Using Dexcom and not finger poke to treat?

[KKEGS, MSN, RN]

Man! I've been so busy in my new district that I rarely even get to check this board much less ask a question!

I have a 4th grade diabetic diagnosed only 6 months ago. He is amazingly responsible and very tuned into how his body is feeling. He uses a Dexcom CGM and his parents monitor his BG throughout the day.

There has been some concern that the teachers were perhaps not responding quickly enough to his monitor and perhaps not accompanying him to the health office as is stated in his 504. I was asked to come to his parent teacher conference this evening along with his case manager so we could all get on the same page regarding his diabetes care at school. I will also add that he is new to this school this year since our elementary is divided between 2 buildings and he is now in the 4-6 building.

At the conference his father said he wants his son to stay in class as much as possible and wants us to treat him based on his CGM and not a finger poke (with a few stipulations) by providing snacks in class so he doesn't have to come to the health office when he is low. The father stated (and I confirmed) that the Dexcom G5 is the only CGM system approved by the FDA to use for treatment decisions rather than a finger poke (again with stipulations). This will be our first diabetic that we treat based on CGM rather than finger poke.

I decided to investigate and visited the Dexcom website. They actually have a pretty good PowerPoint presentation specifically for School Nurses regarding how the system works.

Despite all of this I am nervous about treating based on a CGM! I did ask parents to please get an order from his endocrinologist stating that we are to treat based on the CGM and not a finger poke (with those pesky stipulations I mentioned above -- if student feels low despite the CGM registering a normal blood sugar, if the CGM becomes dislodged, etc.)

Do any of you have diabetics that you treat with CGM and not finger pokes?

[aprilmoss]

The CGM is pretty much what the fancier insulin pumps have been doing for a while now. This is a recognized technology. The diabetes care plan should be signed by a physician (I disagree that it needs to be the endo, though that is probably advisable) but that is no different for CGM than traditional bg testing.

It's not the nurse's job to second guess the efficacy of a physician-ascribed treatment plan.

Sorry, if I'm a little touchy on this, but I've been beating on diabetic treating PREJUDICES like this with my own son and the school system for over a decade.

[OldDude]

The basic first line of intervention with all diabetics if they're not feeling well is to give carbs and sort it out later. I don't see a problem with having an MD order for prn fingersticks for just this reason. As we all need to be reminded of...you treat the patient; not the monitor.

[aprilmoss]

Guessing hypoglycemia is fine if you have a diabetic that is not feeling well because that is more common and more life threatening.

However, just throwing carbs at a diabetic is not care plan. Type 1's who are not on a pump will typically need to do a bg test by some means prior to lunch and if they are not feeling well and are otherwise reasonably responsive.

[OyWithThePoodles, RN]

I've said it before, but the CGM's are supposed to be changed weekly. Parents of type 1 kiddos will often (UNDERSTANDABLY) drag out the lifespan by a week or two since they are so expensive, but this can decrease the accuracy. I've had a CGM say 55 and a finger stick 233. The G5 is supposed to be the most accurate which is what my kiddos have.

In our district we don't give insulin based on a CGM. And we've yet to have a doctor write an order to do so. I did get an order to treat lows based on the CGM. Most times it's pretty accurate, but I've had a few cases where they end up in the 300's not long after.

If you have a doctors order to do it, do it. I think I would be willing to trial an order of "If CGM glucose between --- and --- may give insulin based on number. If below --- or above --- check finger stick prior to treating."

[Flare, ASN, BSN]

I have 2 very diligent diabetic students that have dexcoms and pumps. one wears her dex more conisistently than the other but both still come to me at lunch for finger sticks and to report numbers. So my dex com consistent student will come down to me from time to time when her alert goes off in class telling her "low" and see a number like 60. She will tell me she feels fine, do a finger stick - she has been in the 110's. We will theorize that maybe she is getting ready to drop, and she'll take some carbs - not the whole hypogylcemic 15 but some. Come back for lunch check - blood sugar is a bit on the high side - nothing maddening, but suggestive she perhaps didn't need the carbs earlier. But We have noticed that it's been more apt to do this when it's been in for a while.

[JenTheSchoolRN, BSN, RN]

The CGM is pretty much what the fancier insulin pumps have been doing for a while now. This is a recognized technology. The diabetes care plan should be signed by a physician (I disagree that it needs to be the endo, though that is probably advisable) but that is no different for CGM than traditional bg testing.

It's not the nurse's job to second guess the efficacy of a physician-ascribed treatment plan.

Sorry, if I'm a little touchy on this, but I've been beating on diabetic treating PREJUDICES like this with my own son and the school system for over a decade.

I understand being a little touchy on the subject, but important to note that a school nurse still needs the orders and signed plan to do this. Thus far, it seems like it is a parent request, but needs the physician order to proceed on this new plan.

I have had a few students with a CGM. I work with older students (7th-12th) and honestly, I have not met a teen yet who wants to wear it as prescribed. Who remembers to change it as prescribed. Or who only wears it for about a week prior to an endo appointment. I know it does awesome things from a couple of very good adult friends with type 1 who love it, but it is as good as the user using it, of course.

My follow-up is that if Dad wants student to remain in class, will you be coming to him to treat if needed? Will he dose on his own/with a teacher?

Again, I work with older students and part of the transition of being independent with their diabetic care (I'm trying to help student prep to manage their own health by the time they graduate, my own personal goal) is that if they are stable and compliant, they do their own BG check at lunch and insulin coverage at lunch. Sometimes they call my office for a check to report carbs and insulin given. Parents totally on board with this. I have a 9th grader in this transition currently and she is doing very well. (Flip side, had another HS not do well and back to me tracking student down all the time because student do not want to check BG ever.)

[ohiobobcat]

I would be fine with using the CGM to carb for lows WITH orders (with parameters) to do so from the student's diabetes management team. i wouldn't do this strictly on parents request, but would be happy to work with the parent to get said orders. I think it depends on the responsibility level of the student as well. Will he carb approriatelyt? Will he recheck, or would he need to?

Also, how much class time is this student missing because of lows? If dad is that concerned about missed class time because of frequent lows, then maybe an adjustment needs to be made to the student's overall plan. I would say on average, my diabetic students miss 15-20 minutes of class time with a low, on average of 1-2 times per month. But a few years ago I would have told a different story because I had a student who wasn't SUPER compliant with her diabetes, and another student who would overdose himself on insulin so he could eat (that was a fun year!).

I have had a few students with CGM, one who it didn't work for at all, and another (she's a junior high student- so I am involved peripherally with her care) who seems to be doing well with it.

[halohg, RN]

So here's a question are you covering the snack in the classroom and correcting with what the cgm states?, if so then he might be over correcting if he is dropping as there is a lag in the actual FS and the Cgm reading. I felt pretty good with having the student return to class after a snack if the BS was showing stable or going up on CGM after a low or symptoms. But I always had them do a FS prior to snack or meal to make sure correction was accurate. I found anywhere from a 20-30 lag in results with the cgm and found great comfort in understanding the students trends. Is there a one on one with this student? They can be trained to assist right in the classroom and then report to you as to minimize out of classroom incidents.

[Guest374845]

I don't envy you. My daughter has had the dexcom G4 and G5 on and off this year and we've seen WILDLY inconsistent numbers the closer it gets to calibration time.

[ruby_jane, BSN, RN]

What I learned from the Dexcom of my summer camper - if the Dex is going off (high or low, doesn't matter), the instructions were to manually check. The thing was inaccurate, and that may be from all the reasons mentioned, or the fact that summer camp means more activity for this kid than the school year. Is there a reason to suspect your kid's Dex is not accurate? Is he allowed to keep snacks in the class? He will still need to come check with you for an unusual high or low, right? This is good training for high school (and life).

[PediNurseNYC]

I work with a student who uses the dexcom and treat based on its readings. sometimes if i think the BG reading from the dexcom could be inaccurate, i'll do a finger stick. Almost always the finger stick reading is only one or two numbers away from the CBG reading. My T1 diabetic is nonverbal and is usually asymptomatic with hypo/hyperglycemia (because he can't tell us what he is feeling and is at his baseline even with a BG in the 30s.) so i find this tool so helpful when managing his BG and preventig highs and lows.