Diabetes is one of the most challenging of chronic conditions in terms of clinical management American Diabetes Association’s (ADA) Clinical Practice …
NCCHC Clinical Guideline for Health Care in Correctional Settings Diabetes
Introduction Diabetes is one of the most challenging of chronic conditions in terms of clinical management and improving outcomes in correctional settings This clinical guideline is adapted from the American Diabetes Associations ADA Clinical Practice Recommendations online at http://professionaldiabetesorg and the American College of Physicians Diabetes Portal http://diabetesacponlineorg Background It has long been understood that diabetes mellitus consists of two different pathological processes The differences between the two types influence the focus of treatment Type 1 diabetes is predominately caused by an insulin deficiency secondary to an autoimmune process, which can progress to an absolute lack of insulin, and leads to inadequate amounts of insulin to facilitate glucose metabolism Therefore, the primary treatment focus is to achieve adequate insulin levels related to food intake, and to prevent ketoacidosis and gluconeogenesis Type 2 diabetes is predominately caused by relative insulin resistance and often relative deficiency, which makes available insulin less effective in facilitating glucose
metabolism Obesity is often associated with type 2 diabetes and may directly contribute to insulin resistance Therefore, for many patients, the primary treatment focus is to achieve weight reduction toward ideal body weight Elevated blood sugar levels over time may result in vascular complications to the eye, kidney, heart, and nervous system Diagnosis Patients with either form of diabetes may require insulin treatment at some stage The use of insulin, per se, does not classify the type of diabetes Type 1 diabetes commonly presents at a younger age, such as childhood or adolescence, and at onset the patient may present with symptoms such as polyuria, polydipsia, or polyphagia These patients are prone to develop acute complications such as ketoacidosis and are frequently near their ideal body weight Type 2 diabetes commonly presents in adults, with a higher prevalence among African Americans, Hispanics, and Native Americans These patients frequently are significantly overweight, have insulin resistance, and are not prone to ketoacidosis
Diabetes can be diagnosed in one of three ways: 1 The patient has symptoms of polyuria, polydipsia, polyphagia, and unexplained weight loss, and a
casual plasma glucose 200 mg/dL any time of day regardless of fasting status; 2 the patient has a fasting plasma glucose 126 mg/dL after at least 8 hours of fasting; 3 the patient has a plasma glucose 200 mg/dL 2 hours after ingesting 75 g oral glucose Currently, the ADA prefers the fasting plasma glucose test because of its ease of use and low cost, although this test is less sensitive in older populations characterized by disproportionate prevalence of postprandial hyperglycemia Regardless of the test used, the ADA recommends that it be repeated on another day to confirm the diagnosis Although hemoglobin-A1C HbA1C is used as a measure of hyperglycemia in monitoring diabetes, it is recommended that it not be used for screening or diagnosis Management Overview Correctional settings pose unique challenges for patients and clinicians in achieving effective control of blood glucose and HbA1C levels Self-monitoring blood glucose is the best way to assess and manage glycemic control day to day The ADA recommends that patients with type 1 diabetes self-monitor their glucose at least three times daily Currently, there is no consensus on frequency of self-monitoring in patients who are
not taking insulin; however, the clinician and patient should determine the frequency based on the degree of diabetes control, episodes of hypoglycemia, and other factors Although glucose monitoring is often performed before meals, it is important to measure postprandial blood glucose levels usually 2 hours after a meal, especially if the HbA1C is elevated but fasting glucose levels are within target range, and to determine the adequacy of the pre-meal insulin dosage when using basal-bolus insulin therapy or if the patient is using certain oral agents that target postprandial glucose excursions Because glucose monitoring is critical to achieving good glycemic control, it is recommended that correctional institutions implement procedures that allow a subset of patients with diabetes to keep in their possession finger-stick glucose meters that are safe and can automatically record blood glucose levels In addition, outcomes are improved when patients have a good understanding of their role in attaining and maintaining healthy weight, diet, exercise, and timing of food intake in relation to insulin administration Also, programs that achieve good results do so by creating a treatment
team consisting of the physician and other health care staff, the patient, and correctional staff The ADA position statement on Management of Diabetes in Correctional Institutions 2007 notes the following: All patients must have access to prompt treatment of hypo- and hyperglycemia Correc tional staff should be trained in the recognition and treatment of hypo- and 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 eg, 50 or 350 mg/dl
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Treatment Goals Type 1 Diabetes An important clinical goal in a patient with type 1 diabetes is to maintain a HbA1C level in the normal range, without significant episodes of hypoglycemia Given the potential for morbidity related to hypoglycemia, it is safer to target the goal in the upper range of normal While normal glucose control is the goal for all patients, special
caution must be exercised in attempts at tight control Some patients are not candidates for tight control These include patients with severe coronary artery disease, repeated hypoglycemia, severe retinopathy, and renal failure, and those who lack motivation to participate actively in managing their disease The risks of hypoglycemia must be evaluated for each patient, and the risks and benefits of tight control must be discussed with each patient prior to treatment Type 2 Diabetes An important clinical goal in a patient with type 2 diabetes is to achieve weight loss that approaches the ideal body weight, an HbA1C level 7 through appropriate diet and exercise, and, if necessary, oral medications and/or insulin Assessment on Entry to the System Routine screening for disorders of glucose metabolism may be indicated for certain populations in correctional settings All pregnant women should be screened for diabetes with a glucose tolerance test, and routine screening should be considered at intake for groups known to be at highest risk for the disease, including, but not limited to, Native Americans, Hispanics, African Americans, and adults with a body mass index greater than 25 and a
history of hypertension or dyslipidemia The three components of assessment upon entry to the system are as follows: Initial History The history should include age of onset, hospitalizations, the use of insulin and/or oral hypoglycemic agents, current medications, complications related to diabetes, risk factors such as family history, and personal history of smoking, hypertension, and elevated cholesterol Physical Examination The physical examination should include vital signs, including weight, with a special focus on the eyes, feet, heart, thyroid, abdomen, skin, and nervous system as indicated
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Diagnostic Studies Baseline laboratory studies on the initial assessment should include the following: A B C D E F HbA1C Fasting lipid profile Serum creatinine Thyroid function, which usually includes a TSH Electrocardiogram, if patients age is over 40 Microalbuminuria unless gross proteinuria on urinalysis Follow-Up Visits Frequency Patients with diabetes whose disease is in good control should be seen every 3 to 6 months or more frequently if needed Patients whose disease is in fair control should be evaluated at least
every 2 months, and those whose disease is in poor control should be evaluated at least every month or more frequently as clinically indicated Content History Discussion should include diet and medication adherence, exercise, smoking, foot care especially in those with evidence of neuropathy or vasculopathy, and finger-stick results Objective Data At each follow-up visit, vital signs should be taken, weight recorded, and foot exams documented An HbA1C test should be ordered at least every 3 months for patients on insulin and at least every 6 months for patients with type 2 diabetes who do not require insulin T 
ype 1 diabetes patients should get daily finger-stick tests based on the degree of control Annually, the clinician should order: A B C D E BUN/creatinine Microalbuminuria unless gross proteinuria on urinalysis Urinalysis Fasting lipid profile Dilated funduscopic eye examination by an ophthalmologist or optometrist Assessing Therapeutic Management At each follow-up visit, the health provider should document in the health record an assessment of the patients condition as defined below
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Definitions of Control1 Use
of standard definitions of control does not eliminate the providers obligation to tailor the assessment and treatment plan to each unique patient The following guidelines are suggested for defining degree of control2 Good Control HbA1C of 7 or lower Fair Control HbA1C of 71 to 90 Poor Control HbA1C of 91 or higher Definitions of Status Improved Status The HbA1C or the average of finger-stick results has decreased, or, for type 2 diabetes, there has been an intentional weight loss of 5 or more due to diet and exercise Unchanged Status The HbA1C and the average of finger-stick results are the same as previously recorded, and the weight is relatively unchanged Worsened Status The HbA1C or the average of finger-stick results has increased, or, for type 2 diabetes, there has been a weight gain of 5 or more Treatment Strategies If the assessment of the patient is fair or poor, or if the patients status is worsened, the clinicians plan should reflect new efforts to work with the patient to improve these outcome measures Treatment strategies include the following Medical Nutrition Therapy In general, diets for people with diabetes should be consistent with the American Heart Association
diet consisting of foods in proportions that contain 40 to 50 carbohydrates and not more than 30 fat, of which saturated fat is not more than 10 Patients with type 1 diabetes require counseling that stresses synchronization of eating with the administration of insulin Most type 1 diabetic patients will require an evening snack Nutritional counseling for type 2 diabetes stresses weight reduction toward ideal body weight Appropriate diet counseling for the type of diabetes must be evident in the record on an ongoing basis
In a jail setting, given the relatively rapid turnover of patients, definitions of control may be based on preprandial finger-stick readings where good control 80-120 mg/dL, fair control 121-180 mg/dL, and poor control 180 mg/dL Two-hour postprandial readings should be 180 mg/dL
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Clinicians interpreting HbA1C values should be familiar with the parameters of their laboratory
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Medications Oral Agents Representative agents from all categories of oral hypoglycemic agents should be present on the institutional formulary The two major categories of oral diabetic medications are insulin
secretagogues, such as sulfonylureas, and insulin sensitizers that enhance insulin action, such as metformin Insulin Management of insulin-requiring diabetes stresses as near normal glycemic control as can be achieved safely For type 1 diabetes, this will require frequent finger-stick glucose monitoring with twice or more daily insulin injections For those who cannot be managed safely on multiple-injection therapy, twice-a-day insulin therapy using combinations of long- and shortacting insulin is a reasonable alternative Hypertension therapy The blood pressure goal for patients with diabetes is usually a systolic pressure 130 mmHg and a diastolic pressure 80 mmHg First-line therapy is usually a diuretic or angiotensin converting enzyme ACE inhibitor, especially if the patient has microalbuminuria Aspirin therapy Aspirin therapy should be provided for diabetes patients who have other cardiovascular risk factors or a history of myocardial infarction, vascular bypass, stroke or transient ischemic attack, peripheral vascular disease, claudication, or angina Vaccination Patients with diabetes should receive an annual influenza vaccine in season Most patients should receive a single
lifetime pneumoccocal vaccine; certain high-risk patients may benefit from repeat injections at 5-year intervals, for example, those aged 65 years or older who received their first injection more than 5 years earlier at an age less than 65 Understanding the Therapeutic Process Any decrease in degree of control as manifested by elevations of HbA1C, fasting plasma glucose, or finger-stick results is probably related to one of the following problems: A B C D Inadequate patient understanding of parts of the treatment regimen Institutional obstacles to compliance Inconsistent instruction to the patient from different medical staff Factors such as age, motivation, or medication Correctional Barriers Common impediments to managing diabetes in correctional settings include the following: Access to Health Care Resources In general, the restriction of movement of incarcerated persons greatly influences the delivery and timing of medical services, medications, meals, and availability of personnel to respond to
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serious medical events Access to trained staff should be ensured in all care, but especially in the care of
insulin-dependent patients with diabetes Uncontrolled type 1 diabetes patients require extensive health care resources and institutional flexibility to facilitate self-management Institutions that cannot provide the appropriate environment should transfer these patients to a facility that can accommodate their needs While 24-hour nursing care is available in most facilities with insulin-dependent patients, the relative freedom of self-directed treatment by the patient governs whether the individual and the facility are able to care for most common variations in glucose control Exercise Regular exercise is an important adjunct treatment for all people with diabetes, and good glycemic control is difficult without daily exercise Clinicians should make every effort to ensure that their patients have adequate opportunity and encouragement for exercise regimens Diet Medical nutrition is another challenge in correctional settings, especially with regard to providing acceptable Aheart healthy@ menu alternatives Efforts should be made to train staff on the preparation and patient self-selection of appropriate items to support a good diet Patient should be educated to control carbohydrate
consumption, to select appropriate items and portions, and to limit consumption of excessive supplemental items from commissaries Food on an asneeded basis should be made available for patients with hypoglycemia Patient Self-Management Successful treatment of diabetes requires patient self-management While control of syringes and other sharps is paramount in correctional settings, efforts should be made to allow patients with diabetes to conduct self-monitoring supervised or unsupervised and to prepare and administer their insulin Each medical encounter provides health staff with opportunities to empower the patient to understand the disease Quality Improvement Measures The following quality improvement measurers are suggested, but are not intended to be a complete list necessary to ensure a successful diabetes management program A Percentage of inmates with diabetes who undergo a complete intake health assessment screening within 7 days prison or 14 days jail of intake B Availability of a heart-healthy diet and healthy snacks in commissary C Percentage of patients who have been educated by a diabetes educator D Percentage of inmates transferred with diabetes supplies and
medications E Percentage of patients with a documented dilated eye examination in preceding 12 months F Percentage of patients with a fasting lipid panel in preceding 12 months G Percentage of patients with a urine microalbumin in preceding 12 months
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H Percentage of patients with microalbuminuria 30 mg/g creatinine who are prescribed ACE or ARB therapy I Percentage of patients with a documented foot examination in preceding 12 months J Percentage of patients with HbA1C 9 NCQA benchmark: 20 K Percentage of progress notations describing a strategy for improving diabetes control when the HbA1C is above 7 L Percentage of patients with blood pressure 130/80 mmHg M Percentage of patients with LDL cholesterol 100 mg/dL N Percentage of type 2 patients with BMI 25
Last reviewed: August 2008 Next scheduled review: August 2009 For the current version go to http://wwwncchcorg/resources/clinicalguideshtml
National Commission on Correctional Health Care 1145 W Diversey Pkwy Chicago, Illlinois 60614 773-880-1460 info@ncchcorg wwwncchcorg
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Source:ncchc.org
