Implementation of Networked Continuous Glucose Monitoring With Telemetry Within the Intensive Care Unit (ICU-TeleCGM)

Aim: To assess safety and implementation of networked CGM with ViewsEMR® telemetry within ICU.

The study will be conducted in a two-stage process:

* Phase 1: A single arm (non-randomised) unmasked feasibility study with adjunctive use of networked CGM using the Dexcom G7 system and ViewsEMR® telemetry. This phase will be conducted at a single site at Imperial College Healthcare NHS Trust (ICHNT).
* Phase 2: A randomised, parallel-group pilot study with adjunctive use of networked CGM using the Dexcom G7 system and ViewsEMR® telemetry compared to standard of care. This phase will be conducted at three hospitals within the same site: ICHNT (St Mary's Hospital, Charing Cross Hospital and Hammersmith Hospital). The study will be conducted at Imperial College Healthcare NHS Trust in people with hyperglycaemia on admission to ICU requiring insulin.

• Dexcom G7 (Device): Continuous glucose monitoring.
• ViewsEMR telemetry (Device): ViewsEMR Telemetry is a digital platform used to monitor participants' real-time CGM data and glucose trends

Primary outcomes

• Phase 1: Eligible participants that consent to participate. [Throughout Phase 1 study period, up to 6 months]: Percentage of eligible participants that consent to participate, including the percentage enrolled through participant informed consent, via personal consultee, and via nominated consultee.
• Phase 1: Time from admission to ICU to initiation of CGM [From admission to ICU to initiation of CGM, up to 48 hours]: Time in minutes from admission to ICU to initiation of CGM
• Phase 1: Time from consent to initiation of CGM [From enrollment to the end of intervention at 10 days]: Time from consent to initiation of CGM
• Phase 1: Percentage of CGM data availability for each participant [From enrollment to the end of intervention at 10 days]: Percentage of CGM data availability for each participant
• Phase 1: Percentage of participants successfully set-up on telemetry (ViewsEMR ®) [From enrollment to the end of intervention at 10 days]: Percentage of participants successfully set-up on telemetry (ViewsEMR ®)
• Phase 1: Number of premature sensor failures per participant (defined as <70% of anticipated use) [From enrollment to the end of intervention at 10 days]: Number of premature sensor failures per participant (defined as <70% of anticipated use)
• Phase 1: Number and type of adverse events related to CGM use (e.g., skin irritation, device malfunction) [From enrollment to the end of intervention at 10 days]: Number and type of adverse events related to CGM use (e.g., skin irritation, device malfunction)
• Phase 1: Proportion of participants completing the study [Throughout Phase 1 study period, up to 6 months]: Proportion of participants completing the study
• Phase 1: Proportion of nursing staff completing study survey [Throughout Phase 1 study period, up to 6 months]: Proportion of nursing staff completing study survey
• Phase 2: Number of episodes of hypoglycaemia per participant [Throughout Phase 2, up to 30 days]: Number of episodes of hypoglycaemia per participant (defined as <3.9mmol/L for 15minutes)

Secondary outcomes

• Phase 1: Safety Outcomes [From enrollment to the end of intervention, up to 10 days]: \- Duration of CGM signal loss (units: minutes)

Sex: All, ages: 18 Years to any

Inclusion Criteria:

* Age >18years inclusive
* Hyperglycaemia requiring insulin therapy (subcutaneous injection or intravenous insulin) during admission on ICU
* Admission to ICU within 48hours

Exclusion Criteria:

* Known significant allergy to tape/ adhesives
* Imminent death or anticipated length of stay <24hours
* Women who are pregnant
* Imminent extracorporeal membrane oxygenation (ECMO)
* Requirement for therapeutic temperature control (i.e. cooling) post cardiac arrest

• Wexler DJ, Meigs JB, Cagliero E, Nathan DM, Grant RW. Prevalence of hyper- and hypoglycemia among inpatients with diabetes: a national survey of 44 U.S. hospitals. Diabetes Care. 2007 Feb;30(2):367-9. doi: 10.2337/dc06-1715. No abstract available. PMID 17259511
• Dhatariya KK, Umpierrez G. Gaps in our knowledge of managing inpatient dysglycaemia and diabetes in non-critically ill adults: A call for further research. Diabet Med. 2023 Mar;40(3):e14980. doi: 10.1111/dme.14980. Epub 2022 Nov 16. PMID 36256494
• Tomlin AM, Tilyard MW, Dovey SM, Dawson AG. Hospital admissions in diabetic and non-diabetic patients: a case-control study. Diabetes Res Clin Pract. 2006 Sep;73(3):260-7. doi: 10.1016/j.diabres.2006.01.008. Epub 2006 Feb 28. PMID 16504336
• Sarkisian S, Fenton TR, Shaheen AA, Raman M. Parenteral nutrition-associated hyperglycemia in noncritically ill inpatients is associated with higher mortality. Can J Gastroenterol. 2010 Jul;24(7):453-7. doi: 10.1155/2010/718526. PMID 20652162
• Baker EH, Janaway CH, Philips BJ, Brennan AL, Baines DL, Wood DM, Jones PW. Hyperglycaemia is associated with poor outcomes in patients admitted to hospital with acute exacerbations of chronic obstructive pulmonary disease. Thorax. 2006 Apr;61(4):284-9. doi: 10.1136/thx.2005.051029. Epub 2006 Jan 31. PMID 16449265
• Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002 Mar;87(3):978-82. doi: 10.1210/jcem.87.3.8341. PMID 11889147
• Hulkower RD, Pollack RM, Zonszein J. Understanding hypoglycemia in hospitalized patients. Diabetes Manag (Lond). 2014 Mar;4(2):165-176. doi: 10.2217/DMT.13.73. PMID 25197322
• Curkendall SM, Natoli JL, Alexander CM, Nathanson BH, Haidar T, Dubois RW. Economic and clinical impact of inpatient diabetic hypoglycemia. Endocr Pract. 2009 May-Jun;15(4):302-12. doi: 10.4158/EP08343.OR. PMID 19502209
• Turchin A, Matheny ME, Shubina M, Scanlon JV, Greenwood B, Pendergrass ML. Hypoglycemia and clinical outcomes in patients with diabetes hospitalized in the general ward. Diabetes Care. 2009 Jul;32(7):1153-7. doi: 10.2337/dc08-2127. PMID 19564471
• Cook CB, Kongable GL, Potter DJ, Abad VJ, Leija DE, Anderson M. Inpatient glucose control: a glycemic survey of 126 U.S. hospitals. J Hosp Med. 2009 Nov;4(9):E7-E14. doi: 10.1002/jhm.533. PMID 20013863
• Pickup JC, Freeman SC, Sutton AJ. Glycaemic control in type 1 diabetes during real time continuous glucose monitoring compared with self monitoring of blood glucose: meta-analysis of randomised controlled trials using individual patient data. BMJ. 2011 Jul 7;343:d3805. doi: 10.1136/bmj.d3805. PMID 21737469
• Lind M, Polonsky W, Hirsch IB, Heise T, Bolinder J, Dahlqvist S, Schwarz E, Olafsdottir AF, Frid A, Wedel H, Ahlen E, Nystrom T, Hellman J. Continuous Glucose Monitoring vs Conventional Therapy for Glycemic Control in Adults With Type 1 Diabetes Treated With Multiple Daily Insulin Injections: The GOLD Randomized Clinical Trial. JAMA. 2017 Jan 24;317(4):379-387. doi: 10.1001/jama.2016.19976. PMID 28118454
• Beck RW, Riddlesworth T, Ruedy K, Ahmann A, Bergenstal R, Haller S, Kollman C, Kruger D, McGill JB, Polonsky W, Toschi E, Wolpert H, Price D; DIAMOND Study Group. Effect of Continuous Glucose Monitoring on Glycemic Control in Adults With Type 1 Diabetes Using Insulin Injections: The DIAMOND Randomized Clinical Trial. JAMA. 2017 Jan 24;317(4):371-378. doi: 10.1001/jama.2016.19975. PMID 28118453
• Polonsky WH, Hessler D, Ruedy KJ, Beck RW; DIAMOND Study Group. The Impact of Continuous Glucose Monitoring on Markers of Quality of Life in Adults With Type 1 Diabetes: Further Findings From the DIAMOND Randomized Clinical Trial. Diabetes Care. 2017 Jun;40(6):736-741. doi: 10.2337/dc17-0133. Epub 2017 Apr 7. PMID 28389582
• Litchman ML, Allen NA. Real-Time Continuous Glucose Monitoring Facilitates Feelings of Safety in Older Adults With Type 1 Diabetes: A Qualitative Study. J Diabetes Sci Technol. 2017 Sep;11(5):988-995. doi: 10.1177/1932296817702657. Epub 2017 Apr 5. PMID 28376647
• Deshmukh H, Wilmot EG, Gregory R, Barnes D, Narendran P, Saunders S, Furlong N, Kamaruddin S, Banatwalla R, Herring R, Kilvert A, Patmore J, Walton C, Ryder REJ, Sathyapalan T. Effect of Flash Glucose Monitoring on Glycemic Control, Hypoglycemia, Diabetes-Related Distress, and Resource Utilization in the Association of British Clinical Diabetologists (ABCD) Nationwide Audit. Diabetes Care. 2020 Sep;43(9):2153-2160. doi: 10.2337/dc20-0738. Epub 2020 Jul 15. PMID 32669277
• Roussel R, Riveline JP, Vicaut E, de Pouvourville G, Detournay B, Emery C, Levrat-Guillen F, Guerci B. Important Drop in Rate of Acute Diabetes Complications in People With Type 1 or Type 2 Diabetes After Initiation of Flash Glucose Monitoring in France: The RELIEF Study. Diabetes Care. 2021 Jun;44(6):1368-1376. doi: 10.2337/dc20-1690. Epub 2021 Apr 20. PMID 33879536
• Parkin CG, Graham C, Smolskis J. Continuous Glucose Monitoring Use in Type 1 Diabetes: Longitudinal Analysis Demonstrates Meaningful Improvements in HbA1c and Reductions in Health Care Utilization. J Diabetes Sci Technol. 2017 May;11(3):522-528. doi: 10.1177/1932296817693253. Epub 2017 Feb 1. PMID 28745091
• Holzinger U, Warszawska J, Kitzberger R, Wewalka M, Miehsler W, Herkner H, Madl C. Real-time continuous glucose monitoring in critically ill patients: a prospective randomized trial. Diabetes Care. 2010 Mar;33(3):467-72. doi: 10.2337/dc09-1352. Epub 2009 Dec 10. PMID 20007948
• Sadhu AR, Serrano IA, Xu J, Nisar T, Lucier J, Pandya AR, Patham B. Continuous Glucose Monitoring in Critically Ill Patients With COVID-19: Results of an Emergent Pilot Study. J Diabetes Sci Technol. 2020 Nov;14(6):1065-1073. doi: 10.1177/1932296820964264. Epub 2020 Oct 16. PMID 33063556
• Agarwal S, Mathew J, Davis GM, Shephardson A, Levine A, Louard R, Urrutia A, Perez-Guzman C, Umpierrez GE, Peng L, Pasquel FJ. Continuous Glucose Monitoring in the Intensive Care Unit During the COVID-19 Pandemic. Diabetes Care. 2021 Mar;44(3):847-849. doi: 10.2337/dc20-2219. Epub 2020 Dec 23. PMID 33361145
• Davis GM, Faulds E, Walker T, Vigliotti D, Rabinovich M, Hester J, Peng L, McLean B, Hannon P, Poindexter N, Saunders P, Perez-Guzman C, Tekwani SS, Martin GS, Umpierrez G, Agarwal S, Dungan K, Pasquel FJ. Remote Continuous Glucose Monitoring With a Computerized Insulin Infusion Protocol for Critically Ill Patients in a COVID-19 Medical ICU: Proof of Concept. Diabetes Care. 2021 Apr;44(4):1055-1058. doi: 10.2337/dc20-2085. Epub 2021 Feb 9. PMID 33563655
• Faulds ER, Boutsicaris A, Sumner L, Jones L, McNett M, Smetana KS, May CC, Buschur E, Exline MC, Ringel MD, Dungan K. Use of Continuous Glucose Monitor in Critically Ill COVID-19 Patients Requiring Insulin Infusion: An Observational Study. J Clin Endocrinol Metab. 2021 Sep 27;106(10):e4007-e4016. doi: 10.1210/clinem/dgab409. PMID 34100545
• Avari P, Lumb A, Flanagan D, Rayman G, Misra S, Dhatariya K, Choudhary P. Continuous Glucose Monitoring Within Hospital: A Scoping Review and Summary of Guidelines From the Joint British Diabetes Societies for Inpatient Care. J Diabetes Sci Technol. 2023 May;17(3):611-624. doi: 10.1177/19322968221137338. Epub 2022 Nov 28. PMID 36444418
• Friman O, Soltani N, Lind M, Zetterqvist P, Balintescu A, Perner A, Oldner A, Rooyackers O, Martensson J. Performance of Subcutaneous Continuous Glucose Monitoring in Adult Critically Ill Patients Receiving Vasopressor Therapy. Diabetes Technol Ther. 2024 Oct;26(10):763-772. doi: 10.1089/dia.2024.0035. Epub 2024 May 31. PMID 38758211
• Lumb A, Misra S, Rayman G, Avari P, Flanagan D, Choudhary P, Dhatariya K. Variation in the Current Use of Technology to Support Diabetes Management in UK Hospitals: Results of a Survey of Health Care Professionals. J Diabetes Sci Technol. 2023 May;17(3):733-741. doi: 10.1177/19322968231161076. Epub 2023 Mar 22. PMID 36949718
• American Diabetes Association Professional Practice Committee. 16. Diabetes Care in the Hospital: Standards of Care in Diabetes-2024. Diabetes Care. 2024 Jan 1;47(Suppl 1):S295-S306. doi: 10.2337/dc24-S016. PMID 38078585
• Zelada H, Perez-Guzman MC, Chernavvsky DR, Galindo RJ. Continuous glucose monitoring for inpatient diabetes management: an update on current evidence and practice. Endocr Connect. 2023 Sep 25;12(10):e230180. doi: 10.1530/EC-23-0180. Print 2023 Oct 1. PMID 37578799
• Avari P, Choudhary P, Lumb A, Misra S, Rayman G, Flanagan D, Dhatariya K; Joint British Diabetes Societies for Inpatient Care (JBDS-IP) group. Using technology to support diabetes care in hospital: Guidelines from the Joint British Diabetes Societies for Inpatient Care (JBDS-IP) group and Diabetes Technology Network (DTN) UK. Diabet Med. 2025 Mar;42(3):e15452. doi: 10.1111/dme.15452. Epub 2024 Oct 21. PMID 39432570
• Saunders B, Sim J, Kingstone T, Baker S, Waterfield J, Bartlam B, Burroughs H, Jinks C. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant. 2018;52(4):1893-1907. doi: 10.1007/s11135-017-0574-8. Epub 2017 Sep 14. PMID 29937585
• Bengtsson M. How to plan and perform a qualitative study using content analysis. NursingPlus Open. 2016;2:8-14. doi:10.1016/J.NPLS.2016.01.001
• Heinemann L, Deiss D, Hermanns N, Graham C, Kaltheuner M, Liebl A, Price D. HypoDE: Research Design and Methods of a Randomized Controlled Study Evaluating the Impact of Real-Time CGM Usage on the Frequency of CGM Glucose Values <55 mg/dl in Patients With Type 1 Diabetes and Problematic Hypoglycemia Treated With Multiple Daily Injections. J Diabetes Sci Technol. 2015 May;9(3):651-62. doi: 10.1177/1932296815575999. Epub 2015 Mar 9. PMID 25759183