Diabetes Management in Correctional Institutions

Transcription

1 S104 Diabetes Care Volume 37, Supplement 1, January 2014 Diabetes Management in Corretional Institutions Amerian Diabetes Assoiation POSITION STATEMENT At any given time, over 2 million people are inarerated in prisons and jails in the U.S (1). It is estimated that nearly 80,000 of these inmates have diabetes, a prevalene of 4.8% (2). In addition, many more people pass through the orretions system in a given year. In 1998 alone, over 11 million people were released from prison to the ommunity (1). The urrent estimated prevalene of diabetes in orretional institutions is somewhat lower than the overall U.S. prevalene of diabetes, perhaps beause the inarerated population is younger than the general population. The prevalene of diabetes and its related omorbidities and ompliations, however, will ontinue to inrease in the prison population as urrent sentening guidelines ontinue to inrease the number of aging prisoners and the inidene of diabetes in young people ontinues to inrease. People with diabetes in orretional failities should reeive are that meets national standards. Corretional institutions have unique irumstanes that need to be onsidered so that all standards of are may be ahieved (3). Corretional institutions should have written poliies and proedures for the management of diabetes and for training of medial and orretional staff in diabetes are praties. These poliies must take into onsideration issues suh as seurity needs, transfer from one faility to another, and aess to medial personnel and equipment, so that all appropriate levels of are are provided. Ideally, these poliies should enourage or at least allow patients to self-manage their diabetes. Ultimately, diabetes management is dependent upon having aess to needed medial personnel and equipment. Ongoing diabetes therapy is important in order to redue the risk of later ompliations, inluding ardiovasular events, visual loss, renal failure, and amputation. Early identifiation and intervention for people with diabetes is also likely to redue short-term risks for aute ompliations requiring transfer out of the faility, thus improving seurity. This doument provides a general set of guidelines for diabetes are in orretional institutions. It is not designed to be a diabetes management manual. More detailed information on the management of diabetes and related disorders an be found in the Amerian Diabetes Assoiation (ADA) Clinial Pratie Reommendations, published eah year in January as the first supplement to Diabetes Care,aswellasthe Standards of Medial Care in Diabetes (4) ontained therein. This disussion will fous on those areas where the are of people with diabetes in orretional failities may differ, and speifi reommendations are made at the end of eah setion by the Amerian Diabetes Assoiation. See INTAKE MEDICAL ASSESSMENT Reeption Sreening Reeption sreening should emphasize patient safety. In partiular, rapid identifiation of all insulin-treated persons with diabetes is essential in order to identify those at highest risk for hypo- and hyperglyemia and diabeti ketoaidosis (DKA). All insulin-treated patients should have a apillary blood gluose (CBG) determination within 1 2 h of arrival. Signs and symptoms of hypoor hyperglyemia an often be onfused with intoxiation or withdrawal from drugs or alohol. Individuals with diabetes exhibiting signs and symptoms DOI: /d14-S104 onsistent with hypoglyemia, partiularly altered mental status, agitation, ombativeness, and diaphoresis, should have finger-stik blood gluose levels measured immediately. n-nd/3.0/ for details. Downloaded from by guest on February 8, 2014 Originally approved Most reent revision, 2008.

2 are.diabetesjournals.org Position Statement S105 Intake Sreening Patients with a diagnosis of diabetes should have a omplete medial history and physial examination by a liensed health are provider with presriptive authority in a timely manner. If one is not available on site, one should be onsulted by those performing reeption sreening. The purposes of this history and physial examination aretodeterminethetypeofdiabetes, urrent therapy, alohol use, and behavioral health issues, as well as to sreen for the presene of diabetesrelated ompliations. The evaluation should review the previous treatment and the past history of both glyemi ontrol and diabetes ompliations. It is essential that mediation and medial nutrition therapy (MNT) be ontinued without interruption upon entry into the orretional system, as a hiatus in either mediation or appropriate nutrition may lead to either severe hypo- or hyperglyemia that an rapidly progress to irreversible ompliations, even death. Intake Physial Examination and Laboratory All potential elements of the initial medial evaluation are inluded in Table 7 of the ADA s Standards of Medial Care in Diabetes, referred to hereafter as the Standards of Care (4). The essential omponents of the initial history and physial examination are detailed in Fig. 1. Referrals should be made immediately if the patient with diabetes is pregnant. Reommendations Patients with a diagnosis of diabetes should have a omplete medial history and undergo an intake physial examination by a liensed health professional in a timely manner. E Insulin-treated patients should have a CBG determination within 1 2 hof arrival. E Mediations and MNT should be ontinued without interruption upon entry into the orretional environment. E SCREENING FOR DIABETES Consistent with the ADA Standards of Care, patients should be evaluated for diabetes risk fators at the intake physial and at appropriate times thereafter. Those who are at high risk should be onsidered for blood gluose sreening. If pregnant, a risk assessment for gestational diabetes mellitus (GDM) should be undertaken at the first prenatal visit. Patients with linial harateristis onsistent with a high risk for GDM should undergo gluose testing as soon as possible. High-risk women not found to have GDM at the initial sreening and average-risk women should be tested between 24 and 28 weeks of gestation. For more detailed information on sreening for both type 2 and gestational diabetes, see the ADA Position Statement Sreening for Type 2 Diabetes (5) and the Standards of Care (4). MANAGEMENT PLAN Glyemi ontrol is fundamental to the management of diabetes. A management Figure 1 Essential omponents of the initial history and physial examination. Alb/Cr ratio, albumin-to-reatinine ratio; ALT, alanine aminotransferase; AST, aspartate aminotransferase. Downloaded from by guest on February 8, 2014

3 S106 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014 plan to ahieve normal or near-normal glyemia with an A1C goal of,7% should be developed for diabetes management at the time of initial medial evaluation. Goals should be individualized (4), and less stringent treatment goals may be appropriate for patients with a history of severe hypoglyemia, patients with limited life expetanies, elderly adults, and individuals with omorbid onditions (4). This plan should be doumented in the patient s reord and ommuniated to all persons involved in his/her are, inluding seurity staff. Table 1, taken from the ADA Standards of Care, provides a summary of reommendations for setting glyemi ontrol goals for adults with diabetes. People with diabetes should ideally reeive medial are from a physiianoordinated team. Suh teams inlude, but are not limited to, physiians, nurses, dietitians, and mental health professionals with expertise and a speial interest in diabetes. It is essential in this ollaborative and integrated team approah that individuals with diabetes assume as ative a role in their are as possible. Diabetes self-management eduation is an integral omponent of are. Patient self-management should be emphasized, and the plan should enourage the involvement of the patient in problem solving as muh as possible. It is helpful to house insulin-treated patients in a ommon unit, if this is possible, safe, and onsistent with providing aess to other programs at the orretional institution. Common housing not only an failitate mealtimes and mediation administration, but also potentially provides an opportunity for diabetes self-management eduation to be reinfored by fellow patients. should also help in dietary management by offering healthy hoies and listing the arbohydrate ontent of foods. The use of insulin or oral mediations may neessitate snaks in order to avoid hypoglyemia. These snaks are a part of suh patients medial treatment plans and should be presribed by medial staff. Timing of meals and snaks must be oordinated with mediation NUTRITION AND FOOD SERVICES administration as needed to minimize the risk of hypoglyemia, as disussed more Nutrition ounseling and menu fully in the MEDICATION setion of this planning are an integral part of doument. For further information, see the multidisiplinary approah to the ADA Position Statement Nutrition diabetes management in orretional Therapy Reommendations for the failities. A ombination of eduation, Management of Adults With Diabetes (7). interdisiplinary ommuniation, and monitoring food intake aids patients in URGENT AND EMERGENCY ISSUES understanding their medial nutritional needs and an failitate diabetes ontrol All patients must have aess to prompt during and after inareration. treatment of hypo- and hyperglyemia. Corretional staff should be trained in Nutrition ounseling for patients the reognition and treatment of hypoand hyperglyemia, and appropriate with diabetes is onsidered an essential omponent of diabetes selfmanagement. People with diabetes gluagon. After suh emergeny are, staff should be trained to administer should reeive individualized MNT as patients should be referred for needed to ahieve treatment goals, appropriate medial are to minimize preferably provided by a registered risk of future deompensation. dietitian familiar with the omponents of MNT for persons with diabetes. Institutions should implement a poliy requiring staff to notify a physiian of all Eduating the patient, individually or CBGresultsoutsideofaspeified range, in a group setting, about how as determined by the treating physiian arbohydrates and food hoies diretly (e.g.,,50 or.350 mg/dl,,2.8 or affet diabetes ontrol is the first step in.19.4 mmol/l). failitating self-management. This eduation enables the patient to Hyperglyemia identify better food seletions from Severe hyperglyemia in a person those available in the dining hall and with diabetes may be the result of ommissary. Suh an approah is more interurrent illness, missed or realisti in a faility where the patient inadequate mediation, or has the opportunity to make food ortiosteroid therapy. Corretional hoies. institutions should have systems in,140/80 mmhg The easiest and most ost-effetive plae to identify and refer to medial,100 mg/dl (,2.6 means to failitate good outomes in staff all patients with onsistently mmol/l) patients with diabetes is instituting a elevated blood gluose as well as heart-healthy diet as the master menu interurrent illness. (6). There should be onsistent The stress of illness in those with type 1 arbohydrate ontent at eah meal, as diabetes frequently aggravates glyemi well as a means to identify the ontrol and neessitates more frequent arbohydrate ontent of eah food monitoring of blood gluose (e.g., every seletion. Providing arbohydrate 4 6 h). Marked hyperglyemia requires ontent of food seletions and/or temporary adjustment of the treatment providing eduation in assessing program and, if aompanied by ketosis, arbohydrate ontent enables patients interation with the diabetes are team. to meet the requirements of their Adequate fluid and alori intake must individual MNT goals. Commissaries be ensured. Nausea or vomiting Downloaded from by guest on February 8, 2014 Table 1 Summary of reommendations for glyemi, blood pressure, and lipid ontrol for most adults with diabetes A1C,7.0%* Blood pressure Lipids LDL holesterol *More or less stringent glyemi goals may be appropriate for individual patients. Goals should be individualized based on duration of diabetes, age/life expetany, omorbid onditions, known CVD or advaned mirovasular ompliations, hypoglyemia unawareness, individual and patient onsiderations. Based on patient harateristis and response to therapy, lower SBP targets may be appropriate. In individuals with overt CVD, a lower LDL holesterol goal of,70 mg/dl (1.8 mmol/l), using a high dose of a statin, is an option.

4 are.diabetesjournals.org Position Statement S107 aompanied with hyperglyemia may indiate DKA, a life-threatening ondition that requires immediate medial are to prevent ompliations and death. Corretional institutions should identify patients with type 1 diabetes who are at risk for DKA, partiularly those with a prior history of frequent episodes of DKA. For further information see Hyperglyemi Crisis in Diabetes (8). Hypoglyemia Hypoglyemia is defined as a blood gluose level,70 mg/dl (3.9 mmol/l). Severe hypoglyemia is a medial emergeny defined as hypoglyemia requiring assistane of a third party and is often assoiated with mental status hanges that may inlude onfusion, inoherene, ombativeness, somnolene, lethargy, seizures, or oma. Signs and symptoms of severe hypoglyemia an be onfused with intoxiation or withdrawal. Individuals with diabetes exhibiting signs and symptoms onsistent with hypoglyemia, partiularly altered mental status, agitation, and diaphoresis, should have their CBG levels heked immediately. Seurity staff who supervise patients at risk for hypoglyemia (i.e., those on insulin or oral hypoglyemi agents) should be eduated in the emergeny response protool for reognition and treatment of hypoglyemia. Every attempt should be made to doument CBG before treatment. Patients must have immediate aess to gluose tablets or other gluose-ontaining foods. Hypoglyemia an generally be treated by the patient with oral arbohydrates. If the patient annot be relied on to keep hypoglyemia treatment on his/her person, staff members should have ready aess to gluose tablets or equivalent. In general, g oral gluose will be adequate to treat hypoglyemi events. CBG and treatment should be repeated at 15-min intervals until blood gluose levels return to normal (.70 mg/dl, 3.9 mmol/l). Staff should have gluagon for intramusular injetion or gluose for intravenous infusion available to treat severe hypoglyemia without requiring transport of the hypoglyemi patient to an outside faility. Any episode of severe hypoglyemia or reurrent episodes of mild to moderate hypoglyemia require reevaluation of the diabetes management plan by the medial staff. In ertain ases of unexplained or reurrent severe hypoglyemia, it may be appropriate to admit the patient to the medial unit for observation and stabilization of diabetes management. Corretional institutions should have systems in plae to identify the patients at greater risk for hypoglyemia (i.e., those on insulin or sulfonylurea therapy) and to ensure the early detetion and treatment of hypoglyemia. If possible, patients at greater risk of severe hypoglyemia (e.g., those with a prior episode of severe hypoglyemia) may be housed in units loser to the medial unit in order to minimize delay in treatment. Patients at all levels of ustody should have aess to mediation at dosing frequenies that are onsistent with their treatment plan and medial diretion. If feasible and onsistent with seurity onerns, patients on multiple doses of short-ating oral mediations should be plaed in a keep on person program. In other situations, patients should be permitted to self-injet insulin when onsistent with seurity needs. Medial department nurses should determine whether patients have the neessary skill and responsible behavior to be allowed self-administration and the degree of supervision neessary. When needed, this skill should be a part of patient eduation. Reasonable syringe ontrol systems should be established. In the past, the reommendation that regular insulin be injeted min before meals presented a signifiant problem when lok downs or other Reommendations disruptions to the normal shedule of Train orretional staff in the meals and mediations ourred. The reognition, treatment, and use of multiple-dose insulin regimens appropriate referral for hypo- and using rapid-ating analogs an derease hyperglyemia. E the disruption aused by suh hanges Train appropriate staff to administer in shedule. Corretional institutions gluagon. E should have systems in plae to ensure Train staff to reognize symptoms that rapid-ating insulin analogs and and signs of serious metaboli oral agents are given immediately deompensation, and immediately before meals if this is part of the refer the patient for appropriate patient s medial plan. It should be medial are. E noted, however, that even modest Institutions should implement a poliy delays in meal onsumption with these requiring staff to notify a physiian of agents an be assoiated with all CBG results outside of a speified hypoglyemia. If onsistent aess to range, as determined by the treating food within 10 min annot be ensured, physiian (e.g.,,50 or.350 mg/dl, rapid-ating insulin analogsandoral,2.8 or.19.4 mmol/l). E agents are approved for administration Identify patients with type 1 diabetes during or immediately after meals. who are at high risk for DKA. E Should irumstanes arise that delay MEDICATION patient aess to regular meals following mediation administration, Formularies should provide aess to poliies and proedures must be usual and ustomary oral mediations implemented to ensure the patient and insulins neessary to treat reeives appropriate nutrition to diabetes and related onditions. prevent hypoglyemia. While not every brand name of insulin and oral mediation needs to be The sole use of sliding sale insulin is available, individual patient are strongly disouraged. Both ontinuous requires aess to short-, medium-, and subutaneous insulin infusion and long-ating insulins and the various multiple daily insulin injetion therapy lasses of oral mediations (e.g., insulin (onsisting of three or more injetions a seretagogues, biguanides, a-gluosidase day) an be effetive means of inhibitors, DPP-4 inhibitors, and implementing intensive diabetes thiazolidinediones) neessary for management with the goal of ahieving urrent diabetes management. near-normal levels of blood gluose (9). Downloaded from by guest on February 8, 2014

5 S108 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014 While the use of these modalities may be diffiult in orretional institutions, every effort should be made to ontinue multiple daily insulin injetion or ontinuous subutaneous insulin infusion in people who were using this therapy before inareration or to institute these therapies as indiated in order to ahieve blood gluose targets. It is essential that transport of patients from jails or prisons to off-site appointments, suh as medial visits or ourt appearanes, does not ause signifiant disruption in mediation or meal timing. Corretional institutions and polie lok-ups should implement poliies and proedures to diminish the risk of hypo- and hyperglyemia by, for example, providing arry-along meals and mediation for patients traveling to offsite appointments or hanging the insulin regimen for that day. The availability of prefilled insulin pens provides an alternative for off-site insulin delivery. Reommendations Formularies should provide aess to usual and ustomary oral mediations and insulins to treat diabetes and related onditions. E Patients should have aess to mediation at dosing frequenies that are onsistent with their treatment plan and medial diretion. E Corretional institutions and polie lok-ups should implement poliies and proedures to diminish the risk of hypo- and hyperglyemia during off-site travel (e.g., ourt appearanes). E ROUTINE SCREENING FOR AND MANAGEMENT OF DIABETES COMPLICATIONS All patients with a diagnosis of diabetes should reeive routine sreening for diabetes-related ompliations, as detailed in the ADA Standards of Care (4). Interval hroni disease linis for persons with diabetes provide an effiient mehanism to monitor patients for ompliations of diabetes. In this way, appropriate referrals to onsultant speialists, suh as optometrists/ ophthalmologists, nephrologists, and ardiologists, an be made on an asneeded basis and interval laboratory testing an be done. The following ompliations should be onsidered: Foot are: Reommendations for foot are for patients with diabetes and no history of an open foot lesion are desribed in the ADA Standards of Care. A omprehensive foot examination is reommended annually for all patients with diabetes to identify risk fators preditive of ulers and amputations. Persons with an insensate foot, an open foot lesion, or a history of suh a lesion should be referred for evaluation by an appropriate liensed health professional (e.g., podiatrist or vasular surgeon). Speial shoes should be provided as reommended by liensed health professionals to aid healing of foot lesions and to prevent development of new lesions. Retinopathy: Annual retinal examinations by a liensed eye are professional should be performed for all patients with diabetes, as reommended in the ADA Standards of Care. Visual hanges that annot be aounted for by aute hanges in glyemi ontrol require prompt evaluation by an eye are professional. Nephropathy: An annual spot urine test for determination of miroalbumin-to-reatinine ratio should be performed. The use of ACE inhibitors or angiotensin reeptor blokers is reommended for all patients with albuminuria. Blood pressure should be ontrolled to,140/80 mmhg. Cardia: People with type 2 diabetes are at a partiularly high risk of oronary artery disease. Cardiovasular disease (CVD) risk fator management is of demonstrated benefit in reduing this ompliation in patients with diabetes. Blood pressure should be measured at every routine diabetes visit. In adult patients, test for lipid disorders at least annually and as needed to ahieve goals with treatment. Use aspirin therapy ( mg/day) in all adult patients with diabetes and ardiovasular risk fators or known marovasular disease. Current national standards for adults with diabetes all for Downloaded from by guest on February 8, 2014 treatment of lipids to goals of LDL #100, HDL.40, triglyerides,150 mg/dl, and blood pressure to a level of,140/80 mmhg. MONITORING/TESTS OF GLYCEMIA Monitoring of CBG is a strategy that allows aregivers and people with diabetes to evaluate diabetes management regimens. The frequeny of monitoring will vary by patients glyemi ontrol and diabetes regimens. Patients with type 1 diabetes are at risk for hypoglyemia and should have their CBG monitored three or more times daily. Patients with type 2 diabetes on insulin need to monitor at least one daily and more frequently based on their medial plan. Patients treated with oral agents should have CBG monitoredwithsuffiient frequeny to failitate the goals of glyemi ontrol, assuming that there is a program for medial review of these data on an ongoing basis to drive hanges in mediations. Patients whose diabetes is poorly ontrolled or whose therapy is hanging should have more frequent monitoring. Unexplained hyperglyemia in a patient with type 1 diabetes may suggest impending DKA, and monitoring of ketones should therefore be performed. Glyated hemoglobin (A1C) is a measure of long-term (2- to 3-month) glyemi ontrol. Perform the A1C test at least two times a year in patients who are meeting treatment goals (and who have stable glyemi ontrol) and quarterly in patients whose therapy has hanged or who are not meeting glyemi goals. Disrepanies between CBG monitoring results and A1C may indiate a hemoglobinopathy, hemolysis, or need for evaluation of CBG monitoring tehnique and equipment or initiation of more frequent CBG monitoring to identify when glyemi exursions are ourring and whih faet of the diabetes regimen is hanging. In the orretional setting, poliies and proedures need to be developed and implemented regarding CBG monitoring that address the following: infetion ontrol eduation of staff and patients

6 are.diabetesjournals.org Position Statement S109 proper hoie of meter be used depending on the needs signs and symptoms of, and disposal of testing lanets assessment and the length of emergeny response to, hypo- and quality ontrol programs inareration. Table 2 sets out the hyperglyemia aess to health servies major omponents of diabetes selfmanagement gluose monitoring size of the blood sample eduation. Survival skills mediations patient performane skills should be addressed as soon as exerise doumentation and interpretation of test results possible; other aspets of eduation may be provided as part of an ongoing nutrition issues inluding timing of meals and aess to snaks availability of test results for the eduation program. Reommendations health are provider (10) Ideally, self-management eduation is Inlude diabetes in orretional staff Reommendations oordinated by a ertified diabetes eduation programs. E In the orretional setting, poliies eduator who works with the faility to ALCOHOL AND DRUGS and proedures need to be developed develop polies, proedures, and and implemented to enable CBG protools to ensure that nationally Patients with diabetes who are monitoring to our at the frequeny reognized eduation guidelines are withdrawing from drugs and alohol neessitated by the individual implemented. The eduator is also need speial onsideration. This issue patient s glyemi ontrol and able to identify patients who need partiularly affets initial polie ustody diabetes regimen. E diabetes self-management eduation, and jails. At an intake faility, proper A1C should be heked every 3 6 inluding an assessment of the initial identifiation and assessment of months. E patients medial, soial, and diabetes these patients are ritial. The presene histories; diabetes knowledge, skills, of diabetes may ompliate SELF-MANAGEMENT EDUCATION and behaviors; and readiness to detoxifiation. Patients in need of hange. ompliated detoxifiation should be Self-management eduation is the referred to a faility equipped to deal ornerstone of treatment for all people STAFF EDUCATION with high-risk detoxifiation. Patients with diabetes. The health staff must with diabetes should be eduated in the advoate for patients to partiipate Poliies and proedures should be risks involved with smoking. All inmates in self-management as muh as implemented to ensure that the should be advised not to smoke. possible. Individuals with diabetes who health are staff has adequate Assistane in smoking essation should learn self-management skills and knowledge and skills to diret the be provided as pratial. make lifestyle hanges an more management and eduation of persons effetively manage their diabetes and with diabetes. The health are staff TRANSFER AND DISCHARGE avoid or delay ompliations needs to be involved in the assoiated with diabetes. In the development of the orretional Patients in jails may be housed for a development of a diabetes selfmanagement eduation program in the eduation program should be at a lay transferred or released, and it is not offiers training program. The staff short period of time before being orretional environment, the unique level. Training should be offered at unusual for patients in prison to be irumstanes of the patient should be least biannually, and the urriulum transferred within the system several onsidered while still providing, to the should over the following: times during their inareration. One of the many hallenges that health are greatest extent possible, the elements providers fae working in the of the National Standards for Diabetes what diabetes is orretional system is how to best Self-Management Eduation and signs and symptoms of diabetes ollet and ommuniate important Support (11). A staged approah may risk fators health are information in a timely manner when a patient is in initial polie ustody, is jailed short term, or is Table 2 Major omponents of diabetes self-management eduation transferred from faility to faility. The Survival skills Daily management issues importane of this ommuniation hypo-/hyperglyemia disease proess beomes ritial when the patient has a sik day management nutritional management hroni illness suh as diabetes. mediation physial ativity monitoring mediations Transferring a patient with diabetes foot are monitoring from one orretional faility to another aute ompliations requires a oordinated effort. To risk redution failitate a thorough review of medial goal setting/problem solving information and ompletion of a psyhosoial adjustment transfer summary, it is ritial for preoneption are/pregnany/gestational diabetes management ustody personnel to provide medial staff with suffiient notie before movement of the patient. Downloaded from by guest on February 8, 2014

7 S110 Position Statement Diabetes Care Volume 37, Supplement 1, January 2014 Before the transfer, the health are staff should review the patient s medial reord and omplete a medial transfer summary that inludes the patient s urrent health are issues. At a minimum, the summary should inlude the following: the patient s urrent mediation shedule and dosages the date and time of the last mediation administration any reent monitoring results (e.g., CBG and A1C) other fators that indiate a need for immediate treatment or management at the reeiving faility (e.g., reent episodes of hypoglyemia, history of severe hypoglyemia or frequent DKA, onurrent illnesses, presene of diabetes ompliations) information on sheduled treatment/ appointments if the reeiving faility is responsible for transporting the patient to that appointment name and telephone/fax number of a ontat person at the transferring faility who an provide additional information, if needed The medial transfer summary, whih ats as a quik medial referene for the reeiving faility, should be transferred along with the patient. To supplement the flow of information and to inrease the probability that mediations are orretly identified at the reeiving institution, sending institutions are enouraged to provide eah patient with a mediation ard to be arried by the patient that ontains information onerning diagnoses, mediation names, dosages, and frequeny. Diabetes supplies, inluding diabetes mediation, should aompany the patient. The sending faility must be mindful of the transfer time in order to provide the patient with mediation and food if needed. The transfer summary or medial reord should be reviewed by a health are provider upon arrival at the reeiving institution. Planning for patients disharge from prisons should inlude instrution in the long-term ompliations of diabetes, the neessary lifestyle hanges and examinations required to prevent these ompliations, and, if possible, where patients may obtain regular follow-up medial are. A quarterly meeting to eduate patients with upoming disharges about ommunity resoures an be valuable. Inviting ommunity agenies to speak at these meetings and/or provide written materials an help strengthen the ommunity link for patients disharging from orretional failities. Disharge planning for the patients with diabetes should begin 1 month before disharge. During this time, appliation for appropriate entitlements should be initiated. Any gaps in the patient s knowledge of diabetes are need to be identified and addressed. It is helpful if the patient is given a diretory or list of ommunity resoures and if an appointment for follow-up are with a ommunity provider is made. A supply of mediation adequate to last until the first postrelease medial appointment should be provided to the patient upon release. The patient should be provided with a written summary of his/her urrent health are issues, inluding mediations and doses, reent A1C values, et. Reommendations For all interinstitutional transfers, omplete a medial transfer summary to be transferred with the patient. E Diabetes supplies and mediation should aompany the patient during transfer. E Begin disharge planning with adequate lead time to insure ontinuity of are and failitate entry into ommunity diabetes are. E SHARING OF MEDICAL INFORMATION AND RECORDS Pratial onsiderations may prohibit obtaining medial reords from providers who treated the patient before arrest. Intake failities should implement poliies that 1) define the irumstanes under whih prior medial reords are obtained (e.g., for patients who have an extensive history of treatment for ompliations); 2) identify person(s) responsible for ontating the prior provider; and 3) establish proedures for traking requests. Downloaded from by guest on February 8, 2014 Failities that use outside medial providers should implement poliies and proedures for ensuring that key information (e.g., test results, diagnoses, physiians orders, appointment dates) is reeived from the provider and inorporated into the patient s medial hart after eah outside appointment. The proedure should inlude, at a minimum, a means to highlight when key information has not been reeived and designation of a person responsible for ontating the outside provider for this information. All medial harts should ontain CBG test results in a speified, readily aessible setion and should be reviewed on a regular basis. CHILDREN AND ADOLESCENTS WITH DIABETES Children and adolesents with diabetes, in partiular type 1, present speial problems in disease management, even outside the setting of a orretional institution. Children and adolesents with diabetes should have initial and follow-up are with physiians who are experiened in their are. Confinement inreases the diffiulty in managing diabetes in hildren and adolesents, as it does in adults with diabetes. Corretional authorities also have different legal obligations for hildren and adolesents. Nutrition and Ativity Growing hildren and adolesents have greater alori/nutritional needs than adults. In youth with type 1 diabetes, insulin dosing based on arbohydrate amounts is of partiular importane. The provision of an adequate amount of alories and nutrients for adolesents is ritial to maintaining good nutritional status. Physial ativity should be provided at the same time eah day. If inreased physial ativity ours, additional CBG monitoring is neessary and additional arbohydrate snaks may be required. Medial Management and Follow-up Children and adolesents who are inarerated for extended periods should have follow-up visits at least every 3 months with individuals who are experiened in the are of hildren and adolesents with diabetes. Thyroid

8 are.diabetesjournals.org Position Statement S111 funtion tests and fasting lipid and miroalbumin measurements should be performed aording to reognized standards for hildren and adolesents (12) in order to monitor for autoimmune thyroid disease and ompliations and omorbidities of diabetes. Children and adolesents with diabetes exhibiting unusual behavior should have their CBG heked at that time. Beause hildren and adolesents are reported to have higher rates of noturnal hypoglyemia (13), onsideration should be given regarding the use of episodi overnight blood gluose monitoring in these patients. In partiular, this should be onsidered in hildren and adolesents who have reently had their overnight insulin dose hanged. PREGNANCY Pregnany in a woman with diabetes is by definition a high-risk pregnany. Every effort should be made to ensure that treatment of the pregnant woman with diabetes meets aepted standards (14,15). It should be noted that glyemi standards are more stringent, the details of dietary management are more omplex and exating, insulin is the only antidiabeti agent approved for use in pregnany, and a number of mediations used in the management of diabeti omorbidities are known to be teratogeni and must be disontinued in the setting of pregnany. SUMMARY AND KEY POINTS People with diabetes should reeive are that meets national standards. Being inarerated does not hange these standards. Patients must have aess to mediation and nutrition needed to manage their disease. In patients who do not meet treatment targets, medial and behavioral plans should be adjusted by health are professionals in ollaboration with the prison staff. It is ritial for orretional institutions to identify partiularly high-risk patients in need of more intensive evaluation and therapy, inluding pregnant women, patients with advaned ompliations, a history of repeated severe hypoglyemia, or reurrent DKA. A omprehensive, multidisiplinary approah to the are of people with diabetes an be an effetive mehanism to improve overall health and delay or prevent the aute and hroni ompliations of this disease. Aknowledgments. The following members of the Amerian Diabetes Assoiation/ National Commission on Corretional Health Care Joint Working Group on Diabetes Guidelines for Corretional Institutions ontributed to the revision of this doument: Daniel L. Lorber, MD, FACP, CDE (hair); R. Sott Chavez, MPA, PA-C; Joanne Dorman, RN, CDE, CCHP-A; Lynda K. Fisher, MD; Stephanie Guerken, RD, CDE; Linda B. Haas, CDE, RN; Joan V. Hill, CDE, RD; David Kendall, MD; Mihael Puisis, DO; Kathy Salomone, CDE, MSW, APRN; Ronald M. Shansky, MD, MPH; and Barbara Wakeen, RD, LD. Referenes 1. National Commission on Corretional Health Care: The Health Status of Soon-to- Be Released Inmates: A Report to Congress. Vol. 1. 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