Safe at School with Diabetes

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Incidence of Type 1 DM. ADA-23.6 million people in US with Diabetes (7.8% of population)3 million of those people have Type 1 Diabetes1 in 400/600 children have Type 1 DiabetesJDRF

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Safe at School with Diabetes

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1. Safe at School with Diabetes Updates in Diabetes Care for Wisconsin Schools Tracey Haag, RN, BSN, CDE Children’s Hospital of Wisconsin – Fox Valley Diabetes Program

2. Incidence of Type 1 DM ADA-23.6 million people in US with Diabetes (7.8% of population) 3 million of those people have Type 1 Diabetes 1 in 400/600 children have Type 1 Diabetes JDRF – 15,000 people are diagnosed with Type 1 diabetes every year That’s 40 people per day! Incidence of Diabetes has doubled in the past 20 years ? 3% per year Some increase is recognized in patients being diagnosed during winter months

3. Type 1 Diabetes Occurs most often in children but can be diagnosed in adulthood Auto immune condition Most common auto immune condition in children Causes are still unknown-MULTIFACTORAL Insulin producing cells in pancreas are destroyed by antibodies - hormone deficiency Requires insulin injections to sustain life “Hormone Replacement Therapy”

4. The Evolution of Diabetes Care 1980’s = One or 2 shots per day with none at school 1990’s = 2-3 shots per day with none at school Later 1990’s = New insulin analogs that led to implementing intensive regimens 3-4 shots per day 2000 = 24 hour basal insulin = before meal and snacks fast acting and bedtime basal dose of insulin. Increase in CSII (Pump) in children of all ages.

5. Understanding Insulin Action

6. Flexible Insulin Therapy Children give injections with meals based on an insulin/ carbohydrate ratio – will be individualized 1unit per 15 grams of carbohydrate 1unit per 8 grams of carbohydrate Correction dose of insulin is then applied to that ratio 0.5 unit for every 50 over 150 mg/dl – Target = 120 mg/dl 1.0 unit for every 30 over 130 mg/dl – Target = 100 mg/dl Basal insulin used to cover fasting periods of the day The same method used whether using injections or insulin pump

7. ADA Medical Standard of Care 3 or more injections of insulin per day 4 to 6 blood glucose tests per day Medical Nutrition Therapy Diabetes Self Management Education (DSME) Psychological support, evaluation and care

8. Every day at school a student will……. Learn Socialize Eat Develop emotionally, socially & physically Physical activity

10. 24 hours a day…7 days a week… safe healthy being a kid CHOICES

11. 24 hours a day…7 days a week… Insulin Food Exercise

12. Treatment of Type 1 Diabetes The balance of insulin, food, and exercise with daily activities :

13. Flexible Insulin Management

15. Insulin Dosing Bolus & Correction doses are based on blood glucose patterns, total daily insulin needs, & insulin sensitivity. Humalog, Novolog, or Apidra insulin at meals Basal dose (Glargine = Lantus) usually 0.5 to 0.9 units per kg/day 60 to 70% bolus insulin 30 to 40% basal insulin

16. Safe at School…it takes a team Communication IHP Consents Cooperation Each role is equally important and dependent on the others Education All team members have consistent information

17. Student Parents Friends Other caregivers Health plan administrator (School nurse) School administrators Daily care providers Teachers Diabetes HCP Coaches

18. Cooperation-It takes a community Common Goal-Safe and Healthy Students Define individual’s care/needs Define what is medically necessary Define roles of each partner Achieve goal with available resources

19. Cooperation Each role equally important and dependent on the others All team members adhere to IHP and roles All team members want to or are willing to be part of the team (direct care) Emergent call 24/7 to help with unusual events IHP meetings/ 504 meetings if issues arise

20. IHP Most effective communication tool Outline of care – Written order for implementation Blood sugar monitoring Insulin administration Emergency Care-high and low blood sugar treatment Eating Physical Activity/special considerations

21. IHP Individualized Amount of direct diabetes care Level of supervision Level of autonomy Special considerations Parents responsibility to keep updated

23. Safe at School Blood Sugar Monitoring #1 safety tool Immediate information when in doubt check a blood sugar Parameters for intervention/insulin dosing Overall diabetes control Blood sugar checking anywhere, anytime- ideal Age appropriate Student follows rule meter should go to the student

24. Blood Sugar Monitoring Supervision of BG testing May vary depending on age of child and how long they have had diabetes Interpretation of BGs Support for student to make decisions, not judgments No good or bad numbers!! One teen described BG testing as a pop quiz 4-6 times per day-she failed Quit testing because of the negative feedback she kept getting WORDS not ALLOWED in talking Diabetes Management with kids: Non compliant Non adherent Brittle diabetes Cheating sneakingOne teen described BG testing as a pop quiz 4-6 times per day-she failed Quit testing because of the negative feedback she kept getting WORDS not ALLOWED in talking Diabetes Management with kids: Non compliant Non adherent Brittle diabetes Cheating sneaking

25. Injecting Insulin Injection=Needles YIKES!!! Hurting the student Danger of needle poke Needle phobia/anxiety Stigma

26. Insulin Administration My First grader gives his own shots! Self Injection - Define Must Consider Maturity Responsibility Cognitive ability Fine motor skills Length of diagnosis

27. Eating at school Safety- Meals-Lunch (Breakfast too?) Carb counting accuracy-guesstimate Supervision of what was eaten Dose based on carbs consumed and pre-meal blood sugar Serving sizes are standardized Carb amounts on most Public school menus Less flexibility at lunch (bag lunch) +/- 15 grams will not make or break control target range=fluff As previously discussedAs previously discussed

29. Physical activity Safety All students are active at school or should be Flexible insulin regimen allows for flexibility in activity with less frequency of low blood sugar reaction/compensation for unusual activity Extra blood sugar checks for PE-individualized Athletic participation- Athlete, trainer, coaches accountability – may need extra blood sugar checks during game/practice School staff should be knowledgeable in treatment of low blood sugar reaction Moderate/large ketones – should not be active regardless of blood sugar level

31. Essentials of Successful Diabetes Management Multidisciplinary team approach Child/family, Pediatric Endocrinologist/ Nurse practitioner, Diabetes Nurse educators, Dietitian, Social worker, psychologist, exercise physiologist, school nurse, school staff, friends etc… Newly Diagnosed patients require 10 visits (medical and education visits) total in the first year of diagnosis Chronic conditionChronic condition

32. Outcomes in Management Optimal Hgb A1C levels Decreased incidence of hypoglycemia No increase in BMI Prevention of long term complications Improved patient/parent satisfaction Optimize the highest attainable level of functioning

33. Effective diabetes management is crucial at school for the immediate safety of students with diabetes for the long-term health of students with diabetes to ensure that students with diabetes are ready to learn and to participate fully in school activities and to minimize the possibility that diabetes-related emergencies will disrupt classroom activities

34. Laws Governing Diabetes Care Section 504 of ADA Rehabilitation Act of 1973 Section 504 IDEA Chapter 441 Wisconsin-Board of Nursing; subchapter I-Regulation of Nursing Wisconsin Statute Chapter 118-General School Operations Section 29-Administration of drugs to pupils and emergency treatment (ch.118.29) medication administration and emergency care in schools ADA (American Diabetes Association) standards of care and recommendations

35. Legislative Changes 2009 Senate Bill 414 affecting statutes 115.001-Definition of School Nurse 118.29 Medication administration to pupils in school

36. Why the Change? MADISON — State Superintendent Tony Evers issued the following statement regarding Gov. Jim Doyle signing Senate Bill 414 into law. “Governor Doyle and the Legislature understand that our student population and the nature of school nursing have changed over the years. The provisions of this law are important given the large number of people in the school setting that may have responsibilities for administering medications to students and the increasing proportion of students with special health care needs. With the school nurse to pupil ratio in Wisconsin averaging one nurse for every 2,359 pupils, it is increasingly important for school staff to be prepared and trained”. Reference: Wisconsin Association of School Nurse Legislation Action Center

37. Why the Change? “This law will enhance the health and safety of students by giving schools clear guidance as to what drugs can be administered to students, the instructions that must accompany those drugs, records that must be kept, the training required for those administering drugs, and the education requirements for school nurses”. Reference: Wisconsin Association of School Nurse Legislation Action Center

38. DPI statute 115.001 Definition of school Nurse RN-licensed to practice in the state with a bachelor’s degree and/or was employed by a school district before the bill was passed (grandfather clause) (or grandmother?) Also includes state or federal money to improve nurse/student ratios and salariesAlso includes state or federal money to improve nurse/student ratios and salaries

39. DPI statute 118.29 Definition changes: “Administer” means the direct application of a non-prescription drug product or prescription drug, whether by injection, ingestion or other means, to the human body

40. DPI statute 118.29 Medication Administration changes: The civil liability exemption for administrators and school staff is now contingent on training occurring for all school staff administering medications to students. Does not apply to Health care professional (i.e. School Nurse) Documentation of every dose and errors is required. No training and you administer meds you are liable and/or if a mistake is made. Administrators are liable if they require a non-trained staff to administer medications.No training and you administer meds you are liable and/or if a mistake is made. Administrators are liable if they require a non-trained staff to administer medications.

41. DPI statute 118.29 3. Glucagon may be administered by ANY staff person as long as they are trained and know the child has diabetes. 4. No employee except a health care professional may be required to administer a nonprescription drug or prescription drug to a pupil by any means other than ingestion. You can’t force an employee to give medication via injection, rectally, unless you are a HCP.You can’t force an employee to give medication via injection, rectally, unless you are a HCP.

42. DPI statute 118.29 Written policies must be developed in consultation/assistance with one or more school nurses and must include record keeping, procedures, consents, storage, and be periodically reviewed by the school nurse.

43. DPI statute 118.29 6. Training- No school staff member may administer any drug to a pupil unless they have received training, approved by the department. This does not apply to health care professionals. 7. Schools must provide training either through the WI school meds on-line course and hands on training from a HCP, parent or through a district developed medication training program. If districts use their own program it must be approved by the DPI school nurse consultant. (will be in full effect on March 1, 2011.) Our diabetes training will still be needed at this point as the online tutorial does not cover insulin administration, hands-on training or diabetes info. It does cover glucagon administration but not the hands on section. Our diabetes training will still be needed at this point as the online tutorial does not cover insulin administration, hands-on training or diabetes info. It does cover glucagon administration but not the hands on section.

44. What does this mean? State-wide consistency with basics of medication administration State-wide development and monitoring of competencies for unlicensed assistive personnel DPI owned- adherence to DMMP by school administrators Less 504 meetings or more appropriate 504 meetings???

45. Diabetes Care in WI schools even safer? Basics of diabetes cares streamlined while providing for individual differences Providers and school staff all on same page (everyone taught the same core information, using same forms, etc.) Improves safety of students followed by PMD

46. Diabetes Program at CHW Offer multidisciplinary Comprehensive Care Serve children 0-19 yrs of age Nationally ADA Recognized Education Program in Milwaukee and Fox Valley Serve over 1800 children with diabetes in Wisconsin, UP Michigan, and Northern Illinois ? 302 kids are in the Fox Valley 94% Type 1

47. CHW’s Role Provide school training regarding diabetes and how to care for students with diabetes at school Provide support, resources, consultation for parents and district nurses regarding diabetes care issues May include IHP/DMMP care negotiation Provide consultation/review as DPI develops a diabetes care in school program May include IHP/DMMP care negotiation Provide consultation/review as DPI develops a diabetes care in school program

48. CHW-FV Diabetes Training for School Staff - 2010 Presented by: Tracey Haag. RN, BSN, CDE and Lainie Hintz, RD, CDE AUDIENCE This program is designed for nurses, school health care providers, and school staff involved in the diabetes care of students. OBJECTIVES Upon completing this course the school Health care provider will be able to: Give an insulin injection Test blood sugars Use an insulin pen Test urine ketones Give a Glucagon injection Describe current diabetes care Count carbs in foods and drinks PURPOSE To teach school health care providers and staff to effectively manage and treat children with diabetes. 2010 Course Dates January 29, 2010 February 26, 2010 March 19, 2010 April 23, 2010 August 13, 2010 September 24, 2010 October 22, 2010

49. CHW’s Role Involve/Coach the School Nurse or staff member Be the Student’s advocate “what does the student want to do” What is in the student’s best interest Goal is to minimize class disruption but provide safe care First question I ask Often principal is unaware of larger diabetes in school program.First question I ask Often principal is unaware of larger diabetes in school program.

50. Resources for WI School Nurses New School Nurse Orientation-survival skills for the first year (DPI and WASN sponsored) Oct 6, 2010 and Nov 3, 2010. DAG –DPCP- Release of the updated “Students with Diabetes Resource guide for WI schools and families” Use of standardized DMMP (IHP-Individual Health Plan) for all students with diabetes Consistency = Safety DMMP=IHP we all worked on the development of the form Consistency = SafetyDMMP=IHP we all worked on the development of the form Consistency = Safety

51. Resources for WI School Nurses ADA website- www.diabetes.org living with diabetes/for parents and kids/care at school/state section NDEP- Helping the Student with Diabetes Succeed (Federal handbook) Other District Nurses DPI- Website school nurse handbook consultant: Rachel Gallagher

53. Thank you! [email protected]

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