Schools, Rules and Diabetes

Benita Lopez-Baca, RN, BSN, CDE

Kathleen Patrick, RN, MA, NCSN

R. Paul Wadwa, MD

The ADA Position Statement

• Defines federal laws protecting children with diabetes

• Provides guidelines for children in school and day care settings

• The ADA advocates and supports the rights of children and families with diabetes

What are other states doing?

Safe at School in Virginia

In 1999 Virginia passed a state law requiring non-medical personnel to assist students at school with their diabetes management.

Hellems, M and Clarke, W. Safe at School: The Virginia Experience. Diabetes Care. 2007.

Who trains the school personnel?

• 63% by school nurse• 35% by a parent • 15% by a diabetes specialist

Where does the child do blood testing?• 49% tested in the classroom -41% of elementary, 28% middle school, and 74% of high

school students92% of parents were satisfied with the child’s diabetes care

at school

Hellems, M and Clarke, W. Safe at School: The Virginia Experience.

What is Happeningwith Diabetes Care in

Colorado Schools?

Diabetes Care inColorado Schools Collaborative

• Stakeholders began meeting in 2005• Members included Schools, Parents,

Healthcare Providers, Community agencies

• Four Task Forces:– Guiding Principals– School Nurse Forms & Tools– Parent Toolkit– Diabetes Resource Nurse Program

Accomplishment #1

Guiding Principles: Standards and guidelines for safe management

of children with diabetes in schools

Guiding Principles

• Recognizes all students with chronic health conditions

• Essential collaboration of student, school, healthcare provider and home

• Schools need to provide sufficient resources

• School nurse plans and implements care

Accomplishment #2

School Nurse Toolkit: Standardization of forms to ensure consistency throughout the state and between healthcare providers

School Nurse ChecklistTraining & Delegation

#500 – Diabetes Management in Schools and Child Care Instructor Guide

#501 – Glucose Monitoring Skills Checklist

#502 – Urine Ketone Monitoring Skills Checklist

#503 – Hypoglycemia Skills Checklist #504 – Glucagon Skills Checklist #505 – Hyperglycemia Skills Checklist #506 – Insulin Pen Skills Checklist #507 - Insulin Pump Skills Checklist #508 – Insulin Syringe Skills Checklist #509 – Insulin Syringe Combination

Skills Checklist #510 – Continuous Glucose Monitoring

in the Schools Instructions for #600 Delegation &

Supervision of Diabetes Care Tasks #600 – Delegation Agreement &

Supervision for Diabetes Care Tasks

Accomplishment #3

Parent and School Toolkit– Clarify roles and responsibilities of school and

parent– Provide quick reference guide for teachers,

bus drivers, and other school personnel who are responsible for student with diabetes

Help a Child! Know the Symptoms! Before You Begin a New School

Year Parent Letter to Teacher with Photo Low Blood Sugar Lunchbox Card Low/High Blood Sugar Hand Information to help TEACH my Child

– Impact to Learning Field Trip Considerations Parties and Snacks Psycho-Social Aspects Developmental Stages and Diabetes

Management FAQ’s Glossary Resources

Parent &

School Toolkit

Accomplishment #4

Diabetes Resource Nurse Program

Colorado Diabetes Resource Nurse

Nurse Consultants with expertise in diabetes, staff development and problem solving who serve as

resources for schools throughout Colorado

PURPOSE

• Assure the safety of Colorado’s children with type 1 diabetes within the school community.

• Create a standard of best practice in the state in the management of children with diabetes in the school.

Responsibilities of Diabetes Resource Nurse

• Consult with district school nurses, administrators, & other staff

• Assist with development of healthcare plans & 504 plans

• Provide resources & evidence based training• Troubleshoot individual problems• Collaborate to ensure standardized care and best

practice• Note: does not provide individual care

Board of Nursing

“to protect the people of this state from the unauthorized, unqualified, and improper application of services by individuals in the practice of nursing”

Role of BON is to determine if the practice meets the standards established by the Nurse Practice Act

Nurse Practice Act

State law that licenses and regulates the practice of nursing

Delegation

“The transfer of responsibility for the performance of an activity to another, with the former retaining accountability

for the outcome.”

ANA, 1994

Delegation

• Only a registered nurse can delegate• Only activities that do not require

nursing assessment and/or judgment• Delegation limited to:

– to a specific delegatee– for a specific task– for a specific student– within a specific time frame

Bottom line…

The health, safety and welfare of the student is the primary

consideration in any decision to delegate

New Rules to Chapter XIII

• Section 8: Delegation of insulin and glucagon in the school setting and childcare

• IHP must be developed by the school nurse• Routine injections may be delegated according

to IHP & after appropriate training• Non-routine dosages must be verified by school

nurse or parent according to IHP

New Diabetes Website

www.coloradokidswithdiabetes.org

Discussion and Case Studies

Teddy

• 10 years old and diagnosed last week with Diabetes Mellitus probably Type 1

Discussion

• Is it appropriate to delegate a correction insulin dose based on blood glucose?

• Is it appropriate to delegate the calculation of a carb/insulin ratio insulin dose?

Luis• 12 years old• Diagnosed with Autism

Spectrum Disorder at 4 years of age

• Diagnosed with type 1 diabetes at 9 years of age

• Poor verbal communication skills

• The school nurse does not have any experience with glucagon and is hesitant to delegate what should she/he do?

Discussion

Billy• 9 ½ years old

• Diagnosed with diabetes more than a year ago

• Re-enrolled in school after living with mother out of state for a year

• Can do pokes and shots on his own

Discussion

What steps can be taken to address this issue?

Can the School Nurse request a 504?

What safety measures for Billy can be put in place until the concerns are resolved?

Dad has a change of heart about obtaining Medical Orders

DiscussionCan a CO RN delegate a nursing task from medical

orders from another state?

What nursing care tasks can be provided in the absence of current medical orders?

What steps can be taken to address this issue?

Can the School Nurse request a 504?

What safety measures for Billy can be put in place until the concerns are resolved?

Opie• 6 years old• Diagnosed with type 1

DM at 27 months old• Started using insulin

pump at beginning of this school year

• Can do own finger pokes

• Needs help with other care tasks

Discussion• Describe nursing actions in the

supervision of the teacher and the school secretary.

• Is it necessary for the nurse to document the supervision?

• How often would the nurse need to supervise the delegated tasks?

NDEP - Helping the Student with Diabetes Succeed

Section 1 Diabetes Primer for School Personnel

Diabetes Care Tasks at Diabetes Care Tasks at School:School:

What Key Personnel What Key Personnel Need to KnowNeed to Know

Diabetes Care Tasks at Diabetes Care Tasks at School:School:

What Key Personnel What Key Personnel Need to KnowNeed to Know

DIABETES BASICSDIABETES BASICS BLOOD GLUCOSE BLOOD GLUCOSE MONITORINGMONITORING

LEGAL LEGAL CONSIDERATIONSCONSIDERATIONS

HYPOGLYCEMIA/HYPOGLYCEMIA/HYPERGLYCEMIAHYPERGLYCEMIA

KETONE MONITORINGKETONE MONITORINGNUTRITION & NUTRITION &

EXERCISEEXERCISEINSULININSULIN

GLUCAGON GLUCAGON ADMINISTRATIONADMINISTRATION

Contact information:

Kathleen Patrick RN, MA, NCSNPrincipal Consultant, School Health ServicesColorado Department of Education303-866-6779patrick_k@cde.state.co.us

Benita Lopez-Baca, RN, BSN, CDEBarbara Davis Centerbenita.lopezbaca@uchsc.edu

R. Paul Wadwa, MDBarbara Davis Center303-724-2323paul.wadwa uchsc.edu

Self Care•Should be a team decision

•Must be determined that the student is capable

Insulin Pump•Can delegate routine meal boluses

•Non-routine doses require verification by nurse or parent according to IHP

Diabetes Resource Nurses

– Currently 26 nurses

– 16 District DRN

• Metro-area or larger districts.

– 10 Regional DRN

• Serves several counties or districts.

• Rural and small districts.

Requirements for DRN

• Minimum five years experience as a school nurse or public health nurse.

• Evidence of experience providing care to individuals with diabetes.

• Bachelor of Science degree – preferably in Nursing.