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The COVID-19 pandemic required healthcare providers to quickly pivot and modify usual routines, creating new protocols of care across their systems. Inpatient glycemic management has always been critical to patient safety and outcomes, but COVID presented new challenges and urgency.
During a recent webinar, co-hosted with The Association of Diabetes Care & Education Specialists (ADCES), three nurses shared case studies about how they managed and improved care as COVID emerged as a crisis in early 2020. The strategies and tools they employed included remote monitoring, leveraging technology, mitigating the impact of steroids on blood glucose, bundling care to preserve PPE, as well as collaborating with pharmacy departments to streamline nursing workflows.
The panel’s three expert nurses were:
Each presenter detailed their hospital’s challenges and how they found innovative solutions to meet and improve standards of care and to improve their overall inpatient glycemic management process and outcomes.
Novant Health
Adapting rapidly to the potential influx of COVID-19 patients, Novant Health evaluated how they could take their workforce remote as well as leverage technology wherever possible including glucose surveillance.
Pre-pandemic, every acute facility within the Novant Health system did not have a dedicated diabetes educator and as part of their surge plan they wanted to develop a system to provide their community hospitals with support and resources around glycemic management.
So what did their remote environment look like? Novant Health adopted telehealth to provide a virtual working environment for their diabetes educators and to supplement provider care. They implemented tablets for consults as well as personalized hospital room calls for patients and their family members. In order to streamline their diabetes educators' workflows, Novant Health was able to narrow down their education topics to “diabetes survival skills” and focus on what the patient really needed to know before they were discharged.
In addition to taking their diabetes educators virtual, Novant Health utilized glucose surveillance to identify high-risk patients that had two blood glucose levels of greater than 180 in a 24-hour period. Gallimore stated, “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 on those patients.”
Novant Health was able to reduce health disparities across facilities by increasing diabetes educator coverage to all sites within their North Carolina hospitals. By including community hospitals their staff and especially their nurses felt supported during an unprecedented transition. The telehealth processes also improved efficiency and collaboration between interdisciplinary team members. The glycemic review committee used metrics and insights to educate providers and iterate on improvements, which all positively impacted their hypoglycemic and hyperglycemic events.
University of New Mexico Hospitals
Following an initial well-mitigated first wave of COVID-19 in March 2020, the surge for University of New Mexico Hospital didn’t hit until the second wave this past fall. Because of the increase in patients at the end of 2020 they were challenged to adapt and make process changes they had previously avoided.
UNM Hospital was struggling with the surge of COVID-19 patients being over bed capacity and working to evolve with the virus. Their challenges included maintaining PPE, decreasing time in patient rooms, delivering medications safely and reducing adverse COVID-19 events in patients with diabetes. It was imperative to get insulin cosigned and to maintain safety procedures for staff exposure while getting current blood glucose readings to calculate insulin doses, and then giving that dose without ever leaving the room.
Duran noted, “an additional factor with COVID-19 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. Many of our patients at UNM Hospitals – not only were they new to diabetes and insulin, but adding much-needed steroid into their treatment plan was a challenge in and of itself.”
What has been their solution? Duran said, “one of the best solutions we had, had actually been hiding the whole time.” Several years ago, prior to the pandemic, pharmacy and respiratory therapy had rolled out the install of 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 access to these boxes.
When COVID-19 hit, they started storing rapid-acting insulin and syringes in the lockboxes. This reduced stress by allowing the nurse to draw up the insulin inside the room at the same time that they took the patient’s current blood glucose to determine the appropriate dose. Since UNM Hospital requires the cosignature of insulin, nurses communicated with those outside the room verbally or by using FaceTime.
One of the biggest challenges UNM Hospital experienced was steroid treatment, which continues to be a barrier for excellent insulin management within their system. Duran explained, “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.”
Through many changes in staffing, including traveling nurses and shifting providers, the pharmacy department acted as a consistent presence at UNM Hospital, becoming instrumental in making dosing adjustment recommendations up or down and mitigating some major medication issues. Since diabetes educators at their hospital are remote for COVID-positive patients, pharmacists worked directly with providers to ensure the best possible dosing fit for insulin.
Overall Duran said, “nursing has really adopted this workflow well, and we continue to expand to 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 in real-time. Providers, nursing and pharmacy all work together to help reach our goals, and we’re continuing to make improvements.”
Grady Health System
Grady Health System began their eGlycemic Management System journey in October 2016 and in the first six months of adoption optimized nursing workflows utilizing Glucommander for patients requiring continuous IV insulin. With the normal ratio of 2 ICU patients per every ICU nurse, it was important to continue the optimization of nursing workflows and glucose management amidst the expanding ratio of ICU patients to nurses.
When COVID-19 first hit Grady Health System, they worked to develop a plan and standardize their processes to manage PPE and minimize exposure to staff. This is increasingly difficult in an ICU setting as staff are managing ventilators, insulin, vasopressors, antibiotics and steroids. Oftentimes a nurse was spending 1-2 hours in a room at a time, so there was a clear need to reduce time spent in patient rooms.
In order to reduce this time in the room, Barbara McLean shared that by using extremely long extension tubing Grady Health System placed IV infusion pumps outside of the ICU rooms. While they faced some challenges with delay times between the blood glucose check and the insulin dosing as well as preparing for adverse effects with patients on aggressive vasopressors, this change was successful.
McLean stated that one of the biggest takeaways thus far have been, “recognition that in general, intensive care staff – not being diabetic educators – 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.”
Conclusion
Novant Health, UNM Hospitals and Grady Health System were able to leverage their use of innovative technology, strategic collaboration, and commitment to glycemic management best practice to adapt more quickly to the challenges of glycemic management during COVID-19. Many of the innovations that were meant to be short-term solutions to mitigate PPE shortage and risk of exposure for clinicians may also end up being incorporated into long-term strategies for providing better glycemic management care because they also address longstanding challenges. The pandemic necessitated rapid change and increased teamwork, but it has also positioned these three facilities to meet the unknown challenges the future may bring.
References
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