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American Diabetes Association Diabetes Management in Correctional Institutions 2009

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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

A

t any given time, over 2 million people are incarcerated in prisons and
jails in the U.S (1). It is estimated
that nearly 80,000 of these inmates have
diabetes, a prevalence of 4.8% (2). In addition, many more people pass through
the corrections system in a given year. In
1998 alone, over 11 million people were
released from prison to the community
(1). The current estimated prevalence of
diabetes in correctional institutions is
somewhat lower than the overall U.S.
prevalence of diabetes, perhaps because
the incarcerated population is younger
than the general population. The prevalence of diabetes and its related comorbidities and complications, however, will
continue to increase in the prison population as current sentencing guidelines
continue to increase the number of aging
prisoners and the incidence of diabetes in
young people continues to increase.
People with diabetes in correctional
facilities should receive care that meets
national standards. Correctional institutions have unique circumstances that
need to be considered so that all standards
of care may be achieved (3). Correctional
institutions should have written policies
and procedures for the management of
diabetes and for training of medical and
correctional staff in diabetes care practices. These policies must take into consideration issues such as security needs,
transfer from one facility to another, and
access to medical personnel and equipment, so that all appropriate levels of care
are provided. Ideally, these policies
should encourage or at least allow patients to self-manage their diabetes. Ultimately, diabetes management is
dependent upon having access to needed
medical personnel and equipment. Ongoing diabetes therapy is important in order
to reduce the risk of later complications,
including cardiovascular events, visual

loss, renal failure, and amputation. Early
identification and intervention for people
with diabetes is also likely to reduce
short-term risks for acute complications
requiring transfer out of the facility, thus
improving security.
This document provides a general set
of guidelines for diabetes care in correctional institutions. It is not designed to be
a diabetes management manual. More detailed information on the management of
diabetes and related disorders can be
found in the American Diabetes Association (ADA) Clinical Practice Recommendations, published each year in January as
the first supplement to Diabetes Care, as
well as the “Standards of Medical Care in
Diabetes” (4) contained therein. This discussion will focus on those areas where
the care of people with diabetes in correctional facilities may differ, and specific
recommendations are made at the end of
each section.
INTAKE MEDICAL
ASSESSMENT
Reception screening
Reception screening should emphasize
patient safety. In particular, rapid identification of all insulin-treated persons with
diabetes is essential in order to identify
those at highest risk for hypo- and hyperglycemia and diabetic ketoacidosis
(DKA). All insulin-treated patients should
have a capillary blood glucose (CBG) determination within 1–2 h of arrival. Signs
and symptoms of hypo- or hyperglycemia
can often be confused with intoxication or
withdrawal from drugs or alcohol. Individuals with diabetes exhibiting signs and
symptoms consistent with hypoglycemia,
particularly altered mental status, agitation, combativeness, and diaphoresis,
should have finger-stick blood glucose
levels measured immediately.

Intake screening
Patients with a diagnosis of diabetes
should have a complete medical history
and physical examination by a licensed
health care provider with prescriptive authority in a timely manner. If one is not
available on site, one should be consulted
by those performing reception screening.
The purposes of this history and physical
examination are to determine the type of
diabetes, current therapy, alcohol use,
and behavioral health issues, as well as to
screen for the presence of diabetes-related
complications. The evaluation should review the previous treatment and the past
history of both glycemic control and diabetes complications. It is essential that
medication and medical nutrition therapy
(MNT) be continued without interruption upon entry into the correctional system, as a hiatus in either medication or
appropriate nutrition may lead to either
severe hypo- or hyperglycemia that can
rapidly progress to irreversible complications, even death.
Intake physical examination and
laboratory
All potential elements of the initial medical evaluation are included in Table 5 of
the ADA’s “Standards of Medical Care in
Diabetes,” referred to hereafter as the
“Standards of Care” (4). The essential
components of the initial history and
physical examination are detailed in Fig.
1. Referrals should be made immediately
if the patient with diabetes is pregnant.

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

Recommendations
Patients with a diagnosis of diabetes
should have a complete medical history
and undergo an intake physical examination by a licensed health professional
in a timely manner. (E)
● Insulin-treated patients should have a
CBG determination within 1–2 h of arrival. (E)
● Medications and MNT should be continued without interruption upon entry
into the correctional environment. (E)

Originally approved 1989. Most recent review, 2008.
Abbreviations: CBG, capillary blood glucose; DKA, diabetic ketoacidosis; GDM, gestational diabetes mellitus; MNT, medical nutrition therapy.
DOI: 10.2337/dc09-S073
© 2009 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.
org/licenses/by-nc-nd/3.0/ for details.

SCREENING FOR DIABETES —
Consistent with the ADA Standards of
Care, patients should be evaluated for diabetes risk factors at the intake physical
and at appropriate times thereafter. Those

DIABETES CARE, VOLUME 32, SUPPLEMENT 1, JANUARY 2009

●

S73

Correctional Institutions

Figure 1—Essential components of the initial history and physical examination. Alb/Cr ratio, albumin-to-creatinine ratio; ALT, alanine aminotransferase; AST, aspartate aminotransferase.

who are at high risk should be considered
for blood glucose screening. If pregnant, a
risk assessment for gestational diabetes
mellitus (GDM) should be undertaken at
the first prenatal visit. Patients with clinical characteristics consistent with a high
risk for GDM should undergo glucose
testing as soon as possible. High-risk
women not found to have GDM at the
initial screening and average-risk women
should be tested between 24 and 28
weeks of gestation. For more detailed information on screening for both type 2
and gestational diabetes, see the ADA Position Statement “Screening for Type 2 Diabetes” (5) and the Standards of Care (4).
MANAGEMENT PLAN — Glycemic control is fundamental to the management of diabetes. A management plan
to achieve normal or near-normal glycemia with an A1C goal of Ͻ7% should be
developed for diabetes management at
the time of initial medical evaluation.
Goals should be individualized (4), and
less stringent treatment goals may be appropriate for patients with a history of severe hypoglycemia, patients with limited
life expectancies, elderly adults, and indiS74

viduals with comorbid conditions (4).
This plan should be documented in the
patient’s record and communicated to all
persons involved in his/her care, including security staff. Table 1, taken from the
ADA Standards of Care, provides a summary of recommendations for setting glycemic control goals for adults with
diabetes.
People with diabetes should ideally
receive medical care from a physiciancoordinated team. Such teams include,
but are not limited to, physicians, nurses,
dietitians, and mental health professionals with expertise and a special interest in
diabetes. It is essential in this collaborative and integrated team approach that individuals with diabetes assume as active a
role in their care as possible. Diabetes selfmanagement education is an integral
component of care. Patient selfmanagement should be emphasized, and
the plan should encourage the involvement of the patient in problem solving as
much as possible.
It is helpful to house insulin-treated
patients in a common unit, if this is possible, safe, and consistent with providing
access to other programs at the correc-

tional institution. Common housing not
only can facilitate mealtimes and medication administration, but also potentially
provides an opportunity for diabetes selfmanagement education to be reinforced
by fellow patients.
NUTRITION AND FOOD
SERVICES — Nutrition counseling and
menu planning are an integral part of the
multidisciplinary approach to diabetes
management in correctional facilities. A
combination of education, interdisciplinary
communication, and monitoring food intake aids patients in understanding their
medical nutritional needs and can facilitate
diabetes control during and after incarceration.
Nutrition counseling for patients with
diabetes is considered an essential component of diabetes self-management. People
with diabetes should receive individualized
MNT as needed to achieve treatment goals,
preferably provided by a registered dietitian
familiar with the components of MNT for
persons with diabetes.
Educating the patient, individually or
in a group setting, about how carbohydrates and food choices directly affect di-

DIABETES CARE, VOLUME 32, SUPPLEMENT 1, JANUARY 2009

Position Statement

Table 1—Summary of recommendations for glycemic, blood pressure, and lipid control for
adults with diabetes
Ͻ7.0%*
Ͻ130/80 mmHg

A1C
Blood pressure
Lipids
LDL cholesterol

Ͻ100 mg/dl (Ͻ2.6 mmol/l)†

*Referenced to a nondiabetic range of 4.0 – 6.0% using a DCCT-based assay. †In individuals with overt CVD,
a lower LDL cholesterol goal of Ͻ70 mg/dl (1.8 mmol/l), using a high dose of a statin, is an option.

abetes control is the first step in
facilitating self-management. This education enables the patient to identify better
food selections from those available in the
dining hall and commissary. Such an approach is more realistic in a facility where
the patient has the opportunity to make
food choices.
The easiest and most cost-effective
means to facilitate good outcomes in patients with diabetes is instituting a hearthealthy diet as the master menu (6). There
should be consistent carbohydrate content at each meal, as well as a means to
identify the carbohydrate content of each
food selection. Providing carbohydrate
content of food selections and/or providing education in assessing carbohydrate
content enables patients to meet the requirements of their individual MNT
goals. Commissaries should also help in
dietary management by offering healthy
choices and listing the carbohydrate content of foods.
The use of insulin or oral medications
may necessitate snacks in order to avoid
hypoglycemia. These snacks are a part of
such patients’ medical treatment plans
and should be prescribed by medical staff.
Timing of meals and snacks must be
coordinated with medication administration as needed to minimize the risk of hypoglycemia, as discussed more fully in the
MEDICATION section of this document. For
further information, see the ADA Position
Statement “Nutrition Principles and Recommendations in Diabetes” (7).
URGENT AND EMERGENCY
ISSUES — All patients must have access
to prompt treatment of hypo- and hyperglycemia. Correctional staff should be trained
in the recognition and treatment of hypoand hyperglycemia, and appropriate staff
should be trained to administer glucagon.
After such emergency care, patients should
be referred for appropriate medical care to
minimize risk of future decompensation.
Institutions should implement a policy requiring staff to notify a physician of
all CBG results outside of a specified

range, as determined by the treating physician (e.g., Ͻ50 or Ͼ350 mg/dl).
Hyperglycemia
Severe hyperglycemia in a person with diabetes may be the result of intercurrent
illness, missed or inadequate medication,
or corticosteroid therapy. Correctional
institutions should have systems in place
to identify and refer to medical staff all
patients with consistently elevated blood
glucose as well as intercurrent illness.
The stress of illness in those with type
1 diabetes frequently aggravates glycemic
control and necessitates more frequent
monitoring of blood glucose (e.g., every
4 – 6 h). Marked hyperglycemia requires
temporary adjustment of the treatment
program and, if accompanied by ketosis,
interaction with the diabetes care team.
Adequate fluid and caloric intake must be
ensured. Nausea or vomiting accompanied with hyperglycemia may indicate
DKA, a life-threatening condition that requires immediate medical care to prevent
complications and death. Correctional institutions should identify patients with
type 1 diabetes who are at risk for DKA,
particularly those with a prior history of
frequent episodes of DKA. For further information see “Hyperglycemic Crisis in
Diabetes” (8).
Hypoglycemia
Hypoglycemia is defined as a blood glucose level Ͻ70 mg/dl. Severe hypoglycemia is a medical emergency defined as
hypoglycemia requiring assistance of a
third party and is often associated with
mental status changes that may include
confusion, incoherence, combativeness,
somnolence, lethargy, seizures, or coma.
Signs and symptoms of severe hypoglycemia can be confused with intoxication or
withdrawal. Individuals with diabetes exhibiting signs and symptoms consistent
with hypoglycemia, particularly altered
mental status, agitation, and diaphoresis,
should have their CBG levels checked immediately.
Security staff who supervise patients at

DIABETES CARE, VOLUME 32, SUPPLEMENT 1, JANUARY 2009

risk for hypoglycemia (i.e., those on insulin
or oral hypoglycemic agents) should be educated in the emergency response protocol
for recognition and treatment of hypoglycemia. Every attempt should be made to document CBG before treatment. Patients must
have immediate access to glucose tablets or
other glucose-containing foods. Hypoglycemia can generally be treated by the patient
with oral carbohydrates. If the patient cannot be relied on to keep hypoglycemia treatment on his/her person, staff members
should have ready access to glucose tablets
or equivalent. In general, 15–20 g oral glucose will be adequate to treat hypoglycemic
events. CBG and treatment should be repeated at 15-min intervals until blood glucose levels return to normal (Ͼ70 mg/dl).
Staff should have glucagon for intramuscular injection or glucose for intravenous infusion available to treat severe
hypoglycemia without requiring transport
of the hypoglycemic patient to an outside
facility. Any episode of severe hypoglycemia
or recurrent episodes of mild to moderate
hypoglycemia require reevaluation of the
diabetes management plan by the medical
staff. In certain cases of unexplained or recurrent severe hypoglycemia, it may be appropriate to admit the patient to the medical
unit for observation and stabilization of diabetes management.
Correctional institutions should have
systems in place to identify the patients at
greater risk for hypoglycemia (i.e., those
on insulin or sulfonylurea therapy) and to
ensure the early detection and treatment
of hypoglycemia. If possible, patients at
greater risk of severe hypoglycemia (e.g.,
those with a prior episode of severe hypoglycemia) may be housed in units closer
to the medical unit in order to minimize
delay in treatment.
Recommendations
Train correctional staff in the recognition, treatment, and appropriate referral for hypo- and hyperglycemia. (E)
● Train appropriate staff to administer
glucagon. (E)
● Train staff to recognize symptoms and
signs of serious metabolic decompensation, and immediately refer the patient
for appropriate medical care. (E)
● Institutions should implement a policy
requiring staff to notify a physician of
all CBG results outside of a specified
range, as determined by the treating
physician (e.g., Ͻ50 or Ͼ350 mg/dl).
(E)
● Identify patients with type 1 diabetes
who are at high risk for DKA. (E)
●

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Correctional Institutions
MEDICATION — Formularies should
provide access to usual and customary oral
medications and insulins necessary to treat
diabetes and related conditions. While not
every brand name of insulin and oral medication needs to be available, individual patient care requires access to short-,
medium-, and long-acting insulins and the
various classes of oral medications (e.g., insulin secretagogues, biguanides, ␣-glucosidase inhibitors, and thiazolidinediones)
necessary for current diabetes management.
Patients at all levels of custody should
have access to medication at dosing frequencies that are consistent with their
treatment plan and medical direction. If
feasible and consistent with security concerns, patients on multiple doses of shortacting oral medications should be placed
in a “keep on person” program. In other
situations, patients should be permitted
to self-inject insulin when consistent with
security needs. Medical department
nurses should determine whether patients have the necessary skill and responsible behavior to be allowed selfadministration and the degree of
supervision necessary. When needed, this
skill should be a part of patient education.
Reasonable syringe control systems
should be established.
In the past, the recommendation that
regular insulin be injected 30 – 45 min before meals presented a significant problem when “lock downs” or other
disruptions to the normal schedule of
meals and medications occurred. The use
of multiple-dose insulin regimens using
rapid-acting analogs can decrease the disruption caused by such changes in schedule. Correctional institutions should have
systems in place to ensure that rapidacting insulin analogs and oral agents are
given immediately before meals if this is
part of the patient’s medical plan. It
should be noted however that even modest delays in meal consumption with these
agents can be associated with hypoglycemia. If consistent access to food within 10
min cannot be ensured, rapid-acting insulin analogs and oral agents are approved for administration during or
immediately after meals. Should circumstances arise that delay patient access to
regular meals following medication administration, policies and procedures
must be implemented to ensure the patient receives appropriate nutrition to
prevent hypoglycemia.
Both continuous subcutaneous insulin infusion and multiple daily insulin injection therapy (consisting of three or
S76

more injections a day) can be effective
means of implementing intensive diabetes management with the goal of achieving near-normal levels of blood glucose
(9). While the use of these modalities may
be difficult in correctional institutions,
every effort should be made to continue
multiple daily insulin injection or continuous subcutaneous insulin infusion in
people who were using this therapy before incarceration or to institute these
therapies as indicated in order to achieve
blood glucose targets.
It is essential that transport of patients
from jails or prisons to off-site appointments, such as medical visits or court appearances, does not cause significant
disruption in medication or meal timing.
Correctional institutions and police lockups should implement policies and procedures to diminish the risk of hypo- and
hyperglycemia by, for example, providing
carry-along meals and medication for patients traveling to off-site appointments or
changing the insulin regimen for that day.
The availability of prefilled insulin “pens”
provides an alternative for off-site insulin
delivery.
Recommendations
Formularies should provide access to
usual and customary oral medications
and insulins to treat diabetes and related conditions. (E)
● Patients should have access to medication at dosing frequencies that are consistent with their treatment plan and
medical direction. (E)
● Correctional institutions and police
lock-ups should implement policies
and procedures to diminish the risk of
hypo- and hyperglycemia during offsite travel (e.g., court appearances). (E)
●

ROUTINE SCREENING FOR
AND MANAGEMENT OF
DIABETES COMPLICATIONS —
All patients with a diagnosis of diabetes
should receive routine screening for diabetes-related complications, as detailed in
the ADA Standards of Care (4). Interval
chronic disease clinics for persons with
diabetes provide an efficient mechanism
to monitor patients for complications of
diabetes. In this way, appropriate referrals
to consultant specialists, such as optometrists/ophthalmologists, nephrologists,
and cardiologists, can be made on an asneeded basis and interval laboratory testing can be done.

The following complications should
be considered.
●

●

●

●

Foot care: Recommendations for foot
care for patients with diabetes and no
history of an open foot lesion are described in the ADA Standards of Care. A
comprehensive foot examination is recommended annually for all patients
with diabetes to identify risk factors
predictive of ulcers and amputations.
Persons with an insensate foot, an open
foot lesion, or a history of such a lesion
should be referred for evaluation by an
appropriate licensed health professional (e.g., podiatrist or vascular surgeon). Special shoes should be
provided as recommended by licensed
health professionals to aid healing of
foot lesions and to prevent development of new lesions.
Retinopathy: Annual retinal examinations by a licensed eye care professional
should be performed for all patients
with diabetes, as recommended in the
ADA Standards of Care. Visual changes
that cannot be accounted for by acute
changes in glycemic control require
prompt evaluation by an eye care professional.
Nephropathy: An annual spot urine test
for determination of microalbumin-tocreatinine ratio should be performed.
The use of ACE inhibitors or angiotensin receptor blockers is recommended
for all patients with albuminuria. Blood
pressure should be controlled to
Ͻ130/80 mmHg.
Cardiac: People with type 2 diabetes are
at a particularly high risk of coronary
artery disease. Cardiovascular disease
risk factor management is of demonstrated benefit in reducing this complication 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 achieve goals with
treatment. Use aspirin therapy (75–162
mg/day) in all adult patients with diabetes and cardiovascular risk factors or
known macrovascular disease. Current
national standards for adults with diabetes call for treatment of lipids to goals
of LDL Յ100, HDL Ͼ40, triglycerides
Ͻ150 mg/dl and blood pressure to a
level of Ͻ130/80 mmHg.

MONITORING/TESTS OF
GLYCEMIA — Monitoring of CBG is
a strategy that allows caregivers and peo-

DIABETES CARE, VOLUME 32, SUPPLEMENT 1, JANUARY 2009

Position Statement
ple with diabetes to evaluate diabetes
management regimens. The frequency of
monitoring will vary by patients’ glycemic
control and diabetes regimens. Patients
with type 1 diabetes are at risk for hypoglycemia and should have their CBG
monitored three or more times daily. Patients with type 2 diabetes on insulin need
to monitor at least once daily and more
frequently based on their medical plan.
Patients treated with oral agents should
have CBG monitored with sufficient frequency to facilitate the goals of glycemic
control, assuming that there is a program
for medical review of these data on an
ongoing basis to drive changes in medications. Patients whose diabetes is poorly
controlled or whose therapy is changing
should have more frequent monitoring.
Unexplained hyperglycemia in a patient
with type 1 diabetes may suggest impending DKA, and monitoring of ketones
should therefore be performed.
Glycated hemoglobin (A1C) is a measure of long-term (2- to 3-month) glycemic control. Perform the A1C test at least
two times a year in patients who are meeting treatment goals (and who have stable
glycemic control) and quarterly in patients whose therapy has changed or who
are not meeting glycemic goals.
Discrepancies between CBG monitoring results and A1C may indicate a hemoglobinopathy, hemolysis, or need for
evaluation of CBG monitoring technique
and equipment or initiation of more frequent CBG monitoring to identify when
glycemic excursions are occurring and
which facet of the diabetes regimen is
changing.
In the correctional setting, policies
and procedures need to be developed and
implemented regarding CBG monitoring
that address the following.
●
●
●
●
●
●
●
●
●
●

infection control
education of staff and patients
proper choice of meter
disposal of testing lancets
quality control programs
access to health services
size of the blood sample
patient performance skills
documentation and interpretation of
test results
availability of test results for the health
care provider (10)

Recommendations
In the correctional setting, policies and
procedures need to be developed and
implemented to enable CBG monitor-

●

●

ing to occur at the frequency necessitated by the individual patient’s
glycemic control and diabetes regimen.
(E)
A1C should be checked every 3– 6
months. (E)

●
●
●
●
●
●
●

SELF-MANAGEMENT
EDUCATION — Self-management
education is the cornerstone of treatment
for all people with diabetes. The health
staff must advocate for patients to participate in self-management as much as possible. Individuals with diabetes who learn
self-management skills and make lifestyle
changes can more effectively manage
their diabetes and avoid or delay complications associated with diabetes. In the
development of a diabetes selfmanagement education program in the
correctional environment, the unique circumstances of the patient should be considered while still providing, to the
greatest extent possible, the elements of
the “National Standards for Diabetes SelfManagement Education” (11). A staged
approach may be used depending on the
needs assessment and the length of incarceration. Table 2 sets out the major components of diabetes self-management
education. Survival skills should be addressed as soon as possible; other aspects
of education may be provided as part of
an ongoing education program.
Ideally, self-management education is
coordinated by a certified diabetes educator who works with the facility to develop
polices, procedures, and protocols to ensure that nationally recognized education
guidelines are implemented. The educator is also able to identify patients who
need diabetes self-management education, including an assessment of the patients’ medical, social, and diabetes
histories; diabetes knowledge, skills, and
behaviors; and readiness to change.

STAFF EDUCATION — Policies and
procedures should be implemented to ensure that the health care staff has adequate
knowledge and skills to direct the management and education of persons with
diabetes. The health care staff needs to be
involved in the development of the correctional officers’ training program. The
staff education program should be at a lay
level. Training should be offered at least
biannually, and the curriculum should
cover the following.

DIABETES CARE, VOLUME 32, SUPPLEMENT 1, JANUARY 2009

●

what diabetes is
signs and symptoms of diabetes
risk factors
signs and symptoms of, and emergency
response to, hypo- and hyperglycemia
glucose monitoring
medications
exercise
nutrition issues including timing of
meals and access to snacks

Recommendations
Include diabetes in correctional staff
education programs. (E)

●

ALCOHOL AND DRUGS — P a tients with diabetes who are withdrawing
from drugs and alcohol need special consideration. This issue particularly affects initial
police custody and jails. At an intake facility,
proper initial identification and assessment
of these patients are critical. The presence of
diabetes may complicate detoxification. Patients in need of complicated detoxification
should be referred to a facility equipped to
deal with high-risk detoxification. Patients
with diabetes should be educated in the
risks involved with smoking. All inmates
should be advised not to smoke. Assistance
in smoking cessation should be provided as
practical.
TRANSFER AND
DISCHARGE — Patients 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 incarceration. One of
the many challenges that health care providers face working in the correctional
system is how to best collect and communicate important health care information
in a timely manner when a patient is in
initial police custody, is jailed short term,
or is transferred from facility to facility.
The importance of this communication
becomes critical when the patient has a
chronic illness such as diabetes.
Transferring a patient with diabetes
from one correctional facility to another
requires a coordinated effort. To facilitate
a thorough review of medical information
and completion of a transfer summary, it
is critical for custody personnel to provide
medical staff with sufficient notice before
movement of the patient.
Before the transfer, the health care
staff should review the patient’s medical
record and complete a medical transfer
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Correctional Institutions
care and facilitate entry into community diabetes care. (E)

Table 2—Major components of diabetes self-management education
Survival skills
• hypo-/hyperglycemia
• sick day management
• medication
• monitoring
• foot care

Daily management issues
• disease process
• nutritional management
• physical activity
• medications
• monitoring
• acute complications
• risk reduction
• goal setting/problem solving
• psychosocial adjustment
• preconception care/pregnancy/gestational diabetes
management

summary that includes the patient’s current health care issues. At a minimum, the
summary should include the following.
●
●
●
●

●

●

the patient’s current medication schedule and dosages
the date and time of the last medication
administration
any recent monitoring results (e.g.,
CBG and A1C)
other factors that indicate a need for
immediate treatment or management at
the receiving facility (e.g., recent episodes of hypoglycemia, history of severe hypoglycemia or frequent DKA,
concurrent illnesses, presence of diabetes complications)
information on scheduled treatment/
appointments if the receiving facility is
responsible for transporting the patient
to that appointment
name and telephone/fax number of a
contact person at the transferring facility who can provide additional information, if needed

The medical transfer summary,
which acts as a quick medical reference
for the receiving facility, should be transferred along with the patient. To supplement the flow of information and to
increase the probability that medications
are correctly identified at the receiving institution, sending institutions are encouraged to provide each patient with a
medication card to be carried by the patient that contains information concerning diagnoses, medication names,
dosages, and frequency. Diabetes supplies, including diabetes medication,
should accompany the patient.
The sending facility must be mindful
of the transfer time in order to provide the
patient with medication and food if
needed. The transfer summary or medical
record should be reviewed by a health
S78

care provider upon arrival at the receiving
institution.
Planning for patients’ discharge from
prisons should include instruction in the
long-term complications of diabetes, the
necessary lifestyle changes and examinations required to prevent these complications, and, if possible, where patients may
obtain regular follow-up medical care. A
quarterly meeting to educate patients
with upcoming discharges about community resources can be valuable. Inviting
community agencies to speak at these
meetings and/or provide written materials can help strengthen the community
link for patients discharging from correctional facilities.
Discharge planning for the patients
with diabetes should begin 1 month before discharge. During this time, application for appropriate entitlements should
be initiated. Any gaps in the patient’s
knowledge of diabetes care need to be
identified and addressed. It is helpful if
the patient is given a directory or list of
community resources and if an appointment for follow-up care with a community provider is made. A supply of
medication adequate to last until the first
postrelease medical appointment should
be provided to the patient upon release.
The patient should be provided with a
written summary of his/her current heath
care issues, including medications and
doses, recent A1C values, etc.
Recommendations
For all interinstitutional transfers, complete a medical transfer summary to be
transferred with the patient. (E)
● Diabetes supplies and medication
should accompany the patient during
transfer. (E)
● Begin discharge planning with adequate lead time to insure continuity of
●

SHARING OF MEDICAL
INFORMATION AND
RECORDS — Practical considerations
may prohibit obtaining medical records
from providers who treated the patient
before arrest. Intake facilities should implement policies that 1) define the circumstances under which prior medical
records are obtained (e.g., for patients
who have an extensive history of treatment for complications); 2) identify person(s) responsible for contacting the prior
provider; and 3) establish procedures for
tracking requests.
Facilities that use outside medical
providers should implement policies and
procedures for ensuring that key information (e.g., test results, diagnoses, physicians’ orders, appointment dates) is
received from the provider and incorporated into the patient’s medical chart after
each outside appointment. The procedure should include, at a minimum, a
means to highlight when key information
has not been received and designation of a
person responsible for contacting the outside provider for this information.
All medical charts should contain
CBG test results in a specified, readily accessible section and should be reviewed
on a regular basis.
CHILDREN AND
ADOLESCENTS WITH
DIABETES — Children and adolescents with diabetes present special problems in disease management, even
outside the setting of a correctional institution. Children and adolescents with diabetes should have initial and follow-up
care with physicians who are experienced
in their care. Confinement increases the
difficulty in managing diabetes in children and adolescents, as it does in adults
with diabetes. Correctional authorities
also have different legal obligations for
children and adolescents.
Nutrition and activity
Growing children and adolescents have
greater caloric/nutritional needs than
adults. The provision of an adequate
amount of calories and nutrients for adolescents is critical to maintaining good
nutritional status. Physical activity should
be provided at the same time each day. If
increased physical activity occurs, addi-

DIABETES CARE, VOLUME 32, SUPPLEMENT 1, JANUARY 2009

Position Statement
tional CBG monitoring is necessary and
additional carbohydrate snacks may be
required.
Medical management and follow-up
Children and adolescents who are incarcerated for extended periods should have follow-up visits at least every 3 months with
individuals who are experienced in the care
of children and adolescents with diabetes.
Thyroid function tests and fasting lipid and
microalbumin measurements should be
performed according to recognized standards for children and adolescents (12) in
order to monitor for autoimmune thyroid
disease and complications and comorbidities of diabetes.
Children and adolescents with diabetes exhibiting unusual behavior should
have their CBG checked at that time. Because children and adolescents are reported to have higher rates of nocturnal
hypoglycemia (13), consideration should
be given regarding the use of episodic
overnight blood glucose monitoring in
these patients. In particular, this should
be considered in children and adolescents
who have recently had their overnight insulin dose changed.
PREGNANCY — P r e g n a n c y i n a
woman with diabetes is by definition a
high-risk pregnancy. Every effort should
be made to ensure that treatment of the
pregnant woman with diabetes meets accepted standards (14,15). It should be
noted that glycemic standards are more
stringent, the details of dietary management are more complex and exacting, insulin is the only antidiabetic agent
approved for use in pregnancy, and a
number of medications used in the management of diabetic comorbidities are
known to be teratogenic and must be discontinued in the setting of pregnancy.
SUMMARY AND KEY
POINTS — People with diabetes
should receive care that meets national
standards. Being incarcerated does not

change these standards. Patients must
have access to medication and nutrition
needed to manage their disease. In patients who do not meet treatment targets,
medical and behavioral plans should be
adjusted by health care professionals in
collaboration with the prison staff. It is
critical for correctional institutions to
identify particularly high-risk patients in
need of more intensive evaluation and
therapy, including pregnant women, patients with advanced complications, a history of repeated severe hypoglycemia, or
recurrent DKA.
A comprehensive, multidisciplinary
approach to the care of people with diabetes can be an effective mechanism to
improve overall health and delay or prevent the acute and chronic complications
of this disease.
Acknowledgments — The following members of the American Diabetes Association/
National Commission on Correctional Health
Care Joint Working Group on Diabetes Guidelines for Correctional Institutions contributed
to the revision of this document: Daniel L.
Lorber, MD, FACP, CDE (chair); R. Scott
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; Michael Puisis, DO; Kathy
Salomone, CDE, MSW, APRN; Ronald M.
Shansky, MD, MPH; and Barbara Wakeen,
RD, LD.
References
1. National Commission on Correctional
Health Care: The Health Status of Soonto-Be Released Inmates: A Report to Congress. Vol. 1. Chicago, NCCHC, 2002
2. Hornung CA, Greifinger RB, Gadre S: A
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39 –56
3. Puisis M: Challenges of improving quality
in the correctional setting. In Clinical
Practice in Correctional Medicine. St. Louis,
MO, Mosby-Yearbook, 1998, p. 16 –18
4. American Diabetes Association: Standards of medical care in diabetes—2009

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