Delegation of Diabetic Care

[JoyMomNurse]

Hello. I am well acquainted with the scope and standards of practice in my state when it comes to delegating tasks. Per my stated diabetes care, including blood glucose monitoring, carb counting and subq insulin administration are all tasks delegated to an Unlicensed Assistant, for example, a teacher on a field trip. At the same time, as the school nurse, I have to feel comfortable delegating the care, and technically, the person receiving the training has to demonstrate competency. For me, demonstration means a lot more than you verbalize back to me how to perform a skill. So technically, say for example, a field trip was coming up, and I would be delegating diabetic care to a teacher, I could have that teacher give subq insulin for a period of days so I can see the demonstration of competency. But, I am not sure I wold delegate IM glucagon...b/c there is no way for competency to be demonstrated, as there is no trainer like there is for EPI. Further, while I can technically delegate carb counting, I don't feel that delegating correction dosages is ok. I cannot delegate dosage calculation. It's the same reason teachers can't give ibuprofen or acetaminophen, b/c it involves weight based dosage calc for certain populations. Do you feel that giving correction dosages would be similar. Some students have multiple equations for correction dosages depending on keytones, and while I do suppose the formula is basically laid out, there are a lot of factors involved.

Overall, I am wanting to know how others handle delegating our diabetic tasks for field trips etc when a nurse cannot go. If a student doesn't have a pump, certainly it seems the the unlicensed assistant should have to demonstrate competency on injections. And the whole correction dose thing....really thinking that shouldn't be delegated...but maybe I am over thinking it. I mean really...to demonstrate competency in diabetic care is way more than a 5 minute conversation before a field trip. Thought are appreciated!

In my state only RNs can give insulin and glucagon, so I either have to go or his mom goes (which she likes to chaperone anyway so it has worked out). I agree I would not feel comfortable delegating all of that to a layperson b/c at the end of the day, it is under MY license, so if anything goes wrong, I am liable.

[ruby_jane, BSN, RN]

Just because you CAN delegate, doesn't mean you have to. In Texas we can delegate diabetic care to an unlicensed provider with parental permission. Luckily I'm in high school where the kids are somewhat independent in their management. We have two complex kids (their health choices usually mean they are very high or borderline low) and I do not delegate their care (even with my highly competent aide) because their treatment involves nursing judgment.

You are absolutely correct: You are responsible for your delegee's actions. If you don't feel comfortable...that's an uncomfortable conversation to have with your admin. Let us know how it turns out.

[OhioBPH]

There is a glucagon trainer, FYI.

[ruby_jane, BSN, RN]

There is a glucagon trainer, FYI.

My aide and I practice with expired ones. However....do I believe she can safely mix and administer glucagon (or administer rectal Diastat for that matter)? Makes me uncomfortable. And different than an EpiPen which is just a solid THWOCK in the thigh muscle.

[mainecoonRN92, BSN, RN]

There is a glucagon trainer, FYI.

Where did you get a glucagon trainer. My district desperately needs it!

[ruby_jane, BSN, RN]

Where did you get a glucagon trainer. My district desperately needs it!

Check with the endocrinology practice at the childrens' hospital if available, or ask a parent if you can have their expiring glucagon.

[mainecoonRN92, BSN, RN]

Thanks good ideas!

[OyWithThePoodles, RN]

In my state it is legal to delegate insulin administration to UAP, but in my district we don't. A nurse is always there for insulin. If there is a field trip and the parent cannot go, a nurse must. As far as other diabetic care, if I am out or at another school and my T1D's come up, the office just calls me to see what to do. While they are perfectly capable of reading "If Johnny is less than 70 give him this..." they still want to make sure they are doing the right thing.

ETA: We do delegate glucagon, diastat, and epi-pens.

[JenTheSchoolRN, BSN, RN]

I can't delegate insulin or glucagon, but I can allow student's to self administer insulin on field trip (typically through a pump).

Because of this, I talk with parents but don't send glucagon a day field trip if I am not attending. Instead we make a 911 plan if student becomes unconscious. I would not feel comfortable having any teacher mix glucagon at my school.

I work with the older kids. Truth is, they never carry glucagon with them in every day life. Sure, I wish they would, but chance a stranger would mix it and administer it? I don't know. I really, really wish it had an easier way to be administered like Epi-pens.

[tippeny]

You didn't mention what kind of school you are at (or did I miss it?) When I was at my middle school, the kids were fairly independent. They could work calculations, dial up insulin (all had pens or pumps) and self administer. They were, however, required to have the dosages calculated by me (the RN). That being said, if the kid was responsible I would talk with the parent and student to see what they were comfortable with and get it in writing or email from mom/dad. The responsible kids were allowed to go solo and had to call the HR at lunch time/snack time, etc, to give me their numbers and I would do the calculation and verify the dose before they self administered. Just like if there were standing in my HR. The teacher in charge was made aware of the arrangements so there would be no confusion/questions on the day of the trip. For the irresponsible kids, they had to have someone with them to make sure they didn't flake out.

[ruby_jane, BSN, RN]

Because of this, I talk with parents but don't send glucagon a day field trip if I am not attending. Instead we make a 911 plan if student becomes unconscious. I would not feel comfortable having any teacher mix glucagon at my school.

The one time we had a truly steady diabetic who went on a lot of outings because of his extracurricular activities I handed the teacher a tube of glucose syrup and instructions to administer while someone called EMS....

But you're right. Parents send me the only glucagon they have because we ask for it but they've never needed to use it on their kid.