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Diabetes Care Policy

 

A Proposed Policy Regarding the care of Children with Diabetes in Canadian Schools  

Created by Barbra Wagstaff, Diabetes Advocacy in consultation with Special Educators, Teachers, Principals, and parents

 

Contents:

Introduction

Purpose

Application

Definitions      

Type 1 Diabetes      

Insulin      

Type 2 Diabetes      

Gestational Diabetes      

Glucagon      

Hyperglycaemia      

Hypoglycaemia      

Non-Emergency Situations      

Emergency Situations (Life Threatening)

Responsibilities      

Principal      

Teacher      

Parent      

Student Accommodations

Common law duty of care and related obligations

Diabetes Emergency Treatment Protocol

Form References

 

Appendix

Hyperglycemia Poster

Hypoglycemia Poster

Treatment Protocol

Emergency Procedures for Severe Low Blood Glucose

How to prepare and inject Glucagon®

 

Proposed Policy Regarding the care of Children with Diabetes in Canadian Public Schools

 

1. Introduction
Type 1 Diabetes, also known as Insulin Dependent Diabetes Mellitus or Juvenile Diabetes is an auto-immune disease that occurs when the beta cells of the pancreas produce little or no insulin.  Insulin is a hormone which is essential for processing glucose in the body.  When insulin is present, glucose can be used by the body for energy and unused glucose can be stored for later use.  Lack of insulin causes glucose to remain in the blood.  It is then filtered through the kidneys and spilt in the urine.  If the body cannot get glucose, it will begin to look for an alternate method of energy by breaking down fat and muscle.  This breakdown causes the release of toxins called ketones which are very dangerous to a person with diabetes.

The treatment of Type 1 Diabetes requires a careful balance of diet, exercise and insulin.  Since insulin cannot be produced by someone with Type 1 Diabetes, it must be injected.  Daily doses of insulin either through injections or an insulin pump allow a person with diabetes to live a relatively normal life.  Insulin injections are based on blood glucose levels, nutritional analysis of food eaten, as well as calculation of activities that will be occurring or have previously occurred.

Should the person with diabetes be given too much insulin, they will become “hypoglycemic” or “low”. Hypoglycemia is considered to occur when the blood glucose level drops below 4.0mmol/L.   This is an emergency situation which requires immediate treatment with a fast-acting sugar such as regular pop, juice or glucose tablets.  If treatment is not immediate, the person with diabetes may become unconscious.  At that point, they must receive an injection of Glucagon® or risk brain damage or possible death.

If a person with Diabetes has too little insulin injected into their system, they will become “hyperglycemic” or “high”. Hypoglycemia is considered to occur when fasting blood glucose levels are above 8.0mmol/L or blood glucose levels are above 10.0 mmol/L within 2 hours of eating.  This is also a serious situation.  In this case, the person may have blurred vision, become lethargic, have an unquenchable thirst, and need to constantly use the washroom.  They will require more insulin to be injected into their system.

In the case of children with diabetes, it is important to note that optimum learning occurs when blood glucose levels are between 4.4-8.3 mmol/L.  The human brain is almost totally dependent on a continuous supply of glucose.  Both hyperglycaemia and hypoglycaemia may cause physical, affective, and cognitive symptoms, as well as cognitive-motor disruptions. Even relatively mild levels of extreme blood glucose—either hyperglycaemia or hypoglycaemia—according to a 2002 study, cognitive functioning may decay by one third. According to B.M. Frier’s September 2001 study “cognitive function does not recover fully until 40-90 minutes after blood glucose is restored to normal.”

Physical activities such as a physical education class also require special considerations for the child with Type 1 diabetes.  As noted in the 2002 article by H. Dorchy, “In the young diabetic, during insulin deficiency, and therefore in a poor degree of metabolic control, i.e. Hyperglycaemia and ketotic, exercise accentuates hyperglycaemia and ketosis, leading to extreme fatigue.  If the insulin dosage is too high, the increase in muscular assimilation, combined with the shutdown of liver glucose production, may result in a severe hypoglycaemia.  During the recovery period, repletion of muscular and hepatic glycogen stores may also provoke a hypoglycaemia during hours after the cessation of muscular work.”

2. Purpose

 

2.1.To provide school personnel in the province of Newfoundland and Labrador with information and guidelines regarding requirements of care for students with diabetes. 

2.2. To provide information about the management of risks associated with diabetes for all involved parties. 

2.3 To develop an information and resource manual for school personnel about the management of diabetes in school children. 

2.4. To establish the roles of the school, the parents, and the child in this process.  

 

3. Application

 

    3.1.   This policy will apply to all schools in the province of _________________

 

4.Definitions

 

4.1. Type 1 Diabetes (also known as Insulin Dependent Diabetes Mellitus or Juvenile Diabetes):  occurs when the insulin producing cells of the pancreas no longer function leaving those affected dependent on an external source of insulin in order to survive.  There is currently no cure.

4.2. Insulin:  A hormone produced by the beta cells that allows food to be converted to glucose which is then used as fuel for the body.

4.3. Type 2 Diabetes:  occurs when the body is no longer able to properly use the insulin it is producing.  Type 2 Diabetes is often controlled through diet and exercise.  In some cases pills or injections of insulin may be required.

4.4. Gestational Diabetes:  affects approximately 4% of pregnant women and usually goes away after the baby is born.

4.5. Glucagon:  A chemical hormone produced in the pancreas.  It mobilizes stored sugar and causes the blood sugar level to rise.  It is used to treat severe hypoglycaemia and must be given by injection.

4.6. Hypoglycemia:  a blood glucose reading of under 4mmol/L. This may also be called an “insulin reaction”.  Hypoglycemia is a medical emergency and can lead to seizures and death if not treated properly. Symptoms occur when the body gets too much insulin, too little food, a delayed meal or snack, or more than the usual amount of exercise.  Symptoms include: tremors, sweating, light headedness, irritability/mood changes, confusion, drowsiness, hunger, paleness, blurred vision, the decreased ability to concentrate. The student will need to ingest carbohydrates promptly and may require assistance. Treatment options are set out in the Diabetes Emergency Treatment Protocol

4.7. Hyperglycemia:  a blood glucose reading of over 10mmol/L. High blood glucose levels can affect student learning. Hyperglycemia occurs when the body gets too little insulin, too much food, or too little exercise; stress or an illness such as a cold may also cause it. Symptoms include thirst, frequent urination, blurry vision, tiredness, decreased ability to concentrate, irritability/mood changes.  If untreated for a number of days, hyperglycemia can cause a serious condition called Diabetes Ketoacidosis, which is characterized by nausea and vomiting. This condition can be life threatening. This situation may appear in a matter of hours in children using insulin pumps rather than multiple daily injection therapy.  Parents or caregivers should be made aware of the situation so that steps may be made to correct it in the future.

4.8. Buddy:  for the purpose of this document, a buddy is defined as a child who will be allowed to accompany the child with diabetes to the office or other times that require the child with diabetes to leave the classroom unattended.  The role of the buddy will simply be to assist the child with diabetes by obtaining adult assistance should the child become weak or disoriented when away from the classroom.

4.9. Non Emergency Situations:  include routine care such as blood glucose testing and the administering of insulin injections.

4.10. Emergency Situations (Life Threatening):  occur when a student suffering from low blood sugar is unable to administer the appropriate treatment because they are unresponsive or unconscious.  Immediate action is required.  

 

5. Responsibilities

 

5.1.Responsibilities of The Principal 

5.1.1.Upon notification that a child with diabetes will be attending their school, the principal will arrange to meet with the parents to discuss the details outlined in this policy and to complete the Diabetes Emergency Treatment Protocol Registration. A folder will then be made available to all staff and substitute personnel.

5.1.2. The principal will arrange an annual in-service for all staff members who will supervise any children with diabetes during the school year.  This in-service will involve instruction on care from the Public Health Nurse or a Certified Diabetes Educator, as well as the parents of all children with diabetes.  Sessions will include the treatment of hypoglycemia, hyperglycemia and Glucagon administration

5.1.3. Personnel trained in Glucagon Administration will be identified in the Diabetes Care Plan.

5.1.4. The principal will ensure that at least 2 staff members are trained to administer Glucagon® in case of severe hypoglycemia

5.1.5. The principal will ensure that all staff are aware of the children with diabetes and respond appropriately to all diabetes related emergencies. Personnel will be instructed to remain with the student until appropriate treatment has been administered and blood glucose levels are stabilized.

5.1.6. The school will allow flexibility in the student’s class routine/school rules to ensure that the student with diabetes can appropriately manage his/her diabetes.  Situations may include allowing the student to eat on the bus or at his/her desk, not participate temporarily in certain activities, ask for assistance from school personnel, etc.

5.1.7. The principal will work with the parent(s) to ensure that a plan is developed regarding the supervision of children with diabetes on field trips.  If the parent is able, they should be allowed to accompany their child on all such outings if they wish. 

5.1.8. The principal shall work with the Department of Health to ensure that there are proper storage containers available in the school for the disposal of syringes, lancets and other medical waste.

5.1.9. The principal shall ensure that hypo- and hyperglycemia posters are posted in specific areas of the school to aid in recognizing the signs and symptoms of these reactions.

5.1.10. The school will designate personnel to notify the parent/caregiver if the student does not eat all scheduled meals and snacks (age appropriate) or vomits.

5.1.11. The principal will make sure a  medic alert sticker is placed on the tab of the student's cumulative school file and beside their name on the homeroom register.

5.2. The Teacher

5.2.1.The teacher will ensure that all blood glucose levels, insulin dosages, and treatments are logged properly in a book provided by parents.

5.2.2. The teacher will inform the parent at least 3 days in advance of all class parties, extra snacks, bake sales or treats.

5.2.3. The teacher will introduce diabetes into the classroom to foster acceptance and understanding in an age appropriate manner.

5.2.4. The teacher will advise parents at least 3 days prior to any change in activities such as playtimes or lunchtime schedules.

5.3. The Parent

5.3.1. The parent will advise the school of their child’s diagnosis.

5.3.2. The parent will fill out an Emergency Procedure Protocol Form for their child with diabetes.

5.3.3. The parent will participate in the in-service for staff regarding the care of children with diabetes in school.

5.3.4. The parent will ensure that the child has insulin, syringes, glucometers, test strips, treatment for hypoglycemia, glucagons and other diabetes related supplies at school.

 

5.4. The Student

5.4.1. The student will be responsible for wearing Medic Alert identification at all times.  The school will not require this identification to be removed for any reason.

5.4.2. The student will carry their supplies with them at all times.

6. Accommodations 

6.1. Children with diabetes will be able to keep a bottle of water with them at all times

6.2. Children with diabetes will have unrestricted access to washrooms.

6.3. Children with diabetes will be able to eat snack in the classroom

6.4. Snacks and meals for children with diabetes will be eaten at the same time each day.  Should there be any change in this routine, the parent will be told at least 3 days in advance.

6.5. Children with diabetes may leave the classroom for diabetes related issues

6.6. Children with diabetes should not leave the classroom unattended but should have a “buddy” assigned to them at the beginning of the year who will accompany them.

6.7. Children with diabetes must have immediate access to all diabetes related supplies.

6.8. Children with diabetes must be provided a safe and clean place to test their blood glucose levels.  If the child feels comfortable, this may be done in the classroom to minimize disruptions.

6.9. Children with diabetes will be allowed to inject their insulin whenever and wherever it is necessary.  This again can be done in the classroom or in a separate room as decided upon by the parent and principal.  All syringes will be disposed of properly in the provided containers.

6.10. Children with diabetes will be supervised by a staff member when administering insulin to verify that the correct dosage has been given.

6.11.Children with diabetes in primary and elementary school grades will be monitored by a staff member when eating snacks or meals to ensure that all of their food is eaten and no food is shared with other children.

6.12. Children with diabetes will be given adequate time to finish all of their snacks or meals without punishment.

6.13. Children with diabetes will be able to participate fully in Physical Education classes and extra-curricular activities.

6.14. Children with diabetes will be excused from Physical Education classes if their blood glucose levels are over 16.5 mmol/L with ketones present or have a blood glucose level below 4 mmol/L.

6.15. Children with diabetes will be able to test their blood glucose levels before all examinations and standardized tests.  They will be able to rewrite examinations if their blood glucose levels are over 12.2 mmol/L or below 4 mmol/L at test time.

6.16. Children with diabetes will not be penalized for time spent on diabetes related activities when performing an exam or completing a classroom assignment.

6.17. Children with diabetes will not be penalized for diabetes related absences.

6.18. Children with diabetes will be allowed to carry with them a cell phone for the purpose of contacting parents regarding diabetes care only.  The phone may be turned off when not in use.

7. Common Law Duty Of Care And Related Obligations

 

7.1 All school personnel shall help a student in an emergency situation to the best of their ability. The common law duty of care obligates school system employees and volunteers to take action in support of the physical well-being of students under their care. Employees must act, as would a careful and prudent parent of a large family in the same circumstances. It is, however, not to be construed that all the authority of a parent or guardian is conferred upon employees.

7.2. Qualified Medical Help and Ambulance Use. In the event where school personnel judge a situation, as a medical emergency, qualified medical help shall be sought immediately. Ambulance fees will be assumed by the parent.

 

 

Example of Diabetes Care Plan

 

Province of Newfoundland and Labrador

 

Diabetes care Plan for ____________________________________________________                 

School__________________________ Effective Dates__________________

Date of Birth______________ Grade______ Teacher_________________

 

Contact Information 

 

Parents/Guardians

Home Phone

Work Phone

Cell Phone

Address

 

 

 

 

 

 

 

 

 

 

Student’s Doctor

Home Phone

Work Phone

Cell Phone

Address

 

 

 

 

 

Other Contact

Home Phone

Work Phone

Cell Phone

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


School to contact the parents in the following situations

 

1._______________________________________________________________

   _______________________________________________________________

2._______________________________________________________________

   _______________________________________________________________

3._______________________________________________________________

   _______________________________________________________________

4._______________________________________________________________

   ________________________________________________________________

5._______________________________________________________________

   _______________________________________________________________ 

Hypoglycemia

Usual symptoms___________________________________________________

Treatment for hypoglycemia ________________________________________

_________________________________________________________________ 

 

Location of Hypoglycemia Kit__________________________________________ 

Glucagon Treatment for severe hypoglycemia   □yes □ no

Location of Glucagon Kit _____________________________ 

 

School Personnel Trained to administer Glucagon and dates of training 

 

Name

Date

 

 

 

Hyperglycemia

Usual Symptoms ____________________________________________________

Treatment for Hyperglycemia _________________________________________

___________________________________________________________________

Test for ketones in blood or urine when blood glucose level is greater than _____mmol/L

Test for ketones when student is feeling sick?  yes □ no

Procedure for ketone testing__________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________ 

 

Where are the following Diabetes Supplies kept?

 

Blood Glucose Kits __________________________________________

Insulin Administration supplies _________________________________

Hypoglycemia Treatment kit ___________________________________

Glucagon Kit _______________________________________________

Ketone Testing equipment _____________________________________

Snack foods ________________________________________________ 

 

Blood Glucose Monitoring Protocol

 

Student’s target range is between _________mmol/L and ________mmol/L

The usual times to test during school hours are

___before class begins       ___before lunch                   ___two hours after meal

___before recess                ___after outdoor play

___before gym class          ___before going home

Times that require extra testing

___before exercise     ____when hypoglycemic symptoms are present

___after exercise        ____when hyperglycemic symptoms are present

___other (explain)__________________________________________ 

Can student test him/herself on their own? ____yes  ____no

Exception_________________________________________________

 

School Personnel Trained to monitor blood glucose levels

 

Name

Date of training

 

 

 

Insulin Administration

 

Times, type and dosages to be given in school

 

Time

Type

Dosage

 

 

 

 

Is the child able to inject or bolus insulin on their own? ____yes ____no

If no, indicate personnel trained to inject insulin

 

Name

Date of Training

 

 

 

Is the child able to determine the correct amount of insulin to be used on their own? ___yes   ____no

Is the child able to draw up the required amount of insulin on their own?

 ___yes ___no

 

If the child is using and insulin pump

 

Can the child operate his/her pump?  ___yes  ___no

Can the student handle pump malfunctions?  ___yes   ___no

Who should be contacted in case of pump malfunction?

___________________________________________________

___________________________________________________

Comments __________________________________________

___________________________________________________

____________________________________________________

 

Meals and Snack foods

 

Meal

Time food must be eaten

Morning snack

 

Lunch

 

Afternoon snack

 

 

Snack required before exercise? ___yes  ___no

Type of snack required ________________________________

Snack required after exercise? _____yes  ___no

Type of snack required ________________________________

 

Foods to avoid

___________________________________________________

___________________________________________________

___________________________________________________

Instructions for when food is provided to the class: _________________

__________________________________________________________

__________________________________________________________

__________________________________________________________ 

 

Exercise and Sports

 

Student should not exercise when blood glucose level is below ____mmol/L or above _____mmol/L 

Signature of Parent/Guardian____________________________Date___________ Signature of Principal _________________________________ Date___________

high  lowClick on pictures for larger images

 

Treatment Protocol....When in doubt TREAT!!

Causes

Symptoms

Treatment

 

 Low blood glucose usually develops as a result of one or more of the following:

-insufficient food due to delayed or missed meal

-more exercise or activity than usual without corresponding increase in food and/ or

-too much insulin.

 

A person who is experiencing hypoglycemia will exhibit some of the following signs:

 -cold, clammy or sweaty skin

-pallor

-irritability, hostility, and poor behaviour

-a staggering gait

-eventually fainting and unconsciousness

 

In addition the child may complain of:

-nervousness

-excessive hunger

-headache

-blurred vision and dizziness

-abdominal pain and nausea

 

It is imperative at the first sign of hypoglycemia you give sugar immediately. 

 

If the parents have not provided you with more specific instructions which can be readily complied with, give:

-6 oz/175mL of regular pop (NOT diet) or

--6 oz/175mL of fruit juice, or

-1 tablespoon/15 mL or 3 packets of sugar, or

-4 glucose tablets or

-1 tablespoon/15mL honey

It may take some coaxing to get the child to eat or drink but you must insist. If there is no noticeable improvement in about 10 to 15 minutes repeat the treatment. When the child's condition improves, he or she should be given solid food as dictated by the parent. This will usually be in the form of the child's next regular meal or snack. 

Until the child is fully recovered he or she should not be left unsupervised. Once the recovery is complete the child can resume regular class work. If, however, it is decided that the child should be sent home, it is imperative that a responsible person accompany him or her. 

Parents should be notified of all incidents of hypoglycemia. Repeated low blood glucose levels are undesirable and unnecessary and should be drawn to the parent's attention so that they can discuss the problem with their doctor If unsure whether the child is hypoglycemic, always give sugar! A temporary excess of sugar will not harm the child but hypoglycemia is potentially serious.
from: Kids With Diabetes In Your Care–Canadian Diabetes Association

 

Emergency Procedure for Severe Low Blood Glucose

Hypoglycemia/Insulin Reaction

Glucose Gel Followed by Glucagon Injection

 

Pupil:                         DOB:                                School:                     Grade:

 

1. Glucose gel

2. Glucagon kit

3. Regular (not diet) soda pop

4. Blood Glucose kit

Essential Steps Key Points & Precautions

Essential Steps Key Points & Precautions

1. Verify signs of severe low blood glucose: Unable to swallow - Unconsciousness

Combative -Uncooperative - Seizures

 

Signs are so severe that pupil cannot participate in care.

2. Place pupil on side - or - in upright position if restless/uncooperative, AND Have someone call paramedics, school nurse, and parent.

If seizure occurs, follow standard seizure procedure.

3. Place one of the following in cheek pouch closest to ground and massage:

15 g. pkt. Monogel or Glutose

15 g. of glucose gel: ___

15 g tube Insta-Glucose –

or -___

 

Maintain head position to one side for preventing  aspiration

4. Give glucagon injection (use procedure below).

 

5. When pupil is able to swallow, repeat Step 3, - and - Give sips of regular soda pop (not diet) as tolerated until paramedics arrive.

Glucagon can cause nausea and vomiting

6. When paramedics arrive, pupil will be transported for medical care.

When transported, notify Authorized Health Care Provider.

 

7. Document on Procedure Log.

 

 

 How To Prepare And Inject Glucagon

 

1. Glucagon kit (diluent in syringe and vial of glucagon powder)

2. Alcohol wipes and cotton ball

 

3. Bandage

4. Sharps container

5. Gloves (if indicated)

 

Essential Steps

Key Points & Precautions

Prepare Glucagon syringe

 

1. Remove vial cap, clean vial top with alcohol (if time allows). Remove needle cover.

 

2. Inject contents of syringe into vial (held upright).

 

3. Swirl vial gently until dissolved/clear.

 

4. Hold vial upside down, and withdraw all solution.

 

5. Withdraw needle from vial, hold syringe upright, and remove air/bubbles from syringe, then, create dribble at needle tip.

 

Administer Glucagon:

 

 

1. Expose injection site (upper, outer area of thigh, arm or buttock).

 

2. Hold syringe safely; use other hand to clean injection site with alcohol (if time allows).

District policy may require gloves for injections.

3. Insert needle straight into muscle of buttock, arm or thigh and inject glucagon

 

4. Withdraw needle while pressing gently with alcohol wipe or cotton ball at injection site.

 

5. Massage injection site for 10 seconds; apply bandage if needed.

 

6. Put used syringe and vial in Sharps container.

 

If glucagon is prepared and not used, it is only good for one month if kept refrigerated.

 

 

References:

The Effects of glucose fluctuation on cognitive function and QOL:  the functional costs of hypoglycaemia and hyperglycaemia among adults with type 1 or type 2 diabetes.  By D. Cox, L. Gonder-Frederick; A. McCall; B. Kovatchev, W. Clarke.  Int. J. Clinical Pract. Suppl.  2002 Jul;(129):  20-6 

Sports and type 1 diabetes:  personal experience  By H. Dorchy  Rev. Med. Brux.  2002 Sep; 23(4):A211-7 

Hypoglycaemia and cognitive function in diabetes By B.M. Frier, Int. J. Pract. Suppl. 2001 Sep (123):30-7 

Canadian Diabetes Association 2001 Clinical Practice Guidelines

Prevention and Management of Hypoglycemia in Diabetes 

Lethbridge School District No. 51

Policy 504.1.3.A  Treatment of Diabetic Students  Halton District School Board

Diabetes Management:  A Protocol for Schools 2002 

New Brunswick Policy 704-Policy for Providing Health Support Services in Public Schools 

Ottawa-Carlton District School Board

Diabetes Management in Schools

Procedure PR.632.SCO 

P.E.D.S. Pediatric Education for Diabetes in Schools

Page 21-22

http://www.pedsonline.org/free_materials.asp

 

Drafted by

Barbra Wagstaff, BA

 

 

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