New Paradigms in Diabetes Management From the Epicenter

I have learned, more than ever before, as a clinician and researcher, that creativity and flexibility are needed to provide clinically useful and emotionally supportive care for people with diabetes. Our outpatient diabetes center in New York City, an epicenter of the COVID-19 pandemic, has rapidly transitioned almost exclusively to telemedicine visits with patient-initiated glucose-management device downloads. Within a four-week period, this has become the new treatment paradigm for patients in New York City and across the country. Implementation of this new approach has necessitated flexible, rapid training of clinical and support staff to ensure the provision of timely and clinically rigorous support. At our diabetes center, it quickly became clear that if telemedicine were to be successful, patient education and flexibility on its use would be imperative, particularly for older adults and those with less technological comfort. Many early telemedicine visits led to disconnections, lack of uploaded data, and patient frustration. To address these challenges, our diabetes team engaged staff both onsite and remotely to provide instructions in advance of visits for device downloads and telemedicine connections.^1,2 This creative approach has made these remote interactions more efficient and, synergistically, has enabled our patients and providers to feel supported during these times of social isolation.

During telemedicine “office” visits, the review of a patient’s device download self-reported weight and blood pressure are commonly the only data sources we have for decision-making. No longer do we examine a patient for lipohypertrophy, perform an ophthalmologic exam, or evaluate lower extremities for peripheral pulses. However, telemedicine visits, unlike in-office care, provide some unique advantages; the health care provider has a unique glimpse into a patient’s home environment, support network, and their level of social isolation. We are even more attuned to the importance of obtaining a detailed history, and smiles and friendly waves at the end of a visit take on a new meaning.

Our center’s inpatient management of diabetes for those afflicted with COVID-19 has also presented novel challenges. Common use of steroids to possibly mitigate cytokine storm and inflammation has markedly increased diabetes consultations and nursing needs. ³ Hyperglycemia and ketoacidosis are common. Due to the unfortunate situation of limited personal protective equipment (PPE) and overburdened health care teams, we have implemented alternate methods, sometimes not Food and Drug Administration (FDA)-approved, for inpatient management. Hospitalists, nursing staff, and administrators have agreed to adopt these creative initiatives due to these unprecedented situations. Patients wearing their personal continuous glucose monitors (CGMs) provide a way to manage diabetes without frequent finger sticks and make dosing adjustments more efficient. Our earliest admitted patients with diabetes inspired creative ideas. Access to CGM data further supported treatment decisions, and sensor alerts reduced hyper- and hypoglycemic excursions and risk.^4,5 Review of the cloud-based CGM data enabled more efficient dose titration by clinicians unable to be patient-facing. Flexibility of CGM use and providing patients with personal glucose meters relieved nursing burden, reduced the amount of potential contacts and the need for redonning PPE, and provided relevant and frequent glucose checkpoints. When appropriate, patients could be called on their phones to share fingerstick results, allowing for assessment and adjustment of insulin doses without the nurse entering the room. Automated insulin delivery (often discontinued in the inpatient setting) was more readily welcome. Training hospitalists and nurses on these devices became a hurdle that needed to be quickly overcome. We improvised by rapidly deploying slide decks and one-page guides for providers, readily accessible on inpatient hospital apps and our elctronic medical record, while our diabetes team provided around-the-clock telephone support to answer device questions. To expand our inpatient consultative services, we established protocols for inpatient “e-consults,” where physicians could provide remote recommendations after a chart review and speaking to the patient by telephone. Additionally, diabetes-focused health care teams throughout the greater New York metropolitan area collaborated through email and Dropbox to share ideas to improve outcomes.

In the future, I predict, when COVID-19 is a distant, sad memory, we will remember our creativity and have new considerations for diabetes care. Telemedicine visits will provide a well-accepted option for outpatient care in both the clinical and research arenas. Continuous glucose monitoring and the inpatient use of closed-loop systems may become more widespread and accepted, but the human part of care, separate from technology, will always remain. Those patients, friends, family members, and colleagues who became ill and recovered, or who did not survive, will inspire us to do the best we can during both times of hardship and easier times.