The Top Ten List. Top Ten Frequently Asked Questions: Colorado Standards, Diabetes Technology. Credit to David Letterman. Reverse of Question #1

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1 Credit to David Letterman Top Ten Frequently Asked Questions: Colorado Standards, Diabetes Technology Leah Wyckoff, MS, BSN, RN, NCSN Faculty, Diabetes Nurse Educator Barbara Davis Center for Childhood Diabetes Diabetes Resource Nurse, Colorado School Nurse Consultant, DCS Montessori The Top Ten List 1. Can I communicate with the provider? 2. Can I just use the orders or do I have to write care plans? 3. What care plans do I have to write and can they be individualized? 4. How frequently can a parent change the orders and when do I need a new order? 5. What do I do if I don t have orders? 6. What do I do if I don t have supplies? 7. What do I do when a student s BG is high can they stay in school or attend PE/sports? 8. How do I use the CGM & remote monitoring in the school setting? 9. What does the future hold regarding diabetes and how do we prepare? 10. Where can I find help? Can I communicate with the provider? The School Nurse/Child Care Nurse Consultant has permission for care coordination per signed diabetes health care provider orders, which aligns with both Health Insurance Portability and Accountability Act (HIPPA) and Family Educational Rights and Privacy Act (FERPA) regulations. Communication of blood glucose readings and coordination of care between student, school nurse, health care providers, and/or parents may include a variety of options, e.g. cell phone applications, web-based application, , and texting, which will be noted in the student s Section 504 plan. Reverse of Question #1 If a parent refuses to allow me to communicate to the provider, what do I do? Explain to parent that if you cannot communicate with provider then you cannot carry out the orders, provide care or delegate. Only First Aid. Offer option to do a 3-way call with parent on phone. Consider parent s underlying concern? Contact your administrator, diabetes resource nurse, ADA parent advocate to meet with you and family. Can I just use the orders or do I have to write care plans? Health Care Providers Orders cannot stand alone. The student s health care plan is developed by the school nurse/child care nurse consultant in collaboration with the parent/guardians and health care provider. Based on: Health Care Provider Orders Standards of Care: 1

2 What care plans do I have to write and can they be individualized? The student s health care provider may indicate exceptions to these Standards and individualize on the student s orders. The school nurse and parent can individualize certain components: Examples: Time of BG checks Amount of carbs to treat lows HCP for STUDENT THAT NEEDS ASSISTANCE WITH SELF CARE: 100 IHP Diabetes May 2014 Choose as appropriate: 100-A-Emergency-Action-Plan-Glucose- Monitoring- Treatment AP-Emergency-Action-Plan-PUMP-Glucose- Monitoring-Treatment 100-B-Insulin-Medication-Addendum-Revised-Sep C-Insulin-Pump-Addendum D Continuous Glucose Monitor Addendum 100-E Supplies- Diabetes Management Addendum: 300 Diabetes Classroom Daily Care Hypo-Hyper Flowsheet Plan HCP FOR THE INDEPENDENT STUDENT : 100-A-Emergency-Action-Plan- Glucose-Monitoring-Treatment AP-Emergency-Action-Plan- PUMP-Glucose-Monitoring-Treatment 400-Diabetes-Independent- Management Agreement for Students Ind Mgmt 303 Hypo-Hyper Flowsheet Plan How frequently can a parent change the orders and when do I need a new order? Obtain annually for the start of each school year If ongoing changes to the insulin dosing is a total of +/- 3 units per dose outside the current orders on file Parents could adjust up to 2 units before needing new orders What do I do if I don t have orders? No orders then no individualized care. Can only provide first aid. Meet with parents and find out barrier. Meet with Independent student even if you don t have orders Out of State Orders Yes, this has been clarified through the Board of Nursing by the Health Services, Colorado Department of Education. The statutory language in the Medical Practice Act, specifically (3)(b) allows for physicians in another state to write orders for patients in the state of Colorado under the language of "occasional consultation" along with some added provisions of not having standing contractual arrangements or an office in Colorado. Providing compliance with those requirements, the physician has the ability to practice in Colorado. Also (3)(i) allows for commissioned officers of the armed forces the ability to practice medicine in relation to their lawful duties in this state. 2

3 What do I do if I don t have supplies? Discuss with parents barriers Refer to provider if needs assistance BDC: Helping Hand fund Some pump companies will provide help School Medicaid funds Diabetes Resource Nurse Section 504 Plan: specify who will provide Non- Compliance Issues Barriers: e.g. finances, student managing on their own, perception of disease, Mother s/parents support system Depression/Anxiety (parents and/or student) On-going education: How old were they when they got orginial training how many years ago Team Approach: Referrals, Support Groups, Resources for families What do I do when a student s BG is high can they stay in school or attend PE/sports? See Table in Standards If you see a trend (3 or more highs in a row) contact parent to get new orders Can treat if >3 hours since last insulin dose. health assistant calls school nurse so that school nurse can do assessment. Consider if pump is malfunctioning then give insulin by injection. How do I use the CGM & remote monitoring in the school setting? Shared data plans and/or Wi-Fi will need to be provided by the parents as necessary for cellphone service and/or remote site monitoring. Confirm CGM readings with a fingerstick (Approval still pending for Dexcom G5 The Colorado Collaborative will develop evidence based resources per FDA regulation/guidance to support this practice innovation Remote Monitoring In the school setting is generally not required as the student is usually adult-supervised by trained school staff and frequent routine BG monitoring is scheduled as indicated. It is not the responsibility of school personnel to monitor the CGM readings. However, in certain unique cases (e.g. preschool age, non-verbal, impaired cognition, severe hypoglycemia unawareness) monitoring/remote monitoring may be appropriate and the school nurse/child care nurse consultant along with the Section 504 Team, will determine this need based on the student s individual unique need(s). Take Caution with remote monitoring if you decide to provide service then can you provide it safely? What does the future hold regarding diabetes and how do we prepare? Treatment using CGM readings Dexcom G5 More CGMs to come Hybrid Closed Loop Pumps: (Artificial Pancreas) Will treat highs and lows (predictive & threshold) Will choose on it s own to administer or withhold insulin (basal insulin) If student s BG levels go outside parameters it will then stop closed loop 3

4 Preparing for the future: Where can I find help? School Nurses receive ongoing training Increase training for Health Assistants/school staff Colleges of Nursing increase their training re: outpatient diabetes care. Board of Nursing have a school nurse member Colorado Kids with Diabetes Care and Prevention Collaborative continue to update Standards of Care to reflect new technology. CGM & Pump Medical representatives Endocrinologists NASN American Diabetes Association Safe at School Parent Advocates JDRF Find the Standards at: Contacting the BDC Always try to get a hold of parents first with hypo/hyperglycemic concerns If need an order immediately, call the BDC and ask to speak to the Nurse on Phones: If non-urgent, to Diabetes Nurse Educator may be the best way to contact Firstname.lastname@ucdenver.edu BDC Social Workers: My Contact Information Ellen Fay-Itzkowitz, MS Gladys Villa, MS Leah Wyckoff, MS, BSN, RN, NCSN ljwyckoff@gmail.com 4

5 Questions? Comments? 5