Diabetes Management in Correctional Institutions

P O S I T I O N
S T A T E M E N T
Diabetes Management in Correctional
Institutions
AMERICAN DIABETES ASSOCIATION
Intake screening
Patients with a diagnosis of diabetes
should have a complete medical history
Atanygiventime,over2millionpeo- loss,renalfailure,andamputation.Early and physical examination by a licensed
ple are incarcerated in prisons and
identification and intervention for people
health care provider with prescriptive au-
jails in the U.S (1). It is estimated
with diabetes is also likely to reduce
thority in a timely manner. If one is not
that nearly 80,000 of these inmates have
short-term risks for acute complications
available on site, one should be consulted
diabetes, a prevalence of 4.8% (2). In ad-
requiring transfer out of the facility, thus
by those performing reception screening.
dition, many more people pass through
improving security.
The purposes of this history and physical
the corrections system in a given year. In
This document provides a general set
examination are to determine the type of
1998 alone, over 11 million people were
of guidelines for diabetes care in correc-
diabetes, current therapy, alcohol use,
released from prison to the community
tional institutions. It is not designed to be
and behavioral health issues, as well as to
(1). The current estimated prevalence of
a diabetes management manual. More de-
screen for the presence of diabetes-related
diabetes in correctional institutions is
tailed information on the management of
complications. The evaluation should re-
somewhat lower than the overall U.S.
diabetes and related disorders can be
view the previous treatment and the past
prevalence of diabetes, perhaps because
found in the American Diabetes Associa-
history of both glycemic control and dia-
the incarcerated population is younger
tion (ADA) Clinical Practice Recommen-
betes complications. It is essential that
than the general population. The preva-
dations, published each year in January as
medication and medical nutrition therapy
lence of diabetes and its related comor-
the first supplement to Diabetes Care, as
(MNT) be continued without interrup-
bidities and complications, however, will
well as the “Standards of Medical Care in
tion upon entry into the correctional sys-
continue to increase in the prison popu-
Diabetes” (4) contained therein. This dis-
tem, as a hiatus in either medication or
lation as current sentencing guidelines
cussion will focus on those areas where
appropriate nutrition may lead to either
continue to increase the number of aging
the care of people with diabetes in correc-
severe hypo- or hyperglycemia that can
prisoners and the incidence of diabetes in
tional facilities may differ, and specific
rapidly progress to irreversible complica-
young people continues to increase.
recommendations are made at the end of
tions, even death.
People with diabetes in correctional
each section.
facilities should receive care that meets
Intake physical examination and
national standards. Correctional institu-
INTAKE MEDICAL
laboratory
tions have unique circumstances that
ASSESSMENT
All potential elements of the initial medi-
need to be considered so that all standards
cal evaluation are included in Table 5 of
of care may be achieved (3). Correctional
Reception screening
the ADA’s “Standards of Medical Care in
institutions should have written policies
Reception screening should emphasize
Diabetes,” referred to hereafter as the
and procedures for the management of
patient safety. In particular, rapid identi-
“Standards of Care” (4). The essential
diabetes and for training of medical and
fication of all insulin-treated persons with
components of the initial history and
correctional staff in diabetes care prac-
diabetes is essential in order to identify
physical examination are detailed in Fig.
tices. These policies must take into con-
those at highest risk for hypo- and hyper-
1. Referrals should be made immediately
sideration issues such as security needs,
glycemia and diabetic ketoacidosis
if the patient with diabetes is pregnant.
transfer from one facility to another, and
(DKA). All insulin-treated patients should
access to medical personnel and equip-
have a capillary blood glucose (CBG) de-
Recommendations
ment, so that all appropriate levels of care
termination within 1–2 h of arrival. Signs
● Patients with a diagnosis of diabetes
are provided. Ideally, these policies
and symptoms of hypo- or hyperglycemia
should have a complete medical history
should encourage or at least allow pa-
can often be confused with intoxication or
and undergo an intake physical exami-
tients to self-manage their diabetes. Ulti-
withdrawal from drugs or alcohol. Indi-
nation by a licensed health professional
m a t e l y , d i a b e t e s m a n a g e m e n t i s
viduals with diabetes exhibiting signs and
in a timely manner. (E)
dependent upon having access to needed
symptoms consistent with hypoglycemia,
● Insulin-treated patients should have a
medical personnel and equipment. Ongo-
particularly altered mental status, agita-
CBG determination within 1–2 h of ar-
ing diabetes therapy is important in order
tion, combativeness, and diaphoresis,
rival. (E)
to reduce the risk of later complications,
should have finger-stick blood glucose
● Medications and MNT should be con-
including cardiovascular events, visual
levels measured immediately.
tinued without interruption upon entry
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
into the correctional environment. (E)
Originally approved 1989. Most recent revision, 2008.
Abbreviations: CBG, capillary blood glucose; DKA, diabetic ketoacidosis; GDM, gestational diabetes mel-
SCREENING FOR DIABETES —
litus; MNT, medical nutrition therapy.
Consistent with the ADA Standards of
DOI: 10.2337/dc10-S075
Care, patients should be evaluated for di-
© 2010 by the American Diabetes Association. Readers may use this article as long as the work is properly
cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.
abetes risk factors at the intake physical
org/licenses/by-nc-nd/3.0/ for details.
and at appropriate times thereafter. Those
care.diabetesjournals.org
DIABETES CARE, VOLUME 33, SUPPLEMENT 1, JANUARY 2010
S75

---

Correctional Institutions
Figure 1—Essential components of the initial history and physical examination. Alb/Cr ratio, albumin-to-creatinine ratio; ALT, alanine amino-
transferase; AST, aspartate aminotransferase.
who are at high risk should be considered
viduals with comorbid conditions (4).
tional institution. Common housing not
for blood glucose screening. If pregnant, a
This plan should be documented in the
only can facilitate mealtimes and medica-
risk assessment for gestational diabetes
patient’s record and communicated to all
tion administration, but also potentially
mellitus (GDM) should be undertaken at
persons involved in his/her care, includ-
provides an opportunity for diabetes self-
the first prenatal visit. Patients with clin-
ing security staff. Table 1, taken from the
management education to be reinforced
ical characteristics consistent with a high
ADA Standards of Care, provides a sum-
by fellow patients.
risk for GDM should undergo glucose
mary of recommendations for setting gly-
testing as soon as possible. High-risk
cemic control goals for adults with
NUTRITION AND FOOD
women not found to have GDM at the
diabetes.
SERVICES — Nutrition counseling and
initial screening and average-risk women
People with diabetes should ideally
menu planning are an integral part of the
should be tested between 24 and 28
receive medical care from a physician-
multidisciplinary approach to diabetes
weeks of gestation. For more detailed in-
coordinated team. Such teams include,
management in correctional facilities. A
formation on screening for both type 2
but are not limited to, physicians, nurses,
combination of education, interdisciplinary
and gestational diabetes, see the ADA Po-
dietitians, and mental health profession-
communication, and monitoring food in-
sition Statement “Screening for Type 2 Di-
als with expertise and a special interest in
take aids patients in understanding their
abetes” (5) and the Standards of Care (4).
diabetes. It is essential in this collabora-
medical nutritional needs and can facilitate
tive and integrated team approach that in-
diabetes control during and after incarcera-
MANAGEMENT PLAN — Glyce-
dividuals with diabetes assume as active a
tion.
mic control is fundamental to the man-
role in their care as possible. Diabetes self-
Nutrition counseling for patients with
agement of diabetes. A management plan
management education is an integral
diabetes is considered an essential compo-
to achieve normal or near-normal glyce-
c o m p o n e n t o f c a r e . P a t i e n t s e l f -
nent of diabetes self-management. People
mia with an A1C goal of
7% should be
management should be emphasized, and
with diabetes should receive individualized
developed for diabetes management at
the plan should encourage the involve-
MNT as needed to achieve treatment goals,
the time of initial medical evaluation.
ment of the patient in problem solving as
preferably provided by a registered dietitian
Goals should be individualized (4), and
much as possible.
familiar with the components of MNT for
less stringent treatment goals may be ap-
It is helpful to house insulin-treated
persons with diabetes.
propriate for patients with a history of se-
patients in a common unit, if this is pos-
Educating the patient, individually or
vere hypoglycemia, patients with limited
sible, safe, and consistent with providing
in a group setting, about how carbohy-
life expectancies, elderly adults, and indi-
access to other programs at the correc-
drates and food choices directly affect di-
S76
DIABETES CARE, VOLUME 33, SUPPLEMENT 1, JANUARY 2010
care.diabetesjournals.org

---

Position Statement
risk for hypoglycemia (i.e., those on insulin
Table 1—Summary of recommendations for glycemic, blood pressure, and lipid control for
or oral hypoglycemic agents) should be ed-
adults with diabetes
ucated in the emergency response protocol
for recognition and treatment of hypoglyce-
A1C
7.0%*
mia. Every attempt should be made to doc-
Blood pressure
130/80 mmHg
ument CBG before treatment. Patients must
Lipids
have immediate access to glucose tablets or
LDL cholesterol
100 mg/dl ( 2.6 mmol/l)†
other glucose-containing foods. Hypogly-
*Referenced to a nondiabetic range of 4.0 – 6.0% using a DCCT-based assay. †In individuals with overt CVD,
cemia can generally be treated by the patient
a lower LDL cholesterol goal of
70 mg/dl (1.8 mmol/l), using a high dose of a statin, is an option.
with oral carbohydrates. If the patient can-
not be relied on to keep hypoglycemia treat-
abetes control is the first step in
range, as determined by the treating phy-
ment on his/her person, staff members
facilitating self-management. This educa-
sician (e.g.,
50 or
350 mg/dl).
should have ready access to glucose tablets
tion enables the patient to identify better
or equivalent. In general, 15–20 g oral glu-
food selections from those available in the
Hyperglycemia
cose will be adequate to treat hypoglycemic
dining hall and commissary. Such an ap-
Severe hyperglycemia in a person with di-
events. CBG and treatment should be re-
proach is more realistic in a facility where
abetes may be the result of intercurrent
peated at 15-min intervals until blood glu-
the patient has the opportunity to make
illness, missed or inadequate medication,
cose levels return to normal ( 70 mg/dl).
food choices.
or corticosteroid therapy. Correctional
Staff should have glucagon for intra-
The easiest and most cost-effective
institutions should have systems in place
muscular injection or glucose for intrave-
means to facilitate good outcomes in pa-
to identify and refer to medical staff all
nous infusion available to treat severe
tients with diabetes is instituting a heart-
patients with consistently elevated blood
hypoglycemia without requiring transport
healthy diet as the master menu (6). There
glucose as well as intercurrent illness.
of the hypoglycemic patient to an outside
should be consistent carbohydrate con-
The stress of illness in those with type
facility. Any episode of severe hypoglycemia
tent at each meal, as well as a means to
1 diabetes frequently aggravates glycemic
or recurrent episodes of mild to moderate
identify the carbohydrate content of each
control and necessitates more frequent
hypoglycemia require reevaluation of the
food selection. Providing carbohydrate
monitoring of blood glucose (e.g., every
diabetes management plan by the medical
content of food selections and/or provid-
4 – 6 h). Marked hyperglycemia requires
staff. In certain cases of unexplained or re-
ing education in assessing carbohydrate
temporary adjustment of the treatment
current severe hypoglycemia, it may be ap-
content enables patients to meet the re-
program and, if accompanied by ketosis,
propriate to admit the patient to the medical
quirements of their individual MNT
interaction with the diabetes care team.
unit for observation and stabilization of di-
goals. Commissaries should also help in
Adequate fluid and caloric intake must be
abetes management.
dietary management by offering healthy
ensured. Nausea or vomiting accompa-
Correctional institutions should have
choices and listing the carbohydrate con-
nied with hyperglycemia may indicate
systems in place to identify the patients at
tent of foods.
DKA, a life-threatening condition that re-
greater risk for hypoglycemia (i.e., those
The use of insulin or oral medications
quires immediate medical care to prevent
on insulin or sulfonylurea therapy) and to
may necessitate snacks in order to avoid
complications and death. Correctional in-
ensure the early detection and treatment
hypoglycemia. These snacks are a part of
stitutions should identify patients with
of hypoglycemia. If possible, patients at
such patients’ medical treatment plans
type 1 diabetes who are at risk for DKA,
greater risk of severe hypoglycemia (e.g.,
and should be prescribed by medical staff.
particularly those with a prior history of
those with a prior episode of severe hypo-
Timing of meals and snacks must be
frequent episodes of DKA. For further in-
glycemia) may be housed in units closer
coordinated with medication administra-
formation see “Hyperglycemic Crisis in
to the medical unit in order to minimize
tion as needed to minimize the risk of hy-
Diabetes” (8).
delay in treatment.
poglycemia, as discussed more fully in the
MEDICATION section of this document. For
Hypoglycemia
Recommendations
further information, see the ADA Position
Hypoglycemia is defined as a blood glu-
● Train correctional staff in the recogni-
Statement “Nutrition Principles and Rec-
cose level
70 mg/dl. Severe hypoglyce-
tion, treatment, and appropriate refer-
ommendations in Diabetes” (7).
mia is a medical emergency defined as
ral for hypo- and hyperglycemia. (E)
hypoglycemia requiring assistance of a
● Train appropriate staff to administer
URGENT AND EMERGENCY
third party and is often associated with
glucagon. (E)
ISSUES — All patients must have access
mental status changes that may include
● Train staff to recognize symptoms and
to prompt treatment of hypo- and hypergly-
confusion, incoherence, combativeness,
signs of serious metabolic decompensa-
cemia. Correctional staff should be trained
somnolence, lethargy, seizures, or coma.
tion, and immediately refer the patient
in the recognition and treatment of hypo-
Signs and symptoms of severe hypoglyce-
for appropriate medical care. (E)
and hyperglycemia, and appropriate staff
mia can be confused with intoxication or
● Institutions should implement a policy
should be trained to administer glucagon.
withdrawal. Individuals with diabetes ex-
requiring staff to notify a physician of
After such emergency care, patients should
hibiting signs and symptoms consistent
all CBG results outside of a specified
be referred for appropriate medical care to
with hypoglycemia, particularly altered
range, as determined by the treating
minimize risk of future decompensation.
mental status, agitation, and diaphoresis,
physician (e.g.,
50 or
350 mg/dl).
Institutions should implement a pol-
should have their CBG levels checked im-
(E)
icy requiring staff to notify a physician of
mediately.
● Identify patients with type 1 diabetes
all CBG results outside of a specified
Security staff who supervise patients at
who are at high risk for DKA. (E)
care.diabetesjournals.org
DIABETES CARE, VOLUME 33, SUPPLEMENT 1, JANUARY 2010
S77

---

Correctional Institutions
MEDICATION — Formularies should
more injections a day) can be effective
The following complications should
provide access to usual and customary oral
means of implementing intensive diabe-
be considered.
medications and insulins necessary to treat
tes management with the goal of achiev-
diabetes and related conditions. While not
ing near-normal levels of blood glucose
● Foot care: Recommendations for foot
every brand name of insulin and oral med-
(9). While the use of these modalities may
care for patients with diabetes and no
ication needs to be available, individual pa-
be difficult in correctional institutions,
history of an open foot lesion are de-
tient care requires access to short-,
every effort should be made to continue
scribed in the ADA Standards of Care. A
medium-, and long-acting insulins and the
multiple daily insulin injection or contin-
comprehensive foot examination is rec-
various classes of oral medications (e.g., in-
uous subcutaneous insulin infusion in
ommended annually for all patients
sulin secretagogues, biguanides, -glucosi-
people who were using this therapy be-
with diabetes to identify risk factors
dase inhibitors, and thiazolidinediones)
fore incarceration or to institute these
predictive of ulcers and amputations.
necessary for current diabetes management.
therapies as indicated in order to achieve
Persons with an insensate foot, an open
Patients at all levels of custody should
blood glucose targets.
foot lesion, or a history of such a lesion
have access to medication at dosing fre-
It is essential that transport of patients
should be referred for evaluation by an
quencies that are consistent with their
from jails or prisons to off-site appoint-
appropriate licensed health profes-
treatment plan and medical direction. If
ments, such as medical visits or court ap-
sional (e.g., podiatrist or vascular sur-
feasible and consistent with security con-
pearances, does not cause significant
geon). Special shoes should be
cerns, patients on multiple doses of short-
disruption in medication or meal timing.
provided as recommended by licensed
acting oral medications should be placed
Correctional institutions and police lock-
health professionals to aid healing of
in a “keep on person” program. In other
ups should implement policies and pro-
foot lesions and to prevent develop-
situations, patients should be permitted
cedures to diminish the risk of hypo- and
ment of new lesions.
to self-inject insulin when consistent with
hyperglycemia by, for example, providing
● Retinopathy: Annual retinal examina-
security needs. Medical department
carry-along meals and medication for pa-
tions by a licensed eye care professional
nurses should determine whether pa-
tients traveling to off-site appointments or
should be performed for all patients
tients have the necessary skill and respon-
changing the insulin regimen for that day.
with diabetes, as recommended in the
sible behavior to be allowed self-
The availability of prefilled insulin “pens”
ADA Standards of Care. Visual changes
administration and the degree of
provides an alternative for off-site insulin
that cannot be accounted for by acute
supervision necessary. When needed, this
delivery.
changes in glycemic control require
skill should be a part of patient education.
prompt evaluation by an eye care pro-
Reasonable syringe control systems
fessional.
should be established.
Recommendations
● Nephropathy: An annual spot urine test
In the past, the recommendation that
● Formularies should provide access to
for determination of microalbumin-to-
regular insulin be injected 30 – 45 min be-
usual and customary oral medications
creatinine ratio should be performed.
fore meals presented a significant prob-
and insulins to treat diabetes and re-
The use of ACE inhibitors or angioten-
lem when “lock downs” or other
lated conditions. (E)
sin receptor blockers is recommended
disruptions to the normal schedule of
● Patients should have access to medica-
for all patients with albuminuria. Blood
meals and medications occurred. The use
tion at dosing frequencies that are con-
pressure should be controlled to
of multiple-dose insulin regimens using
sistent with their treatment plan and
130/80 mmHg.
rapid-acting analogs can decrease the dis-
medical direction. (E)
● Cardiac: People with type 2 diabetes are
ruption caused by such changes in sched-
● Correctional institutions and police
at a particularly high risk of coronary
ule. Correctional institutions should have
lock-ups should implement policies
artery disease. Cardiovascular disease
systems in place to ensure that rapid-
and procedures to diminish the risk of
risk factor management is of demon-
acting insulin analogs and oral agents are
hypo- and hyperglycemia during off-
strated benefit in reducing this compli-
given immediately before meals if this is
site travel (e.g., court appearances). (E)
cation in patients with diabetes. Blood
part of the patient’s medical plan. It
pressure should be measured at every
should be noted however that even mod-
routine diabetes visit. In adult patients,
est delays in meal consumption with these
ROUTINE SCREENING FOR
test for lipid disorders at least annually
agents can be associated with hypoglyce-
AND MANAGEMENT OF
and as needed to achieve goals with
mia. If consistent access to food within 10
DIABETES COMPLICATIONS —
treatment. Use aspirin therapy (75–162
min cannot be ensured, rapid-acting in-
All patients with a diagnosis of diabetes
mg/day) in all adult patients with dia-
sulin analogs and oral agents are ap-
should receive routine screening for dia-
betes and cardiovascular risk factors or
proved for administration during or
betes-related complications, as detailed in
known macrovascular disease. Current
immediately after meals. Should circum-
the ADA Standards of Care (4). Interval
national standards for adults with dia-
stances arise that delay patient access to
chronic disease clinics for persons with
betes call for treatment of lipids to goals
regular meals following medication ad-
diabetes provide an efficient mechanism
of LDL
100, HDL
40, triglycerides
ministration, policies and procedures
to monitor patients for complications of
150 mg/dl and blood pressure to a
must be implemented to ensure the pa-
diabetes. In this way, appropriate referrals
level of
130/80 mmHg.
tient receives appropriate nutrition to
to consultant specialists, such as optome-
prevent hypoglycemia.
trists/ophthalmologists, nephrologists,
Both continuous subcutaneous insu-
and cardiologists, can be made on an as-
MONITORING/TESTS OF
lin infusion and multiple daily insulin in-
needed basis and interval laboratory test-
GLYCEMIA — Monitoring of CBG is
jection therapy (consisting of three or
ing can be done.
a strategy that allows caregivers and peo-
S78
DIABETES CARE, VOLUME 33, SUPPLEMENT 1, JANUARY 2010
care.diabetesjournals.org

---

Position Statement
ple with diabetes to evaluate diabetes
ing to occur at the frequency necessi-
● what diabetes is
management regimens. The frequency of
tated by the individual patient’s
● signs and symptoms of diabetes
monitoring will vary by patients’ glycemic
glycemic control and diabetes regimen.
● risk factors
control and diabetes regimens. Patients
(E)
● signs and symptoms of, and emergency
with type 1 diabetes are at risk for hypo-
● A1C should be checked every 3– 6
response to, hypo- and hyperglycemia
glycemia and should have their CBG
months. (E)
● glucose monitoring
monitored three or more times daily. Pa-
● medications
tients with type 2 diabetes on insulin need
● exercise
to monitor at least once daily and more
SELF-MANAGEMENT
● nutrition issues including timing of
frequently based on their medical plan.
EDUCATION — Self-management
meals and access to snacks
Patients treated with oral agents should
education is the cornerstone of treatment
have CBG monitored with sufficient fre-
for all people with diabetes. The health
Recommendations
quency to facilitate the goals of glycemic
staff must advocate for patients to partic-
● Include diabetes in correctional staff
control, assuming that there is a program
ipate in self-management as much as pos-
education programs. (E)
for medical review of these data on an
sible. Individuals with diabetes who learn
ongoing basis to drive changes in medica-
self-management skills and make lifestyle
tions. Patients whose diabetes is poorly
changes can more effectively manage
ALCOHOL AND DRUGS — P a -
controlled or whose therapy is changing
their diabetes and avoid or delay compli-
tients with diabetes who are withdrawing
should have more frequent monitoring.
cations associated with diabetes. In the
from drugs and alcohol need special consid-
Unexplained hyperglycemia in a patient
d e v e l o p m e n t o f a d i a b e t e s s e l f -
eration. This issue particularly affects initial
with type 1 diabetes may suggest impend-
management education program in the
police custody and jails. At an intake facility,
ing DKA, and monitoring of ketones
correctional environment, the unique cir-
proper initial identification and assessment
should therefore be performed.
cumstances of the patient should be con-
of these patients are critical. The presence of
Glycated hemoglobin (A1C) is a mea-
sidered while still providing, to the
diabetes may complicate detoxification. Pa-
sure of long-term (2- to 3-month) glyce-
greatest extent possible, the elements of
tients in need of complicated detoxification
mic control. Perform the A1C test at least
the “National Standards for Diabetes Self-
should be referred to a facility equipped to
two times a year in patients who are meet-
Management Education” (11). A staged
deal with high-risk detoxification. Patients
ing treatment goals (and who have stable
approach may be used depending on the
with diabetes should be educated in the
glycemic control) and quarterly in pa-
needs assessment and the length of incar-
risks involved with smoking. All inmates
tients whose therapy has changed or who
ceration. Table 2 sets out the major com-
should be advised not to smoke. Assistance
are not meeting glycemic goals.
ponents of diabetes self-management
in smoking cessation should be provided as
Discrepancies between CBG monitor-
education. Survival skills should be ad-
practical.
ing results and A1C may indicate a hemo-
dressed as soon as possible; other aspects
globinopathy, hemolysis, or need for
of education may be provided as part of
evaluation of CBG monitoring technique
an ongoing education program.
TRANSFER AND
and equipment or initiation of more fre-
Ideally, self-management education is
DISCHARGE — Patients in jails may
quent CBG monitoring to identify when
coordinated by a certified diabetes educa-
be housed for a short period of time be-
glycemic excursions are occurring and
tor who works with the facility to develop
fore being transferred or released, and it is
which facet of the diabetes regimen is
polices, procedures, and protocols to en-
not unusual for patients in prison to be
changing.
sure that nationally recognized education
transferred within the system several
In the correctional setting, policies
guidelines are implemented. The educa-
times during their incarceration. One of
and procedures need to be developed and
tor is also able to identify patients who
the many challenges that health care pro-
implemented regarding CBG monitoring
need diabetes self-management educa-
viders face working in the correctional
that address the following.
tion, including an assessment of the pa-
system is how to best collect and commu-
tients’ medical, social, and diabetes
nicate important health care information
● infection control
histories; diabetes knowledge, skills, and
in a timely manner when a patient is in
● education of staff and patients
behaviors; and readiness to change.
initial police custody, is jailed short term,
● proper choice of meter
or is transferred from facility to facility.
● disposal of testing lancets
The importance of this communication
● quality control programs
becomes critical when the patient has a
● access to health services
STAFF EDUCATION — Policies and
chronic illness such as diabetes.
● size of the blood sample
procedures should be implemented to en-
Transferring a patient with diabetes
● patient performance skills
sure that the health care staff has adequate
from one correctional facility to another
● documentation and interpretation of
knowledge and skills to direct the man-
requires a coordinated effort. To facilitate
test results
agement and education of persons with
a thorough review of medical information
● availability of test results for the health
diabetes. The health care staff needs to be
and completion of a transfer summary, it
care provider (10)
involved in the development of the cor-
is critical for custody personnel to provide
rectional officers’ training program. The
medical staff with sufficient notice before
Recommendations
staff education program should be at a lay
movement of the patient.
● In the correctional setting, policies and
level. Training should be offered at least
Before the transfer, the health care
procedures need to be developed and
biannually, and the curriculum should
staff should review the patient’s medical
implemented to enable CBG monitor-
cover the following.
record and complete a medical transfer
care.diabetesjournals.org
DIABETES CARE, VOLUME 33, SUPPLEMENT 1, JANUARY 2010
S79

---

Correctional Institutions
care and facilitate entry into commu-
Table 2—Major components of diabetes self-management education
nity diabetes care. (E)
Survival skills
Daily management issues
• hypo-/hyperglycemia
• disease process
SHARING OF MEDICAL
• sick day management
• nutritional management
INFORMATION AND
• medication
• physical activity
RECORDS — Practical considerations
• monitoring
• medications
may prohibit obtaining medical records
• foot care
• monitoring
from providers who treated the patient
• acute complications
before arrest. Intake facilities should im-
• risk reduction
plement policies that 1) define the cir-
• goal setting/problem solving
cumstances under which prior medical
• psychosocial adjustment
records are obtained (e.g., for patients
• preconception care/pregnancy/gestational diabetes
who have an extensive history of treat-
management
ment for complications); 2) identify per-
son(s) responsible for contacting the prior
summary that includes the patient’s cur-
care provider upon arrival at the receiving
provider; and 3) establish procedures for
rent health care issues. At a minimum, the
institution.
tracking requests.
summary should include the following.
Planning for patients’ discharge from
Facilities that use outside medical
prisons should include instruction in the
providers should implement policies and
● the patient’s current medication sched-
long-term complications of diabetes, the
procedures for ensuring that key informa-
ule and dosages
necessary lifestyle changes and examina-
tion (e.g., test results, diagnoses, physi-
● the date and time of the last medication
tions required to prevent these complica-
cians’ orders, appointment dates) is
administration
tions, and, if possible, where patients may
received from the provider and incorpo-
● any recent monitoring results (e.g.,
obtain regular follow-up medical care. A
rated into the patient’s medical chart after
CBG and A1C)
quarterly meeting to educate patients
each outside appointment. The proce-
● other factors that indicate a need for
with upcoming discharges about commu-
dure should include, at a minimum, a
immediate treatment or management at
nity resources can be valuable. Inviting
means to highlight when key information
the receiving facility (e.g., recent epi-
community agencies to speak at these
has not been received and designation of a
sodes of hypoglycemia, history of se-
meetings and/or provide written materi-
person responsible for contacting the out-
vere hypoglycemia or frequent DKA,
als can help strengthen the community
side provider for this information.
concurrent illnesses, presence of diabe-
link for patients discharging from correc-
All medical charts should contain
tes complications)
tional facilities.
CBG test results in a specified, readily ac-
● information on scheduled treatment/
Discharge planning for the patients
cessible section and should be reviewed
appointments if the receiving facility is
with diabetes should begin 1 month be-
on a regular basis.
responsible for transporting the patient
fore discharge. During this time, applica-
to that appointment
tion for appropriate entitlements should
● name and telephone/fax number of a
be initiated. Any gaps in the patient’s
CHILDREN AND
contact person at the transferring facil-
knowledge of diabetes care need to be
ADOLESCENTS WITH
ity who can provide additional infor-
identified and addressed. It is helpful if
DIABETES — Children and adoles-
mation, if needed
the patient is given a directory or list of
cents with diabetes present special prob-
community resources and if an appoint-
lems in disease management, even
The medical transfer summary,
ment for follow-up care with a commu-
outside the setting of a correctional insti-
which acts as a quick medical reference
nity provider is made. A supply of
tution. Children and adolescents with di-
for the receiving facility, should be trans-
medication adequate to last until the first
abetes should have initial and follow-up
ferred along with the patient. To supple-
postrelease medical appointment should
care with physicians who are experienced
ment the flow of information and to
be provided to the patient upon release.
in their care. Confinement increases the
increase the probability that medications
The patient should be provided with a
difficulty in managing diabetes in chil-
are correctly identified at the receiving in-
written summary of his/her current heath
dren and adolescents, as it does in adults
stitution, sending institutions are encour-
care issues, including medications and
with diabetes. Correctional authorities
aged to provide each patient with a
doses, recent A1C values, etc.
also have different legal obligations for
medication card to be carried by the pa-
children and adolescents.
tient that contains information concern-
ing diagnoses, medication names,
Recommendations
Nutrition and activity
dosages, and frequency. Diabetes sup-
● For all interinstitutional transfers, com-
Growing children and adolescents have
plies, including diabetes medication,
plete a medical transfer summary to be
greater caloric/nutritional needs than
should accompany the patient.
transferred with the patient. (E)
adults. The provision of an adequate
The sending facility must be mindful
● Diabetes supplies and medication
amount of calories and nutrients for ado-
of the transfer time in order to provide the
should accompany the patient during
lescents is critical to maintaining good
patient with medication and food if
transfer. (E)
nutritional status. Physical activity should
needed. The transfer summary or medical
● Begin discharge planning with ade-
be provided at the same time each day. If
record should be reviewed by a health
quate lead time to insure continuity of
increased physical activity occurs, addi-
S80
DIABETES CARE, VOLUME 33, SUPPLEMENT 1, JANUARY 2010
care.diabetesjournals.org

---

Position Statement
tional CBG monitoring is necessary and
change these standards. Patients must
(Position Statement). Diabetes Care 33
additional carbohydrate snacks may be
have access to medication and nutrition
(Suppl. 1):S11–S61, 2010
required.
needed to manage their disease. In pa-
5. American Diabetes Association: Screening
tients who do not meet treatment targets,
for type 2 diabetes (Position Statement). Di-
abetes Care 27 (Suppl. 1):S11–S14, 2004
Medical management and follow-up
medical and behavioral plans should be
6. Krauss RM, Eckel RH, Howard B, Appel
Children and adolescents who are incarcer-
adjusted by health care professionals in
LJ, Daniels SR, Deckelbaum RJ, Erdman
ated for extended periods should have fol-
collaboration with the prison staff. It is
JW Jr, Kris-Etherton P, Goldberg IJ,
low-up visits at least every 3 months with
critical for correctional institutions to
Kotchen TA, Lichtenstein AH, Mitch WE,
individuals who are experienced in the care
identify particularly high-risk patients in
Mullis R, Robinson K, Wylie-Rosett J, St
of children and adolescents with diabetes.
need of more intensive evaluation and
Jeor S, Suttie J, Tribble DL, Bazzarre TL:
Thyroid function tests and fasting lipid and
therapy, including pregnant women, pa-
American
Heart
Association
Dietary
microalbumin measurements should be
tients with advanced complications, a his-
Guidelines: revision 2000: a statement for
healthcare professionals from the Nutri-
performed according to recognized stan-
tory of repeated severe hypoglycemia, or
tion Committee of the American Heart As-
dards for children and adolescents (12) in
recurrent DKA.
sociation. Stroke 31:2751–2766, 2000
order to monitor for autoimmune thyroid
A comprehensive, multidisciplinary
7. American Diabetes Association: Nutrition
disease and complications and comorbidi-
approach to the care of people with dia-
recommendations and interventions for
ties of diabetes.
betes can be an effective mechanism to
diabetes (Position Statement). Diabetes
Children and adolescents with diabe-
improve overall health and delay or pre-
Care 31 (Suppl. 1):S61–S78, 2008
tes exhibiting unusual behavior should
vent the acute and chronic complications
8. American Diabetes Association: Hyper-
have their CBG checked at that time. Be-
of this disease.
glycemic crisis in diabetes (Position State-
cause children and adolescents are re-
ment). Diabetes Care 27 (Suppl. 1):S94 –
ported to have higher rates of nocturnal
S102, 2004
Acknowledgments — The following mem-
9. American Diabetes Association: Continu-
hypoglycemia (13), consideration should
bers of the American Diabetes Association/
ous subcutaneous insulin infusion (Posi-
be given regarding the use of episodic
National Commission on Correctional Health
tion Statement). Diabetes Care 27 (Suppl.
overnight blood glucose monitoring in
Care Joint Working Group on Diabetes Guide-
1):S110, 2004
these patients. In particular, this should
lines for Correctional Institutions contributed
10. American Diabetes Association: Tests of gly-
be considered in children and adolescents
to the revision of this document: Daniel L.
cemia in diabetes (Position Statement). Di-
who have recently had their overnight in-
Lorber, MD, FACP, CDE (chair); R. Scott
abetes Care 27 (Suppl. 1):S91–S93, 2004
sulin dose changed.
Chavez, MPA, PA-C; Joanne Dorman, RN,
11. American Diabetes Association: National
CDE, CCHP-A; Lynda K. Fisher, MD;
standards for diabetes self-management
Stephanie Guerken, RD, CDE; Linda B. Haas,
education (Standards and Review Crite-
PREGNANCY — Pregnancy in a
CDE, RN; Joan V. Hill, CDE, RD; David Ken-
ria). Diabetes Care 31 (Suppl. 1):S97–
woman with diabetes is by definition a
dall, MD; Michael Puisis, DO; Kathy
S104, 2008
high-risk pregnancy. Every effort should
Salomone, CDE, MSW, APRN; Ronald M.
12. International Society for Pediatric and
Shansky, MD, MPH; and Barbara Wakeen,
Adolescent Diabetes: Consensus Guidelines
be made to ensure that treatment of the
RD, LD.
2000: ISPAD Consensus Guidelines for the
pregnant woman with diabetes meets ac-
Management of Type 1 Diabetes Mellitus in
cepted standards (14,15). It should be
Children and Adolescents. Zeist, Nether-
noted that glycemic standards are more
References
lands, Medical Forum International,
stringent, the details of dietary manage-
1. National Commission on Correctional
2000, p. 116, 118
ment are more complex and exacting, in-
Health Care: The Health Status of Soon-
13. Kaufman FR, Austin J, Neinstein A, Jeng L,
sulin is the only antidiabetic agent
to-Be Released Inmates: A Report to Con-
Halyorson M, Devoe DJ, Pitukcheewanont
approved for use in pregnancy, and a
gress. Vol. 1. Chicago, NCCHC, 2002
P: Nocturnal hypoglycemia detected with
number of medications used in the man-
2. Hornung CA, Greifinger RB, Gadre S: A
the continuous glucose monitoring system
agement of diabetic comorbidities are
Projection Model of the Prevalence of Se-
in pediatric patients with type 1 diabetes.
lected Chronic Diseases in the Inmate Popu-
J Pediatr 141:625– 630, 2002
known to be teratogenic and must be dis-
lation. Vol. 2. Chicago, NCCHC, 2002, p.
14. American Diabetes Association: Gesta-
continued in the setting of pregnancy.
39 –56
tional diabetes mellitus (Position State-
3. Puisis M: Challenges of improving quality
ment). Diabetes Care 27 (Suppl. 1):S88 –
in the correctional setting. In Clinical
S90, 2004
SUMMARY AND KEY
Practice in Correctional Medicine. St. Louis,
15. Jovanovic L (Ed.): Medical Managementof
POINTS — People with diabetes
MO, Mosby-Yearbook, 1998, p. 16 –18
Pregnancy Complicated by Diabetes. 3rd ed.
should receive care that meets national
4. American Diabetes Association: Stan-
Alexandria, VA, American Diabetes Asso-
standards. Being incarcerated does not
dards of medical care in diabetes—2010
ciation, 2000
care.diabetesjournals.org
DIABETES CARE, VOLUME 33, SUPPLEMENT 1, JANUARY 2010
S81

---