Update on Political Prisoner Robert Seth Hayes – June 2017

This was emailed by Prisoner News, and the link to where it was originally posted is here, by Jericho Movement.

For more information on political prisoner Robert Seth Hayes, who has been in prison since 1973, check out this video/audio.
Or read this bio on Prisonersolidarity.

As people know, Seth has been having serious problems with his blood sugar levels in the past month, especially since finally receiving the insulin pump. While the process of properly calibrating the pump is rather complex, there has also apparently been some medical incompetence in the use of the pump (without the monitor).

Seth’s sugars have, if anything, always tended to run too low, leading to incidents of him passing out, having “Code Blues” called, and being rushed to an outside hospital on an emergency basis. However, since the installation of the pump, his sugars have been running high (in the 200+ to 400+ range). In one recent incident, the infusion set was improperly inserted, and Seth was receiving no insulin whatsoever. His sugars were in the 500-600 range, which is life-threatening.

After one of the nurses arbitrarily removed the pump more than a week ago, stating that Seth was “too delicate” to have it, Dr. Wolf (the prison doctor) has been very concerned, since this is totally undermining her authority as a physician. This occurred during a weekend, when Dr. Wolf is not at Sullivan. (Also, the pump was removed, but the infusion set was still inserted into Seth’s body for 2 days after that. Luckily, he did not develop an infection.)

Dr. Wolf had Seth in the “infirmary” all last week, and that is where I visited him on Father’s Day. The last time I visited Seth when he was in the “infirmary,” he was allowed to come up to the regular visiting room. However, this time I had to visit in the “infirmary,” which was an educational experience for me. When I arrived to the visiting room, the Sergeant called down to the “infirmary” to ask if Seth could come up to the visiting room. I also asked if I could at least bring down some water and light snackage, and was told that I could not.

When I was on the elevator to the infirmary, I asked the CO, who was not wearing his name badge, when visiting was over, and he told me “We will kick you out of here at 2 p.m.” This was fine with me, as the bus driver had requested we all come out with the 2:30 escort.

So Seth and I are in a locked glass-walled small visiting room right in front of the COs’ desk. At around 11:30 a.m., the technician came to do the finger stick. He was very professional, placing the vial of insulin on the table so Seth (and I) could see exactly what he was being injected with. Seth stated that his sugars had been at 70 in the morning, but the fingerstick monitor showed his sugars were 280+. The technician then injected him with 6 cc’s of insulin.

So, the standard practice is that the patient is to eat shortly after receiving the insulin, even if the sugars are high. This is to prevent a precipitous drop and allow for a gradual decline in the sugars. Since the food cart had gone by shortly before that, we had to make sure that Seth got his lunch. Luckily, one of the nurses happened to arrive at that time, and I knocked on the glass to gain her attention. I asked for the lunch tray, but she could not hear me, so I made an eating motion, and she went down to the hall to speak with the COs, and then shook her head. So I made the motion of Seth getting an injection, and she nodded her head and the CO arrived with the food tray within 5 minutes. So kudos to the nurse who did the right thing and did not let herself be intimidated!

So I finally got to see the infamous “Class B” diet that Dr. Koenigsmann insists is an adequate diabetic diet. I don’t know where he went to medical school, but he obviously doesn’t know much about diabetes and nutrition. The lunch consisted of white pasta, a large hamburger on a white roll (with ketchup), and beets, all of which were cold by the time Seth got to eat. (Of course, since Seth’s sugars are high, let’s make sure we give him even more sugar!)

Since they keep giving Seth milk with every meal even though he is lactose intolerant (Seth has had diarrhea off and on for almost a week), I took the little milk container. This caused the CO (same one who brought me down to the infirmary on the elevator: a tall, slim white guy with glasses) to leap out from behind the desk, rush into the visiting room and come within an inch of physically assaulting me. He was screaming at me “That’s what I thought! You did this on purpose so you can eat his food!” with his fists up as if he was going to hit me. I haven’t seen anyone so enraged in a long time. I remained calm and replied, “I was told when I came in that I could not bring anything to eat in here. I’m only drinking the milk because Seth is lactose intolerant, and this gives him diarrhea.” The thought of anyone actually wanting to eat this food (which I would not serve even to a rat) was so hilarious that Seth and I burst out laughing. We couldn’t help ourselves. We were laughing so hard we were practically in tears. Meanwhile, CO FNU LNU (First Name Unknown Last Name Unknown) quickly locked the bathroom door before once again locking us into the visiting room and Seth literally forced himself to eat the hamburger and some of the beets.

Since the inside bathroom was locked, I asked to use the bathroom and thus got an informal tour of the infirmary. One thing I can certainly say is that it is freezing in there. Seth said that luckily, since all the beds are not occupied, he can grab an extra blanket from one of them.

Since I had been told by this same CO when I came in that visiting in the infirmary ended at 2 p.m., I was not concerned about the time, but it certainly seemed longer than it should have been. (There is no clock.) When the escort came to get me, it was already 3 p.m., so of course that meant I was late for the bus. I guess this was FNU LNU’s petty revenge for me having made sure, with the assistance of the nurse, that Seth was given his food (if you can call it that) in a timely manner.So I commented to the escort that I was late for my bus, and she replied, “That’s your responsibility.’ I replied, “Well, since I was told that infirmary visitation ends at 2 p.m., and since I have not yet developed the ability to pass through locked doors and walls, there wasn’t too much I could do about it.”

So I went back up to the regular visiting room with this young woman CO and waited for the rest of the visitors who were there. As we were walking out, we visitors were conversing. People asked where I had been, and I explained that we were visiting in the infirmary, where visitation is supposed to end at 2 p.m. I also commented the FNU LNU seemed to be hyperactive and extremely aggressive and possibly should be given some antipsychotic medication to calm him down.

When I finally arrived outside, it was 3:15 p.m. and the bus was not there. Since the prison now insists we cannot even put our cell phones in the lockers, my phone was also on the bus. I nice woman offered me a ride if I was going toward Albany, and I replied: “Oh, the bus probably went to Woodbourne to pick up people there and will come back for me.” Then I saw the bus coming up the hill. Jeff, the bus driver, said the COs said to leave me behind, and I said, “Yes, they did that once at Mohawk when a visitor was caught in the count and they wouldn’t let him leave. I went inside to see what the delay was, and the COs said to leave without him. I replied; “You are COs. You do that. We are community; we don’t leave our people behind.” Jeff smiled and said, “Exactly. I’ve been doing this for 30 years and have never left anyone stranded in the middle of nowhere!”

Seth called as I was getting off the bus in the Bronx to see how I was doing. He was concerned because I had not had anything to eat. So I told him not to worry about that and asked what his sugars were at 4 p.m. At that time, his sugars were at 202, but if he hadn’t eaten, they probably would have been at around 60 or 70. Seth is to see Dr. Wolf today, June 19, 2017, to discuss the current situation and see what next steps are. Of course, Seth wants to have the insulin pump and monitor and so does the endocrinologist at Coxsackie.

We have an update from Seth this evening, Monday, June 19, 2017 on the outcome of that conversation with Dr. Wolf. When I asked him what his sugars were today, he told me that not everyone is as professional as the technician who was there on Sunday, and he was not told what his glucose level was. He is still in the infirmary, but hopes to be out of there soon. In the meantime, people can write to Seth:

Robert Seth Hayes #74A2280
Sullivan C.F.
P.O. Box 116
Fallsburg, NY 12733-0116

Send him a get well card or write him a letter. Seth loves corresponding with people, and it also shows the prison that people are paying attention.

Also, you can call the facility at 845-434-2080. Ask to speak with the Superintendent and state you are concerned about Robert Seth Hayes #74A2280. Be polite but firm and say you are calling to make sure Seth gets the insulin pump and monitor returned to him as a life-saving measure for his diabetes.

Anne Lamb
NYC Jericho Movement

Seth wants to start a campaign about the issue of the COs, not the doctor and nurses, making medical decisions in the infirmary. Sullivan is supposed to be a regional medical hub, but the doctor and nurses are mostly upstairs in the clinic, and the COs are running the show in the infirmary. I will write this up in a follow-up shortly.

To contribute to ongoing efforts supporting Robert Seth Hayes, please donate online at:
https://fundrazr.com/campaigns/810a58

NYC Jericho received word on May 9, 2017 from Seth’s lawyer, Eve Rosahn, that his Article 78 appeal of his parole denial was also denied. You can read the decision here.


This is from Prisonersolidarity.net:

Seth has always maintained his innocence.

Life in Prison

Jailed for over 30 years, Seth has long since served the time he was sentenced to and while in prison he has worked as a librarian, pre release advisor, and AIDS councilor. He has remained drug and alcohol free throughout his entire period of incarceration and has maintained a charge free record in prison. Seth first came up for parole in 1998, but prison officials refused to release him and gave him another two years, after which he was again denied parole. Prison officials are effectively punishing him for having been a member of the Black Panther Party, and of having remained true to his ideals after 30 years behind bars.

Seth has been diagnosed with Hepatitis C and adult onset Diabetes since the year 2000. Unfortunately, despite his repeated requests Seth has not been receiving adequate health care from Clinton Correction Facility, (the prison where he is currently being held) and his condition has steadily deteriorated.

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Call now to demand freedom & medical care for Mumia


From the Enewsletter of Prison Radio:

Dear friend, 

April 29, 2015

On Monday morning Mumia Abu-Jamal was ordered back to the infirmary at SCI Mahanoy in Pennsylvania. All that day his attorney Bret Grote was at the prison.  No visitors were allowed, he and Pam Africa could not see Mumia.  There has been no contact with Mumia since Sunday, by his family, doctors, lawyers or supporters and there is grave concern that his condition, untreated and mistreated by prison infirmary doctors, could result in his death.

All Out to the Capital

The Dept. of Corrections has turned down Mumia’s petition to be given a accurate diagnosis of his condition(s) and his need to be seen by appropriate medical specialists.  His doctor has been prevented from talking to treatment staff and visiting Mumia.   

On Wednesday, April 29th we will be holding a press conference at Gov. Tom Wolf’s office in Harrisburg, PA at the Capitol Rotunda at 11am. 

At this point we do not know what is happening with Mumia. Keep your eyes on Mumia! Demand family visitation, and legal access.  We must speak out for our brother Mumia, just as he has always spoken out for us. 

Call now to demand freedom & medical care for Mumia:


Often when we call in, prison and state officials have taken their lines off the hook. Know that every single action matters, even when they don’t pick up. If they don’t answer, please leave a voicemail:

John Wetzel, PA Secretary of Corrections: (717) 728-4109
Governor Tom Wolf: (717) 787-2500
SCI Mahanoy: (570) 773-2158, then dial zero
for a more complete list of addresses and faxes etc visit www.prison Radio.org

Voices from Solitary: “No Wonder There Are So Many Suicides”

From: SolitaryWatch
Dec 17th 2012

The following comes from a prisoner currently housed in maximum security housing at Utah State Prison, Draper. He has spent, by his estimate, seven years in either supermaximum or maximum security housing. He recently had a heart attack in maximum security and reportedly has received minimal health care treatment while incarcerated. He describes here the  Uinta 1 facility, where over 90 inmates are held in long-term isolation. –Sal Rodriguez

I spent the first two years of my incarceration in general population at a county jail. I had my first heart attack while at the county jail due to misdiagnosed Type 1 Diabetes. Despite my repeated attempts to get medical help, the officials repeatedly denied that there was anything wrong with me even though I exhibited all of the symptoms and signs of diabetes. Eventually, the misdiagnosed diabetes led to the heart attack.

I spent nine days in Intensive Care at the University Medical Center before being released back to prison where I was promptly placed in supermax–Uinta 1. I had not committed any violations to be placed in supermax other than having a heart attack.

I wasn’t considered a protective custody case, as I had just spent two years in general population. No reason was given for my being housed in supermax. I spent only a few months in supermax before being shipped out to another prison out of state. Once back in Utah I was once again placed in supermax without due process or reason, and I spent the next 20 months locked down. I have spent about seven years or more now housed in either supermax or max. I have never had any write-ups or violations to warrant me being housed in maximum security.

I can tell you that life in supermax (Uinta 1) is inhumane. There are inmates still being housed in that unit who have been there for eight years or more, who started off completely sane but now have lost all sanity. Suicide was common in the Uinta’s just a few years ago, forcing the prison to take preventative measures by installing new vent-housings that wouldn’t allow a rope to be tied to it for hanging. There is still many suicides that occur there, although its not like it used to be years ago.

The abuses still continue today with some of the torture techniques used in foreign interrogation. Cells are kept cold, lights are kept on 24/7, guards purposely make noise at all hours to prevent sleep.
Windows are covered by a small door that is only opened when the guard occasionally  looks in, as for count. Mental health care is a joke, as the mental health worker goes cell to cell not spending more than five seconds at each door and only asks “Are you ok?” It’s no wonder there are so many suicides. Mental health shows a lack of concern for those in supermax. It’s the general attitude there.

Be ashamed, PA DOC! A female prisoner with diabetes dies as a result of direct medical neglect in a PA prison

We received this message from facebook. We urge the authorities to conduct an investigation into the death of this woman in prison who had diabetes and who needed insulin, a life-saving medication, together with her daily intake of food. We left out the name of the person trying to help her for fear of possible retaliation. Those responsible for the death of Tonya Green should be held accountable.

Tonya Green, the inmate in the cell next door, ‘cried and begged 6 days for help, and no-one helped her. She was unable to get herself up off the floor, and no-one helped her get up, so therefore they did not give her food and she did not take her insulin.’

The doctor came and shouted at her, ignoring her pleas for help. On the morning of the seventh day, the fellow prisoner found Tonya lying dead on the floor of her cell. She reported this to the guards but it took them another four hours to decide to go in and check on Tonya. Their attempts to revive her were, by then, futile.

I have no idea what Tonya had done to be serving a prison sentence but the way she was left to die was perverse and inhumane. Her death would probably be classified by law as caused by grave neglect. Manslaughter, maybe? Taking into account everyone knew Tonya was diabetic and needed insulin, you might even call it murder.

Posted earlier on here.

Be ashamed, PA DOC! A female prisoner with diabetes dies as a result of direct medical neglect in a PA prison

We received this message from facebook. We urge the authorities to conduct an investigation into the death of this woman in prison who had diabetes and who needed insulin, a life-saving medication, together with her daily intake of food. We left out the name of the person trying to help her for fear of possible retaliation. Those responsible for the death of Tonya Green should be held accountable.

Tonya Green, the inmate in the cell next door, ‘cried and begged 6 days for help, and no-one helped her. She was unable to get herself up off the floor, and no-one helped her get up, so therefore they did not give her food and she did not take her insulin.’

The doctor came and shouted at her, ignoring her pleas for help. On the morning of the seventh day, the fellow prisoner found Tonya lying dead on the floor of her cell. She reported this to the guards but it took them another four hours to decide to go in and check on Tonya. Their attempts to revive her were, by then, futile.

I have no idea what Tonya had done to be serving a prison sentence but the way she was left to die was perverse and inhumane. Her death would probably be classified by law as caused by grave neglect. Manslaughter, maybe? Taking into account everyone knew Tonya was diabetic and needed insulin, you might even call it murder.

Diabetes: Invest now or pay big later. Patient education essential.

NCCHC CorrectCare

Pay Now or Pay Later: Why the Goal Is Control With Diabetes
By Rebecca B. Jones, RN, BSN, CDE

An epidemic is sweeping the United States. Diabetes affects over 20 million people, almost a third of whom do not know that they have the disease. People with this disease often find out only when an organ has already sustained damage.

The impact extends beyond health. From 1997 to 2002, the annual cost for this disease in medical expenditures and lost productivity rose 35% and the average per capita cost for treatment rose more than 30%.

At any given time, nearly 80,000 people with diabetes are incarcerated. Most of those have type 2 diabetes, which for years was erroneously thought to be a less serious form of the disease. Although any inmate health problem has associated costs for practitioner visits, medications and adjunct therapy, the price tag is even higher for unrecognized and uncontrolled diabetes.

Controlling Complications
Numerous studies, the most familiar being the Diabetes Control and Complications Trial, offer convincing evidence that good control of diabetes, as shown by a lower hemoglobin A1C level, can prevent or reduce the complications (and their related costs) of the disease.

What are those complications? It is well-documented that people with diabetes are two to four times more likely to have a heart attack or stroke. They are 10 times more likely to have an amputation; in fact, comprehensive foot care programs can reduce amputation rates by as much as 85%, according to the American Diabetes Association. Diabetes also is the leading cause of new cases of blindness and of kidney failure in the United States.

The ADA Position Statement on Diabetes Management in Correctional Institutions reflects these findings and provides a framework of preventive and therapeutic interventions that can save health care dollars and achieve better inmate health. The statement addresses such issues as initial and ongoing screening for diabetes, frequency of testing for complications, diabetes management plans, and preventive and educational measures.

ADA clinical practice recommendations also form the basis of the National Commission on Correctional Health Care’s clinical guidelines on diabetes, which are tailored to care in correctional settings.

Although the details of these position statements and guidelines may seem formidable at first glance, good diabetes care primarily requires two things: good understanding of diabetes and knowledge about current therapies, and an organized, methodical approach to management of the inmate’s diabetes care.

One of the most challenging aspects of care is simply staying on top of who gets what test when! For me, an invaluable tool is a spreadsheet of all inmates with diabetes. It notes the required testing and the last results, making it easy to see at a glance who has elevated A1C levels or other out-of-range test results. Another plus of organizing the data this way is that it prevents unnecessary repeats of costly lab work as well as the dreaded FTC (fell through the cracks) syndrome.

Easy as A-B-C
Especially in a correctional facility, the goal is control. All inmates with diabetes should have a management plan that monitors and optimizes their glycemic control. The management plan should focus on three key components, labeled as the ABCs of diabetes management:

A — The A1C test, which measures the average blood glucose level over the past 60 to 90 days, is the gold standard for how well a person’s diabetes is managed overall. Although the goal should be individualized, the management plan should strive for the near-normal A1C goal of less than 7%.

Good glycemic control is achieved through therapies of diet, exercise and medication (if needed). Regular finger-stick blood glucose tests are necessary because they measure the daily effects of the therapies and give practitioners the information needed to make adjustments. Daily blood glucose tests tell us how to fine-tune the therapy; A1C tests tell us the overall success of those adjustments.

B — Blood pressure control is essential in diabetes management. People with diabetes are at especially high risk of coronary artery disease and kidney disease. Blood pressure should be controlled to less than 130/80 mmHg.

C — Cholesterol and triglyceride control are especially important for people with diabetes because of the increased incidence of coronary artery and other blood vessel disease. Often, lipid control follows normalization of blood glucose levels.

I also focus on two other components:

D — Diet, more correctly referred to as medical nutrition therapy, focuses on a healthy way of eating. MNT, by the way, could benefit all inmates in reducing their risk for chronic diseases.
There is no such thing as the “diabetic diet,” at least not any more. Instead, diabetes MNT considers the timing and amounts of carbohydrate intake and choosing “good” fats. It also seeks to add fruit and vegetables to meals and increase fiber intake. This can be very challenging in correctional institutions, but it can be done. Often, there is an almost complete lack of understanding by inmates of making better food choices and portion control.

Which leads to the last, and surely the most important, element of any diabetes management plan:

E — Education. For 25 years I have taught thousands of patients and professionals about diabetes management, and I have learned a valuable lesson: The more you know about diabetes and its management, the better the outcomes.

Knowledgeable health professionals provide better care for patients. And knowledgeable patients make better choices, communicate more effectively with the providers and self-manage their disease better. Diabetes self-management training (DSMT) is a standard of care in the free world, and it can improve the care and cooperation of inmates.

Staff education for both the health care staff and correctional officers should be ongoing to ensure that they have the information and skills to effectively manage inmates with diabetes.

The Bottom Line
Diabetes management really comes down to this: Pay me now or pay me later. You can invest in staff and inmate education, take the necessary steps to follow the standards of care, and make the effort to organize and optimize the medical management of inmates with diabetes, resulting in better outcomes. If you don’t, you most likely will find yourself continually throwing money after the medical problems that plague those with poor diabetes control.

Better glycemic control reduces the complications of diabetes. Fewer complications reduce the health care dollars spent. In the words of Dr. Robert A. Rizza, in an address at the 2006 annual scientific sessions of the ADA, “It costs less to properly treat diabetes than it does to treat the complications that you get if you don’t properly treat diabetes. It’s a wise investment no matter how you look at it.”

About the author: Rebecca B. Jones, RN, BSN, CDE, is a nurse consultant in Wetumpka, AL. To contact her, send an e-mail to thrive.survive@gmail.com.
The position statements and clinical guidelines cited above may be accessed online. For the ADA documents, visit www.diabetes.org. The NCCHC guidelines are posted at the Resources section of our Web site. Additional resources are available from the American Association of Diabetes Educators, www.aadenet.org.

[This article first appeared in the Fall 2006 issue of CorrectCare.]

Diabetes care in prison: American Diabetes Association

This long article about managing diabetes in prison is from the American Diabetes Association’s journal, “Diabetes Care”, January 2008. Clicking on the title will give you the pdf version with charts and all the footnotes.

Also, a new widget has been added to the left margin of this blog, with the link to the National Commission on Correctional Health Care’s standards on diabetes management. Click on the large “Diabetes” sign for that pdf.

——————————–

Diabetes Management in Correctional Institutions

  1. American Diabetes Association

At 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)

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 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 less than 7% onmouseout=”___yoonoLink.onYoonoOut(this)” onmouseover=”___yoonoLink.onYoonoOver(event,this)” onclick=”___yoonoLink.onYoonoClick(this)” keywords=”diabetes management” class=”yoono-link-hover yoono-link-active-link”>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 individuals 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 physician-coordinated 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 self-management education is an integral component of care. Patient self-management 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 correctional institution. Common housing not only can facilitate mealtimes and medication administration, but also potentially provides an opportunity for diabetes self-management 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 diabetes 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 heart-healthy 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 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 (e.g., less than 50 greater than 350 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 less than 60

Security staff who supervise patients at 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 (less than 70 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)

  • Identify patients with type 1 diabetes who are at high risk for DKA. (E)

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, α-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 short-acting 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 self-administration 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 rapid-acting 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 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 lock-ups 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 off-site 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 as-needed 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-to-creatinine 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 less than 130/80

  • 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 ≤100, HDL >40, triglycerides less than 150

MONITORING/TESTS OF GLYCEMIA—

Monitoring of CBG is a strategy that allows caregivers and people 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 monitoring 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 self-management 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 Self-Management 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.

  • What is diabetes

  • 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—

Patients 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 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 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 care and facilitate entry into community diabetes care. (E)

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, additional 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—

Pregnancy in 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.