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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 [email protected]
Benita Lopez-Baca, RN, BSN, CDEBarbara Davis [email protected]
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.