Inpatient Glycemic Management During COVID-19: Case Studies & Discussion

Listen to how three diabetes care and education specialists and their teams have adapted inpatient glycemic management processes during COVID-19.

Learn about their experiences, challenges they faced and the tools they used to attain optimal glycemic management for people with diabetes or stress hyperglycemia in the inpatient setting. 

Speakers Include: 

• Barbara A. McLean, MN, RN, CCRN, CCNS-BC, NP-BC, FCCM Advancing Evidence-Based Practice Clinical Specialist, Grady Hospital
• Christina Gallimore, RN, BSN
  Diabetes Education Specialist, Novant Health
• Melanie Duran, BSN, RN, CDCES
  Inpatient Diabetes Care and Education Specialist, UNM Hospitals
• Betsy Kubacka, MSN, AGPCNP-BC, RDN, CDCES
  Director of Clinical Practice, Glytec

Transcript 

Hello and welcome, everyone. Thanks for joining us today for a webinar sponsored by Glytec titled Inpatient Glycemic Management During COVID-19: Case Studies and Discussion. We will have a Q&A session at the end of the presentation, so if you would like to ask a question, please type that into the Q&A box on your screen at any time. And we encourage you to download the resource about why now is the time to invest in glycemic management, and you can find that in the file share box underneath the Q&A box on your screen. As a reminder, there is no CE credit for this webinar.

I’d like to introduce our moderator for today, Betsy Kubacka. She’s director of clinical practice at Glytec and an endocrinology nurse practitioner for Hartford HealthCare. Betsy’s experience includes working with patients in both the inpatient and outpatient settings as a registered dietician and nurse practitioner. We’re very excited to have her here with us today, and I will turn it over to Betsy to get us started. Betsy?

BETSY KUBACKA: Welcome and thank you for joining us today. Our talk today will focus on COVID-19 changes that needed to be made in inpatient settings. As you were introduced to me – thank you very much for that nice introduction – we have three panelists that’ll be speaking today. Christina Gallimore – she is a nurse with Novant Health. Melanie Duran, who is also a nurse with University of New Mexico Hospital. And Barbara McLean, a nurse practitioner with Grady Health Care Systems.

We’ll take a quick introduction to Glytec. Glytec brings software programs to the market, and we are on a mission to improve the lives of our patients by managing glycemic issues for those who administer insulin. We optimize insulin therapy for patients in the inpatient and outpatient settings. Our eGlycemic Management System has been proven to help hospitals overcome therapeutic inertia and drive the adoption of basal bolus insulin therapy for providers as well as nursing staff. Our FDA-cleared software – Glucommander is the name of it – delivers decision support at the point of care and accounts for a range of variables to provide personalized insulin dosing and maximize workflow efficiencies for both providers and nurses.

Today, we will be talking about best practices for insulin management during COVID-19. COVID-19 caught many of us off guard and required that healthcare professionals pivot and modify usual routines. Inpatient diabetes care was impacted. So today, we’ll be talking about strategies such as remote monitoring, leveraging technology, mitigating the impact of steroids on blood glucose, how to bundle care and preserve PPE, as well as how to facilitate collaboration, streamline workflows. We will hear some creative solutions, and we will also see how real-time data can be used.

At this time, I would like to turn the presentation over to Christina Gallimore. Again, she’s the diabetes education specialist with the diabetes resource team at Novant Health. Christina?

CHRISTINA GALLIMORE: Thank you, Betsy, and thank you to Glytec for allowing this opportunity to share Novant Health’s success in transitioning our diabetes educators to begin to work remote.

What I want to share with you is that first, we had some challenges around our diabetes educators. At that point, they were all working in-person at our hospital facilities. However, when COVID kind of was announced, and things were being put into place, leaders across the system were really asked to evaluate their teams for remote work if possible. So all of this planning had taken place around the potential influx of COVID patients in the acute care settings, and they were developed as part of the hospital’s surge plans to increase space for patient care if needed. This was a very quick process that we had developed just within a one- to two-week timeline.

At that point, every acute care facility did not have a dedicated diabetes educator present. Some of our smaller community care facilities did not have that presence there. So we knew, first off, that we really wanted to develop a plan to include our community hospitals as well for support and resources around glycemic management.

Software solutions – so what does that new virtual working environment look like? We really had to implement and develop three important initiatives. The first one was around leveraging technology. The second one was the use of telehealth. And the third was around our glucose surveillance to really identify those patients that had two blood glucose levels of greater than 180 in a 24-hour period.

With leveraging that technology and doing remote monitoring and metrics, Glytec was a huge assistance to us with team member access for our diabetic educators for reports around hypoglycemia and hyperglycemia events and also patients with hyperglycemia that were not on Glucommander. By using these reports, we were really able to include our smaller community hospitals to our work list, because we were working more efficiently. Plus, it was the right thing to do for our patients as well.

With moving to telehealth and kind of supplementing provider care, we had implemented that with the telehealth platform to implement tablets for our consults as well as personalized hospital room calls to our patients and their family members. We were able to narrow down our education topics as well to something called diabetes survival skills and to focus on what the patient really needs to know before they were discharged home.

With the use of GlucoSurveillance as well, this helped to identify those patients that were at risk and to get their glycemic management addressed earlier, which truly, as we all know, improves their patient outcome. The providers and the nurses at the bedside very much appreciated that we had that extra set of eyes, per se, on those patients.

So the results – let’s move on to that. I would like to say that we really took the approach of no patient left behind. The three things I’d like to share – we reduced health disparities between the facilities by increasing that coverage to all sites within our North Carolina hospitals. This really promoted Novant’s belief in healthcare equity to all of our patients by including the community hospitals. Those nurses really appreciated our virtual presence and support that began during that transition time.

Also, with the telehealth, it improved our efficiency and the collaboration, as I mentioned before, also between the interdisciplinary team members. By narrowing down that education provided to patients and the delivery method, as I mentioned previously, around the diabetes survival skills, we had implemented books that were printed and left on the units as well that nurses can hand to the patients for review upon discharge.

Also, the electronic communication that we had versus before, whenever we were in person, that really improved the metrics around glycemic management and contacting them and making our recommendations aware to them once we did the chart review. 

Creating that glycemic review committee to use metrics and insights to educate providers and iterate on improvements – that improved our Glucommander entries and our glycemic management rates for hypo and hyper events. Whereas in 2019, when we were tracking it, we had not moved the needle very much. So we did all of this in a year of a pandemic, which is what I’m most proud of our organization, and improving the glycemic management of our patients with diabetes.

I’m going to hand this off next to Melanie Duran. Thank you for allowing me to share our Novant story. Melanie?

MELANIE DURAN: Thank you so much, Christina. My name is Melanie Duran, and I’m an inpatient diabetes care and education specialist here at UNM Hospitals in Albuquerque, New Mexico, home of the International Balloon Fiesta, and the weather is great almost all the time, except for today, when we’re getting some snow.

So I want to talk to you a little bit about what else we do. In addition to inpatient diabetes education, I’m also the nursing clinical lead for Glucommander at our hospital, and I wanted to talk with you about some of the challenges we faced with insulin administration when COVID started in March and where we are now.

A little bit of background on our challenges – when we first had COVID hit back in March, our initial surge was really well mitigated here. Mask requirements and closures resulted in successfully slowing the spread. And in the spring, our hospital’s peak was maybe around 50 to 60 patients total, and we were able to handle that pretty well. So we implemented some good practices then. However, the second wave this fall hasn’t been so kind, and we have had to make adaptations and changes that we never had to do in our first wave. It’s been OK, but it’s still definitely a work in progress. 

As of today, our inpatient COVID census is closer to 140 patients just for our hospital, and it’s really taxed us, much like the rest of the country, as we’re out of beds and struggling. So we’re still learning. We’re still evolving.

Some of our challenges included, of course, PPE and decreasing our trips inside the room, making sure we’re getting our insulin cosigned and maintaining safety, getting those glucose readings while using Glucommander to calculate our dosing, and then giving that dose without ever leaving the room.

An additional factor, as we know, with COVID was the hallmark issues of loss of taste and smell.  It is a big barrier to determining how much your patient is going to eat. This was really another barrier and challenge for our nurses.

And then the third was steroid use. Many of our patients we were seeing – not only were they new to diabetes and insulin, we’re throwing steroids on top of it, and that really made a whole other challenge to figuring out their treatment plan.

So what we did – one of the best solutions we had had actually been hiding the whole time. Several years ago, prior to all of COVID, pharmacy and respiratory therapy had gotten together to install lockboxes in each of the patients’ rooms. These were initially installed as a way to house MDIs and respiratory care treatments, but nurses also had used to access these boxes if they needed to stash anything in there. When COVID hit, we started storing our rapid-acting insulin in there and our syringes. This was one big thing that was successful, because it prevented the nurse from having to draw up the insulin outside the room and allowed them to determine the appropriate dose and draw that up inside the room.

Our workflow revolved around a buddy system – one nurse in the room and one nurse outside the room. The nurse would go into the room fully prepared to stay in there. They would have the morning medications and breakfast tray. They would get the CBG. They would talk with their patient, review the food with them, see what they thought they could reasonably eat, and then the nurse would contact their buddy outside the room.

That nurse would use Glucommander, input the glucose, input the percentage of food anticipated to be eating, and then they would relay the dose recommended by Glucommander back into the room, where the nurse would draw up the dose and give the insulin.

Our hospital has an extra challenge in that we still require cosignature of insulin. So nurses have found various ways to communicate this information also. Sometimes, it’s a verbal exchange or sending a picture of the dose or even using FaceTime or showing it through a window, depending on the unit and what we have available. That’s definitely been an extra challenge, but our nurses have really found ways to make this work based upon the units they’re on.

Our second challenge was steroids. Steroids continue to be a barrier to excellent insulin management. As most COVID patients are on dexamethasone, it really adds that extra challenge. We’re currently piloting a new order set that uses a more aggressive multiplier within Glucommander to determine our starting doses as well as changing our insulin ratios to a 40% basal/60% mealtime ratio and modifying as needed to try and get our patients into range more effectively. The challenge remains the same with steroids with or without COVID – trying to up-titrate the dosing to fit the individualized requirements, and then also be prepared for that fall when the steroids stop. 

With COVID, we had a lot of new folks helping, whether it’s shifting providers or traveler nurses, so staff variability has been one of our biggest challenges. However, it turns out the one department that has remained fairly constant has been our pharmacists, and they’ve been absolutely instrumental in making dosing adjustment recommendations up or down and mitigating some of our issues. 

We only have two inpatient educators, only with a total of 1.5 FTEs, so diabetes education has had to stay focused on education. Much like Christina described, our education is remote for our COVID-positive patients, and then we still see COVID-negative patients in person. However, the pharmacists have really taken the lead to work with our providers to ensure the best possible dosing fit for insulin, whether on or off of Glucommander.

So our results – nursing has really adopted this workflow well, and we continue to expand additional COVID units. The workflow continues to get shared. And it’s been generally consistent in all areas where non-ICU COVID patients are housed. Nurses are able to communicate effectively with patients about what they will reasonably be able to eat and dose appropriately real-time. Providers, nursing, and pharmacy all work together to help reach our goals, and we’re continuing to make improvements. 

As an inpatient educator, the number of newly diagnosed patients who came in for COVID and were found to have diabetes has been pretty impressive. We’ve had many patients who this has just been an incidental finding. As a diabetes specialist, I want to hope that this is an earlier identification, which could result in long-term improved outcomes. Many patients have been Spanish-speaking, may or may not have insurance, and may have not seen a provider otherwise. So if we can find one positive to COVID, maybe this will be it later on down the road.

Thank you for your time today, and I am now going to hand it over to Barbara.

BARBARA MCLEAN: Thank you so very much, Melanie and Christina, and I appreciate very much the opportunity to be here with you today. First and foremost, I’m going to tell you I am a nurse practitioner, but I don’t work as a nurse practitioner. I’m a critical care specialist for advanced practice initiatives across multiple intensive care units at Grady Health System in Atlanta, Georgia, and I spend an extraordinary amount of time at the bedside. And particularly during COVID, I’ve spent a tremendous amount of time at the bedside.

My focus is quite different than the prior two speakers, because I work in critical care. My institution, Grady Memorial Hospital, we have over 120 critical care beds, and we expanded our critical care capacity utilizing our step-down units and also educating emergency room nurses to provide critical care – and of course, as everyone, providing critical care outside of the traditional boundaries of intensive care.

In my hospital, we’re four years into an electronic glucose management system using Glucommander. We began in October of 2016. One of the most resounding, I think, outputs from that was – because I’m talking about patients with continuous IV insulin, that at first, the burden of being held accountable to do your blood glucose every single hour, to adjust your insulin every single hour, seemed ominous. Within six months, what we actually saw was a huge nurse adaptation and a transfer of nurse workflow to the utilization of electronic glucose management systems that required a blood glucose done every hour with insulin adjustment.

The reason I felt that it’s important for me to tell you that is as of today, we have had over 3,000 patients receiving IV insulin utilizing Glucommander for both IV DKA and non-DKA, and we have performed 300,000 blood glucoses using our Glucommander. That’s outside of anybody outside of the ICU who might be using long-acting sliding scale. I’m just reporting the ICU numbers. But I want you to appreciate that, because of course, when COVID hit, it was a profound shift for us.

The very first thing that happened when COVID hit is we tried to make plans and standards for how we were going to manage PPE and our staff and protect our staff from exposure. But in intensive care, that’s a very hard thing to do. You’re managing ventilators. You’re managing continuous renal replacement therapy. You’re managing insulin. You’re managing five or six vasopressors, antibiotics, and steroids. And oftentimes, nurses would be in the room for an hour to two hours at a time.

So one of our goals was to actually, as best we could, limit the time that the nurse had to be in the room for tasks that didn’t necessarily require them. One of the first things we thought about was how could we actually place our drips outside the room? We did that with extremely long extension tubing. But we had a very significant concern that the insulin would adhere more aggressively to the longer IV tubing, reducing the amount that was reaching the patient. 

Also, our patients are on aggressive vasopressors – norepinephrine, epinephrine, vasopressin, angiotensin II – and as we all know, particularly catecholamines, norepinephrine, and epinephrine actually promote insulin resistance, making the hyperglycemic episodes much, much worse for those patients.

What we found was that even if we could have our pumps outside the room, the delay between the blood glucose check and the insulin dosing actually was longer than what we were used to, which was less than 60 seconds. So we had some delay related to that as well.

Overall, when you look at a really stressful time, where many staff were overwhelmed, where our normal ratio of one to two patients per one ICU nurse expanded because of the abundance of our patients, and also because many staff stepped back from ICU care during this time, what was really insightful and what was a wonderful learning opportunity for me was the recognition that in general, intensive care staff – not being diabetic educators, intensive care staff generally don’t perceive the administration of insulin as important as titrating norepinephrine. That was a really important perspective, that the standard bedside staff is not really looking at the impact of glycemic control and insulin management – not just for glucose, but for other reasons as well. Didn’t really have a high level of understanding of that impact on critical illness and organ support.

In addition to that, we have begun a new methodology of administering continuous renal replacement therapy. Our consults were brand new. We were the first release with those consults. And we had new solutions that we were using, one of which actually had phosphorus in it, which really reduced the hypophosphatemia that we would see in renal failure patients. But there wasn’t any glucose in that solution, so patients who were diabetic and on CRRT on that solution – that would be a 4 K, 4 potassium solution – you often saw that they could drop their glucose not profoundly aggressively, but puzzlingly so if one wasn’t looking at what was occurring. That required more aggressive adjustment and awareness of the patient’s glucose.

So when I’m thinking of that, it is really important to appreciate that we used some solutions that we already had in house. We actually strategized on those solutions. But at one point, we had 80 intensive care unit beds filled with COVID, and about 45% of those patients were hyperglycemic. So you can appreciate the extraordinary burden that places on the staff to try to maintain their excellence in patient care. 

And it was quite interesting, because in the very beginning, with an introduction of utilizing another hospital – actually, Montefiore Hospital’s algorithm for using sliding scale and long-acting insulin in these critical patients in replacement of IV insulin, and most of the bedside nurses, quite amazingly, said don’t take away my Glucommander. I need Glucommander. 

So we sought some other solutions, and I was very fortunate – very fortunate – that I worked with – I’m an intensive care person, but I work in conjunction or collaboration with endocrinology, and that would be Dr. Humberto Gutierrez (sp?) and Dr. Francisco Pasquel.  Dr. Pasquel worked diligently to receive an EUA from the FDA, an emergency use authorization, to actually utilize continuous glucose monitors in the intensive care unit. That was extraordinary. It wasn’t happening everywhere. There were very few hospitals – there were about 12 hospitals that actually were involved in the study.

What that allowed us to do was to train staff to place tiny sensors that just go under the abdominal wall. That’s now connected to a cell phone.  And that cell phone was in a plastic bag inside the room facing outwards. We validated times four, and then we validated every six hours with point-of-care glucose. But in between those times, we were using the eGlycemic – the continuous glucose monitoring to drive our insulin adjustments. We made accommodations for the longer tubing, recognizing that we would probably have to administer more insulin for the lost insulin in the tubing in order to actually get our patients under control.

One of the most important things, for those of you who might not be familiar, is that in the hands of the ICU nurse who’s doing IV insulin either for non-DKA or DKA, once we get patients into target at my hospital – our target’s 140 to 180 for the standard adult ICU patient. We have some exceptions. Once you’re in target four times in a row, you now only have to actually make an insulin adjustment or measure the blood glucose every two hours. That was really significant for us to be able to do two one-hour blood glucose measures through the window of our ICU room via the phone attached to a sensor in the abdomen and then be able to have an electronic glucose monitoring system that is configured with a correction factor to the fifth decimal point, obliterating any need for human mathematic calculation and facilitating an adjustment of insulin absolutely geared to that patient in that moment at that time.

We used all of this to really educate our providers on why glycemic management in critical illness is so important and why with catecholamine-induced acidosis that we see worsening hyperglycemia that then worsens the acidosis that then makes patients resistant to the very therapies that we are giving them. 

Of course, as very beautifully stated by Melanie, we absolutely had issues with steroids. I do want to let you know that we have always had issues with steroid manipulation of the blood glucose. We do have a very robust burn unit and neuro intensive care unit, where they use higher-dose steroids. And what we worked on in our own hospital was modifying a real activation relationship to the steroid administration, so that actually we bumped our insulin up right after the steroids were administered and then came back down at 30 minutes. I’m not advising that for anyone else. That’s just what we looked at. It’s not approved, and I’m sorry if I said something wrong. It is one of our innovative ways in which we worked with and for our patients and with and for our staff.

So the results of that are that we really integrated these two systems – continuous glucose monitoring and e-glycemic management systems, which we were already experienced with – we actually bonded those together to provide real-time blood glucose data and to reduce the time the nurse had to go in the room in order to measure blood glucose or adjust insulin. Remember, we’re already in the room for many hours out of a 24-hour day, because these patients are so critical. But this was one less burden. I finally came out of the room. Uh-oh, now it’s time to do my blood glucose check and adjust my insulin. Now, I’m out of the room. I’m having a breath. All I have to wear is my mask. I don’t need everything else. And I can adjust outside of the room through those external pumps.

We had a lot of significant innovation that kind of embraced us through the COVID crisis. What really was important is helping providers, particularly, and nurses as well appreciating that proactive care rather than reactive care leads to improved patient outcomes and survival. What I mean by that is when we’re using methodologies that simulate our endogenous insulin release system – that’s how I see glycemic management systems – that we are able to proactively apply insulin instead of waiting until the patient is hyperglycemic, giving them sliding scale. Now, they’re hypoglycemic. And all of us know that basic Somogyi effect. I’m sure in your patients outside of the ICU who are under excellent control from the diabetic educators and the diabetic team that that didn’t happen too much. But in the ICU, it happened a lot, and we have really been able to reduce that.

I think one of the most important points was through education, support, and continuous discussion, that short-term increase in workflow intensity for nurses actually promotes a longer-term reduction in secondary problems – in the evolution of profound and persistent acidosis refractory to vasopressors, the issues that we saw with CRRT when we were using the non-glucose-containing solutions – which are excellent solutions, they just don’t contain glucose – and of course, at the very end, always being sure that we’re doing the very best we can to manage our patients with high quality and concern and to protect our staff by as best as possible limiting exposure.

So I turn it over to Betsy.

KUBACKA:  Thank you so much for those wonderful presentations.  Keep your questions coming into the chat room through your Q&A, and we will answer those questions in just a few moments.

I just want to take a moment to introduce Glytec’s eGlycemic Management System to you all. Glucommander is the only patented, cloud-based, FDA-cleared glycemic management software platform. It supports both IV and subcutaneous insulin dosing. Our product also includes insulin dosing for transition from IV to subcutaneous insulin. It is designed to manage hyperglycemia in patients both with diabetes and stress hyperglycemia. It is also FDA-cleared for pediatrics to adults.

At the core of the program is our insulin dosing decision support software. The software is initiated based on a prescriber’s orders. Once the program is initiated, the insulin doses are adjusted by the program based on an evidence-based proprietary algorithm. The patient’s glucose response will drive those changes in the insulin dosing. Ultimately, your patient receives personalized insulin dosing recommendations based on the calculations by the program.

We also offer GlucoSurveillance. GlucoSurveillance monitors all the patients’ blood glucose readings and populates a list of patients who have experienced two values above 180 milligrams per deciliter in the past 24 hours. This feature helps identify patients in real time who are not in control and not on Glucommander, but may benefit from improved insulin management.

The Glucommander software also integrates with any electronic medical record. We have something called SmartClick, and this allows direct access to Glucommander via a button built in the electronic medical record. The Smart Click makes it convenient to work with the patient’s record and removes the need to leave the EMR in order to open the application.

We also have something called GlucoView monitors, which display all the patients on IV insulin and provide a countdown timer to the next blood glucose check. This helps keep the nurse on track with timely blood glucose checks. And those timely blood glucose checks result in faster time to target and a reduction in hypo- and hyperglycemic events.

With our product, we also bring analytics, reporting, and this is part of the whole solution. So you can track the results and identify areas for improvement.

This is a screenshot of what our product would look like. Glucommander uses its technology to personalize recommendations and safely and effectively manage the blood glucose. What you see on the screen here at the top is where the nurse interacts with the program. So the nurse enters the blood glucose into Glucommander, and then Glucommander offers the insulin doses based on the blood glucose and the calculated insulin doses.

What we look for is we really look for our outcomes. Our clients have realized benefits beyond the reduction of hypoglycemia. They have realized benefits such as reduced readmission rates, reduced length of stay, and overall cost savings. Our proven results and outcomes are well documented in more than 80 evidence-based studies.  Most of the studies were conducted by our clients. And the studies can be found in medical journals and have been presented at scientific sessions. If you are interested, you can locate our studies on our website, which is glytecsystems.com/evidence.

I’m going to now turn this over to Megan (sp?).

F: Great. Thank you so much, everyone. We are going to use the remaining time to take your questions.  As a reminder, you can type your questions into the Q&A box on your screen, and we’ve already got a number of questions in, so I will pass it back over to Betsy.

KUBACKA: Thank you very much. I have a question here for Melanie. Melanie, you mentioned that pharmacists had a role in titrating insulin. Are all the pharmacists trained with insulin adjustments, or is it a special group of pharmacists?

DURAN: Thank you for the question, first off. All of our pharmacists here have kind of just learned how to titrate insulin, because we are a teaching hospital. So if we don’t have some pharmacists who are full of opinions, as I like to say, things don’t get as well managed as we would like. So we don’t have a specific training program, but we do have a fair amount of pharmacists who are assigned to specific teams so that they have the time and ability to support our providers as needed.

KUBACKA: Thank you so much, Melanie. For Christina, how do you teach tactile skills to patients with diabetes when you’re not able to be in the room with them?

GALLIMORE: Absolutely. That’s a great question. That was very important to us as well whenever we were developing our plans for doing virtual education to our patients. As I mentioned in my presentation, it was really important to connect to the interdisciplinary team and include them upon our education with the patient. So we engaged the nursing team members. We went over the technique of doing insulin injections, blood glucose checks, and things like that over the phone or via Zoom. However, our nurses partnered with us and did the in-person kind of check-off list – you could kind of say a competency – with the patient themselves and then allowed the patient to do their injections themselves in front of the nurse. So definitely it was a team approach for that success of the patient. Yeah, that was a great question.

KUBACKA: Thank you very much. Barbara, can you repeat how often you validated the CGM? Also, what CGM were you using?

McLEAN: On initial placement of the sensor, we would validate for the first four measures. As long as they were consistently within a standard deviation of 20, we then said this has been validated, and we would then move to just using the continuous glucose monitor. If there was anything that was significantly abnormal, then we would of course do a point of care, and then we would revalidate every six hours. 

So basically, if you were an IV insulin patient, either DKA or non-DKA, in a 24-hour period, if you were just mildly outside of target, but never hypoglycemic, that would be 24 blood sugars that the nurse would have to do in the room. We were able to reduce that to 12 blood sugars, so we reduced it by 50% requirement of going in the room. But you do, of course, have to validate. 

We used Dexcom, but we used Dexcom not because we believed that it was better than FreeStyle Libre or others, but because that was the device that we were able to get the EUA on. So I’m not promoting one device over another.

KUBACKA: Thank you for that clarification. Thank you. Melanie, what time of day was your Decadron administered, and did you see a huge decrease in glucose as the Decadron wore off?

DURAN: Great question. We did not have a specific set time of day for our Decadron administration. It was typically every 24 hours from the time we initiated it. Sometimes, we’d give it at 9:00 in the morning. Other times, 5:00 at night.

What we saw was that we would definitely see a big swing increase during the day when those patients were eating.  So we saw that increased insulin resistance during mealtimes. But as far as when we stopped it, we would see a decrease in insulin requirements anywhere from 12 to 36 hours afterwards. So it was very patient-specific. There was not a specific algorithm or anything that we could pinpoint yet at this point.

KUBACKA: Thank you very much for that answer. Barbara, what percentage variance did you set for reliability between the CGM and point of care? I think you answered that earlier with your 20%, right?

McLEAN: I did. I did, yeah.

KUBACKA: How did you get funding to cover the cost of the CGM?

McLEAN: I am on the publication. We do have a publication in Diabetes Care. But I was not part of the team that got funding or actually worked on the approval and the IRB. I was involved with the instrumentation and the implementation because of being the clinical lead for Glucommander. So I was the other woman.

KUBACKA: (laughter) Thank you very much. We have a question here about considerations for creatinine with insulin dosing. Who would like to take that question? Do you use creatinine in your insulin dosing calculations, Barbara, like in the ICU? Any considerations?

McLEAN: I’m not positive what that question means, but I think what it means is that when you have a patient with acute renal injury or chronic renal injury, are you more cautious in your initial application of insulin? The answer is yes. We don’t use the number of creatinine in any calculation. But in my practice, if you are a DKA patient, we are assuming that you are going to have a relatively robust response to insulin, so we do that very cautiously.

Utilizing the Glucommander, Glucommander actually gives us what’s known as the multiplication factor. It’s actually a correction factor looking at height and weight, glucose, and percent of decline of glucose with each insulin adjustment. The factor changes in order to give us a correct recommendation for insulin dose. It’s really important to remember that Glucommander doesn’t give insulin. This isn’t a closed-loop system. But in my hospital, Glucommander gives us a doctor’s order, and we follow that order. So if Glucommander says adjust insulin up to 3, then we adjust insulin to 3.

What we would see, even if you went back to that little picture – I don’t know if you have the primary MAR picture – but the multiplier is the mathematic, algorithmic factor that is altering at all times based on the patient’s responsiveness. With renal dysfunction, we always start on the lowest multiplier. For DKA patients, there is only one multiplier choice. That’s 0.01. That’s where you start. If you have kidney injury or chronic renal dysfunction, we always start with the lowest multiplier, because we presume an extreme amount of caution.  Glucommander will adjust that multiplier. That’s how it adjusts the calculation for the insulin rate. That multiplier, again, is to the fifth decimal. That multiplier helps us to stay on track with insulin adjustments that are based on more than just a simple formula, but also patient responsiveness. It’s a very individualized way.

So the short answer is yes, we are aware with patients who have elevated creatinine – that’s acute kidney injury, elderly patients, and previously known diabetic patients. We use the lowest possible multiplier, 0.01. And for our other patients, we have three multipliers that we use. And the thing is, the multiplier is only the first dose, and then that multiplier is adjusting to the patient. I hope that answered the question.

KUBACKA: I think you were very correct. When using Glucommander, the providers are given guidance – that’s which multiplier to start with as well as which target range. So we do have a higher target range to prevent hypoglycemia for these patients. I think that you answered that very well. Thank you so much.

McLEAN: May I answer something? I just wanted to say one other thing. I’d like for you to know – the audience to know that we had a reduction of 37% hypoglycemia to 0.01%. And you heard the numbers that I was talking about before.  0.01% hypoglycemia in over 300,000 blood glucoses – 3,000 patients.

So I think one of the other aspects of the Glucommander is that if your patient’s blood glucose does drop – that can happen because maybe they ate and they didn’t tell you, and your insulin went up, and now they’ve bottomed out, or sometimes you see patients, of course, will drop their glucose as they resolve their fever and their glucose levels drop. It’s extraordinarily rare for us now to have hypoglycemia that requires therapy. But Glucommander also recommends the adjustment of therapy for D50. Just that recommendation of therapy – I’m sorry, D10 – to be appropriate enough to bring the patient out of hypoglycemia, but not back to target. So it works with us on both ends of the coin. I’m so sorry. I just wanted to answer that. Thank you.

KUBACKA: Thank you. Was there someone else that was speaking?

GALLIMORE: Yes, Betsy. This is Christina. I also wanted to talk about how with Novant, we had actually with our team – with those patients that do have those kidney failure-type diseases with the creatinine levels, those are some of our higher-risk patients. So those are some of the patients that we would do those chart reviews on earlier in the day, so we could go ahead and get that feedback back to the providers as well in real time so that adjustments could be made as we look at their labs and look at where their glycemic management has been over the past few hours. That was also one approach that we took whenever we were developing our workflow.

KUBACKA: Thank you, Christina. While I have you, I’d like to pose the next question to you. How did you interact with nutrition and dining services for your patients for better glycemic control?

GALLIMORE: Oh, yeah. That’s a good question. Yeah, we did interact with them very often. Like I mentioned, we were really looking into those records and looking at the glycemic management of those patients and where they were trending and were there hypo events or hyper events?

One thing that we had developed about early summer with this was developing a glycemic management review committee. That was the committee that helped – things would get reported there. If there was something that we saw that we felt like the workflow needed to kind of be tightened up on – we had a lot of work around our meal workflow with nutrition and dietary. 

One thing around that that we worked with was the delivery of food to those patients with COVID. So including them with our glycemic management review committee really helped us change that workflow to improve it for the patients’ overall glycemic management. Like I mentioned, we work really closely with the interdisciplinary team, and developing that committee was a huge success to really kind of streamline workflows in such a stressful time.

KUBACKA: Thank you so much. Melanie, what modifications has your institution made to nutrition support – enteral, parenteral – when a patient is COVID-positive and has hyperglycemia?

DURAN: We generally use a set carbohydrate per tray, so we use our same amount of 60 grams of carb per tray.  Our ICU has had to use tube feed extensively. And honestly, we’ve been running our tube feeds off of Glucommander just because of the changes in requirements and when those tube feeds stop, how quickly they can drop. So we have found it difficult to juggle both enteral feeding along with steroids on some of our critically ill patients. However, as far as our non-ICU patients, they’ve done just fine, and most of them are eating independently. We just count their carbs.

KUBACKA: Would you use IV insulin, though, in those situations? Or would you only use subcutaneous insulin?

DURAN: For the critically ill, we’re sticking with – we are doing some sub-Q with them depending on where they’re at, but we know IV insulin is much more responsive, and we can handle sudden shifts with that a little bit more, whereas sub-Q, once insulin’s in, it’s in. So it really depends on the acuity and critical level of our patients.

KUBACKA: OK, thank you very much. I just want to make sure that in the Q&A, if we’re not going to get to your questions, we would love for you to type in your email address so that we can answer your question. I’m not sure that we’ll get to all the questions today, so I really want to just encourage you to give us your email so we can respond. 

I think I have time for one last question. Let me see. The question is can you omit p.o. intake or carbs due to poor intake where someone is not comfortable with carb counting? So I guess the way I’m interpreting the question has to do with – in Glucommander, when you’re using sub-Q, are you able to use the program without entering the carb intake? Christina, would you like to answer that?

GALLIMORE: We can. It’s best to have all of the carbohydrate information in Glucommander to help out with the whole algorithm, which will then improve the glycemic management of that patient. So that is something that we also would help and support our nurses with – around questions around that or help with that documentation of that from our electronic medical record into Glucommander. Yeah, that’s something that we also help support them with.

KUBACKA: Do you ever use percentage of meal intake, or is it an exact carb amount that you require?

GALLIMORE: Yeah, exact carb amount is what we wish to have in that documentation so that we know exactly how many carbohydrates they did consume.

KUBACKA: Melanie, do you use carbs, or do you use percentage?

DURAN: We heavily encourage percentage, because we know that what is coming up from our cafeteria is not exactly measured and that precise. So I encourage all of my nurses to stay out of the carbohydrate weeds and just use a percentage and to really try and get a best guess from the patient on what they think that they can reasonably eat, knowing that we have alternatives. We can give them some extra crackers or something if they’re not able to actually eat something that we provided and they didn’t like it. But we heavily encourage percentage use.

KUBACKA: So either way, depending on the organization. I’m going to wrap up the Q&A.

McLEAN: Wait, I didn’t get to say what I wanted to say.

KUBACKA: Go ahead, Barbara.

McLEAN: We do what Melanie does, except I’m talking about ICU patients. So our protocol is that our patients do not eat. That doesn’t happen all the time. Lots of times, patients do get fed. We have a default of carbohydrates, and we do percent of tray. I love what you said. We don’t want our nurses to be in the weeds trying to figure out carbohydrates, and they don’t come up from meal services with a carbohydrate list.

But I do want to answer a question that I think was really an important one about tube feeding and parenteral feeding. We require that every patient who is receiving insulin has a carbohydrate source. That either is a D5 solution, or it is tube feed, two-dose, or it is parenteral. This is a constant feeding, so it’s just a constant elevation of their blood glucose, and we match that with our insulin adjustments. We do not put insulin in the parenteral feeding when we have patients on continuous IV insulin using our Glucommander. And then when patients come off Glucommander, if they’re still on parenteral feeds, we add insulin back in.

Sorry, I thought that was also an important –

KUBACKA: No, that was very important.  hank you for that. Yes, thank you very much.

GALLIMORE: This is Christina. I’d like to add one other thing – that we do do the carbohydrate counts, but our dietary does send up a meal ticket list that does list the carbohydrates on that meal – how much each item is. So that has helped support our nursing team members with that.

KUBACKA: Very good point. Absolutely. Anything to help the nurses understand carb counting is very crucial to the success. Thank you.

So we would like to thank you all for your participation and for joining us today. If you would like more information about Glucommander or have questions on how to introduce Glucommander to your organization, please refer to the guide that we have available. It could be downloaded at glytecsystems.com/adces, or you also have it available in your file share here. We really appreciate your time and participation today, and we really look forward to meeting you again. Anyone who has any final questions, please put those in the chat box with your email, and we would love to answer those questions for you.

F: Great, thank you so much. ADCES would like to thank Glytec and our speakers today, and I want to thank all of you for attending today’s webinar. We hope you enjoyed it. This webinar was recorded and will be posted in Danatech, ADCES’s online destination for all things diabetes technology, so make sure you check out danatech.org today. Thank you all. This concludes today’s presentation.

ECO #01078-A