COMMENTARY

CGM in Hospitals as Standard of Care: What Have We Learned?

Athena Philis-Tsimikas, MD; Mark Harmel, MPH

Disclosures

July 22, 2021

This transcript has been edited for clarity.

As an adult endocrinologist, I've used continuous glucose monitoring, or CGM, many times in my patients to manage and get better control of their diabetes and glucose values. Over the past 4 or 5 years, I've been thinking about how we can do this better in a hospital environment where one third of all patients coming in have abnormal glucose levels. I wondered if we could take and translate CGM from the ambulatory environment into the hospital environment.

We created a randomized controlled trial that began to test this. We assigned half of the patients to wearing a CGM where we could see the results, and the other half to wearing that CGM but blinded, so that at the end we could capture and look at what the results were when we could manage using those [CGM] results vs not using them.

We were able to publish a small portion of those results in September of last year. When COVID came around, we thought it might be important for people to understand a little bit better what might happen if you have access to CGM. We found that we could control those hyperglycemia ranges better and lower them. The number of people with time in range between 80 and 250 mg/dL was improved in the group that had access to the CGM, who we could then manage based on those values.

CGM in Hospital as Standard of Care

When the FDA came out with the comment that they would not object to the use of CGM in the hospital, it allowed us the opportunity to try using it as standard of care. We actually withdrew the randomized controlled trial that we were doing and instead instituted standard of care, where patients coming in to the hospital could be placed on a CGM. Teams that we had in place would manage and follow them based on the results.

This was an opportunity because, for patients with COVID-19, the nursing staff who did not want to go into the rooms as often to get their point of care or who didn't want to use as much PPE every time they went into a room could now monitor those values from the nursing station instead of having to go into the room.

We've done this now with more than 400 patients at the hospital and have learned a few really interesting things. One is that you still need a team to go in and place these devices. Our nursing staff, our hospitalists, and our intensivists are not that familiar with how these devices work or even how to place them. Our teams had to train the bedside nurses to go in and simply place the device on patients with COVID-19.

Once the device was placed, we then had nursing staff that could follow remotely, in addition to the bedside nurse, and be able to advise them if the blood sugars were running too high or too low and needed an adjustment with those insulin order sets.

Additionally, we added another layer. We had a component of 24/7 monitoring from a group that would monitor only for hypoglycemia. Patients in the hospital are at risk for hypoglycemic episodes. Now, when their values were trending below 80 mg/dL, we could reach out, call the nursing staff, and ask them to administer glucose or carbohydrates before they reached that critical point below 70 mg/dL or below 54 mg/dL.

It's been interesting because others have also looked at this. Elias Spanakis did this, but he did it in patients who were at high risk for hypoglycemia. He was able to identify these patients and place CGM on them. He also found that you could reduce the incidence of hypoglycemia in these patients.

How Do We Bring It All Together?

Interestingly, we now have the ability to have automated insulin order sets, which are in place in our electronic health record. We have virtual glucose management services that have been looked at by Dr Rushakoff at UCSF. We have also done this now and found that the ability to give virtual recommendations can work very well, especially in this COVID-19 environment. We're also looking at whether we could add a hybrid closed-loop pump for specific patients who might need it as well.

Finally, as Dr Klonoff has recently mentioned, when you look at glucose and consider this in the environment of the hospital and what we manage as other vital signs — we manage heart rate, blood pressure, temperature, oxygen levels — isn't glucose yet another one of the vital signs? As we recently titled our paper, "Glucose as the Fifth Vital Sign," it really should be one of those measurements that we assess on a routine basis in the hospital to allow us to take better care of our patients with diabetes.

Athena Philis-Tsimikas, MD, is the corporate vice president of the Scripps Whittier Diabetes Institute at Scripps Health and director of community engagement at Scripps Research Translational Institute. She has led the development of alternative, team-based care management programs for diverse patient populations and evaluation of digital approaches to care and self-management education.

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