Inpatient Diabetes Management During the COVID-19 Crisis: Experiences From Two Community Hospitals

Introduction

In under two months, the COVID-19 crisis has caused substantial morbidity and mortality in the United States, with over 120 000 hospitalizations and 40 000 deaths.¹ The presence of diabetes mellitus significantly increases the risk for hospitalization, complications, and death from COVID-19,^2,3 highlighting the importance of glycemic control during this pandemic.

Previously, we implemented an Inpatient Diabetes Management Service (IDMS) at two community hospitals within the Johns Hopkins Health System in Maryland, which has led to significant improvements in hyper- and hypoglycemia rates.^4,5 The IDMS, consisting of an endocrine hospitalist, nurse practitioner, and diabetes educator, develops a personalized diabetes care plan with the patient while admitted and on discharge, arranges for follow-up with a certified diabetes educator or remote patient monitoring nurse, and offers to connect the patient with endocrine specialists and other resources postdischarge for continued care.⁶ This treatment plan is offered to all patients with diabetes regardless of their reason of admission and has been shown to reduce patient length of stay and readmission rates.⁴

During this pandemic, hospitals have been forced to modify many of their longstanding practices of inpatient care in the attempt to prevent the spread of this highly infectious disease to patients and care team, while also preserving valuable and scarce personal protective equipment (PPE). Inpatient telemedicine has rapidly increased in popularity and utilization since the beginning of the crisis as physicians seek to limit face-to-face patient interaction, yet still, maintain the engagement necessary to provide high-quality medical care.⁷

Inpatient Diabetes Telemedicine

We found that diabetes telemedicine in the inpatient setting may be clinically appropriate for patients with/or suspected COVID-19 disease. The assessment and plan to direct diabetes care could be usually formulated through history and physical exam limited to observation. Four main factors have created hesitation for institutions when considering telemedicine adoption: ambiguity in payer reimbursement policies, lack of inpatient telemedicine guidelines, lack of inpatient telemedicine equipment/infrastructure, and satisfaction uncertainty in telemedicine use by both patients and providers. On March 6, 2020, the Centers for Medicare & Medicaid Services eased reimbursement concerns with the announcement of the 1135 waiver allowing for Medicare coverage across a range of providers and locations.⁸ The Office of Telemedicine at the Johns Hopkins Medicine Health System identified potential difficulties in this new frontier and sought to streamline best practices issuing its guidance, a tip sheet titled Inpatient Virtual Rounds and TeleConsults that walked providers through delivering virtual care. A remote connection is established via the Zoom app on tablets, which are stored on each inpatient unit. In addition to enabling a virtual history and physical exam, inpatient tablets allow patients to access hospital educational materials and to remain connected with friends and family during an isolating hospital stay.

It has been suggested that COVID-19 positive patients with diabetes are at increased risk for morbidity and mortality, yet their care may be suffering due to a reduction in testing, resources, or physician contact.^9,10 Could inpatient diabetes telemedicine result in both improvements in quality of care and cost savings, as seen with the traditional approach?⁴ This remains to be seen. Anecdotally, patients, hospitalists, and intensivists alike have been thankful to have IDMS input during this pandemic, particularly with difficult-to-control hyperglycemia or critically ill patients.

Satisfaction with telemedicine, for both patients and providers, is a reflection of its effectiveness and ease-of-use. A systematic review evaluating telemedicine infectious diseases consultations found that patients satisfaction with telemedicine was greater than 97% in the majority of studies.¹¹ Studies evaluating diabetes telemedicine in the outpatient setting have also reported high levels of satisfaction for both patients and providers.^12,13 It has never been easier or more necessary for local community hospitals to develop similar telemedicine programs in the inpatient setting.

Limitations of Telemedicine

Inpatient telemedicine has important limitations. Internet Wi-Fi can be poor in some areas of the hospital, leading to frustrations such as delayed audio, interrupted video, or premature disconnection. Patients and/or hospital staff may not know how to join a meeting or troubleshoot errors (such as lack of audio). A lack of tablets on the unit has been another challenge.

To mitigate these challenges, the authors personally conducted over a dozen “in-services” for nurses and medical unit administrators explaining the video conferencing technology.¹⁴ Video translation tablets were repurposed for inpatient telemedicine visits as well. Our team also utilized other alternative video-conferencing mobile applications such as Doximity.com and Doxy.me with intermittent success. Additionally, if the primary team requesting the diabetes consult is not satisfied by the teleconsult, they are entitled to request a face-to-face consultation. Similarly, if the patient or family requests an in-person encounter, this should be honored, if possible. Finally, critically ill patients and patients who have cognitive decline may not be appropriate candidates for teleconsultations.

Summary

As COVID-19 continues to alter how we deliver quality care, it is important to consider how we might leverage telemedicine’s strengths while addressing challenges in adapting care delivery models to the needs of patients, providers, and health systems. Telemedicine usage in the inpatient setting may preserve PPE, prevent patient and provider exposure, and facilitate the high level of patient care desired by all stakeholders involved.