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Colorado Nurse Practice Act and Delegation


									Schools, Rules and Diabetes

    Benita Lopez-Baca, RN, BSN, CDE
     Kathleen Patrick, RN, MA, NCSN
           R. Paul Wadwa, MD
The ADA Position Statement
• Defines federal laws
  protecting children with

• Provides guidelines for
  children in school and day
  care settings

• The ADA advocates and
  supports the rights of
  children and families with
    What are other states doing?
        Safe at School in Virginia

In 1999 Virginia passed a state law
requiring non-medical personnel to
assist students at school with their
diabetes management.
Hellems, M and Clarke, W. Safe at School: The Virginia Experience.
Diabetes Care. 2007.
Who trains the school personnel?
• 63% by school nurse
• 35% by a parent
• 15% by a diabetes specialist
Where does the child do blood testing?
• 49% tested in the classroom
-41% of elementary, 28% middle school, and 74% of high
  school students
92% of parents were satisfied with the child’s diabetes care
  at school

       Hellems, M and Clarke, W. Safe at School: The Virginia Experience.
 What is Happening
with Diabetes Care in
 Colorado Schools?
       Diabetes Care in
Colorado Schools Collaborative
• Stakeholders began meeting in 2005
• Members included Schools, Parents,
  Healthcare Providers, Community
• Four Task Forces:
  – Guiding Principals
  – School Nurse Forms & Tools
  – Parent Toolkit
  – Diabetes Resource Nurse Program
  Accomplishment #1
Guiding Principles: Standards and
 guidelines for safe management
   of children with diabetes in
        Guiding Principles
• Recognizes all students with chronic
  health conditions
• Essential collaboration of student, school,
  healthcare provider and home
• Schools need to provide sufficient
• School nurse plans and implements care
      Accomplishment #2

School Nurse Toolkit: Standardization
 of forms to ensure consistency
 throughout the state and between
 healthcare providers
School Nurse Checklist
 Training & Delegation
              #500 – Diabetes Management in
               Schools and Child Care Instructor Guide
              #501 – Glucose Monitoring Skills
              #502 – Urine Ketone Monitoring Skills
              #503 – Hypoglycemia Skills Checklist
              #504 – Glucagon Skills Checklist
              #505 – Hyperglycemia Skills Checklist
              #506 – Insulin Pen Skills Checklist
              #507 - Insulin Pump Skills Checklist
              #508 – Insulin Syringe Skills Checklist
              #509 – Insulin Syringe Combination
               Skills Checklist
              #510 – Continuous Glucose Monitoring
               in the Schools
              Instructions for #600 Delegation &
               Supervision of Diabetes Care Tasks
              #600 – Delegation Agreement &
               Supervision for Diabetes Care Tasks
        Accomplishment #3

Parent and School Toolkit
  – Clarify roles and responsibilities of school and
  – Provide quick reference guide for teachers,
    bus drivers, and other school personnel who
    are responsible for student with diabetes
Parent &
School Toolkit
 Help a Child! Know the Symptoms!
 Before You Begin a New School
 Parent Letter to Teacher with Photo
 Low Blood Sugar Lunchbox Card
 Low/High Blood Sugar Hand
 Information to help TEACH my Child
  – Impact to Learning
 Field Trip Considerations
 Parties and Snacks
 Psycho-Social Aspects
 Developmental Stages and Diabetes
 FAQ’s
 Glossary
 Resources
Accomplishment #4

 Diabetes Resource Nurse
Diabetes Resource Nurse

 Nurse Consultants with expertise in
   diabetes, staff development and
    problem solving who serve as
  resources for schools throughout

• Assure the safety of Colorado’s
  children with type 1 diabetes within
  the school community.
• Create a standard of best practice in
  the state in the management of
  children with diabetes in the school.
    Responsibilities of Diabetes
         Resource Nurse
• Consult with district school nurses, administrators,
  & other staff
• Assist with development of healthcare plans & 504
• Provide resources & evidence based training
• Troubleshoot individual problems
• Collaborate to ensure standardized care and best
• Note: does not provide individual care
          Board of Nursing
“to protect the people of this state from the
  unauthorized, unqualified, and improper
  application of services by individuals in the
  practice of nursing”

Role of BON is to determine if the practice
 meets the standards established by the
 Nurse Practice Act
  Nurse Practice Act

  State law that licenses and
regulates the practice of nursing

 “The transfer of responsibility for the
performance of an activity to another,
with the former retaining accountability
            for the outcome.”
                              ANA, 1994
• Only a registered nurse can delegate
• Only activities that do not require
  nursing assessment and/or judgment
• Delegation limited to:
  – to a specific delegatee
  – for a specific task
  – for a specific student
  – within a specific time frame
      Bottom line…
The health, safety and welfare
 of the student is the primary
consideration in any decision
          to delegate
    New Rules to Chapter XIII

• Section 8: Delegation of insulin and glucagon in
  the school setting and childcare
• IHP must be developed by the school nurse
• Routine injections may be delegated according
  to IHP & after appropriate training
• Non-routine dosages must be verified by school
  nurse or parent according to IHP
  New Diabetes Website
Discussion and
 Case Studies
  • 10 years old and
    diagnosed last week
    with Diabetes Mellitus
    probably Type 1
• Is it appropriate to delegate a
  correction insulin dose based on
  blood glucose?

• Is it appropriate to delegate the
  calculation of a carb/insulin ratio
  insulin dose?
• 12 years old
• Diagnosed with Autism
  Spectrum Disorder at 4
  years of age

• Diagnosed with type 1
  diabetes at 9 years of age

• Poor verbal
  communication skills
• The school nurse does not have
  any experience with glucagon and
  is hesitant to delegate what should
  she/he do?
• 9 ½ years old
• Diagnosed with
  diabetes more than a
  year ago
• Re-enrolled in school
  after living with mother
  out of state for a year
• Can do pokes and
  shots on his own
                  What steps can be
                   taken to address this
  Dad has a
                  Can the School Nurse
change of heart    request a 504?
about obtaining   What safety measures
Medical Orders     for Billy can be put in
                   place until the
                   concerns are
Can a CO RN delegate a nursing task from medical
  orders from another state?

What nursing care tasks can be provided in the
 absence of current medical orders?

What steps can be taken to address this issue?

Can the School Nurse request a 504?

What safety measures for Billy can be put in place
 until the concerns are resolved?
• 6 years old
• Diagnosed with type 1
  DM at 27 months old
• Started using insulin
  pump at beginning of
  this school year
• Can do own finger
• Needs help with other
  care tasks
• Describe nursing actions in the
  supervision of the teacher and the
  school secretary.

• Is it necessary for the nurse to
  document the supervision?

• How often would the nurse need to
  supervise the delegated tasks?
NDEP - Helping the Student with
      Diabetes Succeed

      Section 1 Diabetes Primer for School Personnel
       Diabetes Care Tasks at School:
             What Key Personnel
               Need to Know
                             BLOOD GLUCOSE MONITORING
                                 LEGAL CONSIDERATIONS
Contact information:

Kathleen Patrick RN, MA, NCSN
Principal Consultant, School Health Services
Colorado Department of Education

Benita Lopez-Baca, RN, BSN, CDE
Barbara Davis Center

R. Paul Wadwa, MD
Barbara Davis Center
Self Care
 •Should be a team decision
 •Must be determined that the student is capable

Insulin Pump
 •Can delegate routine meal boluses
 •Non-routine doses require verification by
 nurse or parent according to IHP
Diabetes Resource Nurses
 – Currently 26 nurses
 – 16 District DRN
    • Metro-area or larger districts.
 – 10 Regional DRN
    • Serves several counties or
    • Rural and small districts.
    Requirements for DRN
• Minimum five years experience as a
  school nurse or public health nurse.
• Evidence of experience providing care to
  individuals with diabetes.
• Bachelor of Science degree – preferably in

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