Educators key to inpatient diabetes care: Insulin pumps, CGM, COVID-19
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Susan Weiner, MS, RDN, CDN, CDCES, FADCES, talks with dietitian and diabetes care and education specialist Rachel Stahl, MS, RD, CDN, CDCES, about inpatient diabetes management plus considerations for COVID-19.
What are some of the challenges of managing blood glucose in the hospital for patients with diabetes?
There are many challenges concomitant with acute illness, such as hyperglycemia, risk for hypoglycemia due to imbalances of food intake and insulin requirements, steroid use, enteral feedings and impaired renal function. Fluctuations in nutritional status may contribute to suboptimal glycemic management secondary to meal interruptions, changes in appetite or intake, available food choices and malnutrition. The COVID-19 pandemic has introduced an unprecedented challenge. People with diabetes and COVID-19 experience increases in insulin resistance and severe hyperglycemia and have increased risks for serious outcomes, including diabetic ketoacidosis, longer length of stay and mortality.
What are some initiatives your organization has taken to focus on reducing episodes of hypoglycemia and hyperglycemia in the inpatient setting?
NewYork-Presbyterian/Weill Cornell Medical Center has a robust inpatient glycemic management team that plays an integral role in developing policies and protocols and providing education and training to staff and patients. We recently transitioned our electronic health record from Allscripts to Epic, and the team played an essential role in creating new insulin order sets and job aids to help health care professionals with the transition. Moreover, our involvement in quality improvement and research has helped us to implement best practices to reduce episodes of hypoglycemia and hyperglycemia and increase time in range. For example, one quality improvement project, published in the Journal of Diabetes Science and Technology, was aimed to identify the root causes of hypoglycemia.
Jane Jeffrie Seley, DNP, MPH, CDCES, BC-ADM, a nurse practitioner specializing in diabetes, formed the Diabetes Champion Committee in 2004, which I have co-chaired for the past few years. The mission of this committee is to provide knowledge and skills training for health care professionals who strive to develop clinical expertise, leadership and passion to improve diabetes care processes for patients with diabetes. In addition to monthly meetings, the group has also held daylong programs and other educational initiatives throughout the year to educate our staff, trainees, patients and the community about diabetes care and education.
What is the role of diabetes care and education specialists in inpatient diabetes management?
Diabetes care and education specialists are valuable assets to the inpatient interdisciplinary team. They play several roles:
- educating patients on diabetes self-management survival skills, including understanding diabetes diagnosis, glucose monitoring, diabetes medications, hypoglycemia and hyperglycemia prevention and management, and meal planning;
- participating in writing policies, protocols and order sets;
- providing staff training and education on glycemic management strategies;
- reviewing hospital-wide insulin error reports and making recommendations to improve patient safety;
- developing and providing access to diabetes self-management tools, such as patient education materials, insulin practice pens and glucose monitoring devices;
- participating in quality improvement projects to optimize glycemic management; and
- developing a safe and effective diabetes discharge regimen in collaboration with the primary team, care management and social work.
What are some of the important considerations when a patient is wearing their own insulin pump or continuous glucose monitor in the hospital? In what situations should they be worn or removed?
Patients wearing their own insulin pumps and/or CGMs are seen with increasing frequency in the inpatient setting, requiring health care institutions to create policies to maximize patient safety. In our institution, when a patient comes in wearing an insulin pump and/or CGM, teams are required to order an endocrine consult. The inpatient glycemic management team assesses and verifies the appropriateness of the insulin pump and/or CGM at that time. The team will then determine whether the patient will continue wearing the devices or recommend discontinuation and consider alternatives for insulin therapy and glucose monitoring.
A consult with a diabetes care and education specialist should be initiated to evaluate the patient’s knowledge of insulin pump management and CGM and provide education and support if necessary. A nutrition consult is also recommended to determine the patient’s proficiency in carbohydrate counting.
Contraindications for use of a patient’s own pump and/or CGM include those who are cognitively impaired or too sick to self-manage. Patients with acute behavioral health issues, such as depression or suicidal ideation, may not be a candidate to wear their device at this time. It is mandatory to disconnect all pumps and CGMs for diathermy treatment and MRI procedures, but not all pumps and CGMs for CT scans and X-rays — this is based on manufacturer recommendations.
What type of meal plan is prescribed for inpatients with diabetes?
The carbohydrate-controlled meal plan is the established standard for hospitalized patients with diabetes. This type of meal plan provides a way to easily match the prandial insulin dose to a specific amount of carbohydrate. At our institution, the carbohydrate-controlled meal plans have three levels to encompass different calorie and carbohydrate gram needs. For example, the carbohydrate-controlled 45 g carbohydrate per meal diet contains about 1,400 calories, and the carbohydrate-controlled 60 g carbohydrate per meal diet contains about 1,800 calories. The menus identify which foods contain carbohydrate and include the number of grams to help patients plan their meals. We encourage carbohydrates from multiple food sources, including vegetables, fruit, whole grains, legumes and low-fat dairy products.
Patients wearing insulin pumps who are competent in advanced carbohydrate counting may prefer a “regular” meal plan so they can choose from a wider variety of foods and calculate their prandial insulin dose using their insulin-to-carbohydrate ratio.
Inadequate oral intake is common in hospitalized patients. To improve oral intake and enhance patient satisfaction, liberalized diets may be provided. Patients may also be encouraged to drink oral supplements to help optimize nutritional intake, such as a Glucerna shake (220 kcal, 26 g carbohydrate and 3 g fiber per serving).
A hot topic in the inpatient setting is the potential use of CGM. Can you discuss some of the evidence to support its use? What are some challenges and safety concerns?
There was tremendous interest in utilizing CGM in the hospital during the recent COVID-19 pandemic surge. The FDA has temporarily exercised enforcement discretion for inpatient use of CGM devices during the pandemic.
Strengths of CGM use in the hospital are the potential to improve clinical outcomes by helping to identify hypoglycemic and hyperglycemic events, allowing for earlier intervention than would be possible with blood glucose monitoring. In fact, a study published in Diabetes Care using the FreeStyle Libre system (Abbott) for hospitalized adult patients with type 2 diabetes admitted to medicine and surgery units showed higher detection of hypoglycemic events, particularly nocturnal and prolonged hypoglycemia, compared with point-of-care monitoring. It is important to note that the CGM accuracy was lower in the hypoglycemic range.
Challenges of using CGM in the hospital include the need for advanced training for health care professionals to learn how to use the device and respond to trends and glucose readings.
In addition, there are safety concerns regarding accuracy of glucose readings of CGM devices in the setting of acute and, particularly, critical illness. Patients who are critically ill may be dehydrated, are often on vasopressors and have hemodynamic instability that may affect their CGM glucose value, which is measured in interstitial fluid and may have a lag time.
Best practices are being explored for transferring CGM data from the device to the EHR and utilizing the data to make treatment decisions. Further research is needed to examine clinical outcomes, accuracy, cost-effectiveness and staffing needs with these devices in the hospital, both in the ICU and non-ICU settings.
Acknowledgment: Stahl would like to thank Jane Jeffrie Seley, DNP, MPH, CDCES, BC-ADM, for her thorough review that greatly improved the article.
For more information:
Rachel Stahl, MS, RD, CDN, CDCES, is a registered dietitian and diabetes care and education specialist in the division of endocrinology, diabetes and metabolism at NewYork-Presbyterian Hospital and Weill Cornell Medicine. She specializes in medical nutrition therapy for conditions such as prediabetes, diabetes, cardiovascular disease, obesity and gastrointestinal disorders. She can be reached at esr9014@nyp.org.
Susan Weiner, MS, RDN, CDN, CDCES, FADCES, is co-author of The Complete Diabetes Organizer and Diabetes: 365 Tips for Living Well. She is the owner of Susan Weiner Nutrition PLLC and is the Endocrine Today Diabetes in Real Life column editor. She can be reached at susan@susanweinernutrition.com; Twitter: @susangweiner.
References:
- Galindo RJ, et al. Diabetes Care. 2020;doi:10.2337/dc19-2073
- Sinha Gregory N, et al. J Diabetes Sci Technol. 2018;doi:10.1177/1932296817744808.
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