Abstract
Background: COVID 19 disproportionately impacts individuals with diabetes leading to increased morbidity and mortality. Hyperglycemia is common in hospitalized patients with COVID requiring intensive monitoring and management. Close monitoring of glucoses requires increased use of personal protective equipment (PPE), which has been in limited supply since the beginning of the pandemic. The FDA granted conditional allowance for use of continuous glucose monitors (CGM) in hospital settings during the COVID pandemic to allow for preservation of PPE. We present the process of implementing a continuous glucose monitoring program in an urban safety net hospital.
Methods: The program was implemented at a county urban safety net hospital. Patients were eligible to be started on Dexcom G6 CGM if they had hyperglycemia requiring multiple insulin injections daily, were in contact isolation, and were located in 1 of 3 units of the hospital (medical intensive care unit [MICU], surgical intensive care unit, COVID 19 floor unit). Initial program was started in the MICU and subsequently expanded. Nurses and staff underwent training using videos, in-person demonstrations, and written guides. Informational Technology modified the electronic medical system to allow for ordering and documentation of CGM values by nurses. Supplies were stored both on unit and in central supply allowing for primary team to initiate monitoring independent of diabetes team. Records of patients participating in program were maintained by the diabetes team. Amount of PPE saved was estimated to be 10 instances/day while on insulin drip and 3/day when using subcutaneous insulin.
Results: A total of 69 patients used a CGM during their hospital course. Average age was 56 years old, 69 % were male, average BMI 31, and 84% had known diabetes prior to admission. The majority of patients were critically ill with 68% intubated, 48% on vasopressors, 6% requiring dialysis, 38% on insulin drip, 46% were on tube feeds, and 74% received steroids. The racial demographics of the patients were 72% White, 3% Black, 4% Native American, 4% Asian, and 14% other. For ethnicity, 73% identified as Hispanic and half spoke Spanish as their primary language. An estimated 2600 instances of PPE were saved. Challenges that were faced in implementing the program included consistent training of large numbers of staff, maintaining supplies in stock, troubleshooting discordant values, and restricting use of CGM to patients who met qualifications.
Conclusion: Overall, the implementation of CGM was successful and received a positive response. Staff in the primary units quickly became comfortable with the application of the technology. Potential challenges in the future include ongoing training, improving troubleshooting of technology, validating the accuracy of the devices, and developing funding for CGM equipment and interpretation.
Extending the ABCDE Bundle to the Post-Intensive Care Unit Setting
