Transcription:
COVID-19 and Diabetes Complications

Melanie:    Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole.

In April, we recorded an episode with Dr. Grazia Aleppo, who detailed some of the protocols, clinical presentations and treatment recommendations for diabetes patients with COVID-19. As we enter into more than nine months of the pandemic, many of the early protocols and treatment recommendations have drastically changed.

Joining me today is Dr. Amisha Wallia. She's an Assistant Professor of Medicine in the Division of Endocrinology. And she's here to talk to us about these updates and give us an update on the situation. Dr. Wallia, it's a pleasure to have you join us today. Can you share a status update with us on where things are and will be, and how have protocols and recommendations changed with this pandemic?

Dr Amisha Wallia: Thank you so much for having me. I wish it was under better circumstances. As we all know, heading into the fall, we are definitely seeing an in-patient surge of patients with COVID-19 and a really high percentage of these patients have either pre-diabetes or diabetes and obesity. And so I think we all have to remember what the major driver is, really localized.

And so what I tell physicians in terms of how they should prepare and what they're thinking about in terms of being a diabetes specialist is really understanding where your community is in terms of percent positivity rates. So for example, in Chicago, we've been hanging at around four to five percent over the summer. And then just, you know, in the last several weeks we have been precipitously going up like many other cities around the country. And so we have various tracking abilities through the Illinois Department of Public Health, as well as the Chicago Department of Public Health. And then also we have the internal data in terms of how this is affecting hospitalizations.

So the number one thing I recommend is just really being on top of what's happening in your community in terms of transmission, because the lag time with COVID-19 rates in the hospital will allow you to prepare if that makes sense. Protocols here in Illinois, again, we had a very prolonged surge back in April, and at that time we created a subcutaneous insulin protocol for diabetic ketoacidosis, which there was a very high percentage of patients who came in with diabetic ketoacidosis. And then also looking at our insulin drip protocols for those with severe insulin resistance. So we did review this in the last podcast, I believe, but there have been definitely complex presentations of new diagnosed diabetes or actually diabetes that's worsening when patients come into the hospital, severe insulin resistance and, like I said, recurrent or first-time diabetic ketoacidosis as well.

Melanie: So because of what you, we're just saying about the fact that we had that prolonged, but sustainable surge, and we've seen this sharp increase in the cases. How has your protocol changed? How are you managing patients right now?

Dr Amisha Wallia: So. in terms of what we're seeing, we're seeing a little bit more of new onset diabetes in the hospital, but we haven't because You know, as of today, our percent positivity rate in Chicago land area was around 10%. We are only starting to see the increase in hospitalizations. So right now, we're in a very controlled environment in terms of our insulin protocols. We are doing everything that we were doing before, but we are looking at, "Okay, what is going to be our surge planning?" Everyone's going into surge planning mode.

So this is where it's really individualized into what your institution has in terms of, you know, who manages the diabetes patients or hyperglycemia patients in the hospital. You know, every hospital, has what we like to call an owner of that. It can be pharmacy. It can be endocrinologists. It can be the internal medicine hospitalist teams.

But usually in the hospital, we have a superuser. And so I think this is where you really have to preplan, and then use the infrastructure that you have. So we have a glycemic control committee where all of us meet. So, IT, diabetes specialists, our nurse practitioner, services who do a lot of diabetes management and the surgical services. We also have pharmacy who comes to these meetings, our quality leaders. And we come together and we think about, "Okay, so are we seeing increased numbers in certain areas?"

And we also follow the trends that we see on our dashboards in terms of just positivity rate. And it's great because we also have, our quality teams there as well as other clinical teams, such as nursing that can tell us, " Okay, in surge planning, this is what we would think," and we can align our protocols with what's happening boots on the ground in terms of, you know, before slipping over. We've been lucky enough that at this point we haven't needed to do that, but this could vary widely.

And I think a lot of this, what COVID-19 has done is really take, you know, the translation of research to practice. But also vice versa, community back to the hospital. So what's going on in the community in terms of transition is really going to drive what's presenting at the hospital. So again, like I said, really understanding what's happening in your community can really help you with what's happening in the hospital.

Melanie: Doctor, what role has technology played in the management of diabetes patients with COVID-19? How have you been utilizing telemedicine and how has it evolved during the pandemic?

Dr Amisha Wallia: So, I mean, in terms of making, you know, lemons into lemonade, one thing that we have been allowed to do now as endocrinologists or diabetes specialists is see more patients and still deliver really good care. So there was really good data from the Rushakoff group at UCSF a few years ago about e-consultations with diabetes, as well as some other smaller groups. And they showed that you could deliver remote inpatient, diabetes or hyperglycemia consultation services very safely.

Now there's still obviously patients you need to see in person, absolutely, especially new consultations. However, on a population management or, from looking at the whole perspective, the idea is the ability to give, the best care to the most number of patients, that's where telemedicine, telehealth has really changed our landscape. And again, this can be really localized as well because it could be state to state dependent. So I was on a phone call the other day, and people in North Carolina have had to change their services, inpatient and outpatient, depending on what the Blue Cross Blue Shield payment structure or other payment structures are depending on state to state. I'm just giving you one example.

And so I think what, you know, we've been allowed to do is in some cases, you know, being able to deliver, especially on the outpatient side, telemedicine to those who, before really, we're not reachable-- and this could be by phone or by video. And it's really given patients the flexibility to be able to see you, you know, and not have to travel, have all the information there and you get an insight. A lot of my patients, I've never seen their homes before, how they were living or how organized their diabetes was. And so it actually allowed me to get a really amazing insight.

On the inpatient setting in the beginning, and I hope this doesn't occur again in terms of PPE, but it allowed us in the inpatient setting to deliver care when there were shortages of PPE. And I think this was critical because at least in terms of diabetes management, if we were able to obtain, you know, information on diet, information from the patient over the phone or other mechanisms, you still can, with appropriate systems, still deliver high value care with minimal, poor outcomes, which I think is the most important thing, especially when we're talking about, increased rates of COVID-19 and surge planning, et cetera.

Melanie: the emergency use authorization for CGM in the hospital setting and how that's impacted care.

Dr Amisha Wallia: I think that's a great question. And so every institution has been looking at this a little bit differently and that's because what the FDA basically said was you can use this. But that is not the same as approval. And so l had really utilized this opportunity in the research area, really to push forward the availability as well as the pilot testing of this.

Interestingly, this happened at a very interesting time, because there are two groups actually that just recently had been in the middle of-- there's actually several groups, but two just recently published their data on inpatient CGM use in the hospital, a lot of which was done outside of COVID-19. This is Athena Philis-Tsimikas' group from Scripps and then Elias Spanakis from Baltimore. And they both published around the same time clinical trials that with, I think seventy to a hundred patients on the inpatient floors and basically showed through their data that CGM is safe as well as that patients', you know, mean glucoses were, lower and hypoglycemic events were very low. And essentially this idea of being able to have glucose telemetry is actually really important. And so while for COVID-19, we may not have, randomized controlled data, at least now, looking at, you know, what is the right level of glucose control that we need. So just for background on that for, people listening, we still want to stick by our guidelines, which are, 140 to 180 milligrams per deciliter in the hospital setting in selected groups being a target of 110 to 140. So that is a large RCT data that's outside of COVID-19.

So we might not have RCT data on that, specifically COVID 19 with those targets, but we extrapolate and we believe that those targets should be similar and we should follow those targets. But for CGM use, this data that has just come out really came out at the most amazing time at the same as this FDA announcement.

And so I think people are bolstered to actually try to see within their system how they can implement CGM, because our sensors are getting better and patients generally prefer it widely. And anecdotally from where people are using it, there is a learning curve with the nurses or whoever would be doing some of the actual, tasks related around CGM placement, et cetera. Once they've gotten over that initial hump, they generally like it as well. And so this idea of CGM in the hospital, I think is going to take off. We definitely need the companies to, you know, be on board and really long-term support this use as well. And essentially, I think for right now, most of what I'm hearing from a lot of hospitals is that they are doing it within the research capacity. Although some people have initiated as pilot testing on certain floors, especially if there is really strong buy-in from the institution. And so if you're thinking about this or you're sitting here and you're listening to this podcast and you see counts in your area going up in your community and you know that you're going to be seeing a surge coming, you know, on the horizon, right, you can preplan and preparation.

And so what I like to personally use when I am talking about really big systematic changes, I use something called the systems engineering initiative for patient safety. It's called the SEIPS model. And it breaks it down into several components that you should think about for any implementation of something new in clinical care. So you have to think about different things. Tasks is one of them. Technology is another. Persons, people, that is another. And then the lastly, you have your environment and your organization.

And so when you are thinking about continuous glucose monitors, let's just take tasks. So you have to think about who's going to place the sensor, who is going to collect the data and interpret it, and who's going to teach the staff, like the actual tasks. For technology, and this is where I keep saying we're going to need help from, Big Tech, I think, in relation to things that are sort of outside of our control to figure out which is the data monitoring, data integration, being able to capture all of that data somehow within the EMR. I mean, right now we're taking snapshots and putting them in the EMR. Some places have started actual integration, but we really need to have more data and more understanding of how to integrate without slowing the systems down. In terms of people or persons, you know, you gotta actually think about procurement, IT, infection control. You know, who's going to be in charge? Is that the primary team? The endocrinologist? Also we have to think about environment. Are you going to do this in the ICU or are you going to do this on the floor generally? And then organization, and this actually is the most critical part, right?

you need to have service and team alignment. You need to make sure that you have the right committee approvals and the right policies and procedures in place. So, if you're just even thinking about this, I think just start jotting these things down and thinking about, "Okay. This is the team I need to assemble to do a pilot" and then start small. You know, Rome wasn't built in a day. You can do one floor and think about, "All right. Well, you see this team, likes it, but you know, patient care techs or nurses, how did they adopt it in their regular workflow," et cetera.

And I think work out the kinks in a small fashion, because again, you don't want to introduce new technology and that learning curve can be very, daunting if you're just not used to the technology. And this is where in healthcare, we know this, that there are always sort of the superusers, who are your friends, your colleagues that are always the first one to adopt technology and take you along every time there's a system update. And so I think you really need to find those superusers who are going to, you know, sell, the actual implementation and get people over that initial hump for learning, in terms of any kind of technology, but specifically CGM.

Melanie: In some instances, dexamethazone is being used to treat patients with severe cases of COVID-19, but could pose potential risk to diabetes patients. Can you talk about balancing that use of corticosteroids in diabetes patients? How should providers regulate insulin when the use of dexamethazone is necessary?

Dr Amisha Wallia: Yes. I think that obviously the idea of some of these moderately to critically ill patients on huge amounts of corticosteroids can be really daunting. But I think my advice is you've got this. You know, we've been treating insulin resistance caused by dexamethazone and critical illness for quite a while. And I think that we just have to stay true to being consistent and keeping up with the insulin needs. So generally I tell my trainees and actually anyone that will listen is, you know, look at the 24-hour total use of insulin unit, divided by the units per kilo, and generally 0.3 units per kilo is, you know, lower end of insulin resistance, 0.5 is moderate and then anything above 1 is severe. Some of these patients get very high, but you just have to keep up and try not to get behind. I think, insulin drips can be very helpful. But when you're getting above a certain amount, you really want to be careful because people can precipitously-- insulin resistance can break, depending on where they're in their course of their illness and where the dexamethazone is. So you just have to stay on top of it. And so I guess my advice is you have got this and it will be okay.

Melanie: And that's great advice. Wrap it up for us doctor, if you would, with. How you think the pandemic will change diabetes care and research in the future and what you'd like endocrinologists to know about COVID-19 to manage their patients.

Dr Amisha Wallia: So I think it's really unfortunate cOVID-19 has really uncovered so many things that we wish, that we, you know, realize that we need to change and has highlighted things that really desperately needed highlighted, but are concerning. And one of those is the care of our diabetes patients and how our patients are really affected and in very high rates. And so what I hope is that we take this opportunity to actually embrace the availability of technology, so telemedicine, telehealth, as well as things like continuous glucose monitoring. Really try to integrate them into care models or at least start talking about it because I do think as endocrinologist, diabetes specialists, internal medicine, you know, anyone who is in this space, we can see more patients safely with this new technology. And I actually think we can meet better glucose targets, having less adverse events.

And so I think we just really need to adapt and work together outside of our silo and within our teams to get this done. And I really hope that we utilize this to come together and share data like we've never had, share protocols like we've never had. One thing I do want to advise people, there's a wonderful website from my colleagues that was started at Emory. It's https://www.covidindiabetes.org I urge you to that site and see how people are sharing. Do you have any questions as we wrap it up? I just want to say, have been so many people who have reached out to me and I've reached out to them during this time, and anyone that needs anything, please do not hesitate to reach out to me or anyone in your community that you may think can help you.

Melanie: That was an excellent episode, dr. Wallia. Wow. You are a great guest and so informative, really educational. Thank you so much for joining us. To refer your patient, please visit our website at NM.org to get connected with one of our providers.

That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.