Revolutionizing Hypoglycemia Management in Long-Term Care: Lessons Learned From a Pilot Quality Improvement Initiative Using Continuous Glucose Monitoring

Abstract

Despite efforts to raise glycemic targets and reduce modifiable risk factors, hypoglycemia continues to impact a large number of long-term care (LTC) residents living with diabetes mellitus and remains one of the leading causes of hospitalization in this cohort. Effective, sustainable practice strategies to monitor and maintain glycemic control in LTC are lacking. We describe the stepwise approach used by 2 LTC homes that switched from traditional fingerstick testing to a continuous glucose monitoring (CGM) system as part of a quality improvement initiative to reduce nursing workload and address hypoglycemia. This was an exploratory pilot project. A working group was established at each of the 2 participating LTC homes, including representatives from management and direct care staff. Kickoff meetings were held with key direct care staff to discuss the limitations of current monitoring practices and potential solutions. The following interventions were agreed upon and implemented by the working groups: (1) the initiation of structured glucose monitoring for residents using CGM (FreeStyle Libre 2), requiring scanning of sensors 4 times per day; (2) provision of staff education and training on CGM by a diabetes expert; and (3) scheduling of interdisciplinary rounds as needed to optimize diabetes management. System changes were gradually introduced in a stepwise manner over a 3-month period (intervention phase), during which the LTC homes progressed from traditional fingerstick testing to point-of-care sensor readings and then to full use of the CGM software platform. Hypoglycemia was defined as a glucose reading of ≤4 mmol/L. Glucose readings were collected from 38 residents living with diabetes mellitus and receiving insulin in the 6 months before the start of the intervention phase (baseline evaluation) and in the 6 months after the end of the intervention phase (post-launch evaluation). All hypoglycemic readings detected by a sensor at a point-of-care test were validated using a fingerstick test. Nursing workload associated with glucose testing was assessed in an anonymous survey of nursing staff at baseline and after the launch. The approach resulted in a 40% reduction in nursing time required to complete a glucose reading (from 5.1 min per test at baseline to 3.1 min per test at the post-launch evaluation). The frequency of glucose monitoring increased from a total of 19,438 glucose readings in the baseline evaluation to 35,971 point-of-care sensor scans in the post-launch evaluation. The number of detected hypoglycemic events increased 12-fold, from 88 in the baseline evaluation to 1049 in the post-launch evaluation. Hypoglycemic events continue to impact a large number of LTC residents living with diabetes mellitus. CGM can improve the detection of hypoglycemic events while decreasing nursing workload. A gradual transition to CGM can help overcome underlying barriers and concerns and ensure a sustainable approach.

Keywords: continuous glucose monitoring; detection; diabetes; hypoglycemia; long-term care; nursing.