Managing Diabetes in School

1. Managing Diabetes in School Forsyth County Health Department Information from American Diabetes Association and Wake AHEC DATA Program

2. What is Diabetes? • Diabetes is a disease in which the body does not produce or properly use insulin. Insulin is a hormone that is needed to convert sugar, starches and other food into energy needed for daily life. The cause of diabetes continues to be a mystery, although both genetics and environmental factors such as obesity and lack of exercise appear to play roles.

3. Diagnosis • Fasting Plasma Glucose Test (FPG) or an Oral Glucose Tolerance Test (OGTT) • With the FPG test, a fasting blood glucose level between 100 and 125 mg/dl signals pre-diabetes. A person with a fasting blood glucose level of 126 mg/dl or higher has diabetes.

4. Statistics • There are 25.8 million children and adults in the United States, or 7.8% of the population, who have diabetes. While an estimated 18.8 million have been diagnosed with diabetes, unfortunately, 7 million people are unaware that they have the disease.

5. Part 1: Overview of SB 911: Care of School Children with Diabetes • Federal & State Support and History of the Law: Diabetes is considered a disability and is covered under the following Federal Acts: • Section 504 of the Rehabilitation Act of 1973 • Individuals with Disabilities Education Act of 1991 • Americans with Disabilities Act

6. Overview of SB 911 continued… • State Board of Education Policy # 04A107 Special Health CareServices (1995) • Shall make available a registered nurse for assessment, care planning, and on-going evaluation of students with special health care service needs in the school setting…

7. Diabetes and School • Students with disabilities have a right to a "free, appropriate public education" without discrimination. In addition, children in many private schools and day care centers are protected against discrimination on the basis of disability. These rights are guaranteed by the following federal civil rights and education laws

8. Section 504 • Section 504 is a federal civil rights law to prohibit discrimination on the basis of disability. The law also prohibits retaliation for asserting the right not to be discriminated against • To be protected by Section 504 the student must have a disability defined as: • a physical or mental impairment that substantially limits one or more of major life activities; • a record of such an impairment, or • being regarded as having such an impairment

9. Section 504 • Public Elementary and Secondary Schools must: • Identify children with disabilities; • Provide a “free appropriate public education” (FAPE) to each child with a disability.  This means providing regular or special education and related aids and services designed to meet the individual educational needs of students with disabilities as adequately as the needs of students without disabilities are met; • Educate children with disabilities with other students as much as possible; • Allow parents/guardians to participate meaningfully in decisions regarding their children; and • Afford children with disabilities an equal opportunity to participate in nonacademic and extracurricular services and activities

10. ADA • The Americans with Disabilities Act (ADA) is a federal law that prohibits discrimination against qualified individuals with disabilities. The law also prohibits retaliation for asserting the right not to be discriminated against • Children with disabilities need equal opportunity

11. IDEA • The Individuals with Disabilities Education Act (IDEA) is a federal law that requires states to provide a "free, appropriate public education" to children with disabilities so they can be educated to the greatest extent possible along with all other children. Qualifying children are entitled to special education and related services at no cost to their parents/guardians

12. IDEA • To receive services under IDEA, a child with diabetes must show that he or she needs special education and related services in order to benefit from an education. An evaluation of the child must show that, because of the child's diabetes (or other qualifying disability), the child has limited strength, vitality, or alertness that adversely affects the child's educational performance. Simply put, the diabetes must make it more difficult for the child to learn.

13. IDEA • Special Education • Least Restricted Setting • IEP (Individualized Education Program • An Individualized Education Program or "IEP" is the document that sets out what the school is going to do to meet the child's individual educational needs.

14. Overview of SB 911 continued… • Implications for NC Schools • Guidelines adopted in every school in the state must meet or exceed American Diabetes Association recommendations.

15. Overview of SB 911 continued… • Section 1 of SB 911 • Procedures for the development of a diabetes care plan if requested by parent • Procedures for the regular review • Included should be: • Responsibilities for teachers and other school personnel • Development of an emergency care plan • Identification of allowable actions to be taken • Extent of student’s participation in diabetes care

16. Overview of SB 911 continued… • Section 2 of SB 911 • Local Boards of Education must ensure that guidelines are implemented in schools in which students are enrolled. • Local Boards of Education will make available necessary information and staff development in order to support care plan requirements for students with diabetes.

17. Overview of SB 911 continued… • An Individual Health Plan (IHP) should be developed by the parent/guardian, the student’s diabetes care team, and the school nurse. • At least 2 school personnel in each school should be trained in diabetes care and emergencies.

18. Overview of SB 911 continued… • Children should have immediate access to diabetes supplies and diabetes treatments as defined in the IHP. • Roles and responsibilities of the parents/guardians and the schools are defined. • DCM roles are also defined.

19. G.S. 115C-375.3April 28, 2005 • House Bill 496 states that local boards of education shall ensure that guidelines for the development and implementation of individual diabetes care plans are followed. Local boards are to make available necessary information and staff development in order to support and assist students with diabetes in accordance with their individual diabetes care plans.

20. Forms to Facilitate Implementation of the Law • Diabetes Care Plan Request • Diabetes Care Plan • Responsibilities of Parent & School • Quick Reference Plan • Care Plan Copies (School, Parent, Nancy Sutton)

21. Role of the Master Trainer(Nancy Sutton and RN) • Participate in regional intensive training sessions. • Set up the intensive training session for the DCMs from each school in the LEA. • Coordinate continuing education for the DCMs.

22. Communication- Role of Nurse • With student, parent & school staff • SB-911 Diabetes School Act • Provide forms • Provide training • Act as a resource • Continuing Education for diabetes management

23. Communication • With student and parent before school year begins • By phone, meeting at the library, by mail • Ask questions about self care • Get to know the student

24. Communicate: Self Care • Procedures done at school • Equipment kept at school • Diabetes care recommendations may change during the school year • Whom to tell about having diabetes • Determine student’s level of maturity • Diet issues: • Meals • Snacks • Emergency snacks

25. Communicate: Parent Responsibilities • Phone numbers • Home, work, cell, pager • Supplies • Snacks • School absences • Care Plan request • Care Plan • Student’s self-care capabilities • Medication forms • Diet form • Student photo • Medic alert ID

26. Communicate: Parent Responsibilities • Student, parent or 9-1-1 may have to assume responsibility for diabetes care until the Care Plan is signed and returned. • A new Care Plan is needed annually. • Communicate on regular basis with school staff and bus driver either verbally or written.

27. Role of the DCMDiabetes Care Managers in Each School • Participate in the Intensive training session. • Obtain certificates of course completion and maintain documentation as proof of completion. • Participate in IHP conferences. • Have ready access to the student’s IHP. • Be readily reached in case of a diabetes emergency.

28. DCM Roles continued… • Communicate with teachers/substitute teachers/student/parents/health care team as indicated or as necessary. • Assist the student with diabetes care as indicated in the IHP. • Be available to go with the student on field trips or to school-sponsored extracurricular activities as indicated. • Attend continuing education sessions as needed.

29. Guidelines for PE Teacher and Coach • Encourage exercise and participation in sports and physical activities for students with diabetes. • Treat the student with diabetes the same as other students except to meet medical needs. • Encourage the student to have blood glucose equipment and treatment for low blood sugar available. • Understand and be aware that hypoglycemia can occur during and after physical activity. • Recognize any changes in student’s behaviors which could be a symptom of a low blood sugar.

30. Guidelines for Bus Drivers • At the beginning of the school year, identify any students on the bus who have diabetes. Be familiar with their DCP. • Be prepared to recognize and respond to the signs and symptoms of a low blood sugar. • Parents should consider giving bus driver their daytime contact numbers. • Student may carry monitor, insulin, glucagon and snacks on bus. • The student, teacher & parent should communicate with bus driver. • Bus driver may consider carrying extra snacks in case of bus breakdown, traffic jam, etc.

31. Actions for Food Service Staff or Lunchroom Monitor • Provide a lunch menu and lunch schedule in advance to parents along with nutrition information including grams of carbohydrate and fat. • Be aware of your students diabetes meal plans and snack plans. • Treat the student with diabetes the same as other students except to respond to medical needs. Understand that hypoglycemia can occur before lunch.

32. Liability Concerns and Issuesfor DCMs • How do I prevent liability situations from occurring? • Be very familiar with the student’s IHP and refer to it often. • If the student needs assistance with administering insulin, make sure the most recent dosage schedule is available for your use.

33. Liability Concerns and Issues • Remember, a vial of insulin kept at room temperature is discarded 30 days after opening. An insulin pen is discarded 30 days after it is first opened even if insulin remains. • Check expirations dates on insulin and glucagon to make sure they are in date. • Triple check yourself when drawing up a dose of insulin. Double check the student’s dose if he/she is drawing up the insulin.

34. Liability Concerns and Issues continued… • But how am I protected from litigation? • The State of NC now has SB911 in place with directives for adoption by all public schools in the state. • Many State Agencies have organized this training program. • You are now going through the training and will receive a certificate of completion once the training has satisfactorily been completed. • You will maintain up to date knowledge through continuing education. You will have resources to call upon if questions or problems arise.

35. Liability Concerns and Issues continued… • Do I have any other protections? • NC General Statute 90-21.14 adopted in 1975: • Provides immunity for rescuers. • Provides immunity for acquirers and enablers. • Encourages/requires CPR & AED training. This is the “Good Samaritan Law”

36. Questions?

37. Types of Diabetes • Type 1 • Type 2 • Gestational Diabetes • Pre-Diabetes

38. Types of Diabetes • Pre-Diabetes: the condition that occurs when a person’s blood glucose levels are higher than normal but are not high enough to be diagnosed with Type 2 diabetes. • Gestational Diabetes: the condition where pregnant women have elevated blood glucose levels.

39. Types of Diabetes • Type 1: the condition when the body fails to produce insulin. • Type 2: the condition when the body fails to use insulin properly. • Type 1 and Type 2 seen the most in school aged children.

40. Type 1 Diabetes • Type 1 diabetes is usually diagnosed in children and young adults, and was previously known as juvenile diabetes. In type 1 diabetes, the body does not produce insulin. Insulin is a hormone that is needed to convert sugar (glucose), starches and other food into energy needed for daily life.

41. Type 2 Diabetes • Most common type of diabetes • Body does not produce enough insulin for the body, or the cells ignore the insulin • Insulin is necessary for the body to be able to use glucose for energy

42. Complications • When you eat food, the body breaks down all of the sugars and starches into glucose, which is the basic fuel for the cells in the body. Insulin takes the sugar from the blood into the cells. When glucose builds up in the blood instead of going into cells, it can cause two problems:

43. Complications • Right away, your cells may be starved for energy • High blood glucose levels can damage eyes, kidneys, nerves, or the heart over time

44. Hyperglycemia • Hyperglycemia is when the blood glucose is too high. • Signs and Symptoms: High blood glucose, high levels of sugar in urine, frequent urination, increased thirst

45. Ketoacidosis • Condition that can happen if high blood glucose is not treated • Signs and Symptoms: Shortness of breath, fruity breath smell, nausea and vomiting, very dry mouth ** This is a life-threatening condition**

46. Treatment for Hyperglycemia • Most people are followed by doctors and they will have a care plan to determine the most effective way to decrease the blood glucose level • Insulin (Injection, Pen, or Pump) • Prevention and Management: Diet and Exercise

47. Hypoglycemia • Hypoglycemia is when the body’s blood sugar is too low. • Signs and Symptoms: Shakiness, Dizziness, Sweating, Hunger, Headache, Pale Skin Color, Mood Changes, Jerky Movements, Seizure, Confusion, Tingling sensation around mouth, Difficulty concentrating

48. Hypoglycemic Emergency • Blood sugar levels can decrease so much that it can result in passing out or even death. If a person with diabetes passes out, always treat as an emergency. Give glucagon if available and call 911. DO NOT try to give insulin, food, or fluids if the person is unconscious.

49. Treatment for Hypoglycemia • Give a fast sugar such as ½ cup of fruit juice, 5-6 pieces of candy, or 3 glucose tablets (Have to follow care plan) • Always check blood glucose 15-20 minutes after fast sugar

50. Nutrition • Carbohydrate Counting • Nutrition Labels • Special Occasions