• Outlines the necessity to notify ordering providers when the blood glucose is below 4.0 mmol/L AND the patient has altered level of consciousness or unable to swallow, or if blood glucose is above 18 mmol/L.

1. Multidisciplinary Champions

Identify, support and mobilize nursing, pharmacy, physician and administrative champions to lead the change locally. It is important, if possible, for these individuals to be “opinion leaders” who can persuade or influence the opinions of their peer group. Having active Multidisciplinary Champions share anecdotes or data can help overcome resistance within groups and provide opportunities for education and social comparison.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

2. Multidisciplinary Continuing Education

Site champions are made aware of implementation resources at Train the Trainer day. All implementation resources are provided in paper and/or electronic form at that time. A summary of this information is available here.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

3. Communication Plan

Establish a communication plan amongst site champions and core implementation team. Bi-directional communication of qualitative and quantitative feedback and user acceptance data, verbal or written feedback, questionnaires, coaching rounds, implementation feedback meetings and via site champions.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

4. Policy

Adopt high level, systemic policy changes supporting recognition and appropriate treatment of hyperglycemia and hypoglycemia The Alberta Health Services Glycemic Management Policy emphasizes:

• The importance of four times daily blood glucose testing (ac meals and hs)
• Appropriate inpatient glycemic targets of 5-10 mmol/L for most inpatients
• Outlines the necessity to notify ordering providers when the blood glucose is below 4.0 mmol/L AND the patient has altered level of consciousness or unable to swallow, or if blood glucose is above 18 mmol/L.

1. Multidisciplinary Continuing Education

Provide multidisciplinary training to address knowledge gaps. This is ideally delivered peer-to-peer. Education sessions may be multimodal, and may be scheduled or impromptu. To overcome the barrier of providers being uncomfortable providing Basal Bolus Insulin Therapy (BBIT) orders to patients with variable nutritional intake, recurrent opportunities to practice ordering/delivering BBIT to increase familiarity of the BBIT protocol. Discussion around which doses should be given (and why), and which doses should be held (and why) are important. Hands-on practice in rounds or with case studies is helpful.

2. Communication Plan

Develop and implement a consistent means of documenting insulin doses, blood glucose values, and planned procedures, ideally co-located within the patient chart. Develop consensus amongst the care team regarding when to notify ordering provider of “out-of-range” blood glucose values, changes in nutritional status, and timing of off-unit procedures and appointment.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

3. Systemic Supports

Collaborate with Provincial Nutrition and Food Services and site services to define meal content and verify site-specific timing of meal delivery.

This tool applies to: Ordering Providers, Nursing Providers, Administrators.

1. Multidisciplinary Champions

Identify, support and mobilize nursing, pharmacy, physician and administrative champions to lead the change locally. It is important, if possible, for these individuals to be “opinion leaders” who can persuade or influence the opinions of their peer group. Having active Multidisciplinary Champions share anecdotes or data can help overcome resistance within groups and provide opportunities for education and social comparison.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

2. Reminders

Develop and implement a system to “flag” patients preparing for discharge, and the need to start discharge planning. Diabetes education and insulin teaching should occur as soon as care provider has made the decision that the patient will be discharged on insulin, so long as the patient is stable and prepared to accept the education. In some instances, when diabetes education cannot be provided in hospital, urgent or semi-urgent outpatient appointments for insulin teaching should be utilized. Whenever possible, bedside nurses should provide insulin teaching. Publish posters and computer screensavers promoting early diabetes discharge planning. Make messages succinct and easily understood. A guide to assist with transitioning to discharge has been developed and can be found here.

This tool applies to: Ordering Providers, Nursing Providers, and Pharmacy.

3. Systemic Supports

Develop a clear understanding of locally available resources (diabetes education, home care, capacity of long term care sites to support three or four times daily blood glucose monitoring and insulin injections), and develop discharge plan that aligns with realistic resource allocation, patient capacity and expectations. Basal Bolus Insulin Therapy (with basal, bolus and correction doses) is rarely required upon discharge in patients who were not admitted on similar protocols. At minimum, steps should be implemented to ensure the patient is not routinely discharged on correction doses.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

1. Multidisciplinary Champions

Identify, support and mobilize nursing, pharmacy, physician and administrative champions to lead the change locally. It is important, if possible, for these individuals to be “opinion leaders” who can persuade or influence the opinions of their peer group. Having active Multidisciplinary Champions share anecdotes or data can help overcome resistance within groups. For time concerns, Administrative champions can intervene to provide protected time for learning, or other multidisciplinary champions can demonstrate how they have integrated the change into their workflow without additional time.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy, and Administrators.

1. Multidisciplinary Champions

Identify, support and mobilize nursing, pharmacy, physician and administrative champions to lead the change locally. It is important, if possible, for these individuals to be “opinion leaders” who can persuade or influence the opinions of their peer group. Having active Multidisciplinary Champions share anecdotes or data can help overcome resistance within groups and provide opportunities for education and social comparison.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

2. Multidisciplinary Continuing Education

Site champions are made aware of implementation resources at Train the Trainer day. All implementation resources are provided in paper and/or electronic form at that time. A summary of this information is available here.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

3. Communication Plan

Establish a communication plan amongst site champions and core implementation team. Bi-directional communication of qualitative and quantitative feedback and user acceptance data, verbal or written feedback, questionnaires, coaching rounds, implementation feedback meetings and via site champions.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

1. Communication Plan

Develop a communication strategy to distribute information to site multidisciplinary champions, and capitalize on the best means of distributing the information from multidisciplinary site champions to their front line peers. For example, email, posters, computer screen savers, prescriber pocket cards, nursing pocket cards, site meetings, unit rounds, times of handover have been used by different sites to communicate messages successfully.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

2. Provincial Basal Bolus Insulin Therapy Adult In-patient Order Set

Ensure appropriate access to paper and/or electronic forms, in high use areas. Samples of the Provincial Basal Bolus Insulin Therapy Forms can be found here and here. For sites within Alberta Health Services, please contact the forms department for Form #20889 and #20115. For sites not within Alberta Health Services, the order set can be found here.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

1. Data Audit

Data audit of the desired outcome of interest (ie. Rate of BBIT ordering, hyper/hypoglycemia, compliance with blood glucose testing frequency and timing, insulin dose administrations) in the pre-implementation period allows for assessment of current state, promotes engagement and facilitates goal-setting. Post-implementation data allows evaluation of implementation success and clinical impact of the change over time. Individualized provider feedback can be undertaken as a quality improvement initiative in units/sites/provider groups, with peer comparator groups. Do not expect that end users will monitor outcome audit data independently (ie. With Tableau); instead, provide brief, visually interesting reports with one or two key highlights and areas of further work or attention. This is best provided sporadically, and across a number of platforms ( posters, email, verbally through Multidisciplinary Champions, etc).

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

2. Multidisciplinary Champions

Identify, support and mobilize nursing, pharmacy, physician and administrative champions to lead the change locally. It is important, if possible, for these individuals to be “opinion leaders” who can persuade or influence the opinions of their peer group. Having active Multidisciplinary Champions share anecdotes or data can help overcome resistance within groups and provide opportunities for education and social comparison.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

3. Communication Plan

Develop a communication strategy to distribute information to site multidisciplinary champions, and capitalize on the best means of distributing the information from multidisciplinary site champions to their front line peers. For example, email, posters, computer screen savers, prescriber pocket cards, nursing pocket cards, site meetings, unit rounds, times of handover have been used by different sites to communicate messages successfully.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.

1. Data Audit

Data audit of the desired outcome of interest (ie. Rate of BBIT ordering, hyper/hypoglycemia, compliance with blood glucose testing frequency and timing, insulin dose administrations) in the pre-implementation period allows for assessment of current state, promotes engagement and facilitates goal-setting. Post-implementation data allows evaluation of implementation success and clinical impact of the change over time. Individualized provider feedback can be undertaken as a quality improvement initiative in units/sites/provider groups, with peer comparator groups.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy, and Administrators.

1. Information Provision

Involving the patient in a shared decision making model is important to increase acceptance. Providers should share information around the glycemic targets, rationale, and method (basal bolus insulin therapy) with the patient. Patient information has been developed and can be found here and here.

This tool applies to: Ordering Providers, Nursing Providers, Pharmacy and Administrators.