As we have discovered over the past few weeks, the U.S. has continued to see increasing incidence of diabetes as one of the top eight disease burdens.  The prevalence has increased globally with a ranking of 3rd in 2016 for the leading cause of disabilities in the U.S. (The U.S. Burden of Disease Collaborators, 2018). This is even more alarming with the world’s aging population who is at greater risk for developing diabetes and the multitude of complex complications.  Adults 60 years or older often have higher co-morbidities secondary to age that when combined with diabetes lead to diabetes-related conditions, such as myocardial infarctions, lower extremity amputations,  renal disease, cognitive impairment and dementia, and visual disturbances, which place them at higher risks for death and disability (Valencia et al., 2018). Diabetes management continues to be essential in the prevention of diabetes related complications. Evidence has shown that diabetes self-management, medication management, dietary compliance and exercise, and patient education continue to be primary interventions in the management of this complex disease. However, as these have not demonstrated improvements in glycemic control or prevention of hypoglycemic serious events, the need to add additional interventions utilizing technology are warranted.  One such intervention is the addition of continuous glucose monitoring in both type 1. Continuous glucose monitoring (CGM) has arisen over the last decade initially as an adjunct treatment to finger sticks and A1C monitoring (Hirsch et al., 2019).  In response to patient preference, compliance with treatment and monitoring plans, quality of monitoring, and cost effectiveness, more studies and evaluation of CGM has emerged. In addition, the need to prevent serious complications related to hypoglycemic events also led to more research and trials in the use of continuous glucose monitoring (Bergenstal, 2018).    In our organization, most patients do not continue using their insulin pumps or continuous glucose monitors during acute events in the hospital. Implementation of a research-based intervention such as CGM for Type 1 diabetics would allow for stabilization of patient glucose levels and prevent serious complications related to hypoglycemia that we often have seen. What are the potential benefits and harms related to your selected practice problem when considering a research-based intervention for your practice change project? The use of CGM in diabetes is believed to allow for several benefits. First, it can assist in the prevention of hypoglycemia in patients who often are not aware of extreme drops in glucose levels.  Routine finger glucose sticks were often the standard in diabetic monitoring but were not always performed as scheduled or felt to be of high importance to adults with diabetes. CGM allows for real time data to be reviewed by patients; can identify quick changes in the patient’s glucose levels with meals.

1. As we have discovered over the past few weeks, the U.S. has
continued to see increasing incidence of diabetes as one of the
top eight disease burdens. The prevalence has increased
globally with a ranking of 3rd in 2016 for the leading cause of
disabilities in the U.S. (The U.S. Burden of Disease
Collaborators, 2018). This is even more alarming with the
world’s aging population who is at greater risk for developing
diabetes and the multitude of complex complications. Adults 60
years or older often have higher co-morbidities secondary to age
that when combined with diabetes lead to diabetes-related
conditions, such as myocardial infarctions, lower extremity
amputations, renal disease, cognitive impairment and dementia,
and visual disturbances, which place them at higher risks for
death and disability (Valencia et al., 2018). Diabetes
management continues to be essential in the prevention of
diabetes related complications. Evidence has shown that
diabetes self-management, medication management, dietary
compliance and exercise, and patient education continue to be
primary interventions in the management of this complex
disease. However, as these have not demonstrated improvements
in glycemic control or prevention of hypoglycemic serious
events, the need to add additional interventions utilizing
technology are warranted. One such intervention is the addition
of continuous glucose monitoring in both type 1.
Continuous glucose monitoring (CGM) has arisen over the last
decade initially as an adjunct treatment to finger sticks and A1C
monitoring (Hirsch et al., 2019). In response to patient
preference, compliance with treatment and monitoring plans,
quality of monitoring, and cost effectiveness, more studies and
evaluation of CGM has emerged. In addition, the need to
prevent serious complications related to hypoglycemic events
also led to more research and trials in the use of continuous

2. glucose monitoring (Bergenstal, 2018).
In our organization, most patients do not continue using their
insulin pumps or continuous glucose monitors during acute
events in the hospital. Implementation of a research-based
intervention such as CGM for Type 1 diabetics would allow for
stabilization of patient glucose levels and prevent serious
complications related to hypoglycemia that we often have seen.
What are the potential benefits and harms related to your
selected practice problem when considering a research-based
intervention for your practice change project?
The use of CGM in diabetes is believed to allow for several
benefits. First, it can assist in the prevention of hypoglycemia
in patients who often are not aware of extreme drops in glucose
levels. Routine finger glucose sticks were often the standard in
diabetic monitoring but were not always performed as scheduled
or felt to be of high importance to adults with diabetes. CGM
allows for real time data to be reviewed by patients; can
identify quick changes in the patient’s glucose levels with meals
or exercise and warns patients of hypoglycemic events that may
otherwise have been unnoticed (Bergenstal, 2018). Studies have
shown that the use of CGM has allowed for better control of
A1C levels, less time in hyperglycemic events, and decreased
incidences of severe hypoglycemic events (Hirsch, et al., 2019).
Using the CGM during the hospitalization allows for
monitoring of glucose levels during times of stress and acute
illness and can be essential in the prevention of hyper-hypo
events during periods of NPO status related to diagnostic
testing.
Studies have shown some concerns related to CGM especially in
the use of older adults. First, as with any new technology,
patients must receive product instructions and all educational
information related to the therapy. To perform this

3. implementation, several guidelines to ensure safe and ethical
patient practices must be followed. Our goals for the
intervention should answer clear questions regarding the
purpose and benefits that CGM will provide to our patients.
Patients are to be provided education regarding the monitoring
that will occur and should have their privacy maintained,
updated on any changes in their treatment plan, and monitored
closely for any adverse effects during their hospitalization
(NIH). Older patients may not have a clear understanding of
this advanced treatment or how the use of smart phones or
recording devices work. They may need additional education
and support while hospitalized.
Are there competing personal or professional values related to
this research-based intervention that might impact the
implementation of this intervention in your practice setting?
There are several types of devices that could be used our
intervention. We would wish to reduce bias and evaluate the
benefits and impediments of various models prior to
implementation. Cost effective monitors would be preferred but
not at the expense of utilizing a poorly reviewed technology
that does not have quality outcomes for our patients. In review
of types of CGM, there are newer models that are inserted into
the subcutaneous tissue and allow for quick removal if needed.
Previous studies show these to be effective and safe for insulin
dosing but do need further evaluation of hypoglycemic events
(Elshimy & Correa, 2020). As it would be necessary to ensure
accuracy of glucose levels via the continuous monitors,
fingersticks, and lab draws may still be needed. Patients may be
confused as to why they are receiving multiple interventions.
We would wish to reduce patient fears and anxiety by
supporting and re-educating as needed.
In addition, education to nursing staff and providers is essential
prior to implementation of this intervention. With some current

4. challenges with nurse staffing in our organization, there may be
barriers to nurse buy-in with additional tasks being assigned to
them during the trial. I would wish to ensure that nurses
understand the reason for the trial and can engage in their
importance to prevent events of hypoglycemia and improve
patient outcomes.
What types of objections might be raised? How will you explain
your decision to key stakeholders to address these objections?
Some objections related to the intervention may be related to
the inexperience and knowledge of providers and nursing staff.
Some may find the process to perform the data retrieval as
difficult or as added tasks to the workload. There may also be
barriers related to cost and accuracy. Sharing that CGM has
noted accuracy of a 10% absolute difference when compared to
capillary glucose results may reduce these concerns (Elshimy &
Correa, 2020). Training superusers to better understand the
CGM, provide education to patients, and insert the monitor can
assist with workflow and quality controls during the
hospitalization (Hirsch et al.., 2019). In addition, the cost of
this intervention may be covered by insurance or Medicare
dependent upon the patient’s current diabetes management.
The continuation of a CGM is shown to improve glycemic
control for patients and could be worn for up to 14 days. This
could provide clearer results for primary care physicians upon
retrieval after discharge. There would be the need to continue
patient education and understanding related to care for the
monitor as well as any self-management interventions based
upon glucose results. Education on the monitor screen and
retrieval of results would be needed. If older or cognitively
challenged patients have difficulties with manipulation or
understanding of the CGM, it may require removal and return to
standard treatment modality and fingersticks may be needed.
Teach-back for patient education is necessary in the evaluation

5. for safe glucose monitoring and care after discharge (Hirsch et
al., 2019).
Diabetes continues to be a leading healthcare concern and relies
upon various modalities of self care in the maintenance of
glucose levels. Using continuous glucose monitoring while in
the hospital could prevent episodes of hypoglycemia that many
diabetics are prone to during acute illness. There is evidence
that this intervention has been successful in maintaining glucose
control in type 1 diabetics and is being evaluated more often
now in the treatment for type 2 as well.
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