As we have discovered over the past few weeks, the U.S. has continued to see increasing incidence of diabetes as one of the top eight disease burdens.  The prevalence has increased globally with a ranking of 3rd in 2016 for the leading cause of disabilities in the U.S. (The U.S. Burden of Disease Collaborators, 2018). This is even more alarming with the world’s aging population who is at greater risk for developing diabetes and the multitude of complex complications.  Adults 60 years or older often have higher co-morbidities secondary to age that when combined with diabetes lead to diabetes-related conditions, such as myocardial infarctions, lower extremity amputations,  renal disease, cognitive impairment and dementia, and visual disturbances, which place them at higher risks for death and disability (Valencia et al., 2018). Diabetes management continues to be essential in the prevention of diabetes related complications. Evidence has shown that diabetes self-management, medication management, dietary compliance and exercise, and patient education continue to be primary interventions in the management of this complex disease. However, as these have not demonstrated improvements in glycemic control or prevention of hypoglycemic serious events, the need to add additional interventions utilizing technology are warranted.  One such intervention is the addition of continuous glucose monitoring in both type 1.

Continuous glucose monitoring (CGM) has arisen over the last decade initially as an adjunct treatment to finger sticks and A1C monitoring (Hirsch et al., 2019).  In response to patient preference, compliance with treatment and monitoring plans, quality of monitoring, and cost effectiveness, more studies and evaluation of CGM has emerged. In addition, the need to prevent serious complications related to hypoglycemic events also led to more research and trials in the use of continuous glucose monitoring (Bergenstal, 2018).   

In our organization, most patients do not continue using their insulin pumps or continuous glucose monitors during acute events in the hospital. Implementation of a research-based intervention such as CGM for Type 1 diabetics would allow for stabilization of patient glucose levels and prevent serious complications related to hypoglycemia that we often have seen.

What are the potential benefits and harms related to your selected practice problem when considering a research-based intervention for your practice change project?

The use of CGM in diabetes is believed to allow for several benefits. First, it can assist in the prevention of hypoglycemia in patients who often are not aware of extreme drops in glucose levels.  Routine finger glucose sticks were often the standard in diabetic monitoring but were not always performed as scheduled or felt to be of high importance to adults with diabetes. CGM allows for real time data to be reviewed by patients; can identify quick changes in the patient’s glucose levels with meals or exercise and warns patients of hypoglycemic events that may otherwise have been unnoticed (Bergenstal, 2018).  Studies have shown that the use of CGM has allowed for better control of A1C levels, less time in hyperglycemic events, and decreased incidences of severe hypoglycemic events (Hirsch, et al., 2019).  Using the CGM during the hospitalization allows for monitoring of glucose levels during times of stress and acute illness and can be essential in the prevention of hyper-hypo events during periods of NPO status related to diagnostic testing.

Studies have shown some concerns related to CGM especially in the use of older adults. First, as with any new technology, patients must receive product instructions and all educational information related to the therapy.  To perform this implementation, several guidelines to ensure safe and ethical patient practices must be followed. Our goals for the intervention should answer clear questions regarding the purpose and benefits that CGM will provide to our patients. Patients are to be provided education regarding the monitoring that will occur and should have their privacy maintained, updated on any changes in their treatment plan, and monitored closely for any adverse effects during their hospitalization (NIH).  Older patients may not have a clear understanding of this advanced treatment or how the use of smart phones or recording devices work. They may need additional education and support while hospitalized.  

Are there competing personal or professional values related to this research-based intervention that might impact the implementation of this intervention in your practice setting?

There are several types of devices that could be used our intervention. We would wish to reduce bias and evaluate the benefits and impediments of various models prior to implementation.  Cost effective monitors would be preferred but not at the expense of utilizing a poorly reviewed technology that does not have quality outcomes for our patients. In review of types of CGM, there are newer models that are inserted into the subcutaneous tissue and allow for quick removal if needed. Previous studies show these to be effective and safe for insulin dosing but do need further evaluation of hypoglycemic events (Elshimy & Correa, 2020).  As it would be necessary to ensure accuracy of glucose levels via the continuous monitors, fingersticks, and lab draws may still be needed. Patients may be confused as to why they are receiving multiple interventions. We would wish to reduce patient fears and anxiety by supporting and re-educating as needed.

In addition, education to nursing staff and providers is essential prior to implementation of this intervention.  With some current challenges with nurse staffing in our organization, there may be barriers to nurse buy-in with additional tasks being assigned to them during the trial. I would wish to ensure that nurses understand the reason for the trial and can engage in their importance to prevent events of hypoglycemia and improve patient outcomes.

What types of objections might be raised? How will you explain your decision to key stakeholders to address these objections?

Some objections related to the intervention may be related to the inexperience and knowledge of providers and nursing staff. Some may find the process to perform the data retrieval as difficult or as added tasks to the workload. There may also be barriers related to cost and accuracy. Sharing that CGM has noted accuracy of a 10% absolute difference when compared to capillary glucose results may reduce these concerns (Elshimy & Correa, 2020).  Training superusers to better understand the CGM, provide education to patients, and insert the monitor can assist with workflow and quality controls during the hospitalization (Hirsch et al.., 2019).  In addition, the cost of this intervention may be covered by insurance or Medicare dependent upon the patient’s current diabetes management.   

The continuation of a CGM is shown to improve glycemic control for patients and could be worn for up to 14 days. This could provide clearer results for primary care physicians upon retrieval after discharge.  There would be the need to continue patient education and understanding related to care for the monitor as well as any self-management interventions based upon glucose results.  Education on the monitor screen and retrieval of results would be needed.  If older or cognitively challenged patients have difficulties with manipulation or understanding of the CGM, it may require removal and return to standard treatment modality and fingersticks may be needed. Teach-back for patient education is necessary in the evaluation for safe glucose monitoring and care after discharge (Hirsch et al., 2019).

Diabetes continues to be a leading healthcare concern and relies upon various modalities of self care in the maintenance of glucose levels.  Using continuous glucose monitoring while in the hospital could prevent episodes of hypoglycemia that many diabetics are prone to during acute illness. There is evidence that this intervention has been successful in maintaining glucose control in type 1 diabetics and is being evaluated more often now in the treatment for type 2 as well. 

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