Facilitators and Barriers to Nursing Implementation of Continuous Glucose Monitoring (CGM) in Critically Ill COVID-19 Patients

Faulds, Eileen R.; Jones, Laureen; McNett, Molly; Smetana, Keaton S.; May, Casey C.; Sumner, Lyndsey; Buschur, Elizabeth; Exline, Matthew; Ringel, Mathew D.; Dungan, Kathleen

AIMS: We (a) describe our implementation of a continuous glucose monitoring (CGM) guideline to support intravenous (IV) insulin administration and reduce point of care (POC) glucose monitoring frequency in the COVID-19 medical intensive care unit (MICU) and (b) evaluate nurses experience with implementation of CGM and hybrid POC + CGM protocol using the PARIHS framework for implementation. METHODS: A multidisciplinary team created a guideline providing criteria for establishing initial sensor-meter agreement within each individual patient followed by hybrid use of CGM and POC. POC measures were obtained hourly during initial validation, then every 6 hours. We conducted a focus group among MICU nurses to evaluate initial implementation efforts using the PARIHS framework with content areas focused on initial assessment of evidence, context, and facilitation to identify barriers and facilitators. The focus group was analyzed using a qualitative descriptive approach. RESULTS: The protocol was integrated through a rapid cycle review process and ultimately disseminated nationally. The Diabetes Consult Service performed device set up and nurses received just-in-time training. The majority of barriers centered on contextual factors, including limitations of the physical environment, complex device set-up, hospital firewalls, need for training, and CGM documentation. Nurses perceived device accuracy and utility were exceptionally high. Solutions were devised to maximize facilitation and sustainability for nurses while maintaining patient safety. CONCLUSION: Outpatient CGM systems can be implemented in the MICU using a hybrid protocol implementation science approach. These efforts hold tremendous potential to reduce healthcare worker exposure while maintaining glucose control during the COVID-19 pandemic.