Linda Young, RN, MS, FRE, BC Nursing Program Specialist South Dakota Board of Nursing
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1 Linda Young, RN, MS, FRE, BC Nursing Program Specialist South Dakota Board of Nursing
2 Ø Background Ø Purpose Ø Methodology Ø Study Results Ø Policy Considerations
3 Inspiration behind study: 1. Access to care for individuals living with diabetes in settings where a nurse may not be present to deliver care 2. Legal barriers to delegation and supervision of insulin administration 3. Cost of sustaining the current economic model of care
4 Schools Assisted Living Centers Group Homes
5 World Café Collective wisdom of stakeholders Generate innovative solutions Shape the future together
6 A virtual model of nursing practice emerged Linked trained unlicensed personnel (UAP) with a virtual nurse by means of technology Nurses managed the care of school children living with diabetes while delegating tasks to UAPs including the administration of insulin Funding was received to test the model Exploratory pilot project/study was developed
7 What possibilities exist to enhance diabetes management when a nurse may not be present to provide care?
8 To what extent is a model of nursing care utilizing a virtual nurse linked to a trained unlicensed provider through technology, safe and effective in the care of school children living with diabetes including the delegation of insulin administration?
9 Developed a Core Consultant Panel consisting of: Researchers, School nurses, Diabetes Clinical Nurse Specialists, Research advisor, and Technology experts Developed an Advisory Stakeholder Council; consisting of: Core consultant group, parents/guardians of children with diabetes, primary care providers, school administrators, nursing administrators, representatives of SD Diabetes Coalition, SD Certified Diabetes Educators Association, SD School Nurses Association, SD Board of Nursing, SD Department of Health, SD Nurses Association Met 3 times: at beginning of study, midpoint, and conclusion of study Guided and assisted in implementation of the project, identified and supported policy recommendations for regulatory changes
10 Study approved by Avera Health Institutional Review Board Implemented from December 1, 2010 through May 2013 Designed to include children Convenience sample School children recruited through: School Administrators Virtual Nurse Diabetes Clinical Nurse Specialists
11 Inclusion criteria: 1. Attend school located in South Dakota; diagnosed with Type I or II insulin dependent diabetes 2. Require insulin administration by injection or pump on a regularly scheduled or sliding scale basis during school day 3. No licensed nurse physically present in the school during lunch time 4. School had appropriate technology available to connect to virtual nurse 5. School identified a UAP, willing to partner with virtual nurse, that was available to student during school day 6. Parents/guardian signed informed consent
12 Collected clinical data elements on: Insulin administration Blood glucose monitoring Carbohydrate counting Activity monitoring
13 Conducted pre and post surveys Parents and school personnel were asked to rate their perceived level of ability to provide safe care of a child with diabetes in the school Questions on the survey were identical for both groups
14 1. Provide Safe Quality Care 2. Obtain Immediate Assistance if a Child Experiences Complications 3. Communicate with a RN to Supervise Medication Administration 4. Respond appropriately to questions about diabetes care 5. Make sound decisions in a timely fashion 6. Use technology to assist with the care of children living with diabetes 7. Experience a level of satisfaction that the best care is provided to children with diabetes in the school setting
15 Technology All schools used identical hardware (laptop, desktop video unit) and secure software Unlicensed personnel chosen by school administrators Virtual Nurses available for weekly consultation visits and by telephone Weekly Care Logs Clinical Interventions Diabetes Medical Management Plan (DMMP)
16 10 hours of training was required Used standardized training curriculum from American Diabetes Association parents-and-kids/diabetes-care-at-school/ school-staff-trainings/diabetes-care-tasks.html Validation of skills required for all UAPs and evaluated by virtual nurses, on: Insulin administration Carb counting Blood glucose monitoring
17 Completed by parents and health care team Required at beginning of each school year Plan outlined: Insulin administration Blood glucose monitoring Carbohydrate counting Activity monitoring Hypoglycemic recognition and treatment Emergency Glucagon administration Hyperglycemic recognition and treatment diabetes-care-at-school/written-care-plans/diabetes-medicalmanagement.html
18 Clinical Data
19 Student Demographics Female = 11 Male = 20 Teen: years Child: 8 to 12 years Young Child: 5 to 7 years Number of Participants
20 Number of Insulin Doses Administered: 5,569 Insulin Pump = 3,335 InjecGon / Pen = 2,234 Total Doses Administered Safely = 5, Young Child: 5 to 7 years Child: 8 to 12 years Teen: years
21 Injection 2,167 (39%) Insulin Pump 3,402 (61%)
22 Performance of Delegated Tasks by UAP 100% 7.5% 30.0% 19.0% 25.0% 90% 0.7% 0.2% 80% 70% 60% 50% 92.5% 70.0% 81.0% 75.0% 99.3% 99.8% 40% 30% 20% 10% 0% Performed Counted Accurate Blood Carbohydrates Glucose without Results Assistance Yes No Performed Accurate Carbohydrate CounGng Performed Blood Glucose Tests before & auer PE According to DMMP Responded to Responded to Hypoglycemic Hyperglycemic Episodes Episodes According to According to DMMP DMMP
23 Pre and Post Implementation Surveys
24 31 pre-surveys sent to parents - 100% return rate Post-surveys 31 sent 10 returned 32.3% return rate 50 Pre-surveys sent to school administrators and trained unlicensed personnel 100% return rate Post-surveys 50 sent 28 returned 56% return rate
25 Paired-samples t-tests Only used responses from participants that completed both pre and post surveys Effect sizes indicated large difference in responding from pre to post project implementation
26 Despite a small sample size, statistically significant differences to all survey items, except: The ability to use technology and Ability to obtain immediate assistance These items had large and medium effect sizes
27 Statistically significant differences from pre to post project implementation on all survey items Effect sizes were large for almost all survey items Obtaining immediate assistance had a medium effect size
28 Very large changes pre versus post project implementation for both parents and school personnel Results complement the clinical data findings Provide additional evidence that The Virtual Nursing Care for Children with Diabetes in the School Setting project demonstrated a safe and effective model for delegating and supervising diabetes management, including insulin administration, to trained unlicensed personnel.
29 Suggest additional research and education in area of handling complications No emergency situations emerged during study Encourage new models of nursing care to ensure access to safest care possible in settings where a nurse may not be present. This study demonstrated how new models can be successfully implemented and tested.
30
31 Schools that participated in the project want to continue Nursing rules regarding delegation of insulin must change to allow for continuation The BON continues to receive calls in regard to insulin administration and reports of children being transported to receive insulin
32 October 2013: Findings presented to Advisory Stakeholder Counsel Support sustaining virtual nurse program and Changing delegation rules March 2014: Hosted stakeholder meeting; discussed, In order to delegate insulin safely, what would the Administrative Rules need to include? Group is meeting again to finalize rules revisions to allow insulin delegation Focusing on UAP training and competence requirements, supervision elements Expect to finalize by July 2014 SD Diabetes Coalition is moving forward to sustain the Virtual Nurse program and has secured funding
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