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Question:
I am a parent of a elementary school child on an insulin pump.
The school she attends has a nurse one day out of the week.
The school district policy is that no person, other than a registered
nurse, is allowed to give insulin. Although, when I look at
the school district policies on medications at school, it states
that others will be trained. I was told by the School District
Nurse that this is only true with all medications EXCEPT insulin.
Insulin can only be given by a nurse. There is another employee
who's child also has diabetes (on a pump) on site at the school.
She was told she cannot touch my child's pump to give insulin.
I know that I should not be required to come down daily at lunch,
class snacks, and class treats to give insulin during the school
day when a nurse is not on sight. What are your suggestions?
Answer:
This is a difficult question to answer, although a very important one.Technically according to the Board of Registered Nursing only a licensed nurse is allowed to give or supervise the administration of insulin, and your child in entitled to have the staff present that can assist with the administration of insulin as needed. You cannot be required to go to the school to administer insulin. As you know, schools are short staffed, and creative answers are being looked at. I would recommend that you ask for a "504" which makes your childs Invidualized School Healthcare Plan a legal document, this will cause the school to look at your child's healthcare needs at school, and come up with a plan to meet these needs. Should this remain a problem, you may wish to call the American Diabetes Association at 1 - 800 - 342 - 2383 or Linda Davis Aldritt (California School Nurse Consultant) at (916) 319 - 0284 .
Question:
I am a school nurse. I have attended several training seminars
lately in preparation for training our clinic staff and educators
on diabetes to meet the requirements of Texas House bill 984.
Each seminar has trained differently on the issue of whether
to pinch/not pinch before giving a shot.
What do you suggest? Also, are you teaching to give the shot
at a 4 degree angle or a 90 degree angle?
Answer:
These are good questions. We generaly recommend that you pinch
up the skin, and then give the subcutaneous injection straight
in and not at an angle as the needles are very short.
These questions were asked by school nurses at our School Nurse Open Forum on Diabetes Management in the School Setting in September of 2006 presented here at CHOC.
Question:
Is there any likelihood of getting grants to help with funding to get school nurses in every school where we have children that need daily lunch insulin?
Answer:
I know there are many grants out there to apply for, and this would certainly be worth exploring.
Question:
If a parent delegates someone to come over to school, are school nurses responsible to see if they have adequate training or judgement?
Answer:
No, the school nurse is only responsible for the unlicensed assistive personnel (UAP's).
Question:
What if the parent insists on 504 and the nurse doesn't see the need?
Answer:
Every child has a right to have the district assess whether their child needs a 504. However, if the district or school 504 Team determines the child does not need a 504 and the parents disagree, the parents should contact the California Department of Education- Office of Equal Opportunity. The Director is Sharon Felix-Rochon. The phone # is (916) 445-9174.
Question:
How do we delegate insulin pump care in young children?
Answer:
At this time, in California, this practice is restricted to a licensed nurse since it is a complex task and requires expanded skill and knowledge.
Question:
Can a 8 to 9 year old do testing in the classroom?
Answer:
Yes. State law permits a child who is able to self-test and monitor his or her blood glucose level, upon written request of the parent or guardian, and with authorization of the child's licensed health care provider, to test his or her blood glucose level and to otherwise provide diabetes self-care in the classroom, in any area of the school or school grounds, during any school-related activity, and, upon specific request by a parent or guardian, in a private location.
Question:
Does a UAP have to have current CPR in order to administer glucagon?
Answer:
California Department of Education, Program Advisory on Medication Administration adopted in May of 2005, recommends that the unlicensed staff member designated to administer life sustaining emergency medication as allowed by law receives documented training and maintains current certification in cardiopulmonary resuscitation (CPR) from recognized source of such training, such as the American Red Cross or the American Heart Association.
Question:
Does California Education Code Section 49414.5 spell out particular aspects of care or is this dependant on MD orders?
Answer:
It is specific to managing severe hypoglycemia, and refers to the administration of glucagon. It also refers to allowing a pupil who is able to self test and monitor his own glucose to do so in the classroom or in a private location.
Question:
What about UAP's verifying a number for an insulin dose on an insulin pen?
Answer:
California law permits the assistance, but not the actual administration of medication. Extreme caution must be used when assigning assisting with insulin to UAP. Documentation of adequate training of the UAP is essential . If the UAP is only being asked to look at the number that the child or the parent has calculated, to verify that in fact that is the number that was dialed into the pen, then there should be no problem. If on the other hand, the UAP is being asked to assess the need for or amount of insulin to be delivered, then the situation is moving into assessment, which can never be assigned to a UAP.
Queston:
Can CHOC help us with non-CHOC 504 plans?
Answer:
I would think we could be a medical advisor in these situations, but not representing the medical provider for that child.
Question:
Can a LVN perform the same functions with respect to insulin that a RN can?
Answer:
An LVN can administer insulin in the school setting.
Question:
Under clarification of facts: can you please refer me to where it says in the law “Child under age of 11 or 12 cannot independently manage their diabetes. RN needs to assess the child's skills regarding independence, despite what provider or parent request.”?
Answer:
Under the California Department of Education – Laws, Regulations and Recommendations fro the Program Advisory on Medication Administration, it explains in detail under section IV, B.#4 a – f, what the nurses responsibilities in assessing the child who has orders from the physician for self administration of medications such as insulin. A specific age is not written into this law, but in general a child less than 11 or 12 is not considered old enough to be independent in mediation administration .
Question:
In our district, parents train and delegate UAP's to assist students with insulin pumps, is this okay?
Answer:
In California, the training for providing health care procedures in school are the responsibility of the credentialed school nurse, public health nurse or licensed physician. This training responsibility includes training, monitoring and supervision of the provisions of healthcare procedures.
Question:
Please discuss AB1667 which is currently on the governor's desk to be signed. This bill will allow UAP's to perform designated tasks only if the school RN feels they are adequately trained.
Answer:
AB 1667 (Saldana) was signed by the Governor. AB 1667 specifies what type of specialized physical health care procedures can be assigned to trained unlicensed school staff. AB 1667 applies only to pupils with exceptional needs and does not apply to medication administration.
Question:
Can a UAP be mandated to do glucagon or epipen if they refuse, but IEP says child needs it?
Answer:
Under California Ed Code 49414.5, school personnel cannot be mandated to perform emergency medical care, they must volunteer.” A school employee who has not been trained pursuant to subdivision (b) may not be required to provide emergency medical assistance …)
Question:
We often have kids with insulin pumps call their parents for insulin doses and the dose often doesn't match the orders. Then the school secretary watches them give what the “parent” ordered?
Answer:
Having a UAP assist a child with an insulin pump bolus is a somewhat gray area in general. However, under no circumstance should a UAP be responsible for assisting with a dose of insulin that a parent has instructed the child to give. If a child is not independent in their management of the pump, and the dose to be given on the pump is not consistent with the orders on the physician school form, the parent or parent delegate needs to assist with that dose.
Question:
If a student has a lunch time dose of insulin ordered based on insulin to carbohydrate ratio, who can calculate the insulin to be given if child cannot do so? Is RN in danger of losing her license if UAP makes mistake?
Answer:
In this situation, what the child is going to eat should be very clear in terms of the # of carbohydrates. The mother can label the items for lunch and snack.
Question:
Is it considered administration or assistance when a UAP pushes the buttons on an insulin pump?
Answer:
If the UAP pushes the buttons on the insulin pump, this is administration of insulin, and not appropriate.
Question:
Based on NASN Consensus Statement, “In some states it is a clear violation of the Nurse Practice Act to delegate to anyone other than another nurse”, is having a UAP assisting in the administration of insulin considered delegating?
Answer:
The California Nurse Practice Act does not allow the delegation of nursing functions. Delegation is the transfer of responsibility for the performance of an activity to another, while retaining accountability for the outcome. Tasks that involve assessment or judgment are nursing functions that cannot be delegated. Actually giving the child an injection of insulin is different than a UAP supervising a child giving an injection with an insulin pen based on specific orders from the physician
Question:
What if parent trains and delegates a staff person to manage insulin pump, is that okay? Our legal rep said this was fine?
Answer:
Parents may delegate and train unlicensed individuals who are family members or family friends to care for their child's medication administration needs in accordance under the gratuitous nursing provision of the California Nurse Practice Act of the Business and Professions Code Section 2727. In this situation, the employee would not be doing this as part of their job.
Question:
If a parent will not give us diabetic orders, we have told parents we can only treat for hypoglycemia. Do parents have to provide orders? What is our liability if they don't?
Answer:
You are correct, if you have no orders then your obligation is to assess for and treat hypoglycemia when indicated. If they don't provide orders, then there would be no authority to do blood glucose testing or insulin administration at school by any school personnel.
These were the nonlegal questions asked by the school nurses at the September 2006 School Nurse Open Forum on Diabetes here at CHOC. Liz Beko RN, CDE and myself answered all of these questions.
Q: Does a child that is getting H & NPH in the AM need to test their BS @ snack .
A: No, unless indicated on the form.
Q: Should children with blood glucose of “HI” stay in school (per meter – 500Or more)
A: Yes, as long as feels O.K. and has no ketones
Q: Ketone testing is ordered but parents don't bring in strips. What should we do?
A: Document that several attempts have been made asking them to bring in the strips and if BS >300 or what is indicated call parents for p/u of child.
Q: We have orders to give Lantus at school and at 6pm in case of a disaster. How do we handle this when we only have 7 nurses for 50,000 students?
A: That is a good question, and we would hope that in a disaster, there will be volunteer medical personnel to assist wherever needed.
Q: Can we know what the A1C's are?
A: The A1C is not information necessary for care at school, however, parents are usually open to give that information.
Q: Glucagon Dosing: Do we follow Glucagon administration using weight or should we really follow the age parameters according to your lecture?
A: Follow the orders written by that student's personal provider. Too much Glucagon is not going to harm the child
Q: What is honeymoon period?
A: The honeymoon period starts within 2-8 weeks after treatment begins. Sugar production is turned off in the liver and a bit of insulin is still being made in the islet cells in the pancreas. This period may last anywhere from a few weeks to several months. During this time the body may not need much extra insulin. When this period is over, more insulin will be needed.
Q: What is the A1C? A: If the blood sugar is high, sugar attaches to the hemoglobin of the blood and remains there for the life of the red blood cell, which is 3 months. When the kids come to clinic every 3 months, we run an A1C. The value is in a percent and we convert it to a number. That value is the average blood sugar over the last 3 months.
Q: What are the resources if the child is not covered by any health insurance?
A: Children whose parents cannot afford insurance can qualify for medi-cal and California Children Services (may be called differently in other states). Qualifications are based on income. No child with type 1 or type 2 diabetes should be without insurance.
Q : I received orders from a doctor who placed the low blood sugar at 80. The parents have the same paper but mom wrote 70. Parents are confused why? I told them we need to follow what the doctor recommended for school setting. Am I right?
A: Yes, If the doctor recommended treatment for a low at 80, then follow the orders. The parent can discuss it with us if needed.
Q: If the physician ordered Glucagon but the parent does not want school to give it, do you have a waiver form for us to use?
A: No, we do not have a waiver form, however we can note to have Glucagon on hand to give to a paramedic to administer or we can edit the form to indicate parents refuse to have Glucagon at school.
Q: Storage of insulin, especially disaster medication, is a big concern at schools with access issues, especially at High Schools. Nurse is NOT on campus daily.
A: All medication should be in a secure area where students do not have access to the medications. Medication should be labeled with the student's name on it so other personal can give to student. Federal regulations require all medications in school be centrally stored and kept under lock and key.
Q: Consent forms are not being signed by parents while they are in the clinic.
A: If a form passes the signature process in clinic, we apologize. Do not accept the form without the parent's signature.
Q: Why is there a charge for the form to be filled out?
A: The charge is only if the school mandates their own forms to be completed. We will only complete the CHOC form for the CHOC patients.
Q: Disaster Forms: Who is suppose to give the insulin? We can't train anyone to give the insulin. Parents go behind our back and teach staff!
A: Insulin is always given by a nurse or a student, if independent.
Q: Knowing what you know, if you were a school nurse, how would you convince a parent to get MD orders, supplies, and food (low) to health office – is it necessary? Is it taught in training and follow up appointments and how important is it to have school in sync with child's diabetics routine?
A: Having diabetes school supplies is taught in teaching and during visits. We are always asking if they need help getting extra supplies. Having diabetes school orders is recommended, however, a child cannot be prevented from coming to school if they are not completed. Reiterating the importance of supplies at school would be my advice, but document, document, document!
Q: What happens if you don't use the control solution with each new bottle of strips? (Parent does not bring it).
A: The purpose of the control solution is to avoid any errors in readings with bad strips. If the strips are bad, you will get false readings. If the blood glucose doesn't match with how the child is feeling, you may want to send a note home indicating a possible problem with the strips and ask for parent to send in the solution at that time.
Q: How can parents waive Glucagon use at school? What should we expect to see?
A: If a parent does not want Glucagon at school, that is their right. Just document, document, document.
Q: Why are diabetic protocols so different from one hospital to another?
A: Endocrinologist have different regimens for different situations. Diabetes care can cater to the different situations. In general the protocols are the same with slight variations.
Q: What is the youngest age you will give a child on a pump?
A: The youngest child on a pump presently from CHOC program is 16 months old.
Q: Issues occur in school when your (CHOC's) orders don't match what parents want to do? What to do?
A: The nurse must follow what the doctor has written, however, we are willing to change the orders within reasonable requests. This is why we are moving to completing forms in person rather than fax!
Q : At one point they said it's just count carbs and not sugar. What is the protocol?
A: Count the total carbs.
Q: What is the hypoglycemic kit so we can duplicate it?
A: We gathered supplies to treat a low blood sugar, and put them in a pencil box. This included small juice box, glucose gel,
Q: Does a child need to test their blood sugar first before treating a low blood sugar? (If they “feel low” is that enough?)
A: Yes, a child must test the blood sugar if they feel low. You need to know what kind of number you are dealing with. It actually may be a high blood sugar. However, if there is no access to a blood glucose meter, and child has symptoms of hypoglycemia, you should treat the low and check blood glucose when you can.
Q: Do all the pumps have bolus wizards?
A: Yes, but not all are turned on.
Q: Does the amount of carbs in snack fluctuate from student to student or is it usually a set number of carbs for all?
A: The numbers of carbs do vary from student to student. Depending on their appetite, it could range from 0- 30 grams .
Q: If blood sugar>300 with moderate-large ketones, but we are unable to locate parents, what do we do?
A: If the child is feeling o.k., keep them in the office and provide water if thirsty, until you can locate parent or emergency contact. If child is ill, nauseated, or vomiting, call 911.
Q: Can we keep Humalog insulin (opened) longer than 30 days if it is refrigerated?
A: No, manufacturer recommends 30 days after opening regardless if in refrigerator. Unopened insulin may stay in refrigerator until expiration date on the box
Q: The correction method or 2 shot method is what we are use to at school. It works well with the lack of school nurses in Orange County. With the increase of use of the multiple dose method, the schools are having a great deal of difficulty covering all of the needs to help young children who cannot calculate their own carbs. Why are young children who are not independent being put on multiple dose method? And what do you suggest for school management when no school nurse is available?
A: Some kids come from other facilities who are already on this regimen and are kept on it. Others are placed on this schedule if they are young and have difficulty sticking to the same amount of carbs from day to day. If this affects the child psychologically we will place them on this regimen to make the disease easier for the child and parents. Unfortunately, many states don't have the ability to delegate the administration of insulin and counting carbs. We highly suggest the parent send in a lunch for the day and label how many carbs are in each “baggie” and write it on the lunch bag. We recognize that having a child on an insulin pump, or needing insulin by pen at snack and/or lunch is more challenging with limited staffing, but we cannot compromise the care of the child because of lack of trained staffing.
Q: Some of my students call you with their blood sugar numbers and insulin changes are frequently made over the phone. What we have in writing from the doctor is not accurate. What can we do about this? We are responsible.
A: If doses are changed, the parent has signed the form indicating they would be responsible for getting new orders. It would be a very rare occasion that insulin changes would be given to a student during school hours by a CHOC provider.
Q: When child is low and treated for hypoglycemia, wait 15 minute, recheck blood sugar. What number do you base insulin dose on?
A: Insulin is given no matter if the child had a low. If it is first thing in he morning, treat the low, get it up above 70 or what we have ordered, give the normal dose of insulin and give the food.
Q: Is this safe practice? Child (preteen) 7 th grade preparing for pump will test every day at 9:30am for snack. Blood glucose usually >200 – so he corrects doses and carbs. He tests @ 12 noon and does correction again.
A: Giving a correction at snack time is not something that is usually done on any regime, as some insulin from breakfast is still on board. If they are multiple injections, they may take insulin at that time for food eaten only.
Q: I have 10 diabetics in a high school. 1 pump, 4 no insulin, and the remainder spot dosing and correcting. Health assistant and secretaries in serviced. Is nurse liable if mistake with wrong insulin or incorrect dose taken?
A: Yes, if they are administering the insulin., or supervising a child who has not found to be ready to be independent. If the nurse has inserviced the secretary to supervise a child giving insulin, she needs to document this training carefully, and keep in mind that in California, RN's are not allowed to delegate the administration of insulin.
Q: Real-time sensor – if BS elevated will pump increase insulin dose automatically or deliver a bolus?
A: No, the sensor will alarm, but not deliver any insulin.
Q: I have a parent who has her own hypoglycemic protocol:
39-49=juice, lunch, play, no retest
50-59=lunch, play, no retest
60-70=lunch, play, no retest
A: Not safe, unacceptable. I would suggest you contact that person's provider and let them know what parent is requesting.
Q: Please repeat target blood sugars:
A: 100-200=<5 yrs
80-180 =<12 yrs
70-150 =12yrs and older
Q: I have a high school girl who takes correction doses at lunch but does not eat lunch at school. She eats when she gets home. Is this o.k.?
A: Yes, if she is on multiple dose injections. However, if she is on two shots per day getting NPH in AM, there is risk of hypoglycemia if she gets insulin at lunch without eating.
Q: What is the nurses responsibilities when not on site with diabetic treatment or emergencies?
A: The nurse is responsible to properly train UAP's to treat emergencies until you are able to get there.
Q: Please expand on appropriate snacks for morning recess
A: A carbohydrate with protein is desired to keep the blood sugar stable (peanut butter and cracker, cheese and cracker, apple with peanut butter, etc), however, some kids are sent to school with chips and cookies, with the correct amount of carbs. This is not ideal, but okay.
Q: How often at school do we check the meters for calibration with control solution?
A: Manufacturer recommends with every bottle change.
Q: Is there a source for control solution?
A: Yes, call the company for the strips and they will send you some.
Q: Re: “Treating hypoglycemia at School”, what do you mean trained staff must always be available?
A: Trained staff must be available to know what to do any time of the day to treat a low blood sugar.
Q: Is there a best time for P.E.?
A: The optimal time would be after lunch.
Q: What should parents at home do when child goes home with ketones?
A: Call the endocrinologist office, or follow the protocol given to them for when child is spilling ketones.
Q: Can you describe the ketone testing by blood? What does it look like? How does a parent get one?
A: Ketone testing by blood reveals ketones present sooner than by testing urine. The meter is the Precision and works similar to testing a blood sugar with a finger poke. The result is compared to a card that comes with the meter that tells how much ketones present. A parent can get them through PADRE Foundation, but needs a doctor's prescription for the test strips
Q: Blood sugar >300 and parents don't give us ketone test strips. Child feels o.k. Stay at school or go home?
A: If there are orders to test urine for ketones when>300 and there are no ketone test strips to check for ketones, parents need to be called for pick up.
Q: 8 th grader on insulin at school. Has injection at lunch based on blood sugar and lunch portion. Student determines units based on those orders. Draws meds and injects. Does RN or UAP need to be present?
A: As long as child has been cleared by MD and school nurse as independent, he does not need to be supervised.
Q: When you say “independent in their management”, as a middle school student, what is the role of the school nurse if the child has a pump? When CHOC has designated them competent are we to assume they are counting carbs and bolusing correctly?
A: Yes.
Q: Blood sugar level is 50. Treated with 2 glucose tablets (8grms). Snack is 45 grams and child is on a pump. What numbers do we input into the insulin pump? Do we input blood sugar of 50 plus the 8 grams plus the 45 gram carbohydrate snack?
A: Treatment is at least 15 grams of fast acting sugar
Retest in 10-15 minutes
If above 70, then give the insulin bolus and the then the carbs
Input the number it goes up to i.e. 85, and only the snack carbs.
Q: Why if on Lantus, NPH in AM?
A: Lantus is a 24-hour basal insulin. It doesn't cover eating. NPH is given to cover lunch and afternoon snack. Humalog is given in am to cover breakfast and am snack. Then Humalog is given at dinner to cover dinner carbs eaten.
Q: What is CHOC's goal for post prandial glucose>300 mentioned as hyperglycemia?
A: If a child has persistent blood sugars out of target range a dose adjustment is needed and the parent can adjust if comfortable or call the endocrinologist office for assistance.
Q: Do you have any diabetic education in Vietnamese?
A: No, not at this time. If a family needs to be educated, then a translator will be summoned.
Q: Are meter test strips available to schools for free?
A: You may call the manufacturer and ask them to send you some samples.
Q: Why do parents resist ketone testing at school?
A: Many parents don't want their child to miss time in class or the playground and feel their child is safe without testing for ketones. If the blood sugars are in control, it should not be an issue. If blood sugar testing is too close to the last time they ate, the blood sugar may show elevation. In these cases the order may be written to only check if the blood sugar is >400, for example. Again the importance of parents to complete the school form with the diabetes nurse face to face, rather than by fax so we can discuss these issues.
Q: What constitutes “training” for lay person on Glucagon injections? Is there a set class? Certificate?
A: There is no class at this time. Training would include knowing when to give Glucagon, how much to give, how to draw up and how to administer an IM injection. You can order for free the Glucagon CD through the American Diabetes Association website for further training.
Q: Insulin pens: how long is it safe to keep in school? How often is it changed?
A: The Humalog and Novolog pens should be changed out every 30 days once they are in use. Unused refrigerated pens are kept until expiration date on box.
Q: Is there any way for children to know that they are in a muscle?
A: No, they need to gently pull the subcutaneous skin from the muscle. An unexpected low blood sugar after an injection may possibly be from getting insulin into a muscle.
Q: We are getting orders for insulin :carbohydrate ratio of 1:6, 1:8, or 1:15. Young children are not able to calculate these carbs. Can this dose be more standardized like 1:10?
A: No, the insulin: carbohydrate ratio is based on their total daily insulin intake. It will vary from child to child. Having the parent label the food is helpful.
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