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With several reports indicating that diabetes and hyperglycemia are linked to worse morbidity and mortality in individuals with coronavirus disease 2019 (COVID-19), maintaining optimal glucose levels in hospitalized patients is a key component of care.1 However, in monitoring patients with diabetes and COVID-19, the need for multiple glucose measurements per day directly opposes efforts to conserve personal protective equipment (PPE) and reduce healthcare professionals’ repeated exposure to the novel coronavirus.
In March 2020, clinical staff at Sheba Medical Center in Ramat Gan, Israel, turned to the use of continuous glucose monitors (CGMs) to address this issue and minimize contact with patients with diabetes under strict isolation for COVID-19.1 Medtronic CGM transmitters and glucose sensors were connected and data were uploaded to the company’s web-based application, Guardian™ Connect. Up to 5 stations were created in each department, with data visualization for up to 4 patients on each screen, creating a real-time glucose monitoring system in viral-free areas. The stations were fully operational the day after the request was made for remote monitoring.1
Positive results were seen in the first 4 patients at Sheba Medical Center who completed 1 week of remote glucose monitoring, with significant decreases in both mean daily glucose measurements (P =.005) and mean glucose levels (P =.0006).1 Members of the clinical care team reported that the greatest challenges in implementing the system were cost and training alternating teams in calibration procedures, which were performed twice daily.1
Around the same time in March 2020, the United States Food and Drug Administration (FDA) issued temporary guidance2 for expanded use of noninvasive remote monitoring devices that reduce contact between clinicians and patients during the COVID-19 pandemic, effectively allowing CGMs to be used in hospital settings in the United States.3
To learn more about the use of CGMs in one of the first US hospitals to incorporate them into care for patients with COVID-19, we interviewed Rasa Kazlauskaite, MD, MS, director of the diabetes technology program at Rush University and associate professor in the department of internal medicine at Rush Medical College in Chicago, Illinois.
In the setting of the COVID-19 pandemic, what are the most significant benefits of using CGMs?
First and foremost, our idea for using glucose sensors and remote glucose monitoring [at Rush University Medical Center] was to help the front-line nurses save time and PPE by not needing to go into the patients’ rooms to test the finger sticks. The second benefit of CGMs is that we feel the patients are safer. With forefinger sticks, you get a rough snapshot of diabetes control and it is easy to miss severe hyperglycemia and hypoglycemia. With the way we use remote glucose monitoring, we are able to detect and prevent most of these highs and lows [in glucose levels]. From the patient perspective, the nice thing is to have less finger sticks.
What did staff training look like before implementing the use of CGM devices for patients with COVID-19?
We did not want to burden the nursing staff with additional training, so we actually dispatched our inpatient diabetes team to service the whole glucose remote monitoring system. We showed the nurses how to look up glucose levels and asked them to document the levels every time they looked. We also trained them to pay attention to system alarms. We felt it would be unfair to the nursing staff to give them yet another complex training at that point.
Because we have an inpatient diabetes service…[these staff members were the ones] helping out and trying to develop a more refined protocol that eventually would train nurses and translate remote glucose monitoring into general practice.
So at this point, you are relying more on the diabetes specialists to implement the use of CGM devices, but you plan on creating a training program for nurses in the future.
Right. On one end, we actually had some of the elements of our remote glucose monitoring system built even before the COVID-19 crisis. [These were used] mostly for outpatient care, but came in handy to be used in inpatient care.
We have a diabetes educator [on staff], but due to the COVID-19 crisis, the load of the patients has increased tremendously — about a quarter of patients with COVID-19 have diabetes, either newly diagnosed or preexisting — so we [collaborated with] diabetes educators who usually work in outpatient care.
I know that other hospitals use nurse practitioners to coordinate and implement programs like this. In terms of diabetes technology in-hospital services, we are now asking our head of nurse training to start…transitioning it to the nurses now that they are not overloaded with new developments, so that they can be more involved.
Have most of your patients using a CGM device already had one, or did you provide it and train them on how to use it?
We knew that a majority of patients admitted with COVID-19 would not have their own devices. Also, if patients are very sick, they may even forget to bring their own device [to the hospital]. We did not count on patients having the devices. We were very lucky that a donor and his wife [who was a prior nurse at our medical center] sponsored the purchase of the devices. We hopefully will get enough data…to show the hospital administration the worth of the program so we can continue it beyond the current cycle.
Several companies including Abbott3 and Dexcom have donated CGMs to hospitals around the United States. How would you recommend clinicians go about sourcing CGMs for use in a hospital right now, especially in low-resource settings?
We felt first and foremost that we should not be biased, so we did not want to ask a company to sponsor us. We knew up front that we would want to use Dexcom G6® sensors because of the accuracy and real-time features. We also looked at the Abbott Freestyle Libre, the Eversense® implantable sensors, and the Medtronic sensors, and felt that the best sensor for our planned hospital use was the Dexcom G6 sensor. We are happy that the company stepped up and is providing the sensors and transmitters at a reduced price [during the COVID-19 pandemic].
The original prices were quite exuberant. The reduced pricing options are really reasonable. There is still cost, but according to our economic analysis, the saving of PPE and of nurses’ time outweighs the cost of the sensor systems currently.
[Editor’s note: Dexcom has an online form for healthcare professionals to request Dexcom CGMs for in-hospital use in response to COVID-19. To access the donated Abbott CGM systems, call Abbott at 1-800-401-1183.3]
The FDA allowing CGM use for hospitalized patients resulted out of necessity. Do you think CGMs have a place in regular hospital care, even after the COVID-19 pandemic?
We were the first [health system] in Chicago to start using the sensors in the hospital. I spent time writing a protocol…laying out why this is a good idea. Even before the FDA issued the nonobjection,2 we asked our institutional review board to review whether, from a human subject perspective, it would be something that they would approve. The Rush Institutional Review Board was quick in reviewing it and it was approved. We feel like we went the correct route because we want to collect and analyze the data to eventually share and publish our experience within this COVID-19 situation…and what lessons we have learned from the inpatient glucose sensors.
Initially when we were designing our remote glucose monitoring system, there were no clear directions on how to convert a personal system to something that would be cyber-safe and actually usable in a hospital setting. Our information technology department also was extremely helpful in getting things done quickly [with] secure channels and secure receiving devices that we feel good about.
However, I still feel that work needs to be done as sensor companies are developing more user-friendly systems. The sensor insertion is not a big deal. If patients are capable of changing and inserting sensors, clearly our highly-skilled nurses are capable of doing so. In terms of how data are received and monitored, that is where the improvements in ease of use still need to come. We are still spending quite a bit of time to make the data secure and interconnected.
Do you have any forward-looking statements or recommendations for clinicians who are at the front lines of the COVID-19 pandemic and interested in implementing CGM in hospitals?
I feel that the glucose sensors in the hospital are total game changers. It is definitely an improvement in patient safety and can be an important tool in improving protocols. The secondary benefits of us using glucose sensors in the hospitals involve the department of dietetics and improving protocols [for diets].
I feel like this is the way of the future and we are now at the early forefront. COVID-19 gave us an opportunity in the chaos, but it truly has been a very good experience. Right now, we are actually thinking of how to simplify and how to make [in-hospital CGM use] mainstream. We are not thinking we should go back to the past century and past decade in terms of how we manage glucose in the hospital. We have to move forward and think forward.
In terms of the implementation, I think the important point is that subcutaneous interstitial fluid glucose technology is not suited for patients in critical care settings where patients are on vasopressors or extracorporeal oxygenation and peripheral circulation is impaired. Interestingly, as one of our nurses explained it, when the patient is very sick…[often] we do not trust capillary glucose measurements to make our dosing decisions. In the same way, when subcutaneous insulin is not appropriate, we use intravenous insulin. This is very important and is [incorporated into] our protocol, as is selecting the correct patients who would benefit the most from CGM.
We do feel in critical care settings that for patients who are admitted with diabetic ketoacidosis or severe hyperglycemia, these glucose sensors can be a very good tool, saving many finger sticks and also helping with [in-hospital] transitions.
Our protocol also includes posthospital transitions. This is where we were happy to have outpatient diabetes educators involved. We start the process of approval while the patients are still in the hospital and in this era of virtual visits, the systems help tremendously with posthospital care. Overall, after people are introduced to CGMs, the acceptability is very high, which transforms care for young patients with type 1 diabetes who frequently return back to the hospital with uncontrolled glucose levels.
This is a golden opportunity. We are learning so much in terms of what is happening with patients after hospitalization and how we can improve hospital care.
I believe we should not [focus on] how expensive it is and that we have to go back because we cannot afford it, we should actually try to think about how to make them cheaper and how to make glucose sensors less labor-intense. Based on our preliminary results…I would not want to go back our original ways of glucose monitoring in the hospital.
References
1. Shehav-Zaltzman G, Segal G, Konvalina N, Tirosh A. Remote glucose monitoring of hospitalized, quarantined patients with diabetes and COVID-19 [published online May 14, 2020]. Diabetes Care. doi:10.2337/dc20-0696
2. US Food and Drug Administration. Enforcement policy for non-invasive remote monitoring devices used to support patient monitoring during the coronavirus disease-2019 (COVID-19) public health emergency. March 2020. Accessed May 21, 2020. https://www.fda.gov/regulatory-information/search-fda-guidance-documents/enforcement-policy-non-invasive-remote-monitoring-devices-used-support-patient-monitoring-during
3. American Diabetes Association. FDA expands remote patient monitoring in hospitals for people with diabetes during COVID-19; manufacturers donate CGM supplies. April 21, 2020. Accessed May 21, 2020. https://www.diabetes.org/newsroom/press-releases/2020/fda-remote-patient-monitoring-cgm
