Poor diabetes care in hospitals has been an issue for some time, but it becomes an even more critical concern as our healthcare workers are being stretched to their breaking point dealing with COVID-19.
For many people with diabetes (PWDs), the scariest part about contracting a severe case of the novel coronavirus is the idea of landing in a crowded hospital, where no one is equipped to properly manage glucose levels to avoid dangerous highs or lows.
Even before this pandemic began, many PWDs shared stories about inadequate care during hospital stays, with medical professionals not being familiar with even basic diabetes management know-how or diabetes tech, to incredible challenges in getting glucose checks or insulin as needed.
But there may be hope on the horizon.
Two continuous glucose monitoring (CGM) companies have secured FDA approval to get their CGM devices directly into hospitals and medical centers to assist in real-time care for those exposed to COVID-19. Meanwhile, the Centers for Medicare and Medicaid Services (CMS) is also developing a new standard for glucose management in hospitalized patients.
On April 8, the FDA announced approval for both Dexcom and Abbott Diabetes Care to offer their systems to hospitals for frontline healthcare workers to better monitor patients with diabetes during inpatient care. Enthusiastic headlines announced that “CGMs Are Joining the COVID-19 Fight“!
Working with the Diabetes Disaster Response Coalition (DDRC), Abbott is donating 25,000 FreeStyle Libre 14-day sensors to hospitals and medical centers in COVID-19 hot spots across the U.S. Healthcare workers will be able to place the 14-day round sensor on a patient’s arm, and remotely monitor their glucose levels using the LibreView cloud-based software.
Dexcom is doing the same. For the first time ever, the California CGM company is shipping its G6 sensors directly to hospitals in need. Dexcom has been working with FDA for weeks to get this real-time CGM tech available for in-hospital use.
The company is producing 100,000 sensors for hospitalized COVID-19 patients, and also donating more than 10,000 handheld receivers and smartphones loaded with the mobile G6 app, the company tells us.
Both the Abbott and Dexcom systems have “dosing designations,” meaning they are considered by FDA to be accurate enough not to require a confirmatory fingerstick test in order to make diabetes treatment and insulin dosing decisions.
These CGM systems allow physicians and nurses to keep a closer eye on hospitalized patients while minimizing COVID-19 transmission risk, because — critically — they will no longer need to get physically close to a patient or come in contact with a blood sample to check glucose levels. This helps preserve scarce personal protective equipment (PPE) and limit risks to other hospital staff.
Diabetes and COVID-19 in the Hospital
A new study backed by Glytec shows that uncontrolled hyperglycemia (high blood sugar) is common among hospitalized COVID-19 patients with diabetes, and the mortality rate is seven times higher among those patients.
“It is paramount that we treat hyperglycemia in COVID-19… with subcutaneous basal-bolus insulin in most non-critically ill patients, and with IV insulin in the critically ill,” concludes lead researcher Dr. Bruce Bode, diabetes specialist at Atlanta Diabetes Associates and Adjunct Associate Professor of Medicine at Emory University School of Medicine.
The Food and Drug Administration (FDA) also just issued an
“There’s been a spike in demand for health technology as hospitals are looking for ways to minimize COVID-19 exposure, especially to high-risk patients such as people with chronic conditions like diabetes,” said Dr. Eugene E. Wright Jr., medical director for performance improvement at Charlotte Area Health Education Center in North Carolina.
Even prior to FDA approval of CGM use in hospitals, we had heard of hospital staff using the systems in creative ways during this public health emergency. One of those instances was in New York, where Dr. Shivani Agarwal at the Albert Einstein College of Medicine in the Bronx reported that nurses and doctors were admitting PWDs who were CGM users, and were taping receivers outside the hospital room door so they wouldn’t have to don PPE or risk exposure in approaching a patient for a fingerstick test.
“That could save massive amounts of time amidst the crisis,” said Dr. Aaron Neinstein, an endocrinologist in San Francisco who heard about this case in a webinar on hospital diabetes care hosted in early April by the American Diabetes Association. “The big deal on this, to be clear, is that they are using CGM for all blood glucose management in acute care hospitalized patients, not just ICU, instead of fingersticks. [This] could portend a future paradigm shift that has been in the making, but to date too slowly.”
Of course, that begs the question: Why hasn’t proper diabetes care in hospital settings been properly addressed to date?
Long before the COVID-19 pandemic, this was a pressing issue given the number of PWDs who land in the hospital for various reasons nationwide.
“There are measures galore for all types of patients… but yet here we are with thousands of patients with diabetes and there is really no eye as to what best practices should be,” says Raymie McFarland, VP of quality initiatives at Glytec Systems, which makes hospital glucose management software Glucommander. “To date, CMS doesn’t even test that on how we can best manage these patients.”
McFarland says that roughly one-third of inpatients with diabetes need special attention ranging from glucose management to insulin dosing or comorbidity issues. Yet up to 50 percent of hospitals haven’t even been monitoring glycemic control for patients.
Glytec research shows that a single hypoglycemia episode of 40 mg/dL or lower can cost a hospital up to $10,000, encompassing everything from the additional patient time in the facility to the testing and staff time needed.
While there were some guidelines recommended for surgeons (to reduce surgical infection rates) and some specialty practices, historically there has not been a broad CMS measure dictating best practices for monitoring blood sugars in hospital settings.
Thankfully, a new measure has been in the works and is on the doorstep of being approved. Developed by Yale researchers and diabetes tech industry experts, it is dubbed “HypoCare” as it primarily addresses hypoglycemia (dangerous low blood sugar).
The new measure would require hospitals to report severe hypo rates, and would tie the results to bonus pay for staff: If they don’t collect baseline data on tracking glucose management in patients, they will lose that additional money.
CMS would eventually establish a penalty for clinics, which could be up to 3 percent of their CMS-billable work. This can add up to multiple millions of dollars depending on the hospital and care system network.
Originally, CMS had aimed to tackle both low and high blood sugars, but given the complexity in gaining consensus, the agency backed off and opted to address hypos first and then later focus on hyperglycemia, McFarland explains.
Whether the new HypoCare measure still gets finalized in 2020 to take effect in 2021 is now TBD, given the COVID-19 crisis. The formal decision is likely to be pushed off until later 2021, at least.
“This is probably a good time to pause, with COVID-19 on everyone’s mind,” McFarland says. “Right now, you can’t get anyone’s attention on diabetes itself. Not unless it’s COVID-19 related or about the hospital recovering financially from what’s going on, no one is listening.”
For doctors and patients, however, glucose care in the hospital remains top of mind.
Endocrinologists across the country are working closely with hospital systems to ensure that patients with diabetes get adequate care, according to Dr. Sandra Weber, current president of the American Association of Clinical Endocrinologists (AACE) and chief of endocrinology at the Greenville Health System in South Carolina.
“Every hospital has been looking at this issue (of glucose management) for the past decade, and determining where they should be aiming. There are some pretty clear ranges of where glucose levels should be,” Weber says.
She notes that in her three-hospital system, she sees how the range of needs of individuals with diabetes can differ greatly. While some may be more engaged in their own care and know what they need, others require more hands-on guidance and action from hospital staff.
“In our hospital system, we’ve been advocates to keep patients using CGMs and pumps as long as they can. We have a protocol in place. And more broadly, AACE has been a proponent of continuing to use those devices, where it’s safe,” she says.
If a hospitalized PWD has the mental capacity to continue using their own diabetes device, Weber believes that person should be allowed to continue using it in order to complement their hospital care.
“Today is a good example,” she says about the COVID-19 crisis. “It’s not ideal to do a fingerstick for someone on an insulin drip and having that regular exposure. So if the technology is there, the research proves that it can be a beneficial tool to use in improving that impatient care.”
In Washington, D.C., longtime type 1 and diabetes advocate Anna McCollister-Slipp is one of many PWDs with heightened worry on the issue of hospital care during this pandemic. She lives with diabetes complications that put her at extra risk.
To ensure a smoother experience if she ever ends up being hospitalized, she keeps an ongoing, frequently updated list of all her health particulars:
- All her treatments — medications and dosages, when those were started, devices and data streams, and nutritional supplements. (She usually brings this to doctors’ appointments in normal times.)
- An overview of “my current health status” in bullet points. Anna says, “When I’m seeing a new doctor, I always update this, so that they have a background on my diabetes, my comorbidities/complications, etc., as well as current/recent health developments and status.”
- Recent lab values, including A1C, kidney and lipid results, etc.
In early March, she had a scare when she experienced symptoms consistent with COVID-19, so she added extra items to her list to create an emergency record of sorts:
- Name/contact info for the physicians she sees most frequently (endo, nephrologist, etc.).
- Name/contact info for friends living nearby and immediate family members.
- Name/contact info for friends “who may be in a position to ensure/would have a vested interest in helping me access to a ventilator if needed.”
- She shared the full document with friends in the district and posted it in a notes folder shared with her siblings, nieces/nephews, and mother, “so that everybody who may be consulted would have the information.”
Fortunately, McCollister-Slipp turned out not to have COVID-19, so she hasn’t had to put this plan to the test yet. But it’s a great guideline for all of us with “underlying health conditions.”
Dr. Anne Peters, professor of clinical medicine at the Keck School of Medicine at the University of Southern California and director of the USC Clinical Diabetes Program, says in a video: “There has been an issue in hospitals where patients on insulin drips can’t get hourly blood glucose readings, because the hospital staff doesn’t have enough PPEs to go in and out of someone’s room to check their glucose levels at necessary intervals.”
“Though CGM is becoming more utilized in hospitals during all of this, it’s still not mainstream. So patients must be prepared to check their own glucose levels in the hospital.”
She urges PWDs to prepare an emergency kit that they bring along to the hospital, especially since family isn’t allowed in. The kit should include testing supplies, CGM and pump necessities, and any charging cords and cables needed for those diabetes devices and mobile app components.
In these uncertain times, anything we can do to be our own advocates for better hospital care is certainly advisable.