Schools, Rules and Diabetes

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Schools, Rules and Diabetes

• Benita Lopez-Baca, RN, BSN, CDE
• Kathleen Patrick, RN, MA, NCSN
• R. Paul Wadwa, MD

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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

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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.
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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 students
• 92 of parents were satisfied with the childs
  diabetes care at school
• Hellems, M and Clarke, W. Safe at
  School The Virginia Experience.

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What is Happeningwith Diabetes Care in
Colorado Schools?
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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

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Accomplishment 1

• Guiding Principles Standards and guidelines for
  safe management of children with diabetes in
  schools

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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

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Accomplishment 2

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

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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

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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

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Parent School Toolkit

• 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
• FAQs
• Glossary
• Resources

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Accomplishment 4

• Diabetes Resource Nurse Program

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Colorado Diabetes Resource Nurse

• Nurse Consultants with expertise in diabetes,
  staff development and problem solving who serve
  as resources for schools throughout Colorado

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PURPOSE

• Assure the safety of Colorados 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.

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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

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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

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Nurse Practice Act

• State law that licenses and regulates the
  practice of nursing

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Delegation

• The transfer of responsibility for the
  performance of an activity to another, with the
  former retaining accountability for the outcome.
• ANA, 1994

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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

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Bottom line

• The health, safety and welfare of the student is
  the primary consideration in any decision to
  delegate

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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

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New Diabetes Website

• www.coloradokidswithdiabetes.org

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Discussion and Case Studies
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Teddy

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

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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?

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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

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Discussion

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

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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
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Discussion

• Can 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?

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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

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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?

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NDEP - Helping the Student with Diabetes Succeed
Section 1 Diabetes Primer for School Personnel
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Diabetes Care Tasks at School What Key
Personnel Need to Know
BLOOD GLUCOSE MONITORING
DIABETES BASICS
HYPOGLYCEMIA/HYPERGLYCEMIA
INSULIN
KETONE MONITORING
NUTRITION EXERCISE
LEGAL CONSIDERATIONS
GLUCAGON ADMINISTRATION
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• Contact information
• Kathleen Patrick RN, MA, NCSN
• Principal Consultant, School Health Services
• Colorado Department of Education
• 303-866-6779
• patrick_k_at_cde.state.co.us
• Benita Lopez-Baca, RN, BSN, CDE
• Barbara Davis Center
• benita.lopezbaca_at_uchsc.edu
• R. Paul Wadwa, MD
• Barbara Davis Center
• 303-724-2323
• paul.wadwa uchsc.edu

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• 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

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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.

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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.