Ohio Nurses Use Their Wits to Solve a Clinical Care Dilemma

When the pandemic hindered care for their ICU patients living with diabetes, nurses in an Ohio health system took advantage of new technology and a federal waiver to solve the problem.

With COVID-19 reducing contact with patients in the ICU, nurses at The Ohio State University Wexner Medical Center found they couldn't manage daily care for their charges living with diabetes. So, they got creative.

Nurses in the medical ICU (MICU) at the Columbus health system partnered with diabetes nurse practitioners to create a digital health-based process that allows nurses to monitor patients' blood glucose levels and administer insulin from outside the patients' rooms.

In doing so, they took advantage of two fast-growing segments of the healthcare innovation space: a booming industry in digital health tools and devices for chronic care management, and a population on the front lines of healthcare in desperate need of new technologies and workflows to improve patient care.

"Nurses are innately innovative," says Hunter Jefferis, MSN, RN, CCRN-K, MICU nurse manager at The Ohio State University Wexner Medical Center. "At the onset of the pandemic, [the] crisis accelerated innovation, driven by a need to protect and support our critical care nursing teams. Through collaboration with our endocrinology team, we seized the opportunity presented by the FDA to develop a hybrid protocol for continuous glucose monitoring for our COVID+ hyperglycemic patients in the ICU setting."

The process recently earned the health system’s University Hospital and nearby Ross Heart Hospital the 2021 Magnet Prize from the American Nurses Credentialing Center (ANCC). As a result, the nurses are in the midst of a multi-site, retrospective study with other health systems that are using the protocol.

"It is truly a testament to our profession that despite the challenges we all face with the COVID-19 pandemic, we are able to remain resilient and create innovative solutions to enhance the care for our patients," Jacalyn Buck, chief nursing officer at Ohio State Wexner Medical Center, said in a press release announcing the award. "This groundbreaking innovation designed by my team has made a lasting impact on the care for COVID-19 patients with hyperglycemia and will continue to improve care for many more."

In creating this new treatment plan, the nurses drew upon home-based blood glucose monitoring tools and platforms that have been in use for years. The consumer-facing digital health market has created a vast number of devices and mHealth apps that allow those living with diabetes to monitor their blood glucose levels—in some cases without invasive finger pricks—and deliver insulin, sometimes through devices attached to the skin.

Laureen Jones, a clinical nurse specialist at the health system, says those continuous glucose monitoring (CGM) systems have only been permitted by the U.S. Food and Drug Administration for outpatient use. However, with the pandemic affecting workflows within hospitals, the FDA issued a statement in April 2020 allowing CGM use in the inpatient setting for the duration of the public health emergency.

Within a month, she says, the health system had created a multidisciplinary team and developed the workflow to replace the traditional process of finger sticks every hour and insulin administered based on those readings. The first patient received a device on May 12, 2020.

"The nurse places a sensor and transmitter on the patient, which emits a signal to a receiver that is placed outside of the patient's room that continually displays a blood glucose reading," Jones explains. "This, along with an externalized IV pump, allows the nurse to assess and treat the patient with hourly IV insulin without having to make an unnecessary trip into the room. This saves the nurse exposure and conserves personal protective equipment as the required trips into the room to treat the patient with insulin is reduced from 24 times to four times a day."

"As we have developed a hybrid protocol, the device is initially validated with every patient and allows for continued validation every six hours with a point-of-care blood glucose to confirm its accuracy," she adds. "This protocol has mitigated any risk that would be associated with device capabilities and has proven to be safe for the patient."

Officials noted the FDA hadn't—and still hasn't—approved CGM for inpatient use because of concerns about the reliability of the data coming from those devices. If that information isn't accurate, a patient might get too much insulin, resulting in hypoglycemia, or the patient might not get enough insulin, which leaders to hyperglycemia. In both cases, the patient could slip into a coma and die.

"In order to ensure safety, we worked with a multidisciplinary team to create a hybrid protocol that ensured the CGM accuracy was validated initially using fingerstick in each patient, and then accuracy was assessed with finger sticks every six hours," says Eileen Faulds, PhD, MS, RN, FNP-BC, CDCES, an associate professor at The Ohio State University College of Nursing and diabetes practitioner at the hospital. "This allowed us to greatly reduce the frequency of nursing contact while ensuring patient safety."

"These outpatient CGM systems transmit data from a transmitter that is connected to a sensor worn on the patient's skin," she says. "The transmitter sends data to a receiver, which can be a small, free-standing device or the Dexcom app on a mobile phone. While the manufacturer says the devices will transmit data up to 20 feet, the team had concerns about the system's ability to transmit data through MICU walls and glass enclosures. The team tested the radius of transmission and any physical barriers ahead of launching the system. When the phones were used to capture and display glucose data, the data could be transmitted to a cloud-based server that allowed the diabetes team to view the data remotely."

"In order to protect patient identity, dummy or anonymous accounts were created and authenticated with dummy emails for each patient," she adds. "This created a unique anonymous data stream for each patient. Additionally, we asked nurses to annotate 'CGM' in the electronic medical record when they documented a CGM glucose value, so we could distinguish finger stick point-of-care from CGM glucose values."

According to Faulds, nurses reported that the new technology helped to improve workflows and efficiency. They also liked that the platform continuously monitored patients' blood glucose levels, displayed trends for each patient, and was set to issue alarms if those trends were dangerous. This, in turn, reduced stress on the nurses.

The FDA action to allow inpatient CGM treatment is one of hundreds taken by state and federal regulators during the pandemic to expand the use of and coverage for telehealth and mHealth tools and platforms. Many of those measures will stop with the end of the public health emergency, which is now expected to take place in 2023.

Health system executives worry that unless these measures are made permanent, hospitals will have to shut down telehealth programs, forcing providers to go back to the old way of doing things and leaving patients struggling to adapt to new and less effective care. With that in mind, telehealth advocates—including organizations like the American Telemedicine Association and Alliance for Connected Care, telehealth vendors and a number of large health systems—are lobbying both Congress and agencies like the FDA and Centers for Medicare & Medicaid Services to make those emergency measures permanent.