Real-Time Continuous Glucose Monitoring in the Hospital: A Real-World Experience.

BACKGROUND: Glycemic control in the hospital setting is imperative for improving outcomes among patients with diabetes. Bedside point-of-care (POC) glucose monitoring has remained the gold standard for decades, while only providing momentary glimpses into a patient's glycemic control. Continuous glucose monitoring (CGM) has been shown to improve glycemic control in the ambulatory setting. However, a paucity of inpatient experience and data remains a barrier to US Food and Drug Administration (FDA) approval and expanded/non-research use in the hospital setting. METHOD: Amid the COVID-19 pandemic, the FDA exercised its enforcement discretion to not object to the use of CGM systems for the treatment of patients in hospital settings to support COVID-19 health care-related efforts to reduce viral exposure of health care workers. Following this announcement, Scripps Health, a large not-for-profit health care system in San Diego, California, implemented CGM as the new "standard of care" (CGM as SOC) for glucose monitoring and management in the hospital. RESULTS: The present report serves to (1) detail the implementation procedures for employing this new SOC; (2) describe the patients receiving CGM as SOC, their glycemic control, and hospital outcomes; and (3) share lessons learned over two years and nearly 900 hospital encounters involving CGM. CONCLUSIONS: Here, we conclude that CGM is feasible in the hospital setting by using a dedicated diabetes care team and the CGM technology with remote monitoring.

Know Diabetes by Heart Campaign and Project Dulce: A Culturally Tailored Mobile-Based Self-Management Program Supports High-Risk Populations with Diabetes to Manage Cardiovascular Disease Risk

Diabetes, high blood pressure, and obesity are major risk factors for cardiovascular disease (CVD) . Access to and awareness of health education programming is often low in ethnic/racial minorities and individuals of low socioeconomic status experience a higher prevalence of T2D, hypertension, CVD and stroke. Additionally, underserved, at-risk patients face barriers to accessing traditional in-person diabetes self-management education and support (DSME/S) due to transportation, caregiving, and work conflicts. To address this gap, the ADA's Know Diabetes by Heart (KDBH) initiative partnered with Project Dulce, an evidence-based culturally and linguistically modified DSME/S program to overlay an innovative digital approach to diabetes support programming and resources in the community. In response to COVID-restrictions, Project Dulce sessions integrating KDBH content were delivered via telehealth group sessions and text messaging to encourage heart healthy self-management behaviors. Pre/post surveys assessed knowledge and self-management, and clinical metrics were evaluated via electronic health records. The KDBH/Project Dulce DSME/S program was delivered to 5 health systems in California: 2 Federally Qualified Health Centers, 2 County health clinics and 1 large community-based health system near the US/Mexico border. Of the N=553 who received KDBH/Project Dulce education, 47% were White, 36% Hispanic, 14% African American, Asian, Native American, Pacific Islander, and 3% other. Of all enrollees, 58% were female, and 15% were </= 45 y/o, 50% were 46-65 y/o and 35% were >/= 66 y/o. Participant feedback indicated acceptance of both the group virtual and texting programs. Findings demonstrate the feasibility of disseminating important heart healthy interventions to diverse ethnic/racial minority groups via a variety of digital and telehealth methods.

Integrating an Evidence-Based Diabetes Digital Texting Program (Dulce Digital) via an EMR Patient Portal in a Large Health System

Dulce Digital (DD) , a simple low-cost text message program designed to enhance clinical diabetes care with educational, motivational and glucose reminder messages when delivered 2-3 times/day over 6 months has been shown to be highly acceptable in diverse racial/ethnic minorities and low SES communities and results in a mean 1% reduction in HbA1c compared to usual care. During the COVID pandemic, barriers to in-person care, including quarantines, stay-at-home work schedules, childcare, and transportation, make digital messaging a practical means of improving patient health. To maximize reach in the T2DM population, a large Southern California health care provider integrated DD into their DSME/S offering. This study aims to learn the reach, acceptability, and effectiveness of Dulce Digital in a real-world patient care setting to motivate patients with daily self-care behaviors. An existing diabetes registry identified N=1423 patients with T2DM and HbA1c>7.5% in the last 6 months. There was enthusiastic adoption of the DD texting program byprimary care clinic sites with 78 providers across the County. Patient recruitment was conducted via a patient portal message (EPIC My Chart) sent from healthcare providers encouraging participation in the program. Within one week of portal outreach, 116 patients (8.2%) enrolled (mean age = 57.3 y/o +/- 14.4, range 24-92;50% female;mean HbA1c= 9.9 % +/- 1.5, range 8.1-16.2) . Program workflows include using support staff to monitor blood glucose responses in the texting platform, assess possible reasons for hyper/hypoglycemia, and encourage follow up with a provider as needed. Adoption by patients and providers to date demonstrate a digital texting program is acceptable and desired equally by men and women across a wide range of ages in patients with T2D and elevated HbA1c. Outreach to enroll patients using a patient EMR portal can be successful and can serve as an enhanced approach to support DSME/S.

Call to Action: COVID-19 Pandemic Prompts Subcutaneous Treatment Option for Diabetes Ketoacidosis (DKA) in Hospital

COVID-19 challenges organizations to modify approaches to optimize diabetes management while reducing Personal Protective Equipment (PPE) use and nurse time, and maintaining patient safety. In April 2020, Scripps Health, a five-hospital health system in southern California created a subcutaneous Diabetes Ketoacidosis (DKA) treatment option for use with adults, admitted with mild to moderate DKA. Primary aims were to achieve DKA resolution and glycemic targets similar to the intravenous (IV) insulin treatment option, and no hypoglycemia <70 mg/dL. The new order set utilized weight-based dosing, with similar orders for labs, electrolyte and IV fluid replacement, and resolution criteria. Differences included automatic insulin dosing and basal/bolus insulin. Key changes were a reduced frequency of point of care testing (POCT) and ≤140 mg/dL hypoglycemia prevention orders. Post-implementation audits between April - July 2020 showed no hypoglycemia and resolution time similar to IV insulin. However, only 6% (N=17) of DKA cases were managed with subcutaneous, as compared to IV insulin. To help understand why there was such a limited uptake, a detailed retrospective chart review was undertaken on a subset of twenty-two DKA cases managed with IV insulin. Findings showed that 17 (77%) had type 2 diabetes, 5 (23%) had type 1 diabetes. 47% of cases had opportunities for subcutaneous management based on DKA classification and no contraindications for subcutaneous therapy. Findings indicate organizations should consider a DKA subcutaneous option. Lack of knowledge of DKA severity may be a factor in low utilization, therefore an EHR DKA Classification tool was implemented to support providers. Research is needed to determine if this increases utilization of the subcutaneous treatment option and what other barriers exist.