Jane Seley on Diabetes Technology in the Hospital

David Klonoff: 0:14

Welcome to the Diabetes Technology Report. I'm David Klonoff, I'm an endocrinologist at UCSF and Sutter Health and we're happy to have you with us. I'm going to introduce my colleague, david Kerr. 

David Kerr: 0:28

Hello everyone. I'm David Kerr. I'm also a diabetes researcher based at Sutter Health. Today, we're going to be talking about the abuse and use of diabetes technologies in hospital, and it gives me enormous pleasure to welcome Jane Seley. Hi, jane, hi, how are you doing? It's lovely to hear you Now. You and I, david Klonoff, we know each other extremely well, but there's maybe one or two people out there who are less familiar with your good self, so can you just give us a quick background about where you've come from and where you are at the moment, and perhaps where you're going? 

Jane Seley: 1:04

So for the last 20 years I've been working at New York Presbyterian and Wild Cornell Medicine in New York City. I am an assistant professor of medicine, nurse practitioner and diabetes care and education specialist in the division of endocrinology, diabetes and metabolism, and my two favorite areas of interest in the diabetes world is inpatient management, which I call the Wild West, and diabetes technology beyond endocrinology, because I really want to see everyone, no matter where they're being cared for, have access to all of these great new tools that we have available to us. 

David Kerr: 1:46

So that's really good. Why do you think it is the Wild West? What do you think the challenges are for people at the moment? 

Jane Seley: 1:55

I think it's so funny because in 2004, I took a job as full-time inpatients at Wild Cornell after working outpatient for quite some time, and at that time there was still the common belief that if your glucosees were in the three and four hundreds, it really didn't matter, because you're only in the hospital for a couple of days right, maybe five days at most, but, believe it or not, it hasn't changed to where it should be, which is that everyone should be under 180 all of the time while they're in the hospital and that it matters. So I have a lot of trouble convincing the hospitalist and intensivist sometimes that the person's running too far and we really need to do something, and that's my frustration. 

David Klonoff: 2:40

Jane, the digital revolution has affected so much of what we do. How would you say it's affected care of patients with diabetes in the hospital. 

Jane Seley: 2:50

Well, the most important thing is that the number of people that are wearing insulin pumps and continuous glucose monitors at home are coming into the hospital for various different reasons, often not related to their diabetes, many times having surgery and other procedures, and no one knows what these devices are or how we can properly care for them, who we should keep on them and who we should take off of them. So that's a very big lift for me is to make sure that anyone who wants to wear their devices during hospitalization, we evaluate them and we support them if we can. 

David Klonoff: 3:29

Jane, what sort of support do you give these patients if they come in with a CGM or an insulin pump? 

Jane Seley: 3:35

Well, if someone comes in with an insulin pump, it's a mandatory endocrine consult. The only exception might be if somebody is pregnant and has diabetes. Maternal fetal medicine is likely following them and maternal fetal medicine has done a really good job in learning these devices and the person is also caring for themselves. So we may or may not be consulted on those people, but many times we are. So insulin pump must see endocrine. We must make sure that right now when they're acutely ill, they know what they're doing, because sometimes they're really too sick to do it right now, or maybe they weren't doing it so great at home and nobody actually knew that. So mandatory assessment and then we would follow them on a daily basis because whatever their settings are, if they're on automatic insulin delivery, all bets are off when they're acutely ill. Cgm is a whole other story because unfortunately there's too many people on CGM. So I can't promise a mandatory endocrine consult unless they're wearing a CGM. That is talking to their insulin delivery device. But we really need to support people to be able to wear the CGM while they're in the hospital. But they really cannot do it legally for treatment. For example, if they think they're low, we have to verify it with the hospital point of care device and for dosing insulin During hospitalization we have to do a double check with the point of care. But hey, it's really great for people to see if their arrow is going up or going down, to call the nurse and ask the nurse to recheck it with our device to make sure that we're doing the right thing. 

David Kerr: 5:12

One of the things that struck me in hospital is the proliferation of different devices, and that generates a lot of data, a lot of information. Do you think we've really sorted or fixed what to do with that information, where it goes, who has access to it, that type of thing or do you think that more of what needs to be done? You mean with the data from pumps and stuff, the data from the devices and going into the EHR and all of that. 

Jane Seley: 5:44

So at this point that's more of an outpatient thing than an inpatient thing. Whatever their data is in their devices is retrospective, and now they're acutely ill so many times. Things have completely changed, but it's really good if I can go into the media section of the electronic record, for example, and look at how they were before. What's happening now is I'm working very hard on a project for integration into our electronic health record and we're also working with having a data aggregator available at all of our 10 sites. I'm hoping even though it's a lot of effort with legal and privacy and all of these concerns IT to get this to happen that people in endocrinology that understand the importance of this help all those departments to come to the conclusion that we can't live without it. And that's how I feel, because I want to make sure that whenever we're seeing someone who's wearing any of these devices, that data is there at the ready in our hands on our computer to be able to view it or how can we take care of them. So take your diabetes with your eyes closed, right? 

David Kerr: 6:56

And that's a good way of thinking about it. I did want to ask you about one particular new technology Maybe. Kornify wrote an article a few years ago with the bold title saying smart pen insulin pens will improve care. Do you think in hospital, the use of a device such as a smart insulin pen that's going to make a difference? 

Jane Seley: 7:18

So that's a really interesting question and it actually has a long answer. I'm sorry, but take your time. In the outpatient setting, when we're caring for people who are not wearing insulin pumps, if they do not have a smart pen or cap, I'm relying on their self-report to know what they're doing and when they're doing it, which anyone that works in diabetes knows. People forget, they guess, they write it in the waiting room while they're waiting to come in and they're just filling in numbers, so all kinds of things can happen. So I don't feel that's the most reliable way to know what's really going on. So in the outpatient setting, we're very lucky that we have more and more devices that can capture the insulin dose without people having to wear a pump, and there's many more coming In the next couple of years. We're going to probably have a handful of them to choose from, if not more, right. But when the person comes into the hospital, the nurse is giving them the dose, so we're relying on the nurse to record the correct dose. And that's not 100% certain either, because there's data entry errors. Anyone in IT knows that. It's something like 11 to 13% errors in the numbers that people put in. So wouldn't it be great in the hospital setting if we had some kind of system which we do have for intravenous insulin that captures the actual doses. That would be amazing. 

David Klonoff: 8:42

Excellent Jane. We've been talking about use and abuse of technology in the hospital. Do you see any situations where it's abused or not used properly? 

Jane Seley: 8:55

The most abusive thing I see is when someone puts on their sensor and then they have to go to radiology or something's up and they have to take it off and then they put it back on again anew and then the next day we send them for another test. We really need to think about where people are placing their devices and what we might be ordering, so that we don't force them to waste a lot of supplies, and a lot of times people come into the hospital and they don't even know they're coming. They may come into the ED or they're coming for a short time, but their visit is extended because of whatever happens and they run out of supplies. I used to keep a drawer full of supplies that I could pretty much give them anything they needed, but that world has changed. There's too many devices and too many unique supplies and new ones have come out, so I can't get samples of the old ones anymore, but they're still using the old one because they have an AID, and so there's a million reasons why I can't keep up with the supplies. So that's something that I don't know how to fix, but it is a very big problem. 

David Kerr: 10:04

At the beginning you alluded that the Wild West was in hospital diabetes care. I'm just wondering if the frontier is shifted and the Wild West is now in the discharged space. I'm wondering if you have any thoughts about whether you feel we could do more for people leaving hospital, say, who have started the CGM. 

Jane Seley: 10:24

I think it's very active in establishing our two Cornell campuses that are general hospitals, not Ozekeacic hospital, sending people home on CGM and the whole idea is start them with it a day or two before they leave. They can't use it for dosing their insulin, they can't use it to treat hypo. It has to be verified with the point of care, so they need to know that. But they can start to understand how it works and they can see the arrows and learn how to use the arrows and so on. I think that this should be a standard of care for probably initially a select group of people, maybe have a high A1C, maybe going home on MDI for the first time. I think we'll have to move toward that for everyone, but eventually it will be everyone that could benefit from CGM in the outpatient setting and they haven't been doing this. This would be a time to start them and then we follow them for at least the life of the first sensor, or I would prefer 30 days and I'm working with my nurse practitioner colleagues that we can set up appointments with them after they leave the hospital so we can make smart adjustments in their therapy and not wait until they wind up with high glucoses again and back in the ED. I think this is going to be very, very important in preventing readmission and ED visits after discharge and also improving quality of life. 

David Klonoff: 11:48

Jane, I have one last question for you. You've talked about projects that you are now creating. Where do you think we'll be with diabetes technology in 10 years from now? 

Jane Seley: 12:01

Well, 10 years from now, we're going to be capturing everyone's insulin doses and many, many people are wearing CGM. And I did want to give a shout out to a project I worked on with Diabetes Technology Society, the ICODE project. The original one was about integration of CGM into the electronic health record and how can we standardize this and what we're looking at in the reports and so on. And now we're working on ICODE 2, which is going to standardize insulin into the electronic record and reports and so on. This is the way to make this universal. People have to understand the data, know how to access the data and know how to utilize the data to help the person in front of us or video wise, to be able to make the right recommendations together using shared decision making. This is what should be accessible to everyone in the next 5 to 10 years. 

David Klonoff: 13:00

Thank you, Jane. 

Jane Seley: 13:01

Thank you Bye. 

David Klonoff: 13:03

So that's what really goes on in the hospital. This completes the interview. We look forward to listeners joining us on the next Diabetes Technology Report. This podcast is available on Spotify, Apple Store and the Diabetes Technology Society website. Thank you and bye-bye.