Patients' blood glucose (BG) levels in many American hospitals run dangerously high, but hospitals aren’t doing nearly enough to address the problem.
Between 70% and 80% of patients with diabetes experience hyperglycemia when they’re hospitalized for critical illnesses or have cardiac surgery. And about 30% of all inpatients experience high blood sugars (>180 mg/dL). Even if you stay in the hospital for just a few days, rising glucose levels increase the mortality risk and the risk of eventual kidney failure, poor healing, dehydration and other problems.
Meanwhile about 6% of hospital inpatients experience potentially dangerous hypoglycemia (low blood sugar) as well!
It doesn’t have to be this way. In this day and age of continuous glucose monitoring (CGM) and closed loop technology, hospital diabetes management has the potential for a seismic shift -- if they choose to adopt these newer innovations.
For example, recently on Oct. 18, the FDA approved a first-of-its-kind CGM for surgical ICUs that can monitor glucose levels and alert physicians and hospital staff of any highs or lows. It's a sign of the times, as this type of tech to monitor glucose and dose insulin promises to improve patient health, reduce hospital readmissions and cut health care costs.
Yet only about 10% of Americans hospitals now use these “e-Glycemic solutions,” says Linda Beneze, CEO of Monarch Medical Technologies, which provides high-tech glucose management systems to hospitals.
Why are most American hospitals stuck in the insulin dosing equivalent of the horse-and-buggy era? Before exploring that, let’s look at the innovations they’ve been unwilling to incorporate.
'Horse and Buggy' Diabetes Tech?
The vast majority of hospitals still follow an old-fashioned, time-consuming, error-prone approach to regulating blood glucose: after checking patients’ BGs, caregivers manually fill out complicated forms every time they calculate the next insulin dosage, then submit the paperwork for a doctor’s approval before treatment is delivered.
In contrast, software developed by Monarch and its competitors -- including Glytec Systems and Medical Decision Network -- uses algorithms to determine patients’ insulin dosages, based on BG readings and other information provided by caregivers and electronic medical records. After data is entered into the systems, they provide recommended dosages in a minute or less, as opposed to the six-to-eight minutes it can take to get answers using paper protocols.
Clearly, all of them have the ability to manage blood glucose more intensively and with more precision than the procedures now used in most hospitals. All of the companies can cite studies that show the overwhelming majority of patients achieve more stable blood sugar levels with extremely low rates of hypoglycemia using their systems.
The Monarch Medical and EndoTool Story
Monarch’s flagship product is named EndoTool, for patients on IVs in critical care settings or health facilities. It also has another version that uses the same platform for people getting insulin subcutaneously by injections or pumps.
Beneze and Monarch’s founder, Dr. Pat Burgess, say that when compared to competitors’ systems, their software takes into account more metabolic factors that affect glucose levels, including kidney function, steroids, and “insulin on board” – the insulin still active in your body from previous bolus doses.
The software uses BG readings from traditional glucose meters used in the hospital settings, whether the data's entered manually or beamed by Bluetooth into the electronic health records. From there, the system comes up with insulin dosages “based on each patient’s individual physiological responses,” Burgess says, echoing claims by competitors. Once the system calculates a new dosage, the caregiver is able to view it on an EndoTool dashboard on their laptop or tablet, along with the patient’s BG and dosing history. The system also has alarms, reminders and other information that helps to prevent insulin dosing errors, which are one of the major patient safety issues in hospitals.
While this is great for PWDs (people with diabetes), the technology also helps those without diabetes whose glucose levels can rise due to infections, stress and other reasons. In fact, Burgess, a kidney specialist and computer modeling expert, came up with some of the key algorithms after a surgeon asked him to help prevent elevated glucose in non-diabetic post-surgical patients.
That was way back in 2003 when the company was formed. The FDA cleared EndoTool in 2006 and it was first installed in a hospital that same year. After a few incarnations, the company became Monarch Medical five years ago based in Charlotte, NC. It’s taken a while but more and more leading-edge hospitals, although clearly not enough, are recognizing the value of automated insulin dosing. Monarch’s EndoTool is now in about 200 hospitals.
Better late than never.
A Competitive Ladscape?
Similarly, Monarch’s main competitor, Glytec Systems (Disclaimer: 'Mine Editor Amy Tenderich serves a board member), has been around since 2006 but has doubled its client base to 200+ hospitals in the last year and a half. The Waltham, MA-based company has a system called Glucommander, which includes a suite of products that determine insulin doses not only for inpatients but also outpatients. This year, the FDA approved its software for patients getting enteral nutrition (directly into the stomach, sometimes via tubes), incorporating insulin-to-carb ratios for outpatients and other improvements.
Once more, several companies are already developing AP and other more automated tech for hospitals. But if hospitals are going to embrace it, they'll have to overcome their reluctance to change.
The Sliding Scale Persists
One troubling aspect of this reluctance is that hospitals won’t use technology that would enable them to ditch an outmoded approach to insulin dosing: sliding scale insulin (SSI) therapy. Endocrinologists have discouraged the use of SSI in hospitals for more than a decade, but it’s still pervasive.
It involves giving fingerstick tests before meals and perhaps at bedtime, then plugging in predetermined bolus insulin doses that caretakers get from charts. It is a “reactive” approach to high blood sugars and “usually does not treat sufficiently or aggressively enough to maintain glucose levels in a normal range, “ according to the American Family Physician.
The American Diabetes Association discourages SSI and recommends that, like most of us at home, hospitalized PWDs should get a combination of basal and bolus insulin with corrective doses as needed. Automated insulin dosing technology can handle that easily, at least for patients not on IVs.
So why haven’t more hospitals embraced this technology and kicked the SSI habit?
Introducing new technology into hospitals is notoriously hard to do (which is why some still use, amazingly, fax machines). At a time of financial uncertainty for the entire health care industry, hard choices need to be made about how to spend money and there are a host of competing priorities.
So it takes a lot of boldness for hospital boards and CEOs to risk investing in new BG management systems.
There are more than a few organizational and technical challenges to incorporating these systems into hospitals, says Dr. Thomas Garthwaite, VP of Diabetes Care for HCA Healthcare, a hospital chain that has signed a deal with Monarch.
Puzzles that need to be solved include: how to change each individuals hospital’s workflow, how to make the programs work in different systems of medical records, how to convince the doctors and nurses that this is in their interests and then integrate training into busy schedules.
HCA is starting slowly on those fronts, Garthwaite points out.
In a pilot program, Monarch’s latest version of EndoTool is now being used in five HCA hospitals and an older version is in a few more. Still, Garthwaite eventually hopes to bring the technology to many more of HCA’s 174 hospitals.
Glytec, for its part, has made a deal with another large hospital chain that will soon be announced.
So it’s doable. It’s scaleable. But too many American hospitals are still resisting. That’s partly because of a mentality that is quite disturbing.
Taking Glucose Management Seriously
“Our biggest challenge,” says Glytec Chief Medical Officer Andrew Rhinehart, “is convincing doctors that glucose management really matters during a four-day hospital stay.”
Most inpatients with diabetes are hospitalized because of other problems, so their care is supervised by cardiologists, nephrologists, and all kinds of surgeons and other specialists who “aren’t focused on glucose,” Rhinehart points out. Nurses are, but many clinicians opt to “just give insulin to correct highs for a few days, let the glucose go up and down, and that’s it… Our biggest competitor isn’t other companies. It’s the status quo.”
Look, Hospital Leaders: We know your jobs are hard. But so is diabetes. Automated insulin dosing and saying “goodbye SSI” will be better for your patients and will save you money. Let’s get with the program(s) here, and convince your doctors to take advantage of this technology!
Thanks for your report, Dan. We hope it helps hospitals improve their diabetes care overall.