‘We knew we needed to get creative’: Inside Mount Sinai’s effort to make glucose management safer during COVID-19
The risk for severe COVID-19 complications is significantly higher for people with diabetes, and glucose management may play a vital role in disease outcomes. At the same time, careful monitoring of inpatient glucose can prove unsafe for clinicians and nurses, who must repeatedly put themselves at risk to perform routine fingersticks for glucose monitoring.
Healio spoke with Carol Levy, MD, clinical director of the Mount Sinai Diabetes Center, about a new initiative to utilize continuous glucose monitors for critically ill hospitalized patients with COVID-19 to reduce patient-provider contact, conserve personal protective equipment and reduce risks for virus transmission. Currently, CGMs are not FDA-approved for inpatient use.
What led you and your colleagues to spearhead this initiative?
Levy: What became very clear as we were hit with this epidemic in New York City was that we needed to come up with appropriate ways to help manage our inpatients and outpatients with diabetes affected by COVID-19. With the challenges that have also occurred with limited ICU capacities as well as limited personal protective equipment — which has improved over time — we knew that we needed to get creative very quickly. Numbers of admitted patients who were very sick escalated quickly. We deployed several different initiatives in a rapid-fire fashion for inpatient diabetes management.
What has also become clear over time is that there seems to be a higher incidence of hyperglycemia and ketoacidosis in patients with diabetes affected by COVID-19. In normal times, most of these patients would all go to the intensive care unit or to stepdown care and managed with insulin drips. We determined that we needed to create additional flexibility for protocols, as well as flexibility for nursing interventions. These protocols are needed for the safety for the patients, while also focusing on the safety of our nurses, physicians and patient care team, while maximizing optimal care.
What diabetes management procedures needed to change in the wake of COVID-19?
Levy: We needed insulin management protocols that did not require IV insulin for management of ketoacidosis and severe hyperglycemia. We needed to become more cautious with fluid management, since patients with COVID-19 sometimes develop greater fluid retention. Additionally, we also became more creative with how we could use alternative mechanisms for fingerstick testing and glucose management. Some of this is off label, and we are not the only institution thinking in this fashion, but we were one of the first. How could we deploy CGM, as well as potentially having patients who are not critically ill help with fingerstick testing?
We made some of the first phone calls on this during a weekend in the middle of March, and we were fortunate to receive very robust responses. Everyone wants to help right now. The diabetes organizations, such as JDRF, Helmsley Trust and the American Diabetes Association, as well as industry, have provided great support for us to help us manage our patients.
What are the advantages with using inpatient CGM, and what are the concerns?
Levy: The advantages of CGM are less fingerstick testing, and physicians can either conduct remote monitoring or simply walk outside the room and look at a glucose receiver and view the glucose results. For some sensors, like Dexcom, you can literally walk by the receiver and see exactly what is going on. For patients who are healthier, they can share their data.
The challenge, however, is that we do not have formalized data yet on use of these devices in the inpatient setting. They have not been formally deployed or tested. We are doing this under unusual pandemic circumstances. At the same time, that has created more flexibility from everyone’s perspective. Instead of saying, “Why?” we are saying, “Why not?” We are evaluating new treatments without proven efficacy in all different fashions. We are trying new treatments for COVID-19. We are considering new treatments for diabetes to ensure we are taking care of our patients in ways that are the safest and most creative to try to improve outcomes.
How is this working at Mount Sinai?
Levy: The nurses have adopted this and embraced this. Our doctors have adopted and embraced this. This is great for us from a clinician’s perspective, because we have easily available glucose data. We needed to train the nurses very quickly in how to use CGM, because they have not utilized these treatment options before. We don’t have the luxury right now of conducting in-service trainings on all the floors — in New York City, we don’t even have the luxury of conducting Zoom sessions, because people are too busy right now — so this has been challenging. Instead, we created detailed slide decks, along with telephone availability from all members of our team. We are available 24/7 to answer any questions. Many of our endocrinologists have been deployed to work on COVID-19 floors, and those of us who are not patient facing are on the floors, helping where needed. Those of us not COVID-deployed are available to support remotely, either talking staff through training, video training, you name it. We are getting as creative as we can.
What do you hope happens with these protocols once things calm down?
Levy: I hope there is going to be continued interest in terms of inpatient CGM deployment. There will be new diabetes management options considered for the inpatient setting — patients on closed-loop insulin delivery systems that are FDA approved may be managed this way. In the past, you would hear, “No, we don’t want these used in the inpatient setting.” After all of this, ideally, we may be more open to utilizing more of this technology in the inpatient setting. That is my hope.
For better or for worse, New Yorkers have had to take the lead in this COVID-19 pandemic. My hope is that others across the country will be able to gain from our initial experiences. This situation is evolving day to day, and we have found that what we created on day 1 was already revised by day 3. We have shared some of our glucose management protocols with other sites. The purpose of that is not because we invented the “perfect” protocol. Rather, we have a protocol that others can use and adapt. See if what we have put in place works for your hospital. We are seeing better outcomes, because good glucose control matters. – by Regina Schaffer
Disclosures: Levy reports she has received research support from Abbott Diabetes, Dexcom, Insulet, Tandem, the Helmsley Foundation, JDRF and the NIH.