Ensuring Diabetes Safety for School Students: Nurse's Guide

1. SAFETY FOR STUDENTS WITH DIABETES: Information and Tools for the School Nurse Alison Bruun, Market Executive Director Taylor Simon, Manager Community Health Strategy American Diabetes Association OSNA Conference Hillsboro, OR April 7, 2016

2. ADA Mission To Prevent And Cure Diabetes And ToImprove The Lives Of All People Affected By Diabetes

3. Diabetes Today SEARCH study found 1.93 per 1,000 youth (aged<20) diagnosed with type 1, with an increase of 21% from 2001 to 2009 in all ethnicities, but with non-Hispanic whites disproportionately affected. SEARCH study reported 0.46 per 1,000 youth with type 2 diabetes, an increase of 30.5% from 2001 to 2009 in all ethnicities. Dramatic increase in type 2 due to prevalence of childhood overweight. Improvements in technology and knowledge have enabled better care, but have increased management demands.

4. Recognizing Symptoms ofType 1 Diabetes If a student suddenly starts drinking more fluids to quench thirst, needs to go to the bathroom more frequently than usual, or loses weight rapidly – contact the parents/guardians and urge that they contact a physician immediately.

5. You Should Know: Child with diabetes cannot take a break Diabetes care is 24/7 Smooth transition from home to school needed Students need to have access to equipment, medication, and assistance is essential Written care plans are essential – physician’s orders and plans as provided for by federal and state laws

6. Every Student Students with diabetes Did I give myself enough/too much insulin to cover for breakfast? How many times should I check my blood sugar? Am I going to go high or low throughout the day? Does my diabetes management make me weird? How will I feel during my exam? • Am I going to get to school on time? • Do I have all my assignments completed? • Who am I going to sit with at lunch? • Am I prepared for my big exam?

7. Each Child with diabetes is different! …And they all can, and must, be accommodated... …going to school should not hamper diabetes care…diabetes should not limit or exclude a student from an equal education!

8. Common Issues Facing Students With Diabetes Lack of coverage during field trips and extracurricular activities. Refusal to permit blood glucose checks outside of the health clinic or office. Refusal to permit self-management and access to supplies and equipment anywhere on school grounds.

9. Useful Information to have when establishing accommodations for a specific student • Student’s biographical details • Their ability/skills to manage their diabetes. • School • Procedures and policies • Schedule • Prior experience managing diabetes • Current experience managing diabetes

10. Current Precepts of Diabetes Care • Goal of treatment is to maintain blood glucose as close to normal as possible • Insulin therapy may be customized to fit a child’s preferred lifestyle • Successful diabetes management requires • attention to coordination of insulin, carbohydrate intake and physical activity • frequent BG monitoring to guide decisions

11. Role of the School Nurse Leader of school diabetes team that includes: student, parent/guardian teachers, administrators, coaches, office staff, counselors, food service, bus drivers, and others Key coordinator and primary provider of care Trainer, supervisor and evaluator of school personnel Communication facilitator Key advocate for students A natural partner for success

12. School Nurse as Advocate • Advocate on behalf of your patient by helping your school to understand it legal obligations under federal and state laws. • Advocate by understanding what kind of services and modifications your patient needs and make sure these are reflected in the students written plans. • Advocate by addressing concerns when they arise.

13. Challenges Identified By School Nurses 13

14. Federal and State Laws 14 These laws can help level the playing field and ensure a safe and fair school environment for our children Federal laws • Americans with Disabilities Act (ADA) • Section 504 of the Rehabilitation Act of 1973 (Section 504) • Individuals with Disabilities in Education Act (IDEA) State laws, regulations and guidelines

15. Oregon State Law School nurses may delegate subcutaneous injections such as insulin to school staff members who are not licensed health care professionals School staff members who are not licensed health care professionals may administer glucagon if a licensed health care professional is not available Capable students may self-manage and self-carry supplies

16. ADA and 504 - Civil Rights Laws • Prohibit discrimination on the basis of disability. • Also prohibit retaliation for asserting the right not to be discriminated against. • Learning/academic progress need not be adversely affected to be eligible

17. Individuals with Disabilities Education Act (IDEA) A child with diabetes is covered if he or she needs special education and related services in order to benefit from an education. Diabetes must adversely interfere with academic performance. School must provide special education program and related services. Children must be educated in the least restrictive environment. Team that includes parents, special education experts, and school staff develop Individualized Education Program (IEP) which outlines plan to achieve specific educational goals.

18. School Plans for Diabetes Management

19. Diabetes Medical Management Plan(DMMP) Sets out patient’s school diabetes care regimen and clarifies how needs should be met by school staff. Used as a basis for development of school generated plans, Section 504 and other written plans. Should be updated annually or if patient’s regimen, level of self-management, or school circumstances change.

20. Diabetes Medical Management Plan(DMMP/Doctor’s Orders) • Document developed by family and health care provider • Signed by health care provider • Describes your child’s diabetes care regimen • Information may include: • Date of diagnosis • Current health status • Emergency contact information • Student’s willingness and ability to perform self-care • List of diabetes equipment and supplies • Orders for bg monitoring, insulin, glucagon, ketone checks, meal and snack plan, exercise • Typical signs, symptoms, and prescribed treatment for hyperglycemia and hypoglycemia

21. Thisincludes children with diabetes! To be protected by Section 504 a student must: • Have a physical or mental impairment that substantially limits one or more of major life activities; • Have a record of such an impairment, or be regarded as having such an impairment.

22. Section 504 applies to all public schools and to private schools that receive federal funds. Who’sCovered?

23. What can a 504 plan address?Plans often include... • Who is responsible for testing blood glucose levels • How to recognize low and high blood sugar • The right to food and water whenever and wherever necessary • Extra trips to the restroom or water fountain

24. 504 plans can also include: • Assurance of trained staff to administer • insulin and/or glucagon • Assurance that any staff member with immediate custodial care of the child is trained to recognize high and low blood sugar levels and knows how to respond. This includes teachers, coaches, and bus drivers. • Assurance of full participation in all sports, extracurricular activities, and field trips with the necessary assistance and/or supervision provided.

25. 504/IEP Plan: Possible Contents Recognition and prompt treatment of hypoglycemia and hyperglycemia by trained school personnel during school day, field trips, and extracurricular activities. Immediate access to diabetes supplies and equipment. Unrestricted access to snacks, water and bathroom. Classroom blood glucose monitoring. Adherence to care schedule (routine blood glucose testing, insulin administration, meals and snacks eaten on time). Reasonable time/instruction to make up assignments and tests missed due to diabetes. No penalties for absences due to diabetes (illness/doctor’s appointments). Identify trained school personnel.

26. 504 Case Studies Case Study: Susan calls and requests a meeting to discuss the needs of her eleven year old daughter relevant to her type 1 diabetes (1). At the meeting Susan says that she wants a 504 plan and an Individual Health Plan (2). The administrator says a 504 plan is not necessary- that the student has excellent grades and has no limitations because of her diabetes (3).You agree to the IHP but they want Jane to go to the office to test her BG (4).

27. 504 Case Studies 1. Who should potentially be at the meeting in addition to the 504 coordinator?

28. 504 Case Studies 1. Who should potentially be at the meeting in addition to the 504 coordinator? Probably at a minimum a nurse, an administrator, the student’s teacher and if appropriate other school personnel who may have custodial care for the student at school activities.

29. 504 Case Studies 2. What should Susan have with her?

30. 504 Case Studies 2. What should Susan have with her? A Diabetes Medical Management Plan, also known as Doctor’s orders or medical orders. This is a necessary document and the IHP is based on the orders. What should the orders be expected to contain? Information on the student’s diabetes care regimen: type of insulin, doses, when insulin is needed when to test BG, BG target range actions if out of range students symptoms for hi and low BGs information on carbs level of student’s self care parent contact and emergency info.

31. Case Studies 3. The administrator says a 504 plan is not necessary- that the student has excellent grades and has no limitations because of her diabetes. How do you handle this? Is the administrator correct?

32. Case Studies 3. The administrator says a 504 plan is not necessary- that the student has excellent grades and has no limitations because of her diabetes. How do you handle this? Is the administrator correct? The fact that a student has straight As has nothing to do with it. In caring for herself the student with diabetes is substantially different from the student without diabetes in many regards. She must check her blood glucose several times a day, make adjustments to her insulin, each time she eats, exercises, or feels funny she must check blood glucose and consider the need for insulin or a snack. At the same time she has the right to fully participate in school and all school activities and not be penalized for having to care for herself in this way.

33. Case Studies 4. Should Jane be allowed to test her BG in the classroom?

34. Case Studies 4. Should Jane be allowed to test her BG in the classroom? Yes, OCR has been very clear on this issue. It is important to minimize the amount of class time lost and the there is no danger to other students if Jane is diligent in how she carries out this task. Students who need help with BG testing also have the right to have it done in the classroom, as it is in places throughout the country.

35. Case Study Johnny, age 6, was diagnosed with T1D two weeks ago and is returning to school next week Johnny is currently on a Humalog/Lantus regimen Johnny’s parents both commute 1 hour to work Johnny is a finicky eater What provisions should be considered for inclusion in Johnny’s 504 Plan?

36. Johnny’s 504 Plan Needs Might Include: Case Studies Provisions for diabetes care when Johnny’s school nurse is not on site during the school day Where care will be provided Plan to check carbohydrate intake Identification of back-up trained personnel to provide care during field trips and school-sponsored extracurricular events Identification of current self-management skills such as choosing an injection site or finger to prick 504 Plan and IEP incorporate and implement the IHP and DMMP 504 plan is not just a plan – but incorporates a process and documents how the student’s needs will be met If a problem arises, the school is better positioned if it has followed the plan

37. 504/IEP Plan: Possible Contents Recognition and prompt treatment of hypoglycemia and hyperglycemia by trained school personnel during school day, field trips, and extracurricular activities. Immediate access to diabetes supplies and equipment. Unrestricted access to snacks, water and bathroom. Classroom blood glucose monitoring. Adherence to care schedule (routine blood glucose testing, insulin administration, meals and snacks eaten on time). Reasonable time/instruction to make up assignments and tests missed due to diabetes. No penalties for absences due to diabetes (illness/doctor’s appointments). Identify trained school personnel.

38. 504/IEP Plan: Possible Contents Who is responsible for testing blood glucose levels How to recognize low and high blood sugar The right to food and water whenever and wherever necessary Extra trips to the restroom or water fountain Assurance of trained staff to administer insulin and glucagon Assurance that any staff member with immediate custodial care of the child is trained to recognize high and low blood sugar levels and knows how to respond. This includes teachers, coaches, and bus drivers. Assurance of full participation in all sports, extracurricular activities, and field trips with the necessary assistance and/or supervision provided. Accommodations necessary for the student in the classroom and when taking State High School Graduation Qualifying Exams.

39. NOTE: In order for a student to receive accommodations on the High School Graduation Qualifying Exam or for College entrance test like the SAT, they must have been previously in place and documented. Using a 504 Plan is the perfect tool to assure the accommodations will be provided.

40. Is an IHP or DMMP (Doctor’s Orders) Enough? IHP and DMMP are not substitutes for a 504 Plan or IEP 504 Plan and IEP incorporate and implement the IHP and DMMP 504 plan is not just a plan – but incorporates a process and documents how the student’s needs will be met If a problem arises, the school is better positioned if it has followed the plan

41. Negotiate Work through problems and concerns through education. Most times problems arise due to ignorance and/or fear. Clarify reasons for school’s concerns and objections, preferably in writing. Collaborate with the ADA, Diabetes Educators, and parents for resources and materials.

42. School Diabetes Care Resources Helping the Student with Diabetes Succeed: A Guide for School Personnel developed by National Diabetes Education Program School Initiative . May be downloaded from www.ndep.nih.gov or accessed via www.diabetes.org/advocacy/school. Diabetes Care Tasks at School: What Key Personnel Need to Know is a series of web-based training modules that can be downloaded from the ADA’s website at www.diabetes.org/schooltraining. Comprehensive information may be found on ADA’s website at www.diabetes.org/advocacy/school. ADA’s National Call Center representatives available to assist families experiencing difficulties at education, negotiation, and litigation stages. Call 1-800-DIABETES for school packet and assistance.

43. Recap Daily support is needed from school personnel Federal and state laws provide protections to students with disabilities including diabetes School nurses are the key facilitators of diabetes care Reality is that most schools do not have a full-time school nurse Unlicensed personnel may be trained to safely provide routine and emergency care There are a variety of excellent resources available for use by school nurses, parents, educators

44. We’re here to help you! • Most disagreements with schools can be resolved as you educateand negotiate with school staff and the family. • Call the local ADA office: 503-736-2770 44

45. Up Coming Events • Safe Sitter Workshop • May 23 • Annual Diabetes Practice Update • November 4 • Contact Taylor for more information about both • tismon@diabetes.org • 503-736-2770 ext 7293

46. Thank you! Questions?