Diabetes Medical Management School Plan – Insulin pump
Effective dates
Student Photo
Student’s name
Date of birth
School
Medical condition
TYPE 1 DIABETES
Contact information
Parents/Guardian
Address
Telephone
Mother’s mobile
Father’s mobile
Other
Diabetes team Contacts
Diabetes consultant
<Select name of consultant here>
Diabetes nurse specialist
<Select name of nurse here>
Address
University College London Hospital, NHS Trust
6th Floor Central, 250 Euston Road, London, NW1 2PQ
Telephone
020 3447 9364
Email
childrensdiabetesnurses@uclh.nhs.uk
Website
www.uclh.nhs.uk/T1
Notify parents/guardian or emergency contact in the following situations:
Severe or sustained Hypoglycaemia
Vomiting
Blood ketones measuring more than 1.0 mmol/L with or without abdominal pain
Other:
Other:
Other:
Blood Glucose
monitoring
Target range
4 mmols/l to <Select blood glucose here>
When student exhibits symptoms of hyperglycemia
Blood glucose levels should
be checked at (tick all that
apply)
When student exhibits symptoms of hypoglycemia
Prior to snacks and meals
Before and after exercise
Additional at
Can student perform own
Yes
Yes, with support
No
blood glucose checks?
Results of any tests taken should be recorded in the diary and communicated with the
parents at the end of each session. Any blood glucose level that is outside of the target
range should be acted upon, following the instructions in this management plan.
Equipment Used
Type of insulin pump
Type of blood glucose meter
Type of finger pricker
Uses a continuous glucose
Yes
No
monitor
If routinely using a continuous glucose sensor at school, please see the additional
management plan regarding this.
Hypoglycaemia (low
blood glucose) – ‘The
15 Rule’
The student displays hypo
symptoms
Yes
Sometimes
No
The following symptoms may indicate that the child/young person has a low blood glucose
level:
sports and activities or school trips.
IF blood glucose is less than 4 mmols and the student is able to eat/ drink

Give <Select grams of carbohydrate here> of glucose (e.g.
)

Repeat blood glucose test after 15 minutes

If blood glucose still below 4 mmols, give a further <Select grams of carbohydrate here>
glucose

Repeat blood glucose test after 15 minutes

If the blood glucose remains below 4 mmols, ‘suspend’ the pump until blood glucose
naturally rises and call parents
It is generally preferable not to eat anything additional in the 15 minutes between these two
blood glucose tests. However, if hypoglycaemia is found immediately before lunch and is not
severe, the young person can be allowed to commence eating lunch with their fellow
2
students. The bolus insulin for lunch should be programmed into the pump after eating
using the blood glucose level from before lunch.
Severe Hypoglycaemia
If drowsy but able to swallow, suspend the pump and then give GlucaGel /Dextragel
Route:
Orally
Dosage:
25 gram tube
Has the school agreed to give
Yes
No
Glucagon on the premises
If unconscious or having a seizure, call 999 for an ambulance. Glucagon should be
administered by a trained member of staff or ambulance crew. Place the young person
in the recovery position.
Glucagen Dose:
<Enter dose here>
Site for Glucagen injection:
Thigh
Student abilities/ skills
The young person is able to do the following
independently
Count carbohydrates
Yes
No
Bolus correct amount for carbohydrates consumed
Yes
No
Calculate and administer corrective bolus
Yes
No
Calculate and set basal profiles
Yes
No
Calculate and set temporary basal rate
Yes
No
Disconnect pump
Yes
No
Reconnect pump at infusion set
Yes
No
Prepare reservoir and tubing
Yes
No
Insert infusion set
Yes
No
Troubleshoot alarms and malfunctions
Yes
No
Sharps disposal - Please refer to the schools own local sharps policy.
When to give insulin at
school by a ‘bolus’
With all food and drink containing carbohydrate
When the blood glucose level is above <Select blood glucose here>
Can student make decisions
Yes
Yes, with support
No
regarding this
Instructions on how to use the pump bolus calculator can be found on the webpage.
These ’how to’ leaflets are to support teaching on how to use these devices
3
Hyperglycemia (high
blood glucose) – ‘The
ABCC Rule’
If the blood glucose level is above <Select blood glucose here> follow the ABCC
Assess
Was a food bolus given within the last 90 minutes? If so, do nothing and retest blood
glucose level again in 1 hour.
Is there insulin in the pump?
Is the pump connected to the child?

Bolus
Give a correction dose of insulin, using the pump bolus calculator

Check
Check blood glucose level 1 hour after this bolus has been given
If blood glucose level is lower than the previous value, no further action is required

If blood glucose level is higher than the previous value, Change the infusion cannula
If blood glucose level is equal to or higher than the previous value, contact parents – they
will need to be change the cannula and additional insulin needs to given by pen injection.
Blood Ketone
monitoring
When student has more than 2 consecutive blood
glucose levels that are greater than 14 mmols
Times to test for ketones
When student has one blood glucose greater than 14
mmols immediately prior to exercise
If vomiting and/or complaining of abdominal pain
Can student perform own
Yes
Yes, with support
No
blood ketone checks?
Blood Ketone levels under 0.6 mmol/L are normal.
Blood Ketone levels over 3.0 mmol/L indicate that the young person requires immediate
medical care. If you are unable to contact the parents, please ring for an ambulance.
Sport and PE Lessons
Before commencing PE, test the blood glucose level.
Decide whether the pump should be disconnected (e.g. for swimming, contact sports)
If Blood Glucose before sport is:
 Less than 3.9 mmols
Follow ‘15 minute rule’
 Between 4 and 6.9 mmols May need a carbohydrate snack e.g. a banana without
insulin
 Between 7.0 to 13.9 mmols No action

Above 14mmols
Test for blood ketones and if greater than 0.6 mmol/L
do not exercise, and follow the ABCC rule. If blood ketones are less than 0.6mmol/L,
follow the ABCC rule giving half the recommended correction amount by the insulin
pump calculator.
After PE, test blood glucose and reconnect pump (if previously disconnected).
4
Temporary Basal rates
The background insulin rate can be overridden by programming a temporary basal rate on
the pump. This is an effective method of managing exercise and its impact on the blood
glucose levels, by decreasing the amount of basal insulin.
Has the school agreed to set
temporary basal rates
Times to set a temporary
basal rate
Yes
No
During exercise at
After exercise at
% for
% for
hours
hours
Supplies to be kept at
School










Fast-acting source of glucose
Glucagel
Glucagon
Spare cannula and reservoir
Spare insulin
Spare battery for pump
Blood glucose testing kit
Blood ketone testing kit
Insulin pen + needle
Other
Where to find my supplies:
THIS DIABETES MEDICAL MANAGEMENT PLAN HAS BEEN APPROVED BY:
Student’s Diabetes Nurse Specialist
Date
I give permission to the school nurse, trained diabetes personnel and other designated staff
members to perform and carry out the diabetes care tasks as outlined by this Medical
Management Plan. I also consent to the release of the information contained in this
Diabetes Medical Management Plan to all staff members and other adults who have
custodial care of my child and who may need to know this information to maintain my child’s
health and safety. A copy of this plan will be kept by the parents, school and hospital
diabetes team.
Acknowledged and received by:
Student’s Parent/Guardian
Date
School staff
Date
5
Item
Individualised
care plan
Provision of
support and
training
Emergency
Supply Box
Blood glucose &
ketone testing
Sharps Disposal
Parents Responsibility
Early years/school
responsibility
Child/Young
persons
responsibility
when deemed
competent
Formulation of the
plan and to update
information when
necessary
Paediatric Diabetes
Specialist Nurse
School Nurse
Formulation of plan and
provide training in order
for information to
disseminated
Formulation of plan and
provide some training in order
for the information to be
disseminated
Formulation of plan & to
update information when
necessary
Formulation of plan and to
disseminate information to
school personnel
To provide box and contents
and to ensure contents are in
date
Provision of appropriate
storage space for supplies
of insulin.
To make parents
aware when
supplies low
To provide training as to
the appropriate use of
emergency supplies.
May provide training as to
correct use of box
To provide supplies of
equipment at the start of a
school term and replenish
whenever necessary.
Undertake regular quality
control measures
To provide sharps bin (refer
to local policy)
Provide correct storage for
supplies where necessary
and request for training
when further required.
To make parents
aware when
supplies low
To train parents to carry
out as per local guidelines
None
To provide parents with
information as to local
policy
To make parents aware if
running out of snacks and
exercise food. To give
permission for CYP to eat
whenever required.
To initiate and complete
risk assessment
documentation
To contact parents in
advance of any trip to
enable planning and
additional training for staff
To make parents
aware when 2/3 full
To provide parents with
information about local
policy
To provide parents / CYP
with recommendations
regarding when to have
additional carbohydrate
To provide parents with
information about local policy
To provide specialist
information as required
To provide specialist
information as required
To provide additional
training/ advice as
required.
To support if required.
Extra Food
To provide food for snacks
and exercise as required
Risk Assessment
To provide information to
facilitate risk assessment
Out of school
activities &
residential trips
To contact the diabetes team
if any additional training is
required. To meet with school
staff to formulate an agreed
care plan for the duration of
the trip
To make parents
aware when
requires more food
supplies
To participate in risk
assessment where
possible
To inform parents of
any trip planned. To
be involved in the
formulation of the
care plan