Guidance: Adapt inpatient insulin, glucose monitoring protocols during COVID-19 pandemic
Clinicians must adapt protocols for optimal inpatient glycemic management during the COVID-19 pandemic as part of an effort to incorporate new therapies, limit direct patient contact and minimize infection risk, researchers wrote.
Current recommendations for inpatient glycemic management for people with diabetes include frequent monitoring of bedside blood glucose with a structured insulin regimen of long-acting and short- or rapid-acting insulin preparations to achieve a glycemic target between 140 mg/dL and 180 mg/dL for critically ill patients. During the COVID-19 pandemic, the ability to safely achieve that goal is “problematic” when limited patient contact is recommended, Mary T. Korytkowski, MD, professor of medicine and director of quality improvement in the department of endocrinology at the University of Pittsburgh School of Medicine, and colleagues wrote in guidance published in The Journal of Clinical Endocrinology & Metabolism.
“Blood glucose control is an important component of the complex care required by these patients that can be associated with improved clinical outcomes,” Korytkowski told Healio. “It is important to coordinate patient care in a way that minimizes the number of exposures of health care personnel to patients with COVID-19 infections. For patients with diabetes, this can be accomplished by organizing tasks that include glucose monitoring, clinical assessment, insulin and medication administration, and meal delivery into one encounter.”
In the guidance, the researchers recommended that hospitals not make major changes to current approaches to managing patients with COVID-19 and hyperglycemia, as this could increase bedside contact with patients.
“However, there are important and emerging issues that directly affect established glycemic management that warrant discussion and consideration during this pandemic,” the researchers wrote.
Insulin regimen considerations
Before the COVID-19 pandemic, IV insulin infusions were recommended for glycemic management for most patients with diabetes and critical illness, the researchers wrote. Due to the need for intensive nursing intervention and blood glucose monitoring every 1 to 2 hours, some institutions have successfully implemented protocols for scheduled subcutaneous insulin therapy; others have adapted nontraditional insulin strategies, such as more frequently dosed intermediate-acting insulin preparations, to accommodate higher insulin requirements for people with COVID-19, the researchers wrote.
“To minimize nursing time at the bedside with IV insulin infusion protocols, some hospitals have decreased the frequency of glycemic measures to every 4 to 6 hours when infusion rates are stable,” the researchers wrote. “With recent allowances by the FDA for use of continuous glucose monitoring devices during the period of the COVID-19 pandemic, some hospitals are using these for remote tracking of glycemic data.”
Insulin therapy remains the standard of care for management of hyperglycemia in individuals with diabetes hospitalized with COVID-19. For select patients with type 2 diabetes who are eating regular meals and a discharge home is anticipated, the use of the DPP-IV inhibitors can be considered, the researchers wrote.
“The pandemic brought renewed attention to the importance of blood glucose management,” Kellie Antinori-Lent, MSN, RN, ACNS-BC, BC-ADM, CDCES, FADCES, a diabetes clinical nurse specialist at the University of Pittsburgh Medical Center Shadyside Hospital and 2020 ADCES president, told Healio. “Regarding medical treatment, insulin remains the best treatment for patients with diabetes and COVID-19, although select DPP-IV may be an option for some patients with type 2 diabetes. SGLT2 inhibitors should not be used in the inpatient setting and some are recommending discontinuing in the outpatient setting for any patient diagnosed with COVID-19.”
The researchers noted that some medications used in treating COVID-19, such as glucocorticoids and hydroxychloroquine, can affect blood glucose levels.
Inpatient CGM use
No CGM devices are currently approved for inpatient use; however, the FDA in April announced it would not object to in-hospital use of CGM to assist with monitoring of COVID-19 patients, following guidance issued in March that approved noninvasive remote monitoring devices for use in the hospital setting.
“The FDA has acknowledged that during this crisis, the use of CGM in the hospital is reasonable, a temporary allowance was provided, and there are now data supporting this in the non-ICU situation,” Irl B. Hirsch, MD, professor of medicine at the University of Washington School of Medicine in Seattle, told Healio. “Patients already using CGM, if not critically ill, can assist nursing with glucose reporting and therefore not using personal protective equipment for monitoring. Alternatively, use of Dexcom G6 can remotely transmit the data to a health care provider not in the hospital room. Still, it is important to note that even with this temporary FDA allowance, using CGM a fingerstick point-of-care is still recommended for insulin dose decision making.”
The researchers noted that manufacturers of the two CGM devices with temporary FDA allowances — Abbott and Dexcom — recommend against using sensor data for making treatment decisions related to insulin therapy. Additionally, staff education and technical support are required before any wide implementation of CGM in the hospital setting.
“A point-of-care blood glucose is recommended for decision-making purposes for insulin dosing,” the researchers wrote. “Until there are studies validating their safety and efficacy in acute care setting, these CGM devices should be viewed as a supplement to and not a replacement for point-of-care blood glucose monitoring.”
Inpatient CGM could be useful for monitoring trends in glycemic data for some patients with alerts for hypoglycemia and hyperglycemia, the researchers wrote, adding that on-site and remote glucose management teams could provide guidance in inpatient glycemic management where there are personnel shortages.
Transition from hospital to home
Individuals with diabetes who were previously comfortable with home management may be discharged with a care regimen that is different from what they followed before hospital admission, the researchers wrote. Diabetes education and training should be a key component in any discharge planning during the COVID-19 pandemic and can be managed via telehealth.
“All self-management education should begin well before the day of discharge,” the researchers wrote. “Patients new to insulin should have the opportunity to practice self-administration using devices they will use at home. Patients need to know how and when to take their diabetes medications, monitor point-of-care blood glucose levels, adjust therapy for low or high blood glucose values, and who to contact in the event of glycemic emergencies.”
Hirsch said the authors hope guidance on inpatient diabetes management will help clinicians prepare in the event of a second spike in COVID-19 infections.
“Right now, in early June 2020, we appear to be over the worst of COVID-19; however, there are still hundreds of people dying each day, and many hospitals are not expert in insulin management,” Hirsch said. “It is our hope this manuscript is used by health care providers as guide on how to think about diabetes during this pandemic, and if there are further spikes in the coming months, we will be prepared for managing the hyperglycemia in the hospital.”
For more information:
Kellie Antinori-Lent, MSN, RN, ACNS-BC, BC-ADM, CDCES, FADCES, can be reached at firstname.lastname@example.org. Irl B. Hirsch, MD, can be reached at email@example.com. Mary T. Korytkowski, MD, can be reached at firstname.lastname@example.org; Twitter: @PittEndo.