During the COVID-19 pandemic, appropriate implementation of continuous glucose monitoring (CGM) in the hospital has the potential to significantly decrease the burden of glucose monitoring and could possibly improve patient outcomes.


 

Appropriate glycemic control can improve patient-centered outcomes by reducing hospital complications and length of stay. During the COVID-19 pandemic, it has become increasingly important to preserve personal protective equipment (PPE) supplies and minimize exposure risk to healthcare workers (HCWs). Continuous glucose monitoring (CGM) is one technology being implemented during the ongoing transformation of care during the COVID-19 pandemic.

“In the hospital, point-of-care (POC) glucose testing is used because of its reliability,” explains Francisco J. Pasquel, MD, MPH. “In the outpatient setting, CGM is revolutionizing diabetes care. Recent data suggest newer CGM devices are also reliable in the hospital setting, but our experience assessing clinical outcomes has been limited. The fact that some devices do not require frequent calibration and allow for remote monitoring are game-changers in glycemic control, meaning CGM may be ideal for a situation like COVID-19. For this reason, the FDA did not object to the use of CGM in the hospital during this public health crisis.”

 

Who Can Benefit?

For an article in the Journal of Diabetes Science and Technology, Dr. Pasquel and colleagues addressed key questions about what is needed to make CGM reliable, safe, and effective for use in the hospital during the pandemic. A key step to optimizing CGM use in hospitals is to identify patients who are most likely to benefit from it. “CGM would be most useful in patients with unpredictable glucose levels, including those with type 1 diabetes and those with type 2 diabetes on multiple-dose insulin injections,” says Dr. Pasquel (Table). “CGM would also be useful in patients taking steroids, for those on medical nutrition therapy, and in the critically ill.”

According to Dr. Pasquel, CGM can be effectively implemented on regular hospital floors, but the ICU is where it would be most helpful during COVID-19. “Keeping glucose levels in a narrow range (ie, 140-180 mg/dl) is difficult with subcutaneous insulin,” he says. “As such, continuous insulin infusion therapy is usually recommended for ICU patients because it is effective and safe, particularly when using computerized algorithms. However, hourly POC glucose monitoring is extremely impractical during COVID-19.”

 

Addressing Concerns

Despite its promise, Dr. Pasquel notes there are concerns about using CGM in some patient groups. “For example,” he says, “the accuracy of CGM in critically ill patients may be questionable, even though this is the setting where CGM would be the most helpful during the pandemic. Continued efforts to learn how to optimize glycemic control with CGM are needed to improve patient outcomes while simultaneously preserving PPE and reducing potential exposures to HCWs.” 

A hybrid model utilizing both POC testing and CGM may be indicated in certain situations. Dr. Pasquel recommends comparing CGM accuracy with POC glucose measurements. “Although CGM has become reliable, additional testing with POC capillary blood glucose is recommended when there is concern for discrepancies between sensor glucose measurements and patient symptoms or their clinical condition,” says Dr. Pasquel. “We also recommend POC testing during rapid glucose changes (>2 mg/dL/min) or outside a predetermined range (ie, glucose levels <85 or >300 mg/dL).”

 

Implementation Needs

Effective implementation of remote glucose monitoring with CGM in the inpatient setting during COVID-19 requires involvement and support from multiple stakeholders, including patients, doctors, nursing staff, hospital administration, information technology specialists, and suppliers. “Engaging all parties early in the conversation can facilitate this process,” says Dr. Pasquel. “Following a quality improvement framework may help identify barriers and potential solutions to implementation.”

Dr. Pasquel and colleagues are collaborating with researchers at Ohio State University and other academic medical centers to learn more about their experiences using CGM in the ICU during COVID-19 to hopefully establish best practices for this approach. “Similar to the #beyondA1c movement in the outpatient setting, we should think about moving beyond POC glucose monitoring in the inpatient setting and look more closely at CGM,” Dr. Pasquel says. He notes that additional resources on implementation of CGM in the hospital setting and recently published studies on CGM in the hospital can be found at covidindiabetes.org

References

Galindo R, 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. J Diabetes Sci Technol. 2020 Jun 14;1932296820932903. Available at: https://journals.sagepub.com/doi/full/10.1177/1932296820932903.

Pasquel FJ, Fayfman M, Umpierrez GE. Debate on insulin vs non-insulin use in the hospital setting-is it time to revise the guidelines for the management of inpatient diabetes? Curr Diab Rep. 2019;19(9):65.

Pasquel FJ, Umpierrez GE. Individualizing inpatient diabetes management during the COVID-19 pandemic. J Diabetes Sci Technol. 2020 May 5 [Epub ahead of print].

Davis GM, Galindo RJ, Migdal AL, Umpierrez GE. Diabetes technology in the inpatient setting for management of hyperglycemia. Endocrinol Metab Clin North Am. 2020;49(1):79-93.