This is a story about innovation, technology and teamwork. It starts with the bold thinking and determination of Magdalena Bogun, MD, an adult endocrinologist at the Naomi Berrie Diabetes Center.
During a three-month time period beginning April 2020, approximately 200 patients came to the NewYork-Presbyterian/Columbia University Irving Medical Center (CUIMC) emergency department with diabetic ketoacidosis (DKA) due to Covid-19. The majority of these patients had pre-existing type 2 diabetes.
“This was highly unusual,” said Dr. Bogun who heads the inpatient service for patients with diabetes at CUIMC, “We haven’t seen numbers like that before. That is a lot of patients with DKA. We knew we were faced with a dilemma.”
Traditionally, patients who come to the emergency department with DKA are treated in the intensive care unit (ICU) because blood glucose checks are required every hour when a patient is in this potentially dangerous state. The ICU is equipped to deal with these strict hourly protocols. Other floors typically don’t have the capacity to conduct hourly finger sticks.
During the Spring of 2020 when Covid-19 was rampant, the ICU was swamped. There was a shortage of ICU beds. Dr. Bogun realized she could help alleviate this problem to some degree.
"Many patients who have DKA and are hemodynamically stable, might not need to go to the ICU,” she said. “They aren’t on ventilators, but traditionally they go to the ICU because they need finger sticks every hour. I realized we needed to make a change and move these patients out of the ICU.”
In addition to a shortage of beds, there was also a shortage of personal protective equipment (PPE) during those initial days. For a nurse to have to take a patient’s blood glucose every hour meant multiple exposures and an increased need for protection.
To address this issue, Dr. Bogun talked with her colleagues at the Berrie Center, nursing leadership, and physicians in the emergency department and stepdown unit at the hospital. Together they devised a plan to monitor glucose levels remotely via a continuous glucose monitor (CGM), the Dexcom G6.
“We all felt this plan would make a considerable impact on the care of patients with diabetes who come to the emergency room with DKA,” said Dr. Bogun.
A continuous glucose monitor (CGM) is a device used to track glucose levels throughout the day and night and can alert someone with diabetes if his or her levels go too high or low. CGM systems take glucose measurements at regular intervals, as frequently as every 5 minutes, and translate them into data to show glucose direction and rate of change.
A CGM works through a tiny sensor inserted under the skin. A transmitter wirelessly sends the information to a monitor, which might be an insulin pump, a separate device, a smartphone or tablet.
“By using a CGM on these patients with DKA, the hourly fingerstick issue is resolved and ICU beds will be available for others who need critical care. We could move these patients in DKA from the ICU to “stepdown”. In addition, a CGM would reduce some of the PPE burden because a nurse would not need to enter the patient’s room hourly; the patient’s blood sugar would be visible on a monitor.”
(The stepdown unit is an area where patients go upon discharge from the ICU or emergency department. Stepdown beds provide an intermediate level of care for patients with requirements somewhere between that of the general ward and the ICU.)
The way the program operates is when a patient is identified by ICU triage as eligible for the CGM program, trained staff (called super-users) put a CGM on the patient (which Dr. Bogun oversees via FaceTime). Once set up is complete, the patient is assigned three phones and brought to a different floor.
One phone which has the Dexcom G6 app, is located on an IV pole next to the insulin infusion. This phone always has to be within 20 feet of the patient. The remaining two phones have Dexcom Follow apps and are given to a nurse and doctor who are taking care of the patient. The nurse and doctor keep those phones with them and can monitor glucose data at all times. This means fewer finger sticks and interruptions for the patient, and more information for the providers.
This project was an enormous undertaking and a huge accomplishment for Dr. Bogun and her team. She said collaboration was key in making this happen.
“Getting everyone on board with this concept, talking to people about the equipment involved, figuring out the logistics and conducting the trainings took months,” she said. “People were initially scared because it was something very new and no one wanted extra work during an already challenging time, but at the same time this is an effort to reduce the work because it eliminates the need to do finger sticks.”
In total, 32 patients have received a CGM in the hospital. Dr. Bogun admits the process needs more fine-tuning, but she hopes one day it will be commonplace.
“If we can show this equipment really works, which we know it does-- even in sick patients, it is my hope to continue this program even after this pandemic ends. I want to keep people with DKA out of the ICU and save the ICU beds for others who are more critically ill.”
Dr. Bogun plans to publish the findings of her program in the near future.