VIII. DIABETES CARE IN SPECIFIC SETTINGS

Section Overview

A. Diabetes care in the hospital

Recommendations

• All patients with diabetes admitted to the hospital should have their diabetes clearly identified in the medical record.
• All patients with diabetes should have an order for blood glucose monitoring, with results available to all members of the health care team.
• Goals for blood glucose levels:
• Critically ill surgical patients’ blood glucose levels should be kept as close to 110 mg/dl (6.1 mmol/l) as possible and generally <140 mg/dl (7.8 mmol/l). (A) These patients require an intravenous insulin protocol that has demonstrated efficacy and safety in achieving the desired glucose range without increasing risk for severe hypoglycemia.
• Critically ill nonsurgical patients’ glycemic targets are less well defined. Intravenous insulin infusion protocols targeting blood glucose levels <110–140 mg/dl have been shown to reduced morbidity and mortality in some, but not all studies. Intravenous insulin infusion protocols that effectively and safely keep blood glucose <140 mg/dl are recommended.
• For non–critically ill patients, there is no clear evidence for specific blood glucose goals. Since cohort data suggest that outcomes are better in hospitalized patients with fasting glucose <126 mg/dl and all random glucoses <180–200, these goals are reasonable if they can be safely achieved. Insulin is the preferred drug to treat hyperglycemia in most cases.
• Due to concerns regarding the risk of hypoglycemia, some institutions may consider these blood glucose levels to be overly aggressive for initial targets. Through quality improvement, glycemic goals should systematically be reduced to the recommended levels.
• Scheduled prandial insulin doses should be appropriately timed in relation to meals and should be adjusted according to point-of-care glucose levels. The traditional sliding-scale insulin regimens are ineffective as monotherapy and are generally not recommended.
• Using correction dose or “supplemental” insulin to correct premeal hyperglycemia in addition to scheduled prandial and basal insulin is recommended.
• Glucose monitoring with orders for correction insulin should be initiated in any patient not known to be diabetic who receives therapy associated with high risk for hyperglycemia, including high-dose glucocorticoids therapy, initiation of enteral or parenteral nutrition, or other medications such as octreotide or immunosuppressive medications. If hyperglycemia is documented and persistent, initiation of basal/bolus insulin therapy may be necessary. Such patients should be treated to the same glycemic goals as patients with known diabetes.
• A plan for treating hypoglycemia should be established for each patient. Episodes of hypoglycemia in the hospital should be tracked.
• All patients with diabetes admitted to the hospital should have an A1C obtained if the result of testing in the previous 2–3 months is not available.
• A diabetes education plan including “survival skills education” and follow-up should be developed for each patient.
• Patients with hyperglycemia in the hospital who do not have a diagnosis of diabetes should have appropriate plans for follow-up testing and care documented at discharge.

The management of diabetes in the hospital is extensively reviewed in an ADA technical review. This review, as well as a consensus statement by the American Association of Clinical Endocrinologists (AACE), with co-sponsorship by ADA and a report of a joint ADA-AACE task force on the topic, form the basis for the discussion and guidelines in this section.

The literature on hospitalized patients with hyperglycemia typically describes three categories:

• Medical history of diabetes: diabetes previously diagnosed and acknowledged by the patient's treating physician.
• Unrecognized diabetes: hyperglycemia (fasting blood glucose 126 mg/dl or random blood glucose 200 mg/dl) occurring during hospitalization and confirmed as diabetes after hospitalization by standard diagnostic criteria but unrecognized as diabetes by the treating physician during hospitalization.
• Hospital-related hyperglycemia: hyperglycemia (fasting blood glucose 126 mg/dl or random blood glucose ≥200 mg/dl) occurring during the hospitalization that reverts to normal after hospital discharge.

The prevalence of diabetes in hospitalized adult patients is not precisely known. In the year 2000, 12.4% of hospital discharges in the U.S. listed diabetes as a diagnosis, but this is likely an underestimate. The prevalence of diabetes in hospitalized adults is conservatively estimated at 12–25%, depending on the thoroughness used in identifying patients. In the year 2003, there were 5.1 million hospitalizations with diabetes as a listed diagnosis, a 2.3-fold increase over 1980 rates.

The management of hyperglycemia in the hospital was traditionally considered secondary in importance to the condition that prompted admission.

A rapidly growing body of literature supports targeted glucose control in the hospital setting for potential improved mortality, morbidity, and health economic outcomes. Hyperglycemia in the hospital may result from stress, decompensation of Type 1 or Type 2 or other forms of diabetes, and/or may be iatrogenic due to withholding of antihyperglycemic medications or administration of hyperglycemia-provoking agents such as glucocorticoids or vasopressors.

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1. In-hospital hyperglycemia and outcomes

a. General medicine and surgery.

Observational studies suggest an association between hyperglycemia and increased mortality. Surgical patients with at least one blood glucose value >220 mg/dl (12.2 mmol/l) on the first postoperative day have significantly higher infection rates.

When admissions on general medicine and surgery units were studied, patients with new hyperglycemia had significantly increased in-hospital mortality, as did patients with known diabetes. In addition, length of stay was higher for the new hyperglycemic group, and patients in either hyperglycemic group were more likely to require intensive care unit (ICU) care and transitional or nursing home care. Better outcomes were demonstrated in patients with fasting and admission blood glucose <126 mg/dl (7 mmol/l) and all random blood glucose levels <200 mg/dl (11.1 mmol/l).

b. CVD and critical care.

A significant relationship exists between blood glucose levels and mortality in the setting of acute myocardial infarction. A meta-analysis of 15 studies compared in-hospital mortality in both hyper- and normoglycemic patients with and without diabetes. In subjects without known diabetes whose admission blood glucose averaged 109.8 mg/dl (6.1 mmol/l), the relative risk for in-hospital mortality was increased significantly. When diabetes was present and admission glucose averaged 180 mg/dl (10 mmol/l), risk of death was moderately increased compared with patients who had diabetes but less hyperglycemia on admission. Another study demonstrated a strong independent relationship between admission blood glucose values and both in-hospital and 1-year mortality; rates were significantly lower in subjects with admission plasma glucose <100.8 mg/dl (5.6 mmol/l) than in those with plasma glucose 199.8 mg/dl (11 mmol/l).

These studies focused on admission blood glucose as a predictor of outcomes, rather than inpatient glycemic management per se. Higher admission plasma glucose levels in patients with a prior history of diabetes could reflect the degree of glycemic control in the outpatient setting, thus linking outpatient glycemic control to outcomes in the inpatient population. In patients without a prior history of diabetes, admission hyperglycemia could represent case finding of patients with previously undiagnosed diabetes, an unmasking of risk in a population at high risk for diabetes or more severe illness at admission.

In the initial Diabetes and Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) study (319,320), insulin-glucose infusion followed by at least 3 months of subcutaneous insulin treatment in diabetic patients with acute myocardial infarction improved long-term survival. Mean blood glucose in the intensive insulin intervention arm was 172.8 mg/dl (9.6 mmol/l), compared with 210.6 mg/dl (11.7 mmol/l) in the “conventional” group. The broad range of blood glucose levels within each arm limits the ability to define specific blood glucose target thresholds.

Three more recent studies (321–323) using an insulin-glucose infusion did not show a reduction in mortality in the intervention groups. However, in each of these studies, blood glucose levels were positively correlated with mortality. In the Hyperglycemia: Intensive Insulin Infusion In Infarction (HI-5) study, a decrease in both CHF and reinfarction was observed in the group receiving intensive insulin therapy for at least 24 h.

c. Cardiac surgery.

Attainment of targeted glucose control in patients with diabetes undergoing cardiac surgery is associated with reduced mortality and risk of deep sternal wound infections. Although these studies used historical controls and were not randomized, they support the concept that perioperative hyperglycemia is an independent predictor of infection in patients with diabetes, with the lowest mortality in patients with blood glucose <150 mg/dl (8.3 mmol/l).

d. Critical care.

A mixed group of patients with and without diabetes admitted to a surgical ICU were randomized to receive intensive insulin therapy (target blood glucose 80–110 mg/dl [4.4–6.1 mmol/l]) or conventional therapy. Intensive insulin therapy achieved a mean blood glucose of 103 mg/dl (5.7 mmol/l) and was associated with reduced mortality during the ICU stay and decreased overall in-hospital mortality (328). Hospital and ICU survival were linearly associated with ICU glucose levels, with the highest survival rates occurring in patients achieving an average blood glucose <110 mg/dl (6.1 mmol/l).

A subsequent study of a similar intervention in patients in a medical ICU showed that the group receiving intensive insulin therapy had reduced morbidity but no difference in mortality overall. Death rates were significantly lower in those patients who were treated for longer than 3 days; but these patients could not be identified before therapy. In another study using a similar intervention targeting a blood glucose range of 4.4–6.1 mmol in patients admitted with sepsis, no difference in mortality from the conventionally treated group was observed. There were more episodes of hypoglycemia, defined as a blood glucose <40 mg/dl (2.2 mmol/l), and more serious adverse events in the group receiving intensive insulin therapy.

While an earlier meta-analysis concluded that insulin therapy in critically ill patients had a beneficial effect on short-term mortality in different clinical settings, a more recent meta-analysis, involving 29 studies and over 8,000 patients, failed to show any mortality benefit from intensive glucose control. Tight glucose control did reduce the relative risk of septicemia by 26%. While this latter meta-analysis investigated strategies with target blood glucose levels of 80–110 mg/dl (4.4–6.1 mmol/l), studies with less stringent glucose targets were also included. Stratification by glucose target did not demonstrate any heterogeneity. The authors of this analysis as well as an accompanying editorial both recommend that glycemic targets in critically ill patients be revisited.

While results from ongoing clinical trials are still pending, it is clear that uncontrolled hyperglycemia is associated with adverse outcomes in critically ill patients and that achieving levels of glucose control below 140 mg/dl are reasonable, provided that protocols that minimize risk for hypoglycemia are utilized and that personnel are well educated in the direct application of these protocols.

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2. Glycemic targets in hospitalized patients

There is relatively strong evidence from randomized controlled trials for a glycemic target of blood glucose <110 mg/dl (6.1 mmol/l) in surgical patients in critical care units. However, in several studies of critically ill medical patients, the incidence of severe hypoglycemia (blood glucose <40 mg/dl) was approximately threefold greater in intensively treated patients. The identification of hypoglycemia as an independent risk factor for death in the medical ICU population (334) may merit caution in widely promoting the 80–110 mg/dl target range for all critically ill populations.

For patients in general medical-surgical units, the evidence for specific glycemic goals is less definitive. Epidemiologic and physiologic data suggest that higher blood glucose levels are associated with worse outcomes, but whether glucose is simply a marker of the severity of underlying illness or a mediator of adverse outcomes is unclear. Glycemic targets similar to those of outpatients may be difficult to achieve in the hospital due to the effects of stress hyperglycemia, altered nutritional intake, and multiple interruptions to medical care. Blood glucose levels shown to be associated with improved outcomes in these patients (fasting glucose <126 mg/dl and all blood glucose readings <180–200 mg/dl) would appear reasonable, if they can be safely achieved.

In both the critical care and noncritical care venue, glycemic goals must take into account the individual patient's situation as well as hospital system support for achieving these goals. A continuous quality improvement strategy may facilitate gradual improvement in mean glycemia hospital wide.

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3. Treatment options in hospitalized patients

a. Noninsulin glucose-lowering agents.

No large studies have investigated the potential roles of various noninsulin glucose-lowering agents on outcomes of hospitalized patients with diabetes. Use of the various noninsulin classes in the inpatient setting presents some specific issues.

The long action of sulfonylureas and their predisposition to hypoglycemia in patients not consuming their normal nutrition serve as relative contraindications to routine use of these agents in the hospital (335). While the meglitinides, repaglinide and neteglinide, theoretically would produce less hypoglycemia than sulfonylureas, lack of clinical trial data for these agents, and the fact that they are primarily prandial in effect, would preclude their use. The major limitation to metformin use in the hospital is a number of specific contraindications to its use, related to risk of lactic acidosis, many of which occur in the hospital. The most common risk factors for lactic acidosis in metformin-treated patients are cardiac disease, including decompensated CHF, hypoperfusion, renal insufficiency, old age, and chronic pulmonary disease. Lactic acidosis is a rare complication in the outpatient setting, despite the relative frequency of risk factors. However, in the hospital the risks of hypoxia, hypoperfusion, and renal insufficiency are much higher, and it is prudent to avoid the use of metformin in most patients.

TZDs are not suitable for initiation in the hospital because of their delayed onset of effect. In addition, they increase intravascular volume, a particular problem in those predisposed to CHF and potentially a problem for patients with hemodynamic changes related to admission diagnoses (e.g., acute coronary ischemia) or interventions common in hospitalized patients. Pramlintide and exenatide work mainly by reducing postprandial hyperglycemia and would therefore not be appropriate for patients not eating (nil per os, NPO) or with reduced caloric consumption. Furthermore, initiation of these drugs in the inpatient setting would be problematic due to alterations in normal food intake and their propensity to induce nausea initially. There is limited experience, and no published data, on the DPP-IV inhibitors in the hospital setting, although there are no specific safety concerns. They are mainly effective on postprandial glucose and therefore would have limited effect in patients who are not eating.

In summary, each of the major classes of noninsulin glucose-lowering drugs has significant limitations for inpatient use. Additionally, they provide little flexibility or opportunity for titration in a setting where acute changes often demand these characteristics. Therefore, insulin, when used properly, is preferred for the majority of hyperglycemic patients in the hospital setting.

b. Insulin

i. Subcutaneous insulin therapy.

Subcutaneous insulin therapy may be used to attain glucose control in most hospitalized patients with diabetes outside of the critical care arena. The components of the daily insulin dose requirement can be met by a variety of insulins, depending on the particular hospital situation. Subcutaneous insulin therapy should cover both basal and nutritional needs and is subdivided into scheduled insulin and supplemental, or correction-dose, insulin. Correction-dose insulin therapy is an important adjunct to scheduled insulin, both as a dose-finding strategy and as a supplement when rapid changes in insulin requirements lead to hyperglycemia. If correction doses are frequently required, the appropriate scheduled insulin doses should be increased to accommodate the increased insulin needs. There are currently no published studies comparing human regular insulin with rapid-acting analogs for use as correction-dose insulin.

The traditional “sliding-scale” insulin regimens, usually consisting of regular insulin without any intermediate or long-acting insulins, have been shown to be ineffective when used as monotherapy in patients with an established insulin requirement. Problems with sliding-scale insulin regimens include the fact that the sliding-scale regimen prescribed on admission is likely to be used throughout the hospital stay without modification, even when control remains poor. Additionally, sliding-scale insulin therapy treats hyperglycemia after it has already occurred, instead of preventing the occurrence of hyperglycemia. This “reactive” approach can lead to rapid changes in blood glucose levels, which may exacerbate both hyper- and hypoglycemia.

A recent study demonstrated the safety and efficacy of using basal-bolus insulin therapy utilizing weight-based dosing in insulin-naïve hospitalized patients with Type 2 diabetes. Glycemic control, defined as a mean blood glucose <140 mg/dl, was achieved in 68% of patients receiving basal-bolus insulin versus only 38% of those receiving sliding-scale insulin alone. There were no differences in hypoglycemia between the two groups. It is important to note that the patients in this study were obese, and the doses used in this study (0.4 to 0.5 units • kg • day−1) are higher than what may be required in patients who are more sensitive to insulin, such as those who are lean or who have Type 1 diabetes.

ii. Intravenous insulin infusion.

The only method of insulin delivery specifically developed for use in the hospital is continuous intravenous infusion, using regular crystalline insulin. There is no advantage to using rapid acting analogs, whose structural modifications increase the rate of absorption from subcutaneous depots, in an intravenous insulin infusion. The medical literature supports the use of intravenous insulin infusion in preference to the subcutaneous route of insulin administration for several clinical indications among nonpregnant adults. These include DKA and nonketotic hyperosmolar state; general preoperative, intraoperative, and postoperative care; the postoperative period following heart surgery; following organ transplantation; with cardiogenic shock; exacerbated hyperglycemia during high-dose glucocorticoid therapy; Type 1 patients who are NPO; or in critical care illness in general. It may be used as a dose-finding strategy in anticipation of initiation or reinitiation of subcutaneous insulin therapy in Type 1 or Type 2 diabetes.

Many institutions use insulin infusion algorithms that can be implemented by nursing staff. Although numerous algorithms have been published, there have been no head-to-head comparisons between insulin infusion strategies. Algorithms should incorporate the concepts that maintenance requirements differ between patients and change over the course of treatment. Ideally, intravenous insulin algorithms should consider both current and previous glucose levels, the rate of change of plasma glucose, and the current intravenous insulin infusion rate. For all algorithms, frequent (Q 1–2 h) bedside glucose testing is required.

iii. Transition from intravenous to subcutaneous insulin therapy.

For those who will require subcutaneous insulin, the very short half-life of intravenous insulin necessitates administering the first dose of subcutaneous insulin before discontinuation of the intravenous insulin infusion. If short or rapid-acting insulin is used, it should be injected 1–2 h before stopping the infusion. If intermediate- or long-acting insulin is used alone, it should be injected 2–3 h before. A combination of short/rapid- and intermediate/long-acting insulin is usually preferred. Basal insulin therapy can be initiated at any time of the day and should not be withheld to await a specific dosing time, such as bedtime. A recent clinical trial demonstrated that a regimen using 80% of the intravenous insulin requirement over the preceding 24 h, divided into basal and bolus insulin components, was effective at achieving blood glucose levels between 80 and 150 mg/dl following discontinuation of the intravenous insulin.

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4. Self-management in the hospital

Self-management of diabetes in the hospital may be appropriate for competent adult patients who have a stable level of consciousness, have reasonably stable daily insulin requirements, successfully conduct self-management of diabetes at home, have physical skills needed to successfully self-administer insulin and perform SMBG, have adequate oral intake, and are proficient in carbohydrate counting, use of multiple daily insulin injections or insulin pump therapy, and sick-day management. The patient and physician, in consultation with nursing staff, must agree that patient self-management is appropriate under the conditions of hospitalization. For patients conducting self-management in the hospital, it is imperative that basal, prandial, and correction doses of insulin and results of bedside glucose monitoring be recorded as part of the patient's hospital medical record. While many institutions allow patients on insulin pumps to continue these devices in the hospital, others express concern regarding use of a device unfamiliar to staff, particularly in patients who are not able to manage their own pump therapy. If a patient is too ill to self-manage either multiple daily injections or CSII, then appropriate subcutaneous doses can be calculated on the basis of their basal and bolus insulin needs during hospitalization, with adjustments for changes in nutritional or metabolic status.

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5. Preventing hypoglycemia

Hypoglycemia, especially in insulin-treated patients, is the leading limiting factor in the glycemic management of Type 1 and Type 2 diabetes. In the hospital, multiple additional risk factors for hypoglycemia are present, even among patients who are neither “brittle” nor tightly controlled. Patients with or without diabetes may experience hypoglycemia in the hospital in association with altered nutritional state, heart failure, renal or liver disease, malignancy, infection, or sepsis. Additional triggering events leading to iatrogenic hypoglycemia include sudden reduction of corticosteroid dose, altered ability of the patient to self-report symptoms, reduction of oral intake, emesis, new NPO status, inappropriate timing of short- or rapid-acting insulin in relation to meals, reduction of rate of administration of intravenous dextrose, and unexpected interruption of enteral feedings or parenteral nutrition.

Despite the preventable nature of many inpatient episodes of hypoglycemia, institutions are more likely to have nursing protocols for the treatment of hypoglycemia than for its prevention. Tracking such episodes and analyzing their causes are important quality improvement activities.

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6. Diabetes care providers in the hospital

Inpatient diabetes management may be effectively provided by primary care physicians, endocrinologists, or hospitalists, but involvement of appropriately trained specialists or specialty teams may reduce length of stay, improve glycemic control, and improve outcomes. In the care of diabetes, implementation of standardized order sets for scheduled and correction-dose insulin may reduce reliance on sliding-scale management. A team approach is needed to establish hospital pathways. To achieve glycemic targets associated with improved hospital outcomes, hospitals will need multidisciplinary support for using insulin infusion therapy outside of critical care units or will need to develop protocols for subcutaneous insulin therapy that effectively and safely achieve glycemic targets.

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7. DSME in the hospital

Teaching diabetes self-management to patients in hospitals is a challenging task. Patients are ill, under increased stress related to their hospitalization and diagnosis, and in an environment not conducive to learning. Ideally, people with diabetes should be taught at a time and place conducive to learning, as outpatients in a recognized program of diabetes education.

For the hospitalized patient, diabetes “survival skills” education is generally a feasible approach. Patients and/or family members receive sufficient information and training to enable safe care at home. Those newly diagnosed with diabetes or who are new to insulin and/or blood glucose monitoring need to be instructed before discharge. Those patients hospitalized because of a crisis related to diabetes management or poor care at home need education to prevent subsequent episodes of hospitalization. An assessment of the need for a home health referral or referral to an outpatient diabetes education program should be part of discharge planning for all patients.

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8. MNT in the hospital

Hospital diets continue to be ordered by calorie levels based on the “ADA diet.” However, since 1994 the ADA has not endorsed any single meal plan or specified percentages of macronutrients, and the term “ADA diet” should no longer be used. Current nutrition recommendations advise individualization based on treatment goals, physiologic parameters, and medication usage. Because of the complexity of nutrition issues in the hospital, a registered dietitian, knowledgeable and skilled in MNT, should serve as an inpatient team member. The dietitian is responsible for integrating information about the patient's clinical condition, eating, and lifestyle habits and for establishing treatment goals in order to determine a realistic plan for nutrition therapy.

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9. Bedside blood glucose monitoring

Implementing intensive diabetes therapy in the hospital setting requires frequent and accurate blood glucose data. This measure is analogous to an additional “vital sign” for hospitalized patients with diabetes. Bedside glucose monitoring using capillary blood has advantages over laboratory venous glucose testing because the results can be obtained rapidly at the “point of care,” where therapeutic decisions are made.

Bedside blood glucose testing is usually performed with portable meters that are similar or identical to devices for home SMBG. Staff training and ongoing quality control activities are important components of ensuring accuracy of the results. Ability to track the occurrence of hypo- and hyperglycemia is necessary. Results of bedside glucose tests should be readily available to all members of the care team.

For patients who are eating, commonly recommended testing frequencies are premeal and at bedtime. For patients not eating, testing every 4–6 h is usually sufficient for determining correction insulin doses. Patients on continuous intravenous insulin typically require hourly blood glucose testing until the blood glucose levels are stable, then every 2 h.

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10. Discharge planning

It is important to anticipate the postdischarge antihyperglycemic regimen in all patients with diabetes or newly discovered hyperglycemia. The optimal program will need to consider the type and severity of diabetes, the effects of the patient's illness on blood glucose levels, and the capacities and desires of the patient. Smooth transition to outpatient care should be ensured, especially in those new to insulin therapy or in whom the diabetes regimen has been substantially altered during the hospitalization. All patients in whom the diagnosis of diabetes is new should have, at minimum, “survival skills” training before discharge. More expanded diabetes education can be arranged in the community. For those with hyperglycemia who do not require treatment upon discharge, follow-up testing through their primary care physician should be arranged, since many of these individuals are found to have diabetes when tested after discharge.

B. Diabetes care in the school and day care setting

Recommendations

• An individualized Diabetes Medical Management Plan (DMMP) should be developed by the parent/guardian and the student's personal diabetes health care team with input from the parent/guardian.
• All school staff members who have responsibility for a student with diabetes should receive training that provides a basic understanding of diabetes and a student's needs.
• While the school nurse is the coordinator and primary provider of diabetes care, a small number of school personnel should be trained in routine and emergency diabetes procedures (including monitoring of blood glucose levels and administration of insulin and glucagon) and in the appropriate response to high and low blood glucose levels and should perform these diabetes care tasks when the school nurse is not available to do so. These school personnel need not be health care professionals.
• As specified in the DMMP and as developmentally appropriate, the student with diabetes should have immediate access to diabetes supplies at all times and should be permitted to self-manage his or her diabetes in the classroom or anywhere the student may be in conjunction with a school activity. Such self-management should include blood glucose monitoring and responding to blood glucose levels with needed food and medication.

There are ∼186,300 individuals <20 years of age with diabetes in the U.S., most of whom attend school and/or some type of day care and need knowledgeable staff to provide a safe environment. Despite legal protections, including coverage of children with diabetes under Section 504 of the Rehabilitation Act of 1973, the Individuals with Disabilities Education Act, and the Americans with Disabilities Act, children in the school and day care setting still face discrimination. The ADA position statement on Diabetes Care in the School and Day Care Setting provides the legal and medical justifications for the recommendations provided herein.

Appropriate diabetes care in the school and day care setting is necessary for the child's immediate safety, long-term well-being, and optimal academic performance. Parents and the health care team should provide school systems and day care providers with the information necessary for children with diabetes to participate fully and safely in the school/day care experience by developing an individualized DMMP.

The school nurse should be the key coordinator and provider of care and should coordinate the training of an adequate number of school personnel and ensure that if the school nurse is not present at least one adult is present who is trained to perform the necessary diabetes procedures (e.g., blood glucose monitoring and insulin and glucagon administration) and provide the appropriate response to high and low blood glucose levels in a timely manner while the student is at school, on field trips, participating in school-sponsored extracurricular activities, and on transportation provided by the school or day care facility. These school personnel need not be health care professionals.

The student with diabetes should have immediate access to diabetes supplies at all times, with supervision as needed. The student should be able to obtain a blood glucose level and respond to the results as quickly and conveniently as possible in the classroom or wherever the child is in conjunction with a school-related activity, minimizing the need for missing instruction in the classroom and avoiding the risk of worsening hypoglycemia or hyperglycemia if the child must go somewhere else for treatment. The student's desire for privacy during blood glucose monitoring and insulin administration should also be accommodated.

The ADA and partner organizations have developed tools for school personnel to provide a safe and nondiscriminatory educational environment for all students with diabetes.

C. Diabetes care at diabetes camps

Recommendations

• Each camper should have a standardized medical form completed by his/her family and the physician managing the diabetes.
• Camp medical staff should be led by with a physician with expertise in managing Type 1 and Type 2 diabetes and include nurses (including diabetes educators and diabetes clinical nurse specialists) and registered dietitians with expertise in diabetes.
• All camp staff, including physicians, nurses, dietitians, and volunteers, should undergo background testing to ensure appropriateness in working with children.

The concept of specialized residential and day camps for children with diabetes has become widespread throughout the U.S. and many other parts of the world. The mission of diabetes camps is to provide a camping experience in a safe environment. An equally important goal is to enable children with diabetes to meet and share their experiences with one another while they learn to be more personally responsible for their disease. For this to occur, a skilled medical and camping staff must be available to ensure optimal safety and an integrated camping/educational experience.

Each camper should have a standardized medical form completed by his/her family and the physician managing the diabetes that details the camper's past medical history, immunization record, and diabetes regimen. The home insulin dosage should be recorded for each camper, including type(s) of insulin used, number and timing of injections, and the correction factor and carbohydrate ratios used for determining bolus dosages for basal-bolus regimens. Campers using CSII should also have their basal rates specified. Because camp is often associated with more physical activity than experienced at home, the insulin dose may have to be decreased during camp.

The diabetes camping experience is short term, with food and activity different than the home environment. Thus, goals of glycemic control at camp are to avoid extremes in blood glucose levels rather than attempting optimization of intensive glycemic control.

During camp, a daily record of the camper's progress should be made, including all blood glucose levels and insulin dosages. To ensure safety and optimal diabetes management, multiple blood glucose determinations should be made throughout each 24-h period: before meals, at bedtime, after or during prolonged and strenuous activity, and in the middle of the night when indicated for prior hypoglycemia. If major alterations of a camper's regimen appear to be indicated, it is important to discuss this with the camper and the family in addition to the child's local physician. The record of what transpired during camp should be discussed with the family at the end of the camp session and a copy sent to the child's physician.

Each camp should secure a formal relationship with a nearby medical facility so that camp medical staff can refer to this facility for prompt treatment of medical emergencies. ADA requires that the camp medical director be a physician with expertise in managing Type 1 and Type 2 diabetes. Nursing staff should include diabetes educators and diabetes clinical nurse specialists. Registered dietitians with expertise in diabetes should have input into the design of the menu and the education program. All camp staff, including medical, nursing, nutrition, and volunteer, should undergo background testing to ensure appropriateness in working with children.

D. Diabetes management in correctional institutions

Recommendations

• Correctional staff should be trained in the recognition, treatment, and appropriate referral for hypo- and hyperglycemia, including serious metabolic decompensation.
• 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 upon entry. Insulin-treated patients should have a capillary blood glucose (CBG) determination within 1–2 h of arrival. Staff should identify patients with Type 1 diabetes who are at high risk for DKA with omission of insulin.
• Medications and MNT should be continued without interruption upon entry into the correctional environment.
• In the correctional setting, policies and procedures should enable CBG monitoring to occur at the frequency necessitated by the patient's glycemic control and diabetes regimen and should require staff to notify a physician of all CBG results outside of a specified range, as determined by the treating physician.
• For all inter-institutional transfers, a medical transfer summary should be transferred with the patient, and diabetes supplies and medication should accompany the patient.
• Correctional staff should begin discharge planning with adequate lead time to ensure continuity of care and facilitate entry into community diabetes care.

At any given time, over 2 million people are incarcerated in prisons and jails in the U.S., and it is estimated that nearly 80,000 of these inmates have diabetes. In addition, many more people with diabetes pass through the corrections system in a given year.

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. 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.

Reception screening should emphasize patient safety. In particular, rapid identification of all insulin-treated individuals with diabetes is essential in order to identify those at highest risk for hypo- and hyperglycemia and DKA. All insulin-treated patients should have a CBG determination within 1–2 h of arrival. 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. It is essential that medication and 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 hyper- or hypoglycemia.

Patients must have access to prompt treatment of hypo- and hyperglycemia. Correctional staff should be trained in the recognition and treatment of these conditions, and appropriate staff should be trained to administer glucagon. 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.

Correctional institutions should have systems in place to ensure that insulin administration and meals are coordinated to prevent hypo- and hyperglycemia, taking into consideration the transport of residents off site and the possibility of emergency schedule changes. The frequency of CBG monitoring will vary by patients’ glycemic control and diabetes regimens. Policies and procedures should ensure that the health care staff has adequate knowledge and skills to direct the management and education of individuals with diabetes.

Patients in jails may be housed for a short period of time before being transferred or released, and patients in prison may be transferred within the system several times during their incarceration. Transferring a patient with diabetes from one correctional facility to another requires a coordinated effort, as does planning for discharge. The ADA position statement on Diabetes Management in Correctional Institutions should be consulted for more information on this topic.

E. Emergency and disaster preparedness

Recommendations

• People with diabetes should maintain a disaster kit that includes items important to their diabetes self-management and continuing medical care.
• The kit should be reviewed and replenished at least twice yearly.

The difficulties encountered by people with diabetes and their health care providers in the wake of Hurricane Katrina highlight the need for people with diabetes to be prepared for emergencies, whether natural or otherwise, affecting a region or just their household. Such preparedness will lessen the impact an emergency may have on their condition. It is recommended that people with diabetes keep a waterproof and insulated disaster kit ready with items critically important to their self-management. These may include glucose testing strips, lancets, and a glucose-testing meter; medications including insulin in a cool bag; syringes; glucose tabs or gels; antibiotic ointments/creams for external use; glucagon emergency kits; and photocopies of relevant medical information, particularly medication lists and recent lab tests/procedures if available. If possible, prescription numbers should be noted, since many chain pharmacies throughout the country will refill medications based on the prescription number alone. In addition, it may be important to carry a list of contacts for national organizations, such as the American Red Cross and ADA. This disaster kit should be reviewed and replenished at least twice yearly.