This communication conceptualizes, defines and describes glucometric guardianship, as a means of ensuring optimal glycemic management. We define glucometric guardianship as the process of ensuring appropriate measurement, monitoring and analysis of glucose levels, so as to ensure alertness in glycemic management, and agility in anticipating and detecting suboptimal glycemic parameters, and responding to them. This paper hopes to draw attention to the need for glucometric science, encourage debate and discussion and facilitate research on the topic.
Keywords: Capillary glucose, glucose monitoring, indoor glucose management
Modern medical practice is characterized by ever increasing complexity. This is especially true for diabetes care, where a wide spectrum of causative factors, clinical presentations and course of illness, complications and comorbidities intersects with an equally vast offering of therapeutic choices.
The permutations and combinations available to the practicing clinician can be put to efficient and effective usage only if our monitoring systems and strategies are robust. While there are well-developed algorithms for glycemic management in indoor and outdoor settings,1,2 they do not integrate the nuances of glucose monitoring. Glucometric measurement and analysis is the limiting factor for, and also the stepping stone to, optimal glycemic control. Standardization of glucometrics3,4 can help improve the process of drug choice and dose titration.
STEWARDSHIP IN SCIENCE
The concepts of antibiotic stewardship, insulin stewardship and steroid stewardship serve to ensure safe and rational usage of these drugs.5-7 These campaigns have contributed to greater awareness about the use of these intervention. We propose a similar framework, glucometric guardianship (GG), to highlight the need for systematic use of glucose monitoring devices, in order to accomplish accurate glycemic analysis, optimal glucose control, and comprehensive overall management.
We define GG as the process of ensuring appropriate measurement, monitoring and analysis of glucose levels, so as to ensure alertness in glycemic management as well as agility in anticipating and detecting suboptimal glycemic parameters, and responding to them. Glucometrics has been defined earlier as the systematic analysis of inpatient glucose data.8 The authors have called for consensus and standardization so that inter-institutional benchmarking can occur. However, the concept of GG extends far beyond this (Table 1).
Table 1. Domains of Glucometric Guardianship
· Choice of glucose monitoring device: e.g., glucometer vs. flash glucose monitoring device; glucometer/FGMS model
· Individual device or common device: e.g., prefer individual glucometer if expected hospital stay of >2-3 days, or if expected number of glucose pricks is >20
· Glucose sticks: available at bedside/central station
· Lancets: available at bedside/central station
· Alcohol swabs: available at bedside or central station
· Meter calibration: needed/not needed and at what frequency
Roles and responsibilities
· Glucose monitoring: by -
· Data entry: by -
· Analysis: by -
· Disposal of used ancillary supplies: by -, at -
· Red flag range: e.g., call duty doctor if plasma glucose <40 mg/dL and >400 mg/dL; check urine/blood ketones if BG >400 mg/dL
· Treatment/titration: by -
· Meter calibration: by -
Patient-specific glucometric guardianship
· Frequency of monitoring
· Site of prick; rotation of fingers
· De-escalation of frequency of monitoring: e.g., if BG 100-200 mg/dL; <20% change in consecutive glucose values at current frequency
· Escalation of frequency of monitoring: e.g., if BG <100 or >200 mg/dL; >20% change in consecutive glucose values
The concept of GG encompasses the physical and electronic infrastructure, as well as the human resources involved in glucose monitoring, analysis and management. Infrastructure includes both hardware (glucose measuring devices and ancillary supplies) and software (data recording and analysis) related to glucometrics. Educated and experienced human resources are essential for glycemic management, and GG delineates the roles and responsibilities of various members of the health care team. GG can be used in every health care setting: outdoor, indoor and critical care, irrespective of the level of resource availability or allocation.
Through this communication, we attempt to create a framework for GG in the indoor care setting. This framework can be used as a foundation to create customized GG protocols for every health care setting. It can be modified to suit needs of individual patients as well. The check list format allows for error-free, efficient, user-friendly incorporation into pre-existing standard operating procedures. GG does not replace, but rather complements the algorithms that are already being used by various hospitals.
- Korytkowski MT, Muniyappa R, Antinori-Lent K, Donihi AC, Drincic AT, Hirsch IB, et al. Management of hyperglycemia in hospitalized adult patients in non-critical care settings: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2022;107(8):2101-28.
- Chawla R, Madhu SV, Makkar BM, Ghosh S, Saboo B, Kalra S; RSSDI-ESI Consensus Group. RSSDI-ESI clinical practice recommendations for the management of type 2 diabetes mellitus 2020. Indian J Endocrinol Metab. 2020;24(1):1-122.
- Kalra S, Saboo B. The glycaemic compass: time in range. J Pak Med Assoc. 2021;71(1(A)):562-3.
- Kalra S, Bantwal G, Sahay RK, Bhattacharya S, Baruah MP, Sheikh S, et al. Incorporating Integrated Personalised Diabetes Management (iPDM) in treatment strategy: a pragmatic approach. Indian J Endocrinol Metab. 2022;26(2):106-10.
- Charani E, Holmes A. Antibiotic stewardship—twenty years in the making. Antibiotics (Basel). 2019;8(1):7.
- Lathia T, Punyani H, Kalra S. Insulin stewardship for inpatient hyperglycaemia. J Pak Med Assoc. 2021;71(1 (B)):379-82.
- Kalra S, Kumar A, Sahay R. Steroid Stewardship. Indian J Endocrinol Metab. 2022;26(1):13-6.
- Thompson BM, Cook CB. Glucometrics and insulinometrics. Curr Diab Rep. 2017;17(12):121.