Diabetes Technology is Improving Inpatient Care

Innovations in Diabetes & Metabolic Care | Fall 2023

Claudia Lewis, MMS, PA-C, joined University Hospitals Diabetes and Metabolic Care Center in 2022 under the leadership of Betul Hatipoglu, MD, and cares for individuals with diabetes in the inpatient setting. She also follows patients through the hospital discharge clinic.

“My favorite things are providing patients with support and education to empower them to live a high quality of life with diabetes and addressing social determinants of health to help individuals access the medications and supplies they need,” she says.

Advancements in diabetes technology are creating new pathways for inpatient care.

“There has been a huge rise in access to diabetes technology,” says Lewis. “Millions of people use continuous glucose monitors (CGMs), and hundreds of thousands use insulin pumps.” And even during a hospital stay, people often want to retain their CGMs and insulin pumps. In addition to providing patients peace of mind, these technologies can help providers oversee and optimize glucose levels for their inpatient diabetes population.

CGMs

The two most common CGMs are Dexcom and Freestyle Libre, although they are currently not approved by the Food and Drug Administration (FDA) for inpatient use.

“CGMs measure glucose in the body’s interstitial fluid,” says Lewis. “In the hospital setting, there can be inaccuracies caused by dehydration, edema, low oxygen saturation, low blood count or medication interactions.” While patients may continue to wear their CGMs, they require finger-stick glucose testing before meals, at bedtime and whenever they self-report that their blood sugar could be high or low.

Insulin Pumps

An insulin pump is made up of an insulin-filled cartridge and a catheter inserted into the subcutaneous tissue. “We see a lot of patients who come into the hospital with pumps,” says Lewis. “First, we determine whether the pump is attached and working correctly.” 

• To be allowed to keep their pump during their hospital stay, patients must meet certain criteria. Contraindications to insulin pumps include impaired level of consciousness, critical illness or psychiatric conditions that could interfere with pump management. Additionally, if patients are in diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemia state (HHS), they cannot keep their pump on. 

Patients who do not meet the exclusion criteria sign a consent form acknowledging that they brought their pump and will be self-administering insulin. They are informed that if their glucose is not well controlled at any point during their hospitalization, they will need to remove their pump and have care providers take over with subcutaneous injections.

“The ADA [American Diabetes Association] Standards of Care goal is 140-180 mg/dL for most critically ill and noncritically ill patients, with some exceptions to an expanded goal of 110-140 or 100-180 without hypoglycemia,” says Lewis. “We want optimal glucose management to reduce infection and support healing in the hospital.” 

At University Hospitals, the pharmacy supplies insulin. “Patients must change their insulin pumps every three days; it is nonnegotiable,” says Lewis. “Sometimes, people in the hospital do not eat as much, so their insulin reservoir might last longer. However, insulin within pumps can become denatured after the three-day mark.”

Closed-Loop Systems

In recent years, closed-loop systems have enabled communication between insulin pumps and CGMs. The pump automatically adjusts insulin dosing based on CGM readings, improving accuracy and safety. “This gives people really good control, and patients are protective of their pump,” says Lewis. “If we are able to let them keep it on during their hospitalization, we would prefer that for them and us.” 

Special Circumstances

There are circumstances specific to the inpatient population that providers need to consider when managing patients with insulin pumps. “If someone is going into surgery, we have to decide if they can keep their pump on,” says Lewis. “For surgeries less than three hours, we generally let them keep the pump on as long as it is not in the way of the surgical site.” To reduce risk of hypoglycemia, pumps can be set to exercise or activity mode, raising their glucose target to 150 mg/dL.  

Steroid use is another concern, increasing risk of hyperglycemia. “There are a multitude of reasons why people need steroids in the inpatient setting,” says Lewis. “Frequently, we let them keep their pumps on, but we give them a shot of NPH [Neutral protamine Hagedorn] insulin to cover the steroid and take it out of the equation.”

For pumps that rely on learning algorithms, a steroid-induced demand for more insulin can impact future dosing. “In those cases, we switch the pumps out of automated mode.”

Additionally, pumps and CGMs must be removed before MRI and CT scans. For X-rays, they need to be removed if they obstruct the imaging field. “If patients have to disconnect their insulin pump or CGM early to have scans completed, we encourage them to call the manufacturer for a replacement,” says Lewis. 

For more information, contact the UH Diabetes and Metabolic Care Center at (440) 860-2353.

Contributing Expert:
Claudia Lewis, MMS, PA-C
Endocrinology Physician Assistant
University Hospitals Diabetes and Metabolic Care Center