Diabetes and COVID-19

Outpatient procedure/policies - an impassioned plea

  • 1.  Outpatient procedure/policies - an impassioned plea

    Posted 05-08-2020 23:44
    Dear colleagues,
    Like many of you, I am a diabetologist and I adore my patients. 
    I request that the ADA create specific guidelines for outpatient diabetes management throughout the first/second/third or annual waves of COVID-19 outbreak.The current guidance is vague.  As an adult diabetologist, my patients are older, overweight/obese, & have several co-morbidities. I see at least 2 and up to 4 new patients daily, the majority whom are referred for management of uncontrolled glycemia. 
    My patients trust me. When the first cases of COVID-19 were reported in my town, I had 5 patients >85 years old scheduled the following week. We successfully pivoted to 100% telehealth within 48 hours to reduce their risk of exposure. While there are several significant deficits (including lack of foot examination), there are viable work-arounds including enlisting the help of family member/caregiver. We coordinated wound care for a burgeoning foot ulcer using these strategies. In truth, a TikTok video could easily teach someone how to perform a basic monofilament examination and take pictures of various aspects of the feet. There are other strategies to bring Telehealth to vulnerable patients lacking access to technology (including mailed cellular-capable tablets that are Zoom/telehealth ready with push of a button - obviates need for wifi). 
    Yet, administrators have voiced concern that there is the lack of "facility fee" reimbursement for the Telehealth visits. As you know, most diabetes clinics do not regularly perform procedures. Our staff may occasionally wipe down the chairs, change the table paper. They use alcohol swab for finger sticks and injections. We do not routinely manage patients with highly contagious diseases. Our nurses have limited experience with appropriate placement of a mask, don/doff PPE or sterilization of our equipment. Thus it is unlikely that we can adequately protect our patients during clinical encounters.  
    I adore my patients. My patients trust me. When the second wave hits, I would like to be certain that I have done everything I can to protect them.  I am a clinician, not an investigator. I do not have NIH funding, prestigious publications or highly reimbursed procedures to leverage influence. I am the low woman on the totem pole in the bureaucratic health care environment. I am comfortable with my cloud residing amongst my patients. Most organizations rely on the recommendations posited by organizations such as the ADA to determine protocol/procedure. 
    I urge you to publish a position statement with guidance for diabetes clinicians, including what constitutes adequate cleaning between visits; which patients should be exposed to the healthcare setting to generate this facility fee; and strategies to  effectively provide care via Telemedicine. Now is NOT the time to debate the pros and cons of telemedicine. Be it a task force driven position statement or basic guidance endorsed by the ADA, we need something  focused specifically on maximizing risk reduction  in patients with diabetes. 
    Help me protect these people who trust me/I adore. 
    Sincerely,




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    Hayley Miller MD, BS
    "Just a Clinician"
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