A proof-of-concept study recently published in Diabetes Care shows how inpatient diabetes technology is advancing and can provide meaningful improvements in care today and in a post-pandemic world.
The research team, led by Francisco J. Pasquel, MD, MPH, assistant professor of medicine in the Division of Endocrinology at Emory University in Atlanta, write that point-of-care (POC) testing during a pandemic like COVID-19 could lead to the use of subcutaneous insulin regimens where continuous insulin infusion (CII) would normally be indicated, and that the severity of COVID-19 in patients in the intensive care unit make the safety and efficacy of subcutaneous insulin regimens difficult to maintain. “Therefore,” the authors write, “it is paramount to develop protocols that reduce PPE waste, nursing workload, and infectious exposures while maintaining glycemic control and reducing the risk of iatrogenic hypoglycemia.”
The researchers, based on preliminary data from using continuous glucose monitoring (CGM) in the cardiac ICU, inpatient CGM use in non-ICU units, and inpatient clinical practice, designed a hybrid CGM/POC testing protocol utilizing Dexcom’s G6 CGM and Glytec’s electronic Glycemic Management System’ (eGMS) Glucommander module integrated with their EPIC EHR instance to treat critically ill patients in the ICU with COVID-19 requiring insulin infusion at Grady Memorial Hospital in Atlanta, Ga. “We report here our proof-of-concept with our first nine patients,” the authors write.
“As the healthcare community works toward a new normal, the use of diabetes technology can help alleviate staff concerns related to work burden, exposure, and PPE consumption, while improving glycemic control during this healthcare crisis.”
All nine patients required mechanical ventilation and corticosteroids, due to the severity of active or suspected COVID-19 – seven of the nine patients had confirmed PCR testing. The authors write that the mean age was 65.9 + 15.2 years, 67% were men, and 89% were African American. All patients had type 2 diabetes and blood glucose values .180 mg/dL before starting CII. The researchers found that during the protocol, 75.7% of sensor values were within 20% of the reference POC glucose with an associated average reduction in POC of 63%. Mean time in range (70–180 mg/dL) was 71.4 + 13.9%. Sensor accuracy was impacted by mechanical interferences in four patients.
The results suggest that CGM use is possible in the ICU and can reduce POC glucose testing without compromising on glycemic control. It also highlights beneficial outcomes for future implementations, including achieving and maintaining adequate glycemic control quickly, minimizing patient discomfort (fingersticks), and remotely monitoring real-time glucose levels.
“A protocol involving multiple stakeholders to implement a hybrid approach (real time CGM with POC validation every 6h) with hourly EHR documentation guiding computerized CII is feasible in the ICU and can reduce POC glucose testing without compromising glycemic control,” the authors conclude. “As the healthcare community works toward a new normal, the use of diabetes technology can help alleviate staff concerns related to work burden, exposure, and PPE consumption, while improving glycemic control during this health care crisis.”