Insulin Pumps and Hybrid Close Loop Systems Within Hospital: A Scoping Review and Practical Guidance From the Joint British Diabetes Societies for Inpatient Care

Review Article - Diabetes Technology in the Hospital: An Update

PURPOSE OF REVIEW

There have been many developments in diabetes technology in recent years, with continuous glucose monitoring (CGM), insulin pump therapy (CSII) and automated insulin delivery (AID) becoming progressively accepted in outpatient diabetes care. However, the use of such advanced diabetes technology in the inpatient setting is still limited for several reasons, including logistical challenges and staff training needs. On the other hand, hospital settings with altered diet and stress-induced hyperglycemia often pose challenges to tight glycemic control using conventional treatment tools. Integrating smarter glucose monitoring and insulin delivery devices into the increasingly technical hospital environment could reduce diabetes-related morbidity and mortality. This narrative review describes the most recent literature on the use of diabetes technology in the hospital and suggests avenues for further research.

RECENT FINDINGS

Advanced diabetes technology has the potential to improve glycemic control in hospitalized people with and without diabetes, and could add particular value in certain conditions, such as nutrition therapy or perioperative management. Taken together, CGM allows for more accurate and patient-friendly follow-up and ad hoc titration of therapy. AID may also provide benefits, including improved glycemic control and reduced nursing workload. Before advanced diabetes technology can be used on a large scale in the hospital, further research is needed on efficacy, accuracy and safety, while implementation factors such as cost and staff training must also be overcome.

Type 1 Diabetes Management in the Hospital Setting

The incidence of diabetes in children and adolescents has increased during the past decades, with a 1.9% increase per year in type 1 diabetes mellitus (T1DM). Patients with diabetes have a greater risk of hospitalizations compared with those without diabetes. Clear evidence has emerged in the past decade that supports appropriate glycemic control in the hospital setting to improve clinical outcomes and reduce the risk of hospital complications and mortality. Determining the appropriate insulin regimen in patients with T1DM in the hospital depends on the clinical status, type of outpatient insulin regimen (multiple daily injections versus pump therapy), glycemic control before admission, nutritional status, procedures, and enteral versus parenteral nutrition. Due to the complexity of the inpatient management of diabetes, institutions should have an inpatient diabetes management team that includes dietitians, diabetes educators, nurses, pharmacists, social workers, and endocrinologists. The use of inpatient diabetes teams has been demonstrated to be beneficial in the management of patients with T1DM.

Society for Ambulatory Anesthesia Updated Consensus Statement on Perioperative Blood Glucose Management in Adult Patients With Diabetes Mellitus Undergoing Ambulatory Surgery

WHAT OTHER GUIDELINES ARE AVAILABLE ON THIS TOPIC

Since the publication of the SAMBA Consensus Statement for perioperative blood glucose management in the ambulatory setting in 2010, several recent guidelines have been issued by the American Diabetes Association (ADA), the American Association of Clinical Endocrinologists (AACE), the Endocrine Society, the Centre for Perioperative Care (CPOC), and the Association of Anaesthetists of Great Britain and Ireland (AAGBI) on DM care in hospitalized patients; however, none are specific to ambulatory surgery.

HOW DOES THIS GUIDELINE DIFFER FROM THE PREVIOUS GUIDELINES

Previously posed clinical questions that were outdated were revised to reflect current clinical practice. Additional questions were developed relating to the perioperative management of patients with DM to include the newer therapeutic interventions.

7. Diabetes Technology: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Glycemic control metrics in a cohort of hospitalized patients with type 1 diabetes using hybrid closed-loop and advanced hybrid closed-loop systems

AIMS

To describe Hybrid closed-loop (HCL) and advanced hybrid closed-loop (AHCL) performance in the hospital setting based on the continuous glucose monitoring (CGM) metrics description.

METHODS

This was an observational study from a cohort of patients with T1D using HCL/AHCL with history of hospitalization. CGM metrics were analyzed during the hospital stay. CGM metrics sub-analysis of the population with active Automated Mode (AM) and SmartGuard (SG) during hospitalization and/or surgical procedure was performed.

RESULTS

Twenty-four patients were included (50 % women; mean age, 49 years [inter-quartile range (IQR), 39-62 years]). During hospitalization 70.8 % patients achieved %Time in Range (TIR) between 70 and 180 mg/dL ≥ 70 %. The overall %TIR was 75.5 % (IQR, 67.3-81.5 %), % time below range (TBR) < 70 mg/dL was 2.1 % (IQR, 0.7-5.4 %) and %TBR < 54 mg/dL was 0 % (IQR, 0-5.4 %). Users of the AHCL with active SG achieved a non-significant higher %TIR during hospitalization (79 % [73.8.88 %] vs. 76 % [72.81 %], p = 0.312) and had a shorter stay (3[IQR, 2.4] vs. 6 days[IQR, 5.7], p = 0.045) compared to the users of the HCL with AM active. No device-related serious adverse events occurred for users of either system.

CONCLUSIONS

HCL/AHCL systems with active AM/SG in patients with T1D in the hospital environment leads to %TIR > 70 % in ranges of 70-180 mg/dL in patients without increasing hypoglycemia.

UK's Association of British Clinical Diabetologist's Diabetes Technology Network (ABCD-DTN): Best practice guide for hybrid closed-loop therapy

This best practice guide is written with the aim of providing an overview of current hybrid closed-loop (HCL) systems in use within the United Kingdom's (UK) National Health Service (NHS) and to provide education and advice for their management on both an individual and clinical service level. The environment of diabetes technology, and particularly HCL systems, is rapidly evolving. The past decade has seen unprecedented advances in the development of HCL systems. These systems improve glycaemic outcomes and reduce the burden of treatment for people with type 1 diabetes (pwT1D). It is anticipated that access to these systems will increase in England as a result of updates in National Institute of Health and Care Excellence (NICE) guidance providing broader support for the use of real-time continuous glucose monitoring (CGM) for pwT1D. NICE is currently undertaking multiple-technology appraisal into HCL systems. Based on experience from centres involved in supporting advanced technologies as well as from the recent NHS England HCL pilot, this guide is intended to provide healthcare professionals with UK expert consensus on the best practice for initiation, optimisation and ongoing management of HCL therapy.

Variation in the Current Use of Technology to Support Diabetes Management in UK Hospitals: Results of a Survey of Health Care Professionals

BACKGROUND

There has been a significant increase in the use of wearable diabetes technologies in the outpatient setting over recent years, but this has not consistently translated into inpatient use.

METHODS

An online survey was undertaken to understand the current use of technology to support inpatient diabetes care in the United Kingdom.

RESULTS

Responses were received from 42 different organizations representing 104 hospitals across the United Kingdom. Significant variation was found between organizations in the use of technology to support safe, effective inpatient diabetes care. Benefits of the use of technology were reported, and areas of good practice identified.

CONCLUSION

Technology supports good inpatient diabetes care, but there is currently variation in its use. Guidance has been developed which should drive improvements in the use of technology and hence improvements in the safety and effectiveness of inpatient diabetes care. Key recommendations include implementation of this guidance (especially for continuous glucose monitoring), ensuring specialist support is available for the use of wearable diabetes technology in hospital, optimizing information sharing across the health care system, and making full use of data from networked glucose and ketone meters.