A t any given time, over 2 million people

Transcription

1 P O S I T I O N S T A T E M E N T Diabetes Management in Corretional Institutions AMERICAN DIABETES ASSOCIATION A t 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, published eah year in January as the first supplement to Diabetes Care,aswell asthe 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. 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 hypo- or hyperglyemia an often be onfused with intoxiation or withdrawal from drugs or alohol. Individuals with diabetes exhibiting signs and symptoms onsistent with hypoglyemia, partiularly altered mental status, agitation, ombativeness, and diaphoresis, should have finger-stik blood gluose levels measured immediately. Intake sreening Patients with a diagnosis of diabetes should have a omplete medial history Originally approved Most reent revision, DOI: /d13-S by the Amerian Diabetes Assoiation. Readers may use this artile as long as the work is properly ited, the use is eduational and not for profit, and the work is not altered. See lienses/by-n-nd/3.0/ for details. 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 are to determine the type of diabetes, urrent therapy, alohol use, and behavioral health issues, as well as to sreen for the presene of diabetes-related 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. 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 DIABETESd 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 S86 DIABETES CARE, VOLUME 36, SUPPLEMENT 1, JANUARY 2013 are.diabetesjournals.org

2 Figure 1dEssential omponents of the initial history and physial examination. Alb/Cr ratio, albumin-to-reatinine ratio; ALT, alanine aminotransferase; AST, aspartate aminotransferase. 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 informationonsreeningforbothtype2 and gestational diabetes, see the ADA Sreening for Type 2Diabetes (5) and the Standards of Care (4). MANAGEMENT PLANdGlyemi ontrol is fundamental to the management of diabetes. A management 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 selfmanagement 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. NUTRITION AND FOOD SERVICESdNutrition ounseling and menu planning are an integral part of the multidisiplinary approah to diabetes management in orretional failities. A ombination of eduation, interdisiplinary ommuniation, and monitoring food intake aids patients in understanding their medial nutritional needs and an failitate diabetes ontrol during and after inareration. Nutrition ounseling for patients with diabetes is onsidered an essential omponent of diabetes self-management. People with diabetes should reeive individualized MNT as needed to ahieve treatment goals, preferably provided by a registered dietitian familiar with the omponents of MNT for persons with diabetes. Eduating the patient, individually or in a group setting, about how arbohydrates and food hoies diretly affet diabetes ontrol is the first step in failitating self-management. This eduation enables the patient to identify better food are.diabetesjournals.org DIABETES CARE, VOLUME 36, SUPPLEMENT 1, JANUARY 2013 S87

3 Table 1dSummary of reommendations for glyemi, blood pressure, and lipid ontrol for most adults with diabetes A1C,7.0%* Blood pressure,140/80 mmhg Lipids LDL holesterol,100 mg/dl (,2.6 mmol/l) *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. seletions from those available in the dining hall and ommissary. Suh an approah is more realisti in a faility where the patient has the opportunity to make food hoies. The easiest and most ost-effetive means to failitate good outomes in patients with diabetes is instituting a hearthealthy diet as the master menu (6). There should be onsistent arbohydrate ontent at eah meal, as well as a means to identify the arbohydrate ontent of eah food seletion. Providing arbohydrate ontent of food seletions and/or providing eduation in assessing arbohydrate ontent enables patients to meet the requirements of their individual MNT goals. Commissaries 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 administration as needed to minimize the risk of hypoglyemia, as disussed more fully in the MEDICATION setion of this doument. For further information, see the ADA Position Statement Nutrition and Interventions for Diabetes (7). URGENT AND EMERGENCY ISSUESdAll patients must have aess to prompt treatment of hypo- and hyperglyemia. Corretional staff should be trained in the reognition and treatment of hypo- and hyperglyemia, and appropriate staff should be trained to administer gluagon. After suh emergeny are, patients should be referred for appropriate medial are to minimize risk of future deompensation. Institutions should implement a poliy requiring staff to notify a physiian of all CBG results outside of a speified range, as determined by the treating physiian (e.g.,,50 or.350 mg/dl). Hyperglyemia Severe hyperglyemia in a person with diabetes may be the result of interurrent illness, missed or inadequate mediation, or ortiosteroid therapy. Corretional institutions should have systems in plae to identify and refer to medial staff all patients with onsistently elevated blood gluose as well as interurrent illness. The stress of illness in those with type 1 diabetes frequently aggravates glyemi ontrol and neessitates more frequent monitoring of blood gluose (e.g., every 4 6 h). Marked hyperglyemia requires temporary adjustment of the treatment program and, if aompanied by ketosis, interation with the diabetes are team. Adequate fluid and alori intake must be ensured. Nausea or vomiting 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. 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 gluoseontaining 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). 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. Train orretional staff in the reognition, treatment, and appropriate referral for hypo- and hyperglyemia. (E) Train appropriate staff to administer gluagon. (E) Train staff to reognize symptoms and signs of serious metaboli deompensation, and immediately refer the patient for appropriate medial are. (E) Institutions should implement a poliy requiringstafftonotifyaphysiianof all CBG results outside of a speified range, as determined by the treating physiian (e.g.,,50 or.350 mg/dl). (E) Identify patients with type 1 diabetes who are at high risk for DKA. (E) MEDICATIONdFormularies should provide aess to usual and ustomary S88 DIABETES CARE, VOLUME 36, SUPPLEMENT 1, JANUARY 2013 are.diabetesjournals.org

4 oral mediations and insulins neessary to treat diabetes and related onditions. While not every brand name of insulin and oral mediation needs to be available, individual patient are requires aess to short-, medium-, and long-ating insulins and the various lasses of oral mediations (e.g., insulin seretagogues, biguanides, a-gluosidase inhibitors, and thiazolidinediones) neessary for urrent diabetes management. 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 shortating 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 disruptions to the normal shedule of meals and mediations ourred. The use of multiple-dose insulin regimens using rapid-ating analogs an derease the disruption aused by suh hanges in shedule. Corretional institutions should have systems in plae to ensure that rapid-ating insulin analogs and oral agents are given immediately before meals if this is part of the patient smedial plan. It should be noted however that even modest delays in meal onsumption with these agents an be assoiated with hypoglyemia. If onsistent aess to food within 10 min annot be ensured, rapidating insulin analogs and oral agents are approved for administration during or immediately after meals. Should irumstanes arise that delay patient aess to regular meals following mediation administration, poliies and proedures must be implemented to ensure the patient reeives appropriate nutrition to prevent hypoglyemia. Both ontinuous subutaneous insulin infusion and multiple daily insulin injetion therapy (onsisting of three or more injetions a day) an be effetive means of implementing intensive diabetes management with the goal of ahieving near-normal levels of blood gluose (9). 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 lokups 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 off-site appointments or hanging the insulin regimen for that day. The availability of prefilled insulin pens provides an alternative for off-site insulin delivery. 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 offsite travel (e.g., ourt appearanes). (E) ROUTINE SCREENING FOR AND MANAGEMENT OF DIABETES COMPLICATIONSdAll 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 as-needed basis and interval laboratory testing an be done. The following ompliations should be onsidered: Foot are: 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 miroalbuminto-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 inreduing 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 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 GLYCEMIAdMonitoring 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 are.diabetesjournals.org DIABETES CARE, VOLUME 36, SUPPLEMENT 1, JANUARY 2013 S89

5 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 monitored with suffiient 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 proper hoie of meter disposal of testing lanets quality ontrol programs aess to health servies size of the blood sample patient performane skills doumentation and interpretation of test results availability of test results for the health are provider (10) In the orretional setting, poliies and proedures need to be developed and implemented to enable CBG monitoring to our at the frequeny neessitated by the individual patient s glyemi ontrol and diabetes regimen. (E) A1C should be heked every 3 6 months. (E) SELF-MANAGEMENT EDUCATIONdSelf-management eduation is the ornerstone of treatment for all people with diabetes. The health staff must advoate for patients to partiipate in self-management as muh as possible. Individuals with diabetes who learn self-management skills and make lifestyle hanges an more effetively manage their diabetes and avoid or delay ompliations assoiated with diabetes. In the development of a diabetes selfmanagement eduation program in the orretional environment, the unique irumstanes of the patient should be onsidered while still providing, to the greatest extent possible, the elements of the National Standards for Diabetes Self-Management Eduation and Support (11). A staged approah may be used depending on the needs assessment and the length of inareration. Table 2 sets out the major omponents of diabetes self-management eduation. Survival skills should be addressed as soon as possible; other aspets of eduationmaybeprovidedaspartofanongoing eduation program. Ideally, self-management eduation is oordinated by a ertified diabetes eduator who works with the faility to develop polies, proedures, and protools to ensure that nationally reognized eduation guidelines are implemented. The eduator is also able to identify patients who need diabetes self-management eduation, inluding an assessment of the patients medial, soial, and diabetes histories; diabetes knowledge, skills, and behaviors; and readiness to hange. STAFF EDUCATIONdPoliies and proedures should be implemented to ensure that the health are staff has adequate knowledge and skills to diret the management and eduation of persons with diabetes. The health are staff needs to be involved in the development of the orretional offiers training program. The staff eduation program should be at a lay level. Training should be offered at least biannually, and the urriulum should over the following: what diabetes is signs and symptoms of diabetes risk fators signs and symptoms of, and emergeny response to, hypo- and hyperglyemia gluose monitoring mediations exerise nutrition issues inluding timing of meals and aess to snaks Inlude diabetes in orretional staff eduation programs. (E) ALCOHOL AND DRUGSdPatients with diabetes who are withdrawing from drugs and alohol need speial onsideration. This issue partiularly affets initial polie ustody and jails. At an intake faility, proper initial identifiation and assessment of these patients are ritial. The presene of diabetes may ompliate detoxifiation. Patients in need of ompliated detoxifiation should be referred to a faility equipped to deal with highrisk detoxifiation. Patients with diabetes should be eduated in the risks involved with smoking. All inmates should be advised not to smoke. Assistane in smoking essation should be provided as pratial. TRANSFER AND DISCHARGEdPatients in jails may be housed for a short period of time before being transferred or released, and it is not unusual for patients in prison to be transferred within the system several times during their inareration. One of the many hallenges that health are providers fae working in the orretional system is how to best ollet and ommuniate important health are information in a timely manner when a patient is in initial polie ustody, is jailed short term, or is transferred from faility to faility. The importane of this ommuniation beomes ritial when the patient has a hroni illness suh as diabetes. Transferring a patient with diabetes from one orretional faility to another requires a oordinated effort. To failitate a thorough review of medial information and ompletion of a transfer summary, it is ritial for ustody personnel to provide medial staff with suffiient notie before movement of the patient. 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 S90 DIABETES CARE, VOLUME 36, SUPPLEMENT 1, JANUARY 2013 are.diabetesjournals.org

6 Table 2dMajor omponents of diabetes self-management eduation Survival skills hypo-/hyperglyemia sik day management mediation monitoring foot are 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 Daily management issues disease proess nutritional management physial ativity mediations monitoring aute ompliations risk redution goal setting/problem solving psyhosoial adjustment preoneption are/pregnany/gestational diabetes management 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. 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 RECORDSdPratial 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. 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 DIABETESdChildren and adolesents with diabetes 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. 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. are.diabetesjournals.org DIABETES CARE, VOLUME 36, SUPPLEMENT 1, JANUARY 2013 S91

7 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 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. PREGNANCYdPregnany 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 POINTSdPeople 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. AknowledgmentsdThe 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. Chiago, NCCHC, Hornung CA, Greifinger RB, Gadre S: A Projetion Model of the Prevalene of Seleted Chroni Diseases in the Inmate Population. Vol. 2. Chiago, NCCHC, 2002, p Puisis M: Challenges of improving quality in the orretional setting. In Clinial Pratie in Corretional Mediine. St. Louis, MO, Mosby-Yearbook, 1998, p Amerian Diabetes Assoiation: Standards of medial are in diabetesd2013 (Position Statement). Diabetes Care 36 (Suppl. 1): S11 S66, Amerian Diabetes Assoiation: Sreening for type 2 diabetes (). Diabetes Care 27 (Suppl. 1):S11 S14, Krauss RM, Ekel RH, Howard B, Appel LJ, Daniels SR, Dekelbaum RJ, Erdman JW Jr, Kris-Etherton P, Goldberg IJ, Kothen TA, Lihtenstein AH, Mith WE, Mullis R, Robinson K, Wylie-Rosett J, St Jeor S, Suttie J, Tribble DL, Bazzarre TL: Amerian Heart Assoiation Dietary Guidelines: revision 2000: a statement for healthare professionals from the Nutrition Committee of the Amerian Heart Assoiation. Stroke 31: , Amerian Diabetes Assoiation: Nutrition reommendations and interventions for diabetes (). Diabetes Care 31 (Suppl. 1):S61 S78, Amerian Diabetes Assoiation: Hyperglyemi risis in diabetes (Position Statement). Diabetes Care 27 (Suppl. 1): S94 S102, Amerian Diabetes Assoiation: Continuous subutaneous insulin infusion (Position Statement). Diabetes Care 27 (Suppl. 1):S110, Amerian Diabetes Assoiation: Tests of glyemia in diabetes (). Diabetes Care 27 (Suppl. 1):S91 S93, HaasL,MaryniukM,BekJ,CoxCE, Duker P, Edwards L, Fisher EB, Hanson L, Kent D, Kolb L, MLaughlin S, Orzek E, Piette JD, Rhinehart AS, Rothman R, Sklaroff S, Tomky D, Youssef G, on behalf of the 2012 Standards Revision Task Fore: National standards for diabetes self-management eduation and support. Diabetes Care 36 (Suppl. 1):S100 S108, International Soiety for Pediatri and Adolesent Diabetes: Consensus Guidelines 2000: ISPAD Consensus Guidelines for the Management of Type 1 Diabetes Mellitus in Children and Adolesents. Zeist,Netherlands, Medial Forum International, 2000, p. 116, Kaufman FR, Austin J, Neinstein A, Jeng L, Halyorson M, Devoe DJ, Pitukheewanont P: Noturnal hypoglyemia deteted with the ontinuous gluose monitoring system in pediatri patients with type 1 diabetes. J Pediatr 141: , Amerian Diabetes Assoiation: Gestational diabetes mellitus (). Diabetes Care 27 (Suppl. 1):S88 S90, Jovanovi L (Ed.): Medial Management of Pregnany Compliated by Diabetes.4thed. Alexandria, VA, Amerian Diabetes Assoiation, 2009 S92 DIABETES CARE, VOLUME 36, SUPPLEMENT 1, JANUARY 2013 are.diabetesjournals.org