Managing Diabetes in School

Forsyth County Health Department

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.

Diagnosis

● A1C, average blood glucose for the past 2 to 3 months

● Fasting Plasma Glucose Test (FPG) or

● Oral Glucose Tolerance Test (OGTT)

Diagnosis

●With the A1C test, diabetes is diagnosed at an A1C of greater than or equal to 6.5%

●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.

Statistics

● In 2012, 29.1 million children and adults in the United States, or 9.3% of the population, had diabetes. Of those 29.1 million, 21.0 million were diagnosed, and 8.1 million were undiagnosed.

● In 2008-2009, the annual incidence of diagnosed diabetes in youth was estimated at 18,436 with type 1 diabetes, 5,089 with type 2 diabetes.

You might be thinking….

Why do teachers/staff members have to take care of children with diabetes in school when they have little to no medical background?

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

Overview of SB 911 continued…

● State Board of Education Policy # 04A107 Special Health Care Services (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…

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

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

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

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

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

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.

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.

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.

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

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.

Overview of SB 911 continued…

– An Individual Health Plan (IHP) or emergency care plan 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.

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.

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.

Forms to Facilitate Implementation of the Law

– Diabetes Care Plan Request– Diabetes Care Plan – Quick Reference Plan– Signs and Symptoms of

Hypo/Hyperglycemia– Care Plan Copies (School, Parent,

Nancy Sutton)

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.

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

Communication

● With student and parent before school year begins

● By phone, by mail, in person

● Ask questions about self care

● Get to know the student

Care Plan

Diabetes Care Plans are located:

● Online on the WSFCS’s Healthy Living page: http://wsfcs.k12.nc.us/Page/63008

● School Nurse

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

Self Care: What do we do?

● If the student does not have a care plan, can we take care of them at school?

● If the student wants self care completely, do we need any forms signed?

● If the student has a care plan, but are able to provide self care, what are we responsible for?

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

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 (each school year).

● Communicate on regular basis with school staff and bus driver either verbally or written.

Role of the DCMDiabetes Care Managers in Each School

● Participate in the Intensive training session.

● Participate in IHP/CP conferences.● Have ready access to the student’s IHP.● Be readily reached in case of a diabetes

emergency.

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.

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.

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.

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.

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.

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.

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.

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”

Think about it….

Will I be held liable if the student needs help but I do not have a care plan to follow?

Will I be held liable if the student has a care plan and I follow it, but something happens to the student?

Will I be held liable if the student has a care plan but I do not follow it and something happens to the student?

Questions?

Types of Diabetes

● Type 1● Type 2● Gestational

Diabetes● Pre-Diabetes● Diabetes in School

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.

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.

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.

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

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:

Complications

● Right away, your cells may be starved for energy

● High blood glucose levels can damage eyes, kidneys, nerves, or the heart over time

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

Hyperglycemia video

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**

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

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

Hypoglycemia Video

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.

● Glucagon video

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

Scenario

● Billy is a student at your school with Type 1 diabetes and he has a completed care plan at school that says to treat blood glucose readings of less than 80 with a fast carb and recheck his sugar in 15 minutes. It is right before lunch and you check his blood sugar and it is 60. What do you do?

● A. Send him to lunch to eat● B. Give him a fast carb and send him to lunch● C. Give him a fast carb and recheck his sugar in 15

minutes● D. Ask the student what he wants to do

Answer

● C. Give him a fast carb and recheck blood sugar in 15 minutes.

* You should always follow the care plan. The student’s blood sugar may continue to drop on the way to lunch and you want to be sure he is within his target range of blood sugar before leaving adult supervision. Also, the food that he is eating may only have slow carbs, which could take a while to increase his blood sugar.

Nutrition

● Carbohydrate Counting

● Nutrition Labels● Special Occasions

Carb Counting

● Not all about the “sugar”● Manage diabetes by counting

carbs● 45-60 grams of carbs per meal

(depends on care plan)● 15 grams= 1 carb choice

Carbohydrates

● starchy foods like bread, cereal, rice, and crackers

● fruit and juice ● milk and yogurt ● dried beans like pinto beans and soy

products like veggie burgers ● starchy vegetables like potatoes and corn ● sweets and snack foods like sodas, juice

drinks, cake, cookies, candy, and chips

Carbohydrate Choices

● 1 small piece of fresh fruit (4 oz) ● 1/2 cup of canned or frozen fruit ● 1 slice of bread (1 oz) or 1 (6 inch) tortilla ● 1/2 cup of oatmeal ● 1/3 cup of pasta or rice ● 4-6 crackers ● 1/2 English muffin or hamburger bun ● 1/2 cup of black beans or starchy vegetable ● 1/4 of a large baked potato (3 oz)

More Carbs

● 2/3 cup of plain fat-free yogurt or sweetened with sugar substitutes ● 2 small cookies ● 2 inch square brownie or cake without frosting ● 1/2 cup ice cream or sherbet ● 1 Tbsp syrup, jam, jelly, sugar or honey ● 2 Tbsp light syrup ● 6 chicken nuggets ● 1/2 cup of casserole ● 1 cup of soup ● 1/4 serving of a medium French fry

Food Labels

● Serving size● Total number of carbs● Protein● Saturated and Trans

Fat● Sodium● Calories

Carbs and Insulin

● Children with Type I diabetes will have a insulin to carb ratio when dealing with meals or snacks. The insulin to carb ratio is the number of units of insulin a student will receive for a specific number of carbs that they ingest.

● Example: 1unit :10grams

The student will receive 1 unit of insulin for every 10grams of carbs they eat/drink.

Try it…

● Sally’s diabetic care plan says that she has an insulin to carb ratio of 1:10. She decides she is going to eat pizza and peaches, and drink white milk for lunch today. The total number of carbs for the food and drink is 51grams. How many units of insulin will she receive?

Special Occasions

● Find out number of carbohydrates in snack or treat if possible

● Talk with parent about special treats● Student can bring healthy snacks for

whole class● Parent or Doctor can adjust treatment

for that day

Management and Treatment

● Glucose Monitoring● Diet and Exercise ● Oral Medication● Insulin Syringe● Insulin Pen● Insulin Pump

Glucose Monitoring

● Checking blood sugar with a glucometer

● Use small amount of blood on test strip

● Strip inserted into glucometer for blood glucose reading

● Reading used to know how to treat hypo/hyperglycemia

Continuous Glucose Monitoring

● Continuous Glucose Monitoring (CGM) is an FDA-approved device that provides real-time glucose readings, throughout the day and night, allowing people with diabetes to see their glucose levels and track how quickly they're increasing or decreasing.

● Unlike fingersticks that give a number for a single point in time, CGM provides dynamic glucose information by showing where your glucose is, where it’s going, and how fast it’s getting there.

● Alerting System - Audible or vibratory alarms for low and high glucose levels

Continuous Glucose Monitoring

CGM Alert Arrows

Glucose and Insulin

● Most students with care plans will have a sliding scale to determine how much insulin they will receive based on their blood glucose reading.

● Example: Blood Glucose Units of Insulin

150-2001

201-2502

251-3003

301-3504

Meals and Snacks: Glucose/Carbs

● Most care plans will instruct to give insulin before meals and snacks based on blood glucose reading and number of carbs. Will use sliding scale and insulin to carb ratio. (Insulin pumps will usually calculate for you)

● Always follow care plan!

Scenario

Johnny has a care plan that uses a sliding scale and an insulin to carb ratio to determine how much insulin he should get before lunch. His insulin to carb ratio is 1:10 and he is going to eat 60grams of carbs for lunch. His blood sugar before eating was 222. His sliding scale says to give 2 units for blood sugar between 200-250. How many units of insulin should he receive?

*Why is it important to use pre-meal/snack blood sugar reading before giving insulin?

Ketones

● Ketones are acids that build up in the blood.

● Show up in urine when blood glucose is too high

● Can poison the body● Urine on test strip to determine if

ketones are present● If ketones are present this could mean

that the student’s diabetes is out of control or the person is getting sick

Diet and Exercise

● Type 2 Diabetes● Special Diet and

Exercising can keep blood glucose levels down

● May not have to use oral diabetic agents or Insulin

Oral Medication

● Many different types

● Typically used for Type 2

● Examples: Metformin, Glyburide, Januvia, etc.

Insulin

● Onset, Peak time, Duration

● Dose depends on doctor’s order and blood glucose level

● Need doctor’s order or care plan signed by doctor to administer insulin

Insulin

● Insulin must be injected into the fat under your skin for it to get into your blood.

● Insulin can be injected by syringe, pen or pump

● There are many different insulins for many different situations and lifestyles and there are more than 20 types of insulin sold in the United States (Novolog, Humulin, NPH, mixtures, etc.)

Types of Insulin

● Rapid-acting insulinbegin to work about 5 minutes after injection, peak in about 1 hour, and continue to work for 2 to 4 hours.

● Regular or Short-acting insulinusually reaches the bloodstream within 30 minutes after injection, peaks anywhere from 2 to 3 hours after injection, and is effective for approximately 3 to 6 hours.

Types of Insulin

● Intermediate-acting insulingenerally reaches the bloodstream about 2 to 4 hours after injection, peaks 4 to 12 hours later and is effective for about 12 to 18 hours.

● Long-acting insulin reaches the bloodstream 6 to 10 hours after injection and is usually effective for 20 to 24 hours

Insulin Syringe

● Vial of insulin and syringe used

● Some need to refrigerated ● Check expiration date● Draw ordered amount in

syringe and administer to student

● Use new syringe each time

Sharps Disposal

● Insulin Syringes and lancets for checking blood sugar should be placed in the correct container after being used.

● Examples: Laundry detergent bottle, Soda bottle, etc.

Insulin Pens

● Pens have pre-measured amount of insulin inside.

● Does not need to be refrigerated

● Turn dial to amount of insulin that needs to be administered

● Need to make sure pen is working before injecting in student

Insulin Pump

● Needle or catheter is placed into the subcutaneous tissue and remains there for 48-72 hours for insulin delivery, we do not reinsert if they come out.

● Needle or catheter is attached to Insulin Pump by tubing.

● Pump delivers basal rate of insulin to maintain correct blood glucose level

● Can give a bolus dose for meal or high blood glucose level

● Some have glucometer attached● Some pumps can calculate needed dose● Pump Video

Common Concerns

● Sickness● Travel● Emergencies

Sickness

● Blood sugar can increase when sick● Stick to normal meal plan● Drink lots of fluids● Continue diabetes medication● May need to check blood glucose more

often● Watch for interactions with other

medications (non-diabetic)

Travel

● School field trips● Plan ahead● Need to have all medication, supplies,

and snacks● Bring a copy of care plan

Emergencies

● Follow care plan● If there is no care plan and there is an

emergency, call 911● Use quick carbs for low blood glucose● Use glucagon if available and ordered● Always contact parent for extreme low

or high blood glucose levels

Resources

● American Diabetes Association (www.diabetes.org)

● Diabetes at School (www.diabetes.org/safeatschool)

● JDRF (www.jdrf.org)● Your school nurse!

Resources

Pumps (common ones, not all)Animas - (Ping and Vibe): http://www.animas.comMedtronic - http://www.medtronicdiabetes.com/homeOmnipod - http://www.myomnipod.comTandem (Tslim) - http://www.tandemdiabetes.com

CGM’sDexcom - http://www.dexcom.comMedtronic - http://www.medtronicdiabetes.com

Questions