Purpose of Review This review discusses the interplay between coronavirus disease 2019 (COVID-19, caused by SARS-CoV-2 infection), diabetes mellitus, and hyperglycemia in the hospital setting. There are data emerging about diabetes and hyperglycemia, their prevalence, and potential risks in the setting of SARS-CoV-2 infection and COVID-19. Recent Findings It is known that viral infections exert effects on beta cell function and insulin resistance. Therefore, much can be learned about SARS-CoV-2/COVID-19 from examining these known relationships. Such pathophysiological underpinnings may unlock greater understanding as we navigate atypical cases of hyperglycemia, severe insulin resistance, and diabetic ketoacidosis amidst COVID-19. Glycemic outcomes likely have beneficial effects on morbidity and mortality, but this needs to be studied. Summary Changes in diabetes-related protocols and new technology can be deployed in the inpatient setting to potentially improve healthcare worker and patient safety; however, one must weigh the risks and benefits of implementation during a pandemic. Ultimately, knowledge and research must be shared at record speed to combat this global crisis.

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Diabetes mellitus (DM) self-care teaching is often provided at point of care, but “clinician-centered” feedback about teaching is lacking. Semi-structured, facilitated interviews of front-line clinicians involved in DM care (e.g., meter, medications, injection technique) were conducted. Clinicians were asked their perspectives on the needs of newly diagnosed DM patients, specifically during transitions of care (e.g., discharge home). Clinicians were also asked to review current DM education materials (training supplies, print handouts) and subsequently developed potential solutions. Interview transcripts were independently coded by 3 coders, using a constant comparative method, to identify themes. MAXQDA software was used. Key themes were additionally audited by a diabetologist. Eleven sessions were conducted with clinicians (N=14, 2 certified DM educators, 4 endocrinology MD fellows, 3 advanced practice providers, 1 DM nurse, 2 pharmacists, 2 internal medicine MDs). The most commonly identified theme across clinician type was simplified, understandable content (8/11 sessions). Participants identified lack of centralization of supplies and education materials as the most significant barrier (9/11 sessions) to optimal care. Other top themes were insurance coverage for diabetes supplies and medications, need for customization, and limited access to diabetes educators. The most preferred solution was use of patient simulation (repetitive practice) [7/11 sessions], followed by teaching videos (5/11 sessions). Clinicians preferred comprehensive but simplified, understandable, customizable, diabetes teaching content. The lack of centralization of supplies and content and insurance coverage for supplies/medications are major barriers for clinicians to deliver optimal DM self-care teaching. These data also suggest that use of simulation could facilitate improvement in DM teaching by front-line clinicians. Disclosure K. Coyne: None. S. Hakimian: None. T. Pollack: None. S. Karam: None. G. Prince: None. E.K. Touma: None. D.W. Gatchell: None. R. Khorzad: None. B. Ankenman: None. J.L. Holl: None. A. Wallia: Research Support; Self; Eli Lilly and Company, Novo Nordisk Inc., UnitedHealth Group. Funding American Diabetes Association (1-13-JF-54 to A.W.); Chicago Center for Diabetes Translation Research/National Institute of Diabetes and Digestive and Kidney Diseases (P30DK092949); Agency for Healthcare Research and Quality (5R18HS026143-02)

Learning diabetes mellitus (DM) survival skills is critically important, especially for those newly diagnosed upon discharge. COVID-19 has created new educational challenges, as DM self-management education and support is difficult to deliver remotely and can be time intensive. Content and format have not been re-designed for remote delivery; however, learning sciences research can help us create effective remote education strategies. We conducted interviews with users to identify critical needs in assuming immediate DM self-care at discharge from the hospital. We then mapped these user needs to relevant learning science theories to inform potential re-designs for remote delivery of DM education and survival skills at discharge. We conducted 12 semi-structured interviews with “users,” which included 18 participants (8 minority; 6>65 years): patients newly diagnosed with DM at discharge (N=6 [33%]), their caregivers (N=4 [22%]), and laypersons new to DM (N=8 [45%]). Users were asked about their discharge needs, laypersons about perceived needs. Three investigators performed iterative rounds of inductive coding of the transcripts (using MAXQDA software), utilizing a constant comparative method to identify codes describing dominant user needs. Learning science theory was applied to identify potential re-designs for remote delivery. Dominant user needs during hospitalization included being overwhelmed with DM self-care information (6/12 sessions) and difficulty organizing self-care equipment (5/12 sessions). Dominant user needs at home included remembering DM self-care steps (6/12 sessions), understanding correct insulin dosing (9/12 sessions), feeling fearful injecting insulin (9/12 sessions), with some noting difficulty in tracking glucose (4/12 sessions) and confusing insulin types (4/12 sessions). When learning science theory was applied, analysis mapped to three discrete educational strategies, most dominant of which is the spiral design approach—cycles of teaching the same topic but with increasing complexity. This design follows the pre-teaching principle—curriculum-based conceptual overview of self-care. Self-care at home mapped to the need for segmented learning and goal directed practice and feedback, with the potential need for behavioral therapies to reduce fear. Learning sciences has demonstrated that learning complex procedures and concepts, such as DM self-care, requires time, repetition, and continued support. With short hospital stays and the complexity of learning DM self-care, patients cannot gain needed knowledge structures to organize the information received during hospitalization. This study suggests specific learning science strategies for the design of an effective remote delivery of DM education and skills.

Training of diabetes (DM) skills is critical to assure competency of DM survival skills (e.g. glucose testing) for immediate self-care. While DM assessments exist, we sought to develop a culturally acceptable DM Skills and Knowledge Assessment (DM-SKA) tool. A systematic search of Pubmed/Medline and Scopus (1980-2017) of assessments for DM knowledge was performed. 24 studies were identified, only 33% reported minority populations. Studies were classified by topic: measurement of DM skills, objectives of DM training, assessments of DM education, and other non-patient assessments. Content from existing assessments was adapted to create a 12 question DM-SKA to address 6 domains: DM, blood glucose and self-monitoring, support services, identification management of hypo and hyperglycemia, and insulin administration. To assess cultural acceptance, cognitive evaluations were conducted in individual user sessions and focus groups. The DM-SKA had a baseline Flesch reading score of 81.3 (low complexity language) and Flesch-Kincaid reading grade level of 5.3. Of 39 approached, 85% (N=33) participated (6 inpatients refused, feeling “overwhelmed”). Participants were diverse, including 8 clinicians, 10 patients/caregivers, and 15 laypersons; 46% were non-Hispanic whites, 33% non-Hispanic blacks, 12% Hispanics, and 9% Asian Americans. Mean age of patient/caregiver/laypersons was 57.8±17 (44% > age 65) and 40.1±12 years for clinicians (12.5% > age 65). All clinicians reported that appropriate DM skill domains were included and felt patients would complete the tool. All patients/caregivers and laypersons (N=25) verbalized adequate comprehension of each question; 96% reported willingness to complete the DM-SKA if provided and 88% reported their family, friends or someone in their community would be willing to complete it. However, both providers (N=2) and patients (N=2) reported concerns about assessment format and delivery [e.g. “testing” or “quiz”]. Some younger (<65 years) patients/caregiver/laypersons (N= 4) reported concerns about potential willingness of elderly family members to complete the tool. However, acceptability of the DM-SKA was noted from all participants >65 years. Vision problems and older age were identified as potential barriers. Of those offered the assessment (N = 25), 5 (20%) participants needed assistance [N=2 vision, N=3 English as second language]. Mean DM-SKA score was 10.2±1.7 of 12. Incorrect answers mostly occurred for questions with multiple correct answers. The DM-SKA has acceptable literacy characteristics, cognitive validity, and cultural acceptability by racial/ethnic minority populations, including elderly persons. Future work includes integration into clinical workflows and incorporation of patient preferences.