Care of Students with Diabetes in Schools: Frequently Asked Questions

1. When does the law take effect?
   The law was signed on October 1, 2009 and is effective January 29, 2010.
   
   
2. Does the law apply to nonpublic schools or early childhood programs?
   No. The law defines a school as an elementary or secondary public school located within the state.
   
   
3. Who coordinates diabetes care in the school?
   The law requires the school nurse to coordinate the provision of diabetes care at that school.  The school nurse develops the individualized healthcare plan (IHP) and an emergency healthcare plan (IEHP), communicates regularly with the student, parents/guardians, and the healthcare team, and documents care.
   
   
4. Why does the law require an individualized healthcare plan (IHP) and an emergency healthcare plan (IEHP)?
   The IHP and the IEHP are developed by the school nurse, in consultation with the parent/guardian and other appropriate medical professionals, to establish a set of procedural guidelines and directions for the care of the student with diabetes while at school or at school-sponsored activities.
   
   
5. What information must be included in the IHP/IEHP?
   The law states each individualized health care plan (IHP) shall include, and each individualized emergency healthcare plan may include the following information:
   • the symptoms of hypoglycemia and recommended treatment;
   • the symptoms of hyperglycemia and recommended treatment;
   • the frequency of blood glucose testing;
   • written orders from the student’s physician or advanced practice nurse outlining the dosage and indications for insulin administration and glucagon, if needed;
   • the times of meals and snacks and indications for snacks with exercise;
   • full participation in exercise and sports and any contraindications or accommodations;
   • accommodations for field trips, after school activities, parties, and other school-related activities;
   • medical and treatment issues that may impact the educational process for that student; and,
   • how to maintain communication between the parents, the healthcare providers, and school staff.
     
     
6. How often must the IHP/IEHP be updated?
   The law requires that the parents/guardians annually provide to the board of education written authorization for the provision of diabetes care.  The school nurse is required to update the IHP/IEHP prior to the beginning of each school year and as necessary to address any changes in the health status of the student.
   
   
7. Can a student be permitted to self-manage his/her diabetes while in school?
   Yes. The student’s parents/guardians and healthcare providers must provide authorization for self-care and include written certification from the student’s physician or advanced practice nurse that the student is capable of and has been instructed in the management and care of his diabetes.
   
   
8. How does the law define self-management?
   As provided in the student’s IHP, a student is permitted to attend to management and care as needed in the classroom, in any area of the school or grounds, or at any school-related activity.  Self-management activities might include testing blood glucose levels, administering insulin, and treating hypoglycemia or hyperglycemia. Self-management activities require written authorization from the student’s parent/guardian and the child’s physician or advanced practice nurse.
   
   
9. Are students permitted to possess medical equipment such as syringes and medications?
   Yes.  The law states that the possession and use of syringes consistent with the purposes of diabetes management shall not be considered a violation of applicable statutes and regulations.
   
   
10. Does this mean that a student can conduct glucose testing or administer insulin in a classroom setting?  What about bloodborne pathogens issues?  What if it upsets other students or staff?
    For students deemed sufficiently responsible and as authorized by their healthcare providers, students can conduct blood glucose monitoring and insulin injections safely and discreetly in any setting.  Students should be trained to safely dispose of medical waste including lancets and needles.  Students should also be trained to clean the desk or counter after testing (e.g., using special wipes to clean the area, using a disposable tray for medical equipment that might contain blood).  If students or school personnel are upset by these procedures occurring in the classroom, the school should take steps to educate them about diabetes care.
    
    
11. Should diabetic students be permitted to eat or drink in classrooms?
    Timing of meals, the quantity of food, and nutrient quality of food are major parts of the management of diabetes.  The student’s IHP/IEHP should outline the diabetes meal plan and any need for additional snacks related to exercise.  The student with diabetes may need to have access to snacks and water in the classroom and can do so in an unobtrusive manner.  Students with diabetes may need such accommodations during academic examinations as well.  Permitting such access is less disruptive and ensures that the student will not miss classroom instruction.  Parents/guardians should provide a ready supply of snacks that can be eaten quietly, with minimal preparation or mess, and that can be safely stored or carried during the school day.   In no instance should a meal/snack be withheld because of discipline or lack of payment for school food services.
    
    
12. Should students with diabetes take physical education or participate in sports?
    Yes.  Exercise is an important part of diabetes care.  Specific accommodations for physical education and sports should be noted in the student’s IHP/IEHP.  In general, the child should be permitted to check his/her blood sugar level before, during, and after exercise.  Students may need to eat before intensive exercise and extra snacks may be needed to prevent low blood sugar.  Students may need extra water, especially in hot weather.  Coaches and physical education teachers must be keenly aware of the child’s medical condition, the signs and symptoms of hypoglycemia, and appropriate treatments.
    
    
13. What if the school nurse is out of the building and a diabetic emergency occurs?
    The law permits the school nurse to designate, in consultation with the board of education, additional employees of the school district who volunteer to administer glucagon to a student experiencing severe hypoglycemia (low blood sugar) when the nurse is not physically present.  This can occur when the nurse is out of the building or when a nurse is not present such as at a school-sponsored event after school, at night, during the summer or on weekends.
    
    
14. What kind of training should a trained delegate have?
    Glucagon is a life-saving hormone that raises the blood glucose level.  Since glucagon is an injected medication, volunteers must be trained to recognize the signs and symptoms of hypoglycemia and to mix, withdraw, and inject the medication into a student’s arm, thigh, or buttock.  It is recommended that trained delegates also be CPR-AED certified.
    
    
15. How often should this training occur?
    The law does not state how often the training should occur. However, newly trained volunteers may require monthly practice sessions to increase their comfort with the procedure.  In addition, the law does require that the school nurse update the student’s IHP/IEHP at the beginning of each school year and as necessary to address any changes in the health status of the student.  Therefore, the trained delegate should be informed of any changes to the student’s care at least annually as part of the school nurse’s update to the IHP/IEHP, and more often if the student’s health changes requiring modifications to the plan of care. Since the school nurse is delegating this emergency task, the nurse should assess the volunteer’s skill and comfort-level with the procedure and document accordingly.
    
    
16. Can a school employee be required to serve as a trained delegate?
    No.  The law specifically states the individual must be a volunteer.  The law requires that the school nurse designate, in consultation with the district board of education, employees who can be trained to administer glucagon in an emergency.  The designated employee must demonstrate proficiency in handling a diabetic emergency including administering an injection and providing supportive care until emergency medical services arrives for transport and follow-up care.
    
    
    
17. Can a school employee be held liable for any care or aid provided under this law?
    No school employees, including the school nurse, bus driver, bus aide or other officer or agent of the board of education shall be held liable for any good faith act or omission consistent with the provisions of this act nor shall any action before the New Jersey State Board of Nursing lie against a school nurse for any such action taken by a person trained in good faith (trained delegate) by the school nurse pursuant to the law.
    
    
18. Can licensed athletic trainers serve as volunteer delegates?
    Yes, the law specifies that should an athletic trainer volunteer under the provision of this law, it shall not constitute a violation of licensure.  However, since the administration of glucagon is not within the scope of practice of the athletic trainer, he/she should participate in the same training as any other volunteer.
    
    
19. What should schools do to educate all school personnel about diabetes?
    The school nurse is encouraged to provide an overview of diabetes to all employees and more student-specific training to those most likely to have responsibility or supervision of a student with diabetes.  Topics should include hypoglycemia and hyperglycemia and when to call for assistance.  Staff working with school-sponsored programs outside the regular school day such as coaches, athletic trainers, club advisors, afterschool care providers, and others responsible for the supervision of students, should be included in the training.    The law also requires schools to post a reference sheet which identifies the signs and symptoms of hypoglycemia in students with diabetes.  A sample reference sheet can be accessed on the department’s website at http://www.nj.gov/education/edsupport/diabetes/qrh.pdf.
    
    
20. How does the law address the sharing of confidential medical information?
    The school nurse is required to obtain a release from the parent/guardian to authorize sharing of medical information between the student’s physician or advanced practice nurse and other health care providers.  The release shall also authorize the school nurse to share medical information with other school personnel as necessary.
    
    
21. How should bus drivers address diabetic emergencies?
    The law requires bus drivers who transport student with diabetes to be given notice of the student’s condition, how to treat hypoglycemia, who to contact in an emergency, and parent contact information.  School district transportation coordinators should be included in any diabetes care training since the coordinator is responsible for ensuring that bus drivers, whether contracted or district employees, comply with the requirements of this law.
    
    
22. Can a school nurse accept changes in a child’s insulin dosage from the parent/guardian?
    No.  Changes to a student’s dosage should be included in the IHP/IEHP and changes must be authorized by the child’s physician or advanced practice nurse.
    
    
23. What resources are available to assist schools to address this law?
    The New Jersey Department of Education has developed or adapted materials to assist schools to meet the requirements of this new law.  In addition to this FAQ, the department’s website features sample Power Points on the law and glucagon administration.  It also includes Action Steps for School Personnel, which outline the responsibilities of administrators, school personnel, and parents. In collaboration with the American Diabetes Association, the department is sending every school district and charter school a copy of Diabetes Care Tasks in Schools: What Key Personnel Need to Know.  This kit includes 13 Power Point modules and a DVD containing video segments to supplement the Power Point slides.  Additional tools found on the department’s website will include a sample IHP/IEHP, reference sheets, and links to training videos.
    
    
24. Currently, we do not have any students with diabetes enrolled in our district.  How should we prepare for the possibility and what costs might the district anticipate?
    Even if there are no students on roll with diabetes, all personnel can be provided with the basic overview of diabetes at an in-service-day or faculty meeting.  Because the ADA modules are Power Point slides and videos, school personnel can view them from their desktop computer or even at home on a personal computer. Should a student with diabetes enroll, the basic training can then be easily expanded to include student-specific information.  For schools with students with diabetes on roll, districts may need to consider the possible costs of training delegates, access to glucagon for emergencies for those students who cannot carry their medication, the cost of the delegate to attend special events outside the school day such as field trips or athletic events, and training in CPR-AED should the district require it for all delegates.
    
    
25.  What happens if the school nurse or delegate is not available during the school day or for all school-sponsored activities?
    N.J.A.C. 6A:16-1.4 requires district boards of education to develop and adopt written policies and procedures to address the care of any student who becomes injured or ill while at school or during participation in school-sponsored activities.  Should the school nurse or delegate not be immediately available, personnel should initiate district emergency protocols, including calling 911.