Diabetes Safety Checklist

What, if anything, is getting in the way of you taking care of your health? For some people it is finances, stress, access to food, family violence or depression. 

Or review PHQ.

Calgary Distress Centre:

• 403-266-4357 (Calgary only) or AHS Mental Health Line: 1-877-303-2642 if client verbalizes intent to act on suicidal thoughts.

Family Violence Resources:

• https://www.alberta.ca/family-violence-find-supports.aspx 

Patient Mental Health Resources regarding COVID-19:

• On the homepage of endometab.ca​.

DCC Psychosocial Services:

• Referrals accepted during COVID-19. 

Diabetes Supplies:

• Full resources for supplies are listed here (Topics Catalogue - Cost Coverage).
• Patient letter listing supply resources is here.
• DCC clinicians contact education consultants if emergency supplies need to be provided. 

Insulin dose error with too much rapid insulin:

1. What is your name, address you are currently at, phone number and is someone there with you? 
2. What is your blood sugar now? Do you have sugar or jam there? 
3. How many units rapid do you usually give and how many did you actually give?
4. How many grams of carbohydrate do you usually eat at this time or what do you usually eat for breakfast?

1. Inform patient you may call 9-1-1 to have EMS assist if the patient becomes non-responsive or you cannot reach at a planned call. 
2. Have the patient consume 1/4 cup sugar (60g carb) or less depending on blood sugar, age etc dissolved in water so you have time to ask the following questions and do math. 
3. Do this math: 
   A. Units of rapid insulin given DIVIDED by usual rapid insulin dose 
   B. Multiply this by usual grams carb eaten at the meal
   C. Subtract 60 g carb eaten as sugar.
   D. The answer is how many extra grams carb they need to eat. 
4. You may have to add up the grams of carbohydrate they usually eat if they don't carbohydate count.Each of the following is about 15 grams: 1 bread, 1/2 cup potato, 1 cup milk, 1 cup fruit, 2/3 cup juice, 1 tbsp sugar/regular jam.
5. Instruct the patient to check blood sugars at least hourly for 6 hours. If unable to maintain readings over 4 mmol/L or to ingest adequate CHO due to nausea have the patient, caregiver or educator  call 911. Advise client NOT TO operate a car.

See your program's full policy or refer the patient to PADIS (Poison and Drug Information Centre 1-800-332-1414 for Alberta)

1. Have you had 3 or more readings a week less than 4.0 mmol/L? (If elderly, less frequent)
   
   
2. Have you had periods of sweating, shaky, dizziness, extreme hunger, sweating, bad dreams or or damp pillow when you wake?

• "Do you usually follow a low carb or ketogenic diet?" 
  
  
• "Have you had bariatric surgery?" 
  
  
• "Is there any chance you could be pregnant?"

• Adjust medication if appropriate.
• Provide and review Hypoglycemia symptoms / treatment handout if patient on insulin or secretagogue (treatment, symptoms, causes, prevention.)
• Review  troubleshooting hypoglycemia and discuss the insulin pump items on this list if within your scope.
• If on an insulin pump, refer to a Diabetes Educator with specialty in Insulin Pump Therapy (e.g Diabetes Centre Calgary).
• Consider if CGM is appropriate.
• If on low carb or ketogenic diet, be supportive. Explain you can help adjust medications to prevent lows.  Ask how they treat lows. If no or ineffective treatment, with the patient's permission, review rationale for using fast carbs. Note that untreated hypo may increase immediate risks or development of future hypo unawareness which could impact driving. Encourage a referal to RD to help them maintain their diet preferences safely.
• If the patient had bariatric surgery, even a few years prior, postprandial hypoglycemia may be a side effect even if not on insulin or secretagogue. Adjust the latter medications if appropriate and refer to a dietitian to address post-bariatric hypoglycemia.
• In the first trimester, hypoglycemia can occur more frequently. If pregnant, refer immediately to a Diabetes in Pregnancy Program as well as make appropriate medication adjustments. 

1. Strict avoidance of hypoglycemia by considering ac targets 6.0-10.0 mmol/l for 1-3 months (or individualized).
2. Driving guidelines handout
3. Hypoglycemia Unawareness handout 
4. Suggestion for referral to endocrinologist
5. Consider if CGM is appropriate.

• Discuss use of glucagon in clients with type 1 diabetes and review glucagon handout.
• Investigate frequency, causes and preventative measures and assess for hypoglycemia unawareness. 
• Chart “severe” hypoglycemia only if client was unable to treat episode by him/herself.
• Consider higher glycemic targets if recurrent severe hypoglycemia.

Review Hypoglycemia symptoms / treatment handout.
Treatment 15 g glucose, retest in 15 minutes, retreat if needed. Review appropriate carbohydrate choices for treatment and need to treat lows before eating meal.

If CGM indicates extended period of hypoglycemia requiring repeat treatments, advise test fingerstick blood glucose. Repeated treatments may not be needed and may result in hyperglycemia.  Some educators recommended fingerstick verification for all low CGM readings to rule out false lows. 

Hypo: if on CGM: 

1. Are you taking a drug containing hydroxyurea?   
2. Do you check your blood glucose (fingerstick) when symptoms don't match sensor readings? 
3. What is your "low" alert set at? 
4. Does your sensor require calibaration and are you using blood glucose for this? 

1. Hydroxyurea in Hydrea™, Apo-Hydroxyurea™, Mylan-Hydroxyurea™* and hydroxycarbamide (used for treating some cancers) can falsely elevate sensor glucose readings in Medtronic and Dexcom sensors. Not Libre as of 2021. 
2. Advise fingerstick glucose test if symptoms don't match sensor reading. Especially at night as there may be compression lows.
3. Set low alert above 4.0 mmol/L so action can be taken to prevent hypoglycemia.
4. Advise calibration per manufacturer’s guidelines using only fingerstick blood glucose and a verified accurate meter. People have experienced hypoglycemia because of incorrect or missed calibration.

1. Are your blood sugars mostly over 14 mmol/L or A1c over 12%?
   
   
2. If you have type 1 diabetes, do you test for ketones if over 14.0 mmol/L?
   
   
3. ​If you are on a pump, do you carry a safety kit with ketone strips, insulin and syringe?

DKA can result in death. Review appropriate handouts: 

• Review How to Manage Illness in Type 1 Diabetes and Prevent DKA  handout. 
• Prevention of Diabetic Ketoacidosis (DKA) in Insulin Pump Therapy (AHS).
• Coming Off The Pump (AHS)- in case a pump educator is not available.
• SGLT-2: STOP DKA in Type 1

Check ketones if over 14 mmol/L in type 1 (give1.5 X correction if over trace ketones in urine, or over 0.6 mmol/L ketones in blood). Adjust other insulins as appropriate. Assess for causes of hyperglycemia: insulin omission, illness, accident, “bad” insulin, injection technique, insulin pump related issues .

Click here for pictures of Bayer Ketostix and Accu-Chek Chemstrips (common medical urine ketone strips available at pharmacies).

ADVISE EMERGENCY SERVICES IF:

DKA (diabetic ketoacidosis) suspected: nausea, vomiting, abdominal pain, rapid deep labored breathing, confusion and dehydration (dry mouth, cracked lips, decreased skin turgor, dark urine). Contacting physician as required.

HHS (Hyperosmolar, Hyperglycemic State) suspected: type 2 diabetes with blood sugars > 25.0 mmol/L and is physically unwell, dehydrated, hypotensive and confused with an altered state of consciousness as HHS may be considered. This is extremely rare.

NOTE: Patients with stage 5 renal disease (dialysis) are often on fluid restrictions. Caution advising increased fluid intake for the prevention of DKA.  Pleases contact the endocrinologist and nephrologist involved for appropriate instructions for DKA prevention in dialysis. 

Are you on an SGLT-2 inhibitor?  

1. Note: DKA can occur with normal, slightly elevated or elevated glucose readings in those using SGLT-2s. This applies to those with type 2 and type 1 diabetes. Do not rely on blood glucose readings alone to assess for DKA in SGLT-2 use. 
2. Regardless of blood glucose level, send to emergency if on SGLT-2 inhibitor with overt symptoms of DKA (nausea, vomiting, abdominal pain, rapid deep labored breathing, confusion,  dehydration e.g. dry mouth and cracked lips, decreased skin turgor, dark urine). 
   
   
3. If the patient is feeling unwell without overt symptoms either check for ketones or instruct your patient to obtain ketone strips (likely urine as easiest). If moderate to large ketones in the urine, send to urgent care regardless of blood glucose levels.
   
   
4. In all cases provide and review: SGLT-2 Diabetes Canada Handout. 
   
5. In type 1 diabetes review the handout SGLT-2: STOP DKA in Type 1

1. Do you give second correction by syringe if first correction doesn’t work and ALSO change infusion set?
2. Do you carry a backup syringe in a safety kit?
3. Do you have a plan for insulin replacement if pump fails?
4. Do you have a copy of your current basal rates, ICR and ISF at home? 

Review and provide: 

1. Prevention of diabetic ketoacidosis (DKA) in insulin pump therapy (AHS) handout
2. Coming Off Pump handout
3. Troubleshooting list for hyperglyemia in insulin pump webpage
4. A copy of the client's pump settings

Summary of DKA prevention in pump therapy: 

1. Carry safety kit (insulin no older than a month,  syringe, ketone strips, glucose, meter, strips even in on CGM.)
2. Test for ketones if > 14.0 mmol/L
3. Give 1.5 times correction dose using syringe if ketones present (> trace in urine, > 0.6 mmol/L blood) or ir first correction (no ketones) didn't work
4. Change infusion set if ketones or if unsuccessful first correction and still over 14.0 mmol/L
5. Retest in 2 hrs

Hyper: If on CGM:

1. If you have increased thirst, tiredness and your sensor reading shows your glucose level is fine, what do you do? 
2. When you calibrate your CGM, how often do you input a CGM sensor reading instead of a fingerstick blood glucose reading? How often do you calibrate (if required).
3. Do you "reset" sensors for longer use? 
4. What is your "high" alert set at? 

1. Advise fingerstick glucose test if symptoms don't match sensor reading. 
2. Advise calibration per manufacturer’s guidelines using only fingerstick blood glucose and a verified accurate meter. Inform patient that some people developed DKA as a result of repeatedly inputting sensor glucose readings for calibration.
3. Advise additional fingerstick testing if “resetting” the sensor for longer wear than intended by the manufacturer. Accuracy and safety concerns may arise.
4. Ask about settings and use of alerts/alarms to aid prevention of hyperglycemia. 
5. Note that Hydroxyurea in Hydrea™, Apo-Hydroxyurea™, Mylan-Hydroxyurea™* and hydroxycarbamide (used for treating some cancers) can falsely elevate sensor glucose readings in Medtronic and Dexcom sensors. Not Libre as of 2021.

Do not assume the patient is using reliable birth control.

Discuss importance of contraception: hyperglycemia in early pregnancy increases risk of stillbirth and fetal malformation and can worsen diabetes complications in the mother.

Discuss role of metformin and insulin sensitizers in increasing fertility. Emphasize importance of adequate contraception.

Discuss lixisenatide (Adlyxine or Soliqua: lantus + lixisenatide) interfering with absorption of oral contraceptive agent (OCA). The patient must take OCA AT LEAST one hour before the lixi or 11 hours after.

Do not assume the patient will tell you she is pregnant. Ask about last menstrual period.

If pregnant, refer the patient to a Diabetes in Pregnancy Clinic.

If pregnant, discuss with the MD an order to discontinue the following: (Refer to Diabetes Centre Calgary DIP document "Guidelines for discontinuing medications during pregnancy and preconception" or your program's procedures)

• ACE or ARB
• DPP-4 inhibitors
• GLP-1 agonists
• Lantus (MD dependent)
• SGLT-2 inhibitors
• Secretagogues
• Statin
• TZD

Advise start 1 mg folic acid daily.

Blood Pressure in Pregnancy:

• Have you had any elevated BP readings at OB appointments? Do you have any swelling to feet and/or legs?
• Have you had any of the following symptoms: headaches; blurred vision; nausea and vomiting; feeling of general malaise “heartburn” or pain in your right upperquadrant? (symptoms of HELLP)

• If BP is 140/90-160/100, call patient’s OB.
• If BP >160/100, send client to L&D for assessment.

Hypoglycemia in pregnancy:

• See notes to the right as well as section above on hypoglycemia. 

• Assess for whether patient has been feeling appropriate fetal movement. If not, direct immediately to labour and delivery for assessment
• Assess for potential causes of decreased insulin requirements.
• Notify endocrinologist responsible for patient.

Hyperglycemia in pregnancy:

• See notes to the right as well as section above on hyperglycemia.

• If sugars remain elevated for >4 hours with appropriate correction and/or patient has nausea and vomiting and can’t keep food down, patient should go to Labor & Delivery unit or Emerg for assessment.
• DKA could occur at glucose levels lower than 14.0 mmol/L in pregnancy. 
• Inform client that DKA is associated with fetal loss.
• Inform clients on insulin pump that infusion set changes will likely be needed daily in the third trimester.

Obstetrical concerns:

• Could you be in labor? (Are you having contractions; has your water broke;do you have loose stools, backache or just "don't feel right"?)

• Refer client to Labor & Delivery unit if labor is suspected.

Note that for urgent obstetrical concerns prior to 20 weeks gestation, women are directed to Emergency Department. For over 20 weeks, refer to Labour and Delivery unit at your site.

Have you had trouble speaking, understanding, seeing, walking, sudden numbness, sudden weakness (of face, arm or leg), dizziness, loss of balance, sudden severe unexplained headaches or any other unusual symptoms especially when blood sugars were not less than 4 mmol/L?

Have you had chest discomfort (pressure, squeezing, fullness or pain, burning or heaviness), unusual sweating, upper body discomfort (in the neck, jaw, shoulder, arms, back), shortness of breath, nausea, lightheadness?

1. Assist client in seeking emergency care if symptoms currently present.
2. If no current symptoms, advise patient discuss sympotms with MD.
3. Discuss with patient the risk of stroke and MI and advise to seek urgent care if symptoms return. 
4. Communicate symptoms to MD.
5. (Investigate if hypoglycemia is a contributing cause of any symptoms.) 

Do you have wounds, cuts or urgent concerns about your feet or legs?

1. If, "No," book an appointment for a foot assessment with a nurse if the patient reports this has not been completed by a community partner in the last year (podiatrist, MD, PCN educator, foot clinic).
2. If "Yes,"and the patient is not currently receiving care for this, complete a full foot exam if this is in your scope and you have time, or assess visually (safety foot check) by asking patient to remove sock/shoe of offending foot and look for the following (see images here).  If unsure if the case is urgent, consult a peer (or Education Consultants) or advise patient see GP soon to discuss.
   
   1. Red, swollen, and/or sudden pain. 
   2. Draining wound (ulcer). 
   3. White, painful foot/leg/part of foot. 
   4. Gangrene 
      
      If present, contact patient's MD,  if unavailable, refer to urgent care services. 
      If within your scope and you have time, also consider referring to High Risk Foot Services. 
3. Assess at next visit if foot health or foot exam has been addressed.