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DiabetesMEDICAL PRACTICE GUIDELINESState of FloridaAgency for Health Care AdministrationThese guidelines are endorsed under the authority of theFlorida Health Care and Insurance Reform Act of 1993,Section 408.02, Chapter 93-129, Laws of Florida.Endorsed on October 19, 2001Permission to duplicate and distribute granted. Table of ContentsTable of Contents. .1State of Florida Agency for Health Care Administration Notice on Practice Parameters. . . . . .3Florida Diabetes Practice Guideline Advisory Committee. . . . . . . . .4Introduction. . . . . . . . . . . . . . . .5 Definitions. . . . . . . . . . . . . . . . 6Minimum Standards of Care for Children with Diabetes. . . .8Assessment of Need for Hospitalization for Stabilizationof Newly Diagnosed Children with Diabetes. . . . . . . 8Indications for Hospitalization for Diabetic Ketoacidosis (DKA).8After Medical Stabilization (One to Three Days) . . . .8Ongoing Disease Management First Year . . . . . 8.Office Visits. . . . . . . . . . . . . . . . . . 9Annual Assessment . . . . . . . . . . . . . . .9Second Year and Beyond. . . . . . . . . . . . . . . . 9Criteria that Suggest Children or Adolescents have Type 2 Diabetes. . . . . . . 9Treatment Goals for Children with Type 2 Diabetes. . . . . .10Treatment Components for Type 2 Diabete . . . . 11Education. . . . . . . . . . .11Monitoring. . . . . . . . . . .11Nutrition herapy. . . . . . . . . . .11Exercis. . . . . . . . . . .11Follow-Up Visit . . . . . . . . . . .11Drug Therapy. . . . . . . . . . . .11Additional Medication .12Monitoring for Complication .12Treatment of Complications . . . . .12Hypertension. . . . . . . . . . . . . .12Hyperdipidemia. . . . . . . . . . . .12Minimum Standards of Care for Adults. . . .13Hospital Admission Guidelines for Adults . . . . . .14Initial Assessment . . . . . . . . . .14Assess Patients Disease Status and Risk Factor. . .14Follow-up Assessments (Three-Month Intervals) . . . .16Prevention/Assessment of Complications. . . . . . .17Glucose Control . . . . . . . . . . .17Retinal Evaluation . . . . . . . . . . . 17Cardiac Peripheral Vascular Evaluation . . . . . .17Aspirin Therapy . . . . . . . . . . . . . . .18Tobacco Cessation . . . .18Renal Evaluation. . . . . . . . . . . .18Neuropathy Evaluation . . . . . . . . .18Immunization Evaluation. . .19Preconception Counseling .20Gestational Diabetes . 22Detection and Diagnosis. . . . . . . . . . . .22Therapeutic Strategies .23Maternal Strategies . . . . . 23Fetal Strategies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23Nutritional Counseling . 23Insulin Therapy . . . . . . . . . . .23Postpartum Follow-up Care . 24Diabetes Self-Management Training. 25Diabetes Overview . . . . . . . . . . 26Medication . . . . . . . . . . . 26Monitoring and Use of Results. . . . 27Nutrition . . . . . . . . . . . 27Immunizations . . . . . . . . . . .28Prevention, Detection and Treatment of Acute and Chronic Complications. . . . 29Exercise and Activity . . . . . . . . . . . . . . . 29Importance of An Individualized Exercise Plan . 30Reducing Exercise Risk. 30Guidelines for Safe Exercise Including Preparing for Exercise(Adjustment of Food and Insulin). 30Benefits of Exercise . 30Glycemic Response to Exercise. 30Stress and Psycho-Social Adjustment. 30Children . . . . . . . . . . . . 31Adolescents . . . . . . . . . . . . . 31Young Adults. . . . . . . . . . . . . 31Older Adult . . . . . . . . . . .31Foot, Skin and Dental Care. 32Use of Health Care Systems and Community Resources. 32Reference . . . . . . . . 33Appendices . . . . . . . 35State of FloridaAgency for Health Care AdministrationNotice on Practice ParametersThese practice guidelines, produced in consultation with the Diabetes Practice Guideline AdvisoryCommittee, are endorsed by the Florida Agency for Health Care Administration (AHCA) pursuant tothe Florida Health Care and Insurance Reform Act of 1993, Chapter 93-129, section 408.02, Laws ofFlorida.These guidelines are endorsed for information, education and review by the medical community, other professionals, and the public.These guidelines are not to be used as fixed protocols. They merely identify typical courses ofintervention. There may be patients who require more or less treatment. However, those cases thatexceed or fall below the guidelines may be subject to more careful scrutiny and may requiredocumentation of the special circumstances. Treatment must be based on patient need as well asprofessional judgment.In summary, medical guidelines are patient management strategies, which are not entirely inclusive orexclusive of all methods of reasonable care that can obtain the same results, or of those which consider the particular needs of the patient and available resources.While standards are intended to be rigid and mandatory making exceptions rare and difficult tojustify guidelines are more flexible, although they should be followed in most cases. Guidelines can be tailored to fit individual needs that are influenced by the patient, setting, resources and other factors. Deviations can be justified by individual circumstances. Options are intended to be neutral. They merely note the interventions available to practitioners.Guidelines are revisited every three years or less. Review is based on valid scientific update. Theseguidelines were initially endorsed on January 16, 1998. Revisions have been made to the originalguidelines and endorsed on October 19, 2001.Practice Parameter Subject: DiabetesGuideline Review CommentsaGuidelineReview Conmments and InformationOrder from:CostDiabetes MedicalPractice GuidelinesFor technical information on theseguidelines, and to submit yourscientifically-valid review comments,please contact:Debby WaltersDivision of Health PolicyAHCAAddress at rightAgency for Health Care AdministrationCall CenterToll Free: (888) 419-3456Free CopyOrder From: CostFlorida Diabetes Medical Practice Guideline AdvisoryCommitteePauline EllisDirectorPrograms and Government RelationsAmerican Diabetes AssociationFlorida Affiliate, Inc.Maitland, FloridaGigi Foster, RNCommunity Health NurseDiabetes Control ProgramDepartment of HealthTallahassee, FloridaBonnie Gaughan-BaileyHealth Care CoordinatorDiabetes Control ProgramDepartment of HealthTallahassee, FloridaBarbara Joswick, RN, MS, CDEFlorida Hospital Medical CenterDiabetes CenterOrlando, FloridaJohn I. Malone, MDUniversity of South Florida, College ofMedicineTampa, FloridaState of Florida Diabetes AdvisoryCouncil MembersSamuel Crockett, MDChairpersonFlorida Diabetes ImplementationWork Group Members Larry Deeb, MDPrimary FacilitatorDiabetes Medical PracticeGuideline Advisory CommitteeChairpersonLarry Deeb, MDPediatric Endocrinology ConsultantAgency for Health Care Administrationand Childrens ClinicTallahassee, FloridaDiabetes Medical PracticeGuideline Advisory CommitteeVice ChairpersonLouis Chaykin, MDEndocrinology21110 Biscayne BoulevardAventura, FloridaDiabetes Medical PracticeGuideline Advisory CommitteeTechnical Advisor and CoordinatorDebby WaltersSenior Health Policy AnalystAgency for Health Care AdministrationTallahassee, FloridaIntroductionDiabetes is a chronic illness requiring continual medical care and education in order to prevent acutecomplications and reduce the risk of long-term medical problems. In Florida, over 1,000,000 individuals have been diagnosed as having diabetes. It is estimated that over 300,000 additional adults have diabetes but will not know it until confronted with one of its serious complications. Recognizing the devastating effects of this disease without a comprehensive approach to treatment, the Florida Legislature passed legislation in 1996 that requires all insurance policies and HMO plans to provide coverage for all medically appropriate equipment and supplies in addition to diabetes outpatient self-management training and educational services used to treat diabetes. The legislation directed the Florida Agency for Health Care Administration to develop standards for self-management training.In 1997 the agency, in conjunction with the Department of Health, Florida affiliate of the American Diabetes Association, endocrinologists, internists, dietitians, diabetes self-management educators and other experts in the delivery of treatment services for individuals with diabetes, developed the initial practice guidelines to address the complex needs of patients with this illness.In 2001 revisions were made to the original guidelines to reflect the most current medical standards used in the treatment of children and adults having Type 1 and Type 2 diabetes. It is important for members of the health care team to consider the following: Each patient is an individual and requires care that addresses their individual specific medical and psychosocial needs. It is imperative that the intensity and level of medical and psycho-social support necessary to accomplish treatment goals meet ongoing changes in the patients needs, care and lifestyle. A critical element for the successful treatment of all patients with diabetes is participation in acomprehensive self-management care and education program. Ongoing support, maintenance, andmodifications in treatment regimes and lifestyle changes, all require continued patient and caregiverparticipation. Self-management education is necessary to accomplish these goals.These guidelines were developed using the American Diabetes Association (ADA) “Standards of Medical Care for Patients With Diabetes Mellitus,” ADA National Standards for Diabetes Self-Management Education, current World Health Organization Diagnostic Criteria, the American Association of Clinical Endocrinologists Diabetes Care Guideline, and the Lawson Wilkens Pediatric Endocrine Society Diabetes Guideline.The guidelines are organized into the following areas: Definitions, Minimum Standards of Care for Children and Adults (which includes guidelines for hospital admission, initial and follow-up assessments), Strategies for Treatment of Gestational Diabetes, Guidelines for a Comprehensive Diabetes Self-Management Treatment Program, References, and Appendices.Definitions(AACE) American Association of Clinical Endocrinologists.(ADA) American Diabetes Association - is the not-for-profit national voluntary health agency concerned with diabetes.Board-Certified Adult Endocrinologist - refers to a physician who has completed a residency program in internal medicine and a fellowship program in endocrinology, diabetes and metabolism and passed the certification examinations of the American Board of Internal Medicine to become board certified in endocrinology, diabetes and metabolism.Board-Certified Pediatric Endocrinologist - refers to a physician who has completed a residency program in pediatrics and a fellowship program in pediatric endocrinology, diabetes, and metabolism and has passed the certification examinations of the American Board of Pediatrics to become board-certified in Pediatric Endocrinology.Certified Diabetes Educator - refers to a health care professional who has passed the certification exam of, and is currently certified by, the National Certification Board for Diabetes Educators and meets the criteria set forth by the American Association of Diabetes Educators (AADE) and has passed the national exam established by the AADE.Diabetes - is a chronic disorder charac