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 students
92% 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 Happening
with Diabetes Care in
Colorado Schools?
Diabetes Care in
Colorado 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 Checklist
Training & Delegation
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#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
Parent &
School Toolkit
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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
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
Discussion
• The school nurse does not have
any experience with glucagon and
is hesitant to delegate what should
she/he do?
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
Dad has a
change of heart
about obtaining
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?
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?
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 School:
What Key Personnel
Need to Know
DIABETES BASICS
HYPOGLYCEMIA/HYPERGLYCEMIA
KETONE MONITORING
GLUCAGON ADMINISTRATION
BLOOD GLUCOSE MONITORING
INSULIN
NUTRITION & EXERCISE
LEGAL CONSIDERATIONS
Contact information:
Kathleen Patrick RN, MA, NCSN
Principal Consultant, School Health Services
Colorado Department of Education
303-866-6779
patrick_k@cde.state.co.us
Benita Lopez-Baca, RN, BSN, CDE
Barbara Davis Center
benita.lopezbaca@uchsc.edu
R. Paul Wadwa, MD
Barbara Davis Center
303-724-2323
paul.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.