Back Up for Insulin Injections

[seedanurse]

Hello! I work at a middle school. We have a student who is Type I diabetic and takes insulin via an injection pulled up from an insulin pen (not with the pen needle...parent's don't trust the pens). He has a 504 outlining his medical accommodations.  

At the start of the year I was told to identify a couple staff who could cover his injections on days I am out the building. Our front office manager has a background in physical therapy and is OK with needles so she was trained. My first day off campus there was a med error (student was fine) but I decided I was not comfortable delegating this task any longer. Sooo, on days when I take PTO or am home with a sick kid I have to come in at lunch time to administer his dose, or if I absolutely cannot come in, I FaceTime the office manager to verify the math and dosing, and check the syringe. 

In my state, the nurse practice act allows nurses to delegate as they see fit, but they are responsible for the actions of their delegees. Higher ups in the district continue to want me to delegate his injections to a non-licensed staff member, I continue to refuse to delegate.

How do you all handle this? (I know that most kids are on pumps, but if you had a student with vial and syringe injections, how would you feel comfortable handling back up?)

Thank you for any input ?

[NutmeggeRN, BSN]

Your state NPA should have guidelines for delegation. Follow them to the letter of the law. Good Luck!

[Flare, ASN, BSN]

how involved is the student in their own care?  Would they be able to take a more active role in determining their dosage?   And further, can you have a student self admin?  I'm not saying that the onus should be placed entirely on the student, but if they are competent in their care and comfortable with taking a more active role in their care and they are permitted to take such a role, it may give you more peace of mind in delegating such a task.  In my state, I can't delegate insulin injections.  In fact, I have a special needs type 1 dm student who needs a pdn, since his bs will drop without him being able to adequately articulate it.  I have to be the one to actually do his bolus through the pump due to the med admin laws.  He is such a love!  He likes to walk me through the steps every day!   

[k1p1ssk, BSN, RN]

Insulin admin cannot be delegated in my state and it is so tightly regulated in my state, that we had a policy on the inpatient pedi unit I worked on where all insulin doses had to be double checked by another RN on the unit and co-signed in the eMAR.  

So, if I am out sick and there is no sub, the office staff would call the family of the student, notify them of our situation, and give them two options - keep the student home or offer for the parent to come in for the day to provide care. I imagine if the family gave a lot of pushback, the office might arrange for a nurse from another building to come over during scheduled administration times and called over again for hyper- and hypo-glycemic situations.

[seedanurse]

3 hours ago, NutmeggeRN said:

Your state NPA should have guidelines for delegation. Follow them to the letter of the law. Good Luck!

The state allows RN's to delegate any work, as long as they provide training, and feel the delegee is competent. The nurse is responsible for any actions taken for delegated tasks. 

There is no restriction on diabetic care here, but I still don't feel comfortable delegating that task. (If it was a pump, that would be OK, but not a hand drawn injection)

[seedanurse]

2 hours ago, Flare said:

how involved is the student in their own care? 

Student is unwilling to be involved. He does not know the terms, reasoning, math, etc. Will not draw up insulin, will not inject even if I draw it up. His parents are supportive of his approach and feel he should get to "be a child" and not worry about it. I had a tough conversation with them about his need to develop the skills to manage his care, but they are not very receptive. 

[Flare, ASN, BSN]

how long has he been type 1 dm?  And what grade??

[seedanurse]

Approx 18 months. 8th grader

[k1p1ssk, BSN, RN]

On 5/6/2022 at 5:19 PM, seedanurse said:

Approx 18 months. 8th grader

OK, while his diagnosis is still relatively new, he is of an age where he does need to start taking responsibility. He is an adolescent who (if he hasn't already) will be wanting to be more and more independent - are the parents going to follow him everywhere and do all this stuff for him or train all the other adults in his friend group to take care of him? I can imagine that is going to present a problem very soon... 

I found this handout that goes over expectations based on age groups: https://www.childrensal.org/workfiles/clinical_services/endocrine/age-related-diabetes-management-guidelines.pdf

It might be worth going over this with him and seeing what HE thinks about it....

[RatherBHiking, BSN, RN]

In the state I work I cannot delegate thankfully. I had an offer to work in another state where I live (I live on the border) and it was my kid’s school and I refused for this very exact reason. I didn’t want held accountable for someone else’s actions. I’ve trained enough lay people on emergency meds like epi pens and action plans for seizures to know many of them just aren’t that smart when it comes to stuff like this. I also have a newly diagnosed 8th grader who I’m gently encouraging to be more self sufficient who just doesn’t care or want anything to do with diabetes. It’s a fine line because you can’t force them and this is the age they like to rebel anyway. I think your plan of FaceTiming is good but there really should be a backup in case you just can’t for some reason. If there is no other nurses in your area that could stop by for you I’d ask the parent to intervene for you. Even if it’s just calling the school and asking the right questions to verify the correct dose is being given. Also sometimes you’ll have a teacher (or other staff) that is a diabetic and wiling to help out in those situations!