Devices Allow Remote Monitoring of Blood Glucose Levels
ATLANTA—A silver lining in the dark cloud of the COVID-19 pandemic might be that healthcare systems have been forced to reconsider many processes, especially those involving close contact with patients.
According to a recent viewpoint article, one of those is glucose monitoring in inpatients with diabetes. A new study argued that the move to continuous glucose monitoring devices because of the extreme conditions has “revealed the impracticality of current hospital glucose monitoring strategies.”
The Emory University-led study included researchers from both the Atlanta and Baltimore VAMCs and is of special importance to the VHA, where about one-fourth of patients have a diabetes diagnosis. The report in the Journal of Diabetes Science and Technology made the case that the current circumstances create an ideal situation to access the value of CGM.1
“We believe that CGM may be on the threshold of becoming a widely accepted form of continuous automated physiologic monitoring in the hospital setting (depending on what future research data will show), and during the pandemic this technology can be used to immediately address emergent needs when there is a high demand for both nursing staff and PPE,” wrote first author Rodolfo J. Galindo, MD, of the Division of Endocrinology, Metabolism and Lipids at Emory, and colleagues, adding, “The accommodations made in the short term enabling immediate CGM use for patients with COVID-19 create an opportunity to evaluate this technology in the inpatient setting.”
The study suggested several barriers to more widespread usage, including that:
- Food and Drug Administration clearance will be required to move this technology from the research setting into mainstream hospital practice.
- More data is required to assess the performance of CGM in widespread hospital use, and the short-term implementation for treating COVID-19 patients during the pandemic will not generate sufficient data for more widespread use after the pandemic.
- Hospitals’ electronic health records must be modified to accept CGM glucose data directly.
- Economic analyses also will be needed to justify a wider implementation of this technology but should not delay immediate implementation efforts.
“Today it is possible to remotely monitor cardiac rhythm and vital signs continuously on the hospital wards, where close nursing observation is not always possible,” the authors argued. “Given the importance of treating diabetes and uncontrolled hyperglycemia in every unit of the hospital and the improvements in performance of current-generation CGM systems, we say, why not continuously measure glucose in the hospital as well?”
One issue, according to the article, is critical shortages of supplies, especially personal protective equipment available to healthcare workers. “The increasing proportion of hospitalized patients with diabetes mellitus (DM) and concurrent COVID-19 only increases the burden on healthcare systems, forcing HCW to choose between providing necessary bedside care and maintaining their own personal safety in light of extreme limitations in available PPE,” it points out.
Galindo and co-authors made note of the large number of hospitalized patients with both diabetes and COVID-19, emphasizing that appropriate glycemic control can improve patient-centered outcomes by reducing hospital complications and length of stay.
“However, an approach is needed that also addresses priorities of community-centered care, such as preserving supplies of PPE, minimizing exposure risk to HCW, and limiting transmission to the community,” they added. “The traditional approach to care for patients with diabetes in the hospital is complex and requires portable glucose monitors for frequent point-of-care (POC) testing with fingersticks and associated technical and comfort limitations. Four or more capillary blood glucose measurements per day are typically recommended for patients receiving multiple daily insulin injections, with hourly glucose measurements recommended for those receiving intravenous continuous insulin infusion (i.e., patients with critical illness, diabetic ketoacidosis or hyperosmolar hyperglycemic state). These recommendations have been rendered nearly unachievable under current conditions, where an increased need for bedside glucose monitoring has been undermined by rising patient-to-nurse ratios, an increase in the overall acuity of the inpatient population, and a scarcity of PPE.”
The authors proposed that a better answer than reducing bedside encounters is expanding the use of CGM, noting, “Factory-calibrated CGM provides a uniquely practical alternative, by allowing real-time glucose monitoring and alarms to prevent untoward glycemic issues, while reducing the need for frequent inpatient fingerstick testing. Less frequent fingerstick testing, in turn, decreases exposure time and PPE use.”
The authors wrote that, in early April, the Food and Drug Administration did not object to the use of CGM devices in the inpatient setting in response to the COVID-19 pandemic and that anecdotal reports described widespread use of CGM in many U.S. hospitals.
The article advised that patients admitted with mild-to-moderate hyperglycemia—defined as blood glucose <180-200mg/dL—and not on outpatient insulin therapy, might be effectively treated with simple regimens requiring less frequent glucose testing. Those with moderate to severe hyperglycemia—defined as blood glucose ≥200mg/dL—require treatment with more complex insulin regimens after they arrive in the hospital, however, probably would benefit from CGM. The authors said that includes patients with:
- Type 1 diabetes;
- Regimens of high-dose insulin or multiple noninsulin agents;
- A long-standing history of diabetes;
- Significant glucotoxicity related to the current infection;
- New DM diagnosis;
- Chronically uncontrolled hyperglycemia; or
- Iatrogenic hyperglycemia caused by high-dose steroid or medical nutrition therapy (enteral or parenteral nutrition).
The authors pointed out that investigators from the Baltimore VA Center/University of Maryland and Emory University are systematically evaluating the implementation of a system to alert nursing staff to downward trending glucose values and simultaneously provide remote glucometric data to guide glycemic control. Three components—a CGM device, a smartphone (a phone with internet connectivity), and a tablet (i.e., iPad)—are required to .send glucose values through Bluetooth from the CGM transmitter to the smartphone, located next to the patient, and from there wirelessly to the tablet or any other device with internet connection, which can be located near the nursing station.
- Galindo RJ, Aleppo G, Klonoff DC, et al. Implementation of Continuous Glucose Monitoring in the Hospital: Emergent Considerations for Remote Glucose Monitoring During the COVID-19 Pandemic [published online ahead of print, 2020 Jun 14]. J Diabetes Sci Technol. 2020;1932296820932903. doi:10.1177/1932296820932903