Nursing Guidelines for the Delegation of Care for Students with Diabetes in Florida Schools Permission to duplicate and distribute granted

Transcription

1 Nursing Guidelines for the Delegation of Care for Students with Diabetes in Florida Schools 2003 Permission to duplicate and distribute granted Florida Department of Health Jeb Bush Governor John O Agwunobi, M.D., M.B.A Secretary, Department of Health

2 Thank you to the following agencies for providing support and personnel to develop these guidelines: Florida Department of Health o Children's Medical Services Program Office o Diabetes Control Program o Emergency Medical Services o Family Health Services o General Counsel o Florida Board of Nursing o Office of Public Health Nursing o School Health Program Health Departments o Escambia County o Marion County o Palm Beach County o Sarasota County Florida Department of Education o Coordinated School Health Program o Food and Nutrition Management o School Transportation Management o University of South Florida Student Support Services Project School Districts o Alachua County School Board o Lake County o McIntosh Middle School, Sarasota, Florida o Seminole County Universities o Florida Atlantic University o University of Florida o University of South Florida Family Medicine of Boca Raton Florida Nurses Association Governor s Diabetes Advisory Council Nemours Children's Clinics 1

3 Acknowledgements Individuals on the initial Nursing Work Group Jeannette Battaglin, R.N., M.A. Nursing Consultant Project Facilitator Tallahassee, FL Gigi Foster, R.N. Nursing Consultant Diabetes Program Bureau of Chronic Disease Florida Department of Health Penny Kehoe, B.S.N., R.N., N.C.S.N., C.R.R.N. Community Health Nursing Consultant School Health Program Florida Department of Health Dianne Mennitt, R.N., M.S., N.C.S.N Nursing Consultant USF Student Support Services Project Florida Department of Education Yolanda Sacipa, M.P.H. Government Operations Consultant II Diabetes Control Program Florida Department of Health Trena Webb, R.N., M.S., N.C.S.N. Assistant Community Health Nursing Director School Health Program Escambia County Health Department Charlotte Barry, Ph.D., N.C.S.N. Assistant Professor College of Nursing Florida Atlantic University Robert P. Daniti, Esquire Senior Attorney Assistant General Counsel Florida Department of Health Marsha Fishbane, M.D. Senior Physician School Health Medical Director Palm Beach County Health Department Barbara Lumpkin, R.N. Florida Nurses Association Janet Silverstein, M.D. Professor and Chief of Pediatric Endocrinology University of Florida Susan Watson, R.N. Parent of student with diabetes Escambia County Sylvia Byrd, A.R.N.P., M.P.H., N.C.S.N. Executive Community Health Nursing Director School Health Program Florida Department of Health Paula Jameson, A.R.N.P., M.S.N., C.D.E. Endocrine Nurse Practitioner Nemours Children s Clinic Lynda Kinard, B.S. Executive Director Coordinated School Health Program Florida Department of Education Susan Novak, R.N., M.S.N., C.R.R.N. Nursing Consultant/Coordinator School Health Program Florida Department of Health Lucia Schatteleyn, R.N. Acting School Health Supervisor, Sarasota County Health Department Reviewers Charles Bement Bureau Chief Emergency Medical Services Florida Department of Health Larry C. Deeb, M.D. Pediatric Endocrinology Consultant Children s Clinic Tallahassee, Florida Loyce Hill, R.N., M.P.H. Registered Nursing Consultant Office of Public Health Nursing Florida Department of Health Gwenn Major, R.N. School Health Specialist School Board of Alachua County Bonita J. Sorensen, M.D., M.B.A. Deputy State Health Officer Florida Department of Health Julie Wammack, M.S, CCC-SLP Special Needs Transportation Liaison Florida Department of Education Keay Forman, R.N. Community Health Nurse Supervisor Marion County Health Department Tammie Johnson, M.P.H. Program Administrator Diabetes Control Program Florida Department of Health Eileen McGatlin, R.N., B.S.N., N.C.S.N Lead School Board Nurse Seminole County Public Schools Ann Proie, R.N., B.S.N., N.C.S.N Health Education Coordinator Lake County School District Brenda Tune, R.N., B.S.N. Registered Nursing Consultant Children s Medical Services Program Office Florida Department of Health Dan Coble, R.N., Ph.D. Executive Director MQA-Board of Nursing Florida Department of Health Laureen Fleck, M.S.N., A.R.N.P., C.D.E. N.C.S.N. Nurse Practitioner Family Medicine of Boca Raton, Florida Cynthia Studenic Lewis, R.N., M.P.H. Bureau Chief Family and Community Health Florida Department of Health Annette Phelps, A.R.N.P, M.S.N. Director Family Health Services Florida Department of Health Tim Tankersley Program Director Food and Nutrition Management Florida Department of Education Emily Laymon, RD Food and Nutrition Management Florida Department of Education 2

4 Table of Contents Purpose and Background 4 Major Factors in Maintaining Health... 7 Legal Aspects. 11 Criteria For Safe Delegation Planning and Implementation Meeting Components of Individualized Health Care Plan Roles and Responsibilities Recommendations for Staff Education.. 26 Disaster Preparedness Monitoring and Evaluation. 29 References Appendixes A Glossary.. 33 B Nutritional Requirements and Snacks 37 C Exercise and Sports D Hypoglycemia and Hyperglycemia.. 47 E Insulin F Resources 60 G Sample Check Lists 63 H Sample Supply List I Sample Forms. 72 J Monitoring and Evaluation Tool 76 K Students With Chronic Illnesses: Guidance for Families, Schools, and Students

5 Nursing Guidelines for the Delegation of Care for Students with Diabetes in Florida Schools Purpose and Background The purpose of this document is to provide guidelines for school nurses and other personnel from the county health departments and local school districts to help ensure that students with diabetes are provided a safe learning environment and are integrated into school activities. Guidelines do not represent a mandate to school districts but establish best practices. This document is designed to provide basic information about diabetes, describe the medical and legal requirements for meeting the needs of students in school, and provide guidelines for determining when delegation to unlicensed assistive personnel is safe and in the best interest of the child. These guidelines will also assist the nurse in developing the plan of care in cooperation with the parent/guardian, student and designated care providers in the school. To ensure the safety of the students, advanced planning and preparation are required to safely identify and train individuals in the schools who are ready to provide all the special services these children may need. These guidelines do not negate the need for calling 911 in accordance with local policies when the student s condition is life threatening or when immediate access to licensed school health individuals is not possible. These guidelines represent the outcome of many meetings, current literature review, and the collection of documents from local school districts, county health departments and other states. They do not represent the specific opinion of any individual or any institution. The guidelines are not intended to replace clinical judgment or individualized consultation with medical care providers, nor are they intended to be used as fixed protocols. They are designed to identify best practices for the management of the students with diabetes while they are under the care and supervision of the school. Guidelines describe a process of patient care management which has the potential for improving the quality of clinical and consumer decision making. Guidelines address the care of specific patients and populations. Position statements and other publications of the National Association of School Nurses, the American School Health Association, the American Public Health Association s Public Health Nursing Section, the National Association of State School Nurse Consultants, the American Nurses Association and others, when specific to aspects of school nursing practice, may be regarded as guidelines (National Association of School Nurses [NASN], 2001). While standards are intended to be rigid and mandatory making exceptions rare and difficult to justify guidelines are more flexible, although they should be followed in most cases. Guidelines can be tailored to fit individual needs that are influenced by the patient [student], setting, resources and other factors (State of Florida Agency for Health Care Administration [AHCA], 2001). 4

6 The Florida School Health Services Act, s F.S. (Florida Statutes), authorizes the Florida Department of Health, in cooperation with the Florida Department of Education, to supervise the administration of the school health services program in Florida. School health services should be carried out to appraise, protect and promote the health of students. School Health Services supplement, rather than replace, parental responsibility and are designed to encourage parents to devote attention to child health (s (1), F.S.). Health services are made available to students and provided by a school health care team led, in most instances, by a registered nurse. The registered nurse is responsible for the onsite management of illness or injury pending the student s return to the classroom or release to parent, guardian, designated friend or designated health care provider. The school nurse is responsible for the development of the student s individualized health care plan. (See Appendix A for definitions of school nurse and individualized health care plan as used in this document.) Although the School Health Services Act addresses the need to plan for and respond to any health care problem that needs to be addressed in the school setting, these guidelines were developed specifically to address the management of students with diabetes. According to the American Diabetes Association (2001), appropriate diabetes care in the school is necessary for the student s long-term well being and optimal academic performance. Even mild low blood glucose levels can lead to immediate consequences in the classroom such as a decrease in cognition, lack of attention to detail and difficulty with decision making. Extremely low blood glucose levels can cause unconsciousness or even death. High blood glucose levels can contribute to long-term complications such as damage to the eyes, kidneys, nerves and blood vessels. While school enrollments and the need for health services in the schools are steadily growing, the supply of school nurses remains static or in some cases, is diminishing. During the school year, the county health departments and local school districts reported that the average registered school nurse-to-student ratio was 1 to 2,663. This disproportionate ratio prevents school nurses from providing individual attention to all students. To meet the special needs of the students with diabetes, unlicensed assistive personnel (UAP) must be involved. (For the purpose of this document, the terms unlicensed assistive personnel and non-medical assistive personnel are considered synonymous. See Appendix A for definitions.) It is imperative that these unlicensed assistive personnel have both general and studentspecific training in accordance with s F.S., Administration of medication and provision of medical services by district school board personnel. In addition to school nurses and school health aides, all other school-based personnel should have an understanding of diabetes to facilitate the appropriate care of the student with diabetes. The National Association of School Nurses states, Knowledgeable personnel must be available at all times including during extracurricular activities and field trips to assist students in managing their diabetes and to respond to emergencies (2001). NASN further states, Under the direction of the school nurse, management strategies may be incorporated in a seamless fashion between home and 5

7 classroom to help the student with diabetes stay healthy, be academically focused and participate in all desired academic and extra curricular activities. Diabetes Diabetes is one of the most common chronic diseases of childhood, with a prevalence of approximately 1.7 per 1,000 in children less than 20 years old (American Diabetes Association, 2001). In a survey by the Florida Department of Health School Health Program in March of 2002, county health departments and local school districts reported a prevalence of 1.4 per 1,000 students with diabetes in Florida s public schools. According to the American Diabetes Association (2001), diabetes is a disease in which the body does not produce or properly use insulin, a hormone that is needed to convert sugar, starches, and other food into energy. There are two major types of diabetes: Type 1 diabetes is more commonly diagnosed in children than in adults. In this form, the body has no ability to produce insulin, and the blood glucose is controlled with the administration of insulin, along with blood glucose monitoring, exercise, and food intake. Failure to maintain control of blood glucose levels may result in coma if levels are too high, or unconsciousness and even death if levels are too low for too long. Type 2 diabetes is a metabolic disorder resulting from the body's inability to make enough, or properly use, insulin. It was generally thought of as adult diabetes; however, it is becoming increasingly prevalent in school children, most likely due to increases in childhood obesity. Children with type 2 diabetes need observation and care, but are not as prone to dramatic swings between high and low blood sugars as children with type 1 diabetes. There is no cure for diabetes but good health care and self-management, as outlined in the Diabetes Medical Practice Guidelines (AHCA, 2001), can greatly improve the health outcome for children with diabetes. Achieving good blood glucose control usually requires frequent blood glucose monitoring, regular physical activity, and nutrition therapy and may require multiple doses of insulin per day or insulin administered with an infusion pump (American Diabetes Association, 2001). Good blood glucose control has the potential to prevent or delay the development of serious diabetes complications (Diabetes and Complications Trial Research Group, 1993, and Turner, 1999). The medical treatment plan is directed at managing diabetes by balancing exercise, nutrition and insulin and/or oral diabetic medications. Students who can control their diabetes by maintaining normal or close to normal blood sugar levels lower their risk of complications and enjoy a better quality of life. The individualized health care plan, written by the school nurse, should outline student-specific signs and symptoms of hypo- and hyperglycemia (low and high blood glucose levels) and guidelines for carrying out the medical treatment plan in the school setting. (See Appendix D for general information on hypoglycemia and hyperglycemia.) 6

8 Major Factors in Maintaining Health Maintaining health for the student with diabetes requires a careful balance of a variety of factors. Some of these include exercise and sports, diet, medication management, and blood glucose monitoring. All of these factors should be considered in preparing the student s individualized health care plan and in planning for the least restrictive environment. Exercise and Sports Participation in physical activity and school sports helps all students, including students with diabetes, feel healthier, improves self-esteem, and fosters a sense of empowerment. The benefits of physical activity include cardiovascular fitness, long-term weight control, and social interaction. In addition, physical activity can help lower blood glucose levels. General physical activity guidelines include: Drinking lots of sugar-free fluids, especially water. Keeping rapid-acting carbohydrate sources available. Monitoring blood glucose levels before, during, and after physical activity, as ordered by the health care provider. Wearing diabetes identification tag or jewelry. Monitoring low blood glucose levels carefully and reporting any problems to an adult immediately. Addressing low blood glucose levels promptly. The school nurse should list any specific exercise or physical activity requirements or restriction in the student s individualized health care plan as indicated in the medical plan of care. (See Appendix C for general information on exercise and sports.) Nutrition and Meal Planning Meal planning is an important component in the treatment of diabetes. The dietary considerations require an adequate caloric and nutritional intake for growth and development and a balance of food with insulin and activity. The health care provider or a registered dietitian experienced in nutrition therapy for children with diabetes should develop the student s meal plan. The meal plan should reflect consideration of the developmental needs of the student as well as food preferences, cultural influences and family eating patterns. Meals and snacks should be timed appropriately to coincide with the peak effects of the student s insulin unless the student has advanced to a more intensive treatment program. Such programs include insulin pump therapy and multiple daily injections (basal/bolus therapy). These intensive programs enable a student to eat on a more flexible schedule, as the student covers the actual carbohydrate intake at the time it is eaten with rapid or short-acting insulin. These students can vary the amount of carbohydrates eaten from day-to-day and/or the times at which they are eaten. However, to determine the insulin needed to cover the carbohydrate intake (see 7

9 Appendixes B and E), the student must independently, or with assistance, determine the correct dose by a mathematical formula. (See Appendix E for sample calculations for determining the bolus dose.) These students may not need to have snacks routinely because the careful control will eliminate the insulin peaks between meals. Students with diabetes may participate in school meal programs and school parties. Families can review the published school menu ahead of time and plan, with their children, to make the best choices or any modifications necessary to meet their health care providers plans of care. School meal programs should support all students, including those with type 1 and type 2 diabetes, in achieving and maintaining a healthy body weight by providing appropriate food choices, including appealing low-fat items. Parents may also provide meals from home and attach the carbohydrate content to assist school nurses and unlicensed assistive personnel in the calculation for proper insulin coverage. The school nurse should list any specific nutritional requirements or restrictions as well as the timing of meals and snacks in the student s individualized health care plan. (See Appendix B for general information on nutrition and snacks.) Insulin Insulin administration is the third important component in diabetes management. The health care provider will prescribe the type and dose of insulin as well as the method of delivery specific to the needs of the student. The health care provider will also prescribe any treatments or medications to be administered to correct blood glucose levels that are too high or too low. The school nurse should list any specific insulin or other diabetic medication requirements as well as emergency medications in the student s individualized health care plan. (See Appendix E for general information relating to insulin.) Oral Diabetes Medications In cases of type 2 diabetes, the student s medical management will include meal planning, exercise and weight management. However, some students with type 2 diabetes require oral medications, also called oral agents, and/or insulin to control their blood glucose levels. There are three classes of these medications: insulin secretion stimulators (secretagogues), insulin sensitizers, and starch-blockers. Usually, the student would take these medications before breakfast and/or dinner. However, in the case of the insulin secretion stimulators, the student may also need to take a dose before lunch. Because this class of drugs stimulates the release of insulin, it is possible for the student to have hypoglycemic (low blood sugar) episodes. The medication policies for local school districts should reflect the same caution for administering oral diabetic medications as they do for administering insulin. 8

10 Glucagon Glucagon is often prescribed as an emergency response for hypoglycemia when the student has lost consciousness, is unable to take liquid or food by mouth or has had a seizure. It is a hormone that helps the liver release sugar, thus increasing the level of sugar in the blood. Since untreated severe hypoglycemia can lead to permanent brain damage or even death, the need for glucagon is considered a medical emergency. (See Appendix D for Recommendations of the Governor s Diabetic Advisory Council: Glucagon as an Emergency Treatment for Reversing Hypoglycemia in Children and Young Adults in the School Setting.) If the student s medical care provider prescribes glucagon, the school nurse will include that information in the individualized health care plan and provide training for two or more unlicensed assistive personnel to administer this medication. Authority to allow unlicensed assistive personnel to administer emergency injectable medication is provided in s (4)(d) F.S. Blood Glucose Monitoring Physicians generally recommend that students check their blood glucose during the school day, usually before eating snacks or lunch, before physical activity, or when there are symptoms of high blood glucose or low blood glucose. Although school nurses support that the best-equipped and safest site for blood glucose monitoring and insulin administration is the school health room, students may be allowed to check their blood glucose levels and respond to the results in the classroom, at other campus locations, during any school activities, and during field trips. Taking immediate action is important so that the symptoms do not get any worse and the student does not miss classroom time. The experience is less stigmatizing and blood glucose monitoring loses its mystery when handled as a regular occurrence. If the student requires assistance to monitor blood glucose, privacy may be a concern until the student is skilled in performing the task independently. Assistance or supervision with this procedure will be necessary until the health care provider and the school nurse determine the student is ready to monitor independently within the school setting and whenever a low blood glucose level is suspected. The school nurse will document the need for assistance and/or supervision of blood glucose monitoring in the student s individualized health care plan and can delegate unlicensed assistive personnel to assist with or perform blood glucose monitoring for a student as long as child-specific training has been provided by the school nurse or other medically licensed persons in accordance with s (4)(c) F.S. In the event of hypoglycemia, blood glucose testing should occur at the scene of the hypoglycemic episode in order to: Guide prompt and appropriate treatment Prevent further lowering of blood glucose and possible injury by requiring the student to move to another location A secure location to store the necessary supplies must also be identified and provided. The school nurse should list any specific information on when, where, and how blood glucose monitoring is performed in the student s individualized health care plan. 9

11 Because there are numerous brands of monitors available, each with specific features, it is recommended that directions for using a particular monitor be copied and attached to the care plan. 10

12 Legal Aspects to Consider The Nurse Practice Act, Chapter 464 F.S., regulates the practice of nurses in Florida. In section (3)(a) the practice of professional nursing is defined as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such mediations and treatments. 3. The supervision and teaching of other personnel in the theory and the performance of any of the above acts. Further clarification of the nurse s role in delegation and supervision is provided in Chapter 64B , Florida Administrative Code (F.A.C.). This rule describes the Delegation of Tasks or Activities (64B F.A.C.), and the Delegation of Tasks Prohibited (64B F.A.C.). The Florida law governing administration of medication and provision of medical services in the school setting is s F.S. Federal laws that may apply to children with diabetes include the Rehabilitation Act of 1973, Section 504; Title II of the Americans with Disabilities Act (ADA) of 1990; the Individuals with Disabilities Education Act (IDEA) of 1990, amended 1997; and federal regulation 34 C.F.R (9)(i), Child with a Disability. Copies of these Federal laws and regulations can be obtained at the following Internet sites: Section 504 of Rehabilitation Act of Title II of Americans with Disabilities Act of Individuals With Disabilities Education Act 34 C.F.R., Part Child with a disability php Using an evaluation process, the school district determines whether the student with diabetes is covered by Section 504, ADA, or IDEA. If it is determined that the student is covered under Section 504, the school district develops a Section 504 Plan to document the related aids and services the school district will provide. If it is determined that the student is covered under IDEA, the school district documents the related aids and services needed in the student s individualized education plan. The individualized health care plan developed by the school nurse should be attached to either plan to clearly document the health care services the student needs and should receive. 11

13 Criteria for Safe Delegation The safety of the student is the primary consideration in the delivery of all health related services provided in the school. In view of the newly mandated training for all health care providers regarding preventing medical errors and the reported high incidence of medication errors even among licensed health care workers, Florida Department of Health School Health Program recommends that special care needs to be taken when delegating diabetes related services to unlicensed assistive personnel. The school nurse is responsible for training and monitoring the individual designated to perform these services (s F.S.). Unsafe Delegation In keeping with the Nurse Practice Act (Chapter 464 F.S.), the delegation rule (64B9-14 F.A.C.), and position statements from the National Association of School Nurses, delegating diabetes-related tasks to unlicensed assistive personnel in the following circumstances would be considered unsafe, and should not be done: When students are newly diagnosed and the individualized health care plan has not been written or approved. When the student is medically fragile with health complications or multiple health problems that require nursing assessments before performing any authorized task. When the student has a history of non-compliance with treatment plans or following local guidelines and safety precautions therefore making standing orders subject to frequent changes pending nursing assessments. When the student who has been authorized to function independently by the health care provider cannot consistently demonstrate competence in diabetes related tasks in the school setting. These students must be referred back to the health care provider for further evaluation and training before delegating their care to an unlicensed assistive person. When the unlicensed assistive person has not been trained or has not demonstrated competence in the assigned activity/task. Safe Delegation The school nurse should use professional judgment and consider the following criteria to determine when and to whom to delegate diabetes-related health care services. For the student who needs assistance with some or all of the diabetes related services: An individualized health care plan written by the school nurse and approved by the parent/guardian should be in place. A copy of the individualized health care plan should be sent to the health care provider. The school nurse has received specific written orders related to sliding scale dose administration of insulin from the health care provider in charge of the medical management. The school nurse should request that, whenever possible, the prescribed method of insulin administration be by pump or pen to limit the potential for medication errors related to drawing up insulin into a syringe. 12

14 The school nurse has arranged to be available for supervision, monitoring and consultation in an emergency. The delegated unlicensed assistive person has completed an initial in-depth diabetes-related training and is willing to participate in ongoing related training as well as student-specific training. The delegated unlicensed assistive person has demonstrated competence in blood glucose monitoring and insulin administration. The delegated unlicensed assistive person has demonstrated competence in recognizing the signs and symptoms of hypoglycemia or hyperglycemia and in responding with the student-specific interventions, including, if necessary, glucagon injections. The delegated unlicensed assistive person has demonstrated competence in carbohydrate counting and insulin dose calculation based on anticipated carbohydrate intake if required by student-specific intensive management medical treatment plans. The delegated unlicensed assistive person has a history of only providing services that are within the range of knowledge, skills, and abilities for the position. The delegated unlicensed assistive person is certified in cardiopulmonary resuscitation (CPR) and first aid (strongly recommended). When any parent/guardian selects an outside provider, such as a relative or friend, it is recommended that the outside provider should also meet the requirements listed above if delivering services to a specific student while the student is in the care of the school; however, the parent/guardian retains the responsibility for the performance of the outside provider. The parent/guardians have provided the school and/or school nurse with the necessary equipment and supplies to monitor blood glucose and administer insulin or other diabetes medication, as well as any snacks or medications to be used to regulate blood glucose levels. The parent/guardians have provided the school and/or school nurse with the required diabetes history information, authorization forms and emergency information specific to the needs of the student. The parent/guardians have participated in a minimum of one yearly planning/ evaluation meeting with the school nurse and school staff, and have contributed to and approved the individualized health care plan. The parent/guardians have agreed to notify the school and/or school nurse promptly when there are changes in the student s medical condition or plan of care and provide a revised medical authorization sheet. 13

15 The parent/guardians have agreed to encourage their child to comply with local guidelines and safety precautions. The parent/guardians have agreed to make a diligent effort to be available by phone to the school nurse in case of an emergency. Verification that the student has completed the initial diabetes education series provided by the health care provider (strongly recommended). In addition to the conditions listed above, the school nurse should use professional judgment and consider the following items when delegating an unlicensed assistive person to monitor or provide emergency assistance to a student prepared to perform some or all of the diabetes related tasks independently: Documentation from the health care provider indicating the student s level of independent functioning. Documentation that the student has demonstrated competence in blood glucose monitoring and insulin administration according to locally designed skills checklists. Documenting on in the individualized health care plan where and when blood glucose testing and insulin administration may take place, and ensuring there is a safe place to store equipment and dispose of contaminated materials. Assurance that the student will follow the local policies and safety procedures. The school nurse should also encourage parents of students on insulin pumps to help their children become proficient in self-management. The student should learn carbohydrate counting and pump skills for insulin administration consistent with their level of development and competence in reading and math. For the student who requires assistance with insulin administration or has not demonstrated competence in insulin dose calculation, it is recommended that two unlicensed assistive personnel, trained by the school nurse in accordance with s F.S., check any calculations to determine the dose to be given and verify the actual dose prepared before it is given. A student who has demonstrated competence for calculation and dosage may have one trained unlicensed assistive person confirm the calculation and dosage. Finding a Solution and Providing Safe Care Situations may occur in which existing school health staff are unavailable or have conflicting responsibilities that would interfere with their ability to devote appropriate time and attention to the student with diabetes. In those situations, some alternative solutions which the school nurse, the local school district, and county health department may consider are: Find and train another person from existing school staff to be delegated as an unlicensed assistive person. Seek a licensed provider or volunteer from community partners. Allow parents, on request, to enroll the student permanently or temporarily in a school where a licensed care provider is available. 14

16 Allow parents to have the child assigned to a school close to their workplace so they may more conveniently provide the services for their child. Temporarily change staffing patterns to put an RN or LPN in the school until child and/or unlicensed assistive persons demonstrate competence. Suggest having the parent/guardian provide necessary care or provide a relative or friend who can meet the competency requirements to do the care until a school-based solution can be found. Explore any other locally designed solution that protects the health and safety of the child and promotes the child s ability to attend school in the least restrictive environment. 15

17 Planning and Implementation Meeting At the beginning of each school year and at other times during the school year for students newly diagnosed, the school nurse should organize and facilitate a planning and implementation meeting. When possible, it is best to conduct this meeting before school starts. The three major purposes of the planning and implementation meeting are to: 1. Coordinate the development of the individualized health care plan by the school nurse after the parent/guardian and the school nurse identify the student s needs and discuss the components of the care plan. 2. Provide input to key school staff regarding any health-related accommodations required by Section 504 or IDEA legislation. 3. Plan for any student-specific training that the school nurse must provide or arrange to have provided for any school-based personnel who are delegated or assigned roles and responsibilities in the plan. No individuals should be forced to take on this role against their will. The meeting participants should include anyone who may have a role in the student s diabetes care such as: Family and the student Principal or designee School nurse Current teacher(s) Past year teacher(s) Food service manager Counselor or social worker Individuals expected to respond to a school health emergency Student s Children s Medical Services (CMS) nurse and/or a representative of the student s health care team Bus drivers, bus attendants Unlicensed assistive personnel designated as direct caregivers. The agenda topics should include: How long the student has been diagnosed and treated for diabetes. Student s current health status and how diabetes is managed in the home. The current medical management plans for blood glucose monitoring and medication administration. Any special requirements or restriction relating to nutrition or exercise. The student s level of knowledge and skills related to the management of diabetes. Student-specific signs and symptoms of hypo- and hyperglycemia. A plan for responding to an emergency related to diabetes management. A plan for the student s care in the event of a disaster. 16

18 Expectations of the parent/guardian regarding the provision of health related services to be provided by the school based staff. Expectations of the school-based staff regarding what equipment and health related services must be provided by the parent/guardian. A discussion involving all relevant factors in the selection of school-based staff willing and able to take on the responsibility of providing health/diabetes related services in the school safely. How and when health care personnel will train the designated unlicensed assistive personnel and other members of the school-based staff. Student s status under IDEA or Section 504. o Under these laws, when a condition interferes with the educational experience, it is considered a disability. According to Schwab and Gelfman (2001), diabetes is such a condition. Any school that receives federal funding must reasonably accommodate the special needs of children with diabetes. The required accommodations should be provided within the student s usual school setting with as little disruptions to the school s and the student s routine as possible. o Some of the common accommodations might include: Allowing the student to eat snacks whenever or wherever necessary. Allowing the student unrestricted access to the bathroom and/or water fountain. Facilitating the student s participation in extra-curricular activities including sports and field trips. Allowing absence for medical visits without penalty and arranging for the opportunity to make up missed schoolwork. Providing assistance with blood glucose monitoring and insulin injections whenever and wherever it is necessary to meet the medical plan of care. Arranging lunch periods to meet the student s medical plan of care. 17

19 Components of Individualized Health Care Plan The school nurse will write the individualized health care plan based on the information obtained in the planning and implementation meeting and the information provided by the health care provider on the history and information sheets. (See Appendix F for sources of guidance on developing individualized health care plans for diabetes.) The plan of care should comply with local policies and procedures and be formatted according to local standards. For repetitive activities, flow sheets may be devised to aid in documentation. It is strongly recommended that all care plans for the student with diabetes include the following components: Student-specific demographic information Whenever possible, a current photo of the student Student-specific information regarding how to respond in an emergency and where to contact the parent/guardian and health care provider List of any known allergies Assessment of the student s developmental level and compliance/adherence history Nursing assessment and nursing diagnosis Desired goals and outcomes for health and education Specific nursing interventions related to monitoring blood glucose or administering insulin. (The agreed upon site(s) must be noted in the student s individualized health care plan.) Student-specific signs and symptoms of hypo- and hyperglycemia and the protocol to follow The anticipated level of independent functioning, as identified by the student s health care provider. Specific information regarding any delegated nursing interventions. (Include the specific designated unlicensed assistive person who was or will be trained and authorized to provide the services.) Specific information regarding all medications as ordered by the health care provider, including doses and routes of administration Specific information regarding the student s physical activities including any limitations Specific information regarding the student s meal plan including time, amounts and snacks Information on any special accommodations that must be made for field trips or extra-curricular activities 18

20 Roles & Responsibilities The well being of a student with diabetes involves a collaborative relationship among the health care provider, the school, and the home. The student s family and the health care team are responsible for the medical management and should contribute information for the individualized health care plan. The school should be responsible for assuring that the services needed to implement the plan of care are provided by persons specifically trained to provide the needed services in the least restrictive environment while preserving the safety of the student. The school district and its administrator should be familiar with the school issues and responsibilities associated with students with diabetes and assure consistent care through district-wide policies. Several national health and educational organizations have jointly issued guidance regarding students with chronic diseases. A copy of this guidance is provided for your reference. (See Appendix K, Students With Chronic Illnesses: Guidance for Families, Schools, and Students.) Principal The principal should set the example for the rest of the school-based staff to create a safe environment for the student with diabetes. The principal or the administrative designee should participate in Level I: Awareness Diabetes Information. (See page 26 for details on the content of proposed educational in-service requirements.) In some cases the principal or the administrative designee may choose to complete Level II and Level III diabetes training to be available to function in an emergency when the designated and trained unlicensed assistive person is unavailable. The principal should: Provide leadership for all school-based personnel to ensure that all health policies related to diabetes management at school are current and implemented. At a minimum, participate in Level I: Awareness Diabetes Education and require all school-based personnel to participate in this in-service education. Be aware of the federal and state laws governing the educational requirements for students with diabetes. Collaborate with the school nurse in selecting and designating unlicensed assistive personnel to provide the student-specific services required for each student with diabetes in their school. Require that each designated unlicensed assistive person complete the necessary general and student-specific training and meet the locally designed competency requirements. Facilitate problem solving and negotiations among members of the school team and the student s family. Provide physical resources on campus to safely execute all accommodations and activities noted in the individualized health care plan. Respect the student s confidentiality and right to privacy. 19

21 School Nurse The school nurse should function under the scope of practice defined by Florida s Nurse Practice Act. The school nurse may be the only full or part time licensed health care professional in the school setting. When the school nurse is assigned to multiple schools, the nurse should recognize the need to set students with diabetes as a high priority whenever part or all of their care is delegated to an unlicensed assistive person. To insure the safety of the students, the school nurse should: Obtain and maintain a current knowledge base and update skills and abilities related to the medical management of diabetes in the school-age population. Included in this is knowledge relating to the current standard of care prevalent in the community. Organize and facilitate planning meetings with the student s parent/guardian and other key school staff to discuss planning and implementation of the student s individualized health care plan. Perform a nursing assessment on the student based on a home or school health room visit to obtain health and psychosocial information. Develop an individualized health care plan in cooperation with the student, the parents/guardians, the health care provider, and other school-based staff. Regularly review and update the individualized health care plan whenever there is a change in medical management or the student s response to care. If necessary, request the health care provider to re-evaluate the student s competency level to further enhance the student s independence or, if necessary, to require closer supervision until the student s knowledge and skills improve. Collaborate with the principal to select and delegate the most appropriate unlicensed assistive personnel for each student. Train and supervise the unlicensed assistive person designated to provide intrusive procedures for the student with diabetes. It is recommended that two or more back-up persons be trained in each school to assure adequate coverage in an emergency. Practice universal precautions and infection control procedures at all student encounters and include information in the training for all unlicensed assistive personnel. Train and supervise unlicensed assistive personnel who can serve as a second adult to verify any dose of insulin administered in the schools. Provide or arrange for child-specific training to all school-based personnel who will have direct contact with the student on how to respond in an emergency. Maintain appropriate documentation of the training and care provided and monitor the documentation of services provided by unlicensed assistive personnel. Act as a resource to the principal and other school-based personnel, providing or arranging for in-service education appropriate to their level of involvement with the student with diabetes. Establish a diabetes resource file of pamphlets, brochures, and other publications for use by school personnel. 20

22 Establish and maintain a working relationship with the student s parent/guardians and health care provider and act as a liaison between the student s authorized health care provider and the school. Participate in Individualized Education Planning or Section 504 planning meetings and provide relevant health information. Serve as the student s advocate. Respect the student s confidentiality and right to privacy. Establish a process for on-going and emergency communication with: o The parent/guardian (this should include a parental notification procedure to address repairing or replacing equipment, and replenishing supplies and medications), o The authorized health care provider, o The unlicensed assistive personnel, and o The school staff that come into direct contact with the student. School Health Aide In schools where a full time school health aide is assigned, that individual may be the person designated to provide the intrusive services for the student with diabetes. However, when the responsibilities of the school health aide require administration of other medications to multiple students at the same time that students with diabetes will require monitoring, insulin administration, or services outside of the health room, the school nurse may need to train other unlicensed assistive personnel to specifically assist the student with diabetes. School health aides should participate in Level I: Awareness Diabetes Management. The school health aide delegated to provide direct care for students with diabetes will also need Level II and III Diabetes Education and will need to meet all the requirements listed under The Criteria for Safe Delegation (see pages 12-15). Teachers/Coaches and Before- and After-School Program Staff To the extent possible, teachers and coaches should provide a supportive learning environment and treat the student with diabetes the same as any other student while at the same time making the required accommodations. Not all teachers or coaches in a school will have direct contact with the student who has diabetes. If no direct contact is anticipated, the teacher or coach will just need to attend the Level I: Awareness Diabetes Education. If the teachers or coaches are scheduled to have direct contact with the student, the teachers/coaches and before- and after-school program staff should: Be aware of which students have diabetes and cooperate with the accommodations listed in the individualized health care plan or Section 504 Plan. Attend the Level II: In-depth Diabetes Education and be able to recognize the signs and symptoms associated with hypo- and hyperglycemia. Be aware of any student-specific emergency actions that might be necessary. 21

23 To the extent possible, provide the student with a safe location to monitor blood glucose or administer insulin in accordance with the student s individualized health care plan. Be sure that blood glucose levels are monitored before exercise or strenuous activity and allow for snacks before and after the physical activity if indicated in the student s individualized health care plan. Understand that accommodations may be necessary even during standardized testing periods. Communicate with the student s parents/guardians when a field trip or class party might require adjustment in their meal plan or insulin administration. Leave a clear message for any substitute regarding the special needs of the student. Respect the student s right to confidentiality and privacy. With the parents/guardians and the student s permission, the teacher or the school nurse may educate the class about the special needs of an individual with diabetes and use this as an opportunity to educate students regarding nutrition, exercise, and health. School Counselor/Social Worker While the school counselor and/or social worker may not always have direct contact with the student, they should be aware of the students in their schools who have diabetes and the potential impact of diabetes and its treatment on the student s behavior and performance. They should attend, at a minimum, the Level I: Awareness Diabetes Education and be prepared to work with the school nurse to assure that the necessary accommodations are made to comply with state and federal laws. The school counselor or social worker may be called upon to assist the student with any expressed concerns regarding diabetes and to identify and respond to ineffective coping mechanisms demonstrated by the student or the family as they relate to school performance and attendance. The school counselor/social worker should be familiar with community resources and services available to assist the student and family. Dietary Food Services Although it is the parent/guardian s responsibility to supply the student with the necessary snacks to maintain the appropriate blood glucose levels, it may be necessary to have emergency snacks available. If possible, the food service staff should work with a dietitian to develop and publish a carbohydrate count for the week s menu so that parents/guardians can plan the anticipated insulin needs with their students. (See Appendixes B and E for a list of common snacks, and general information on carbohydrate counting.) The food service staff should attend the Level I: Awareness Diabetes Education so they will be able to connect their activities with the over-all health and safety of the students. 22