Requirements for school nurses to change insulin pump site

FolksBtrippin, BSN, RN · Sep 17

My thoughts:

The child is in 6th grade which means he is 11-12. An 11-12 year old should be more responsible for his own insulin pump. He should not be purposely removing it. He should be taught and empowered to put it back on himself. If he needs assistance in putting it back on, or if he needs a private space or supplies, he should be supported at school in this way, by the school nurse. The school nurse should know how to put the pump back on or should learn how to put the pump back on, but only to support the child in taking responsibility. This should be in the IEP and care plan. The eventual goal should be independence in management of insulin pump.

tlessman · Sep 17

This student is in the EBD program and cannot be trusted with his cares at this point so the parent has always done it. In my 14 years I have never had a diabetic that was so irresponsible and non-compliant with his cares. Usually by the time my diabetics are in 5th grade, they rarely come to see me because they do their own cares. It's definitely a situation I haven't been in yet so just trying to navigate his cares now that he is in the middle school

FolksBtrippin, BSN, RN · Sep 17

The behavior needs to be addressed. You said EBD, but not sure exactly what's going on here. It could be a way to self harm. It could be oppositional. This needs to be explored, an interdisciplinary approach applied. Can you ask for an interdisciplinary meeting for the child or is one due soon? You need a plan to address the non adherence.

tlessman · Sep 17

We are. We have been having meetings since he was in 2nd grade about this. Mom worked in the same building so did everything for him and he was never held accountable. Now that they are in different schools it's a bigger issue. Having another meeting today. I am just trying to see if anyone has any legal statues on requiring a nurse to change his pump site.

Home Health Columnist / Guide · Sep 17

Modern diabetes devices in the school setting: Perspectives from school nurses

Quote

Currently, there are no unifying clinical guidelines for the use of modern diabetes devices in schools, and little is known about how these technologies translate from the home to the school setting.

Diabetes Care Tasks at School

Quote

These modules focus specifically on how diabetes care should be done in the school setting and may also be used to train caregivers in the child care, camp, and other settings.

Check your states nursing practice act and state education regulations-- unaware of any requirement for the school nurse to be required to change continuous glucose monitoring sensor, especially since not part of an IEP.

Webinar for School Nurses Free CEU School Nurse On-Demand Webinars Offered

Quote

Safe at School® recently concluded its seven-part live webinar series attended by hundreds of school nurses from across the country covering topics such as core diabetes concepts, CGM and insulin pump use, nutrition, and legal protections. These recorded one-hour webinars are now available from the ADA's Institute of Learning offering one free CEU for each webinar completed.

Continuous Glucose Monitors (CGMs) in the School Setting

Hope our school nurses can chime in.

tlessman · Sep 17

Thank you! Just to clarify, this is for an insulin pump, not a CGM sensor

k1p1ssk, BSN, RN · Sep 17

Mom/Admin can't just throw pump maintenance into an IEP or 504 - Nurses follow orders from Doctors, not parents. If you do not have orders to perform the change (it may be referred to as pump "maintenance"), then I think you legally can't change the pump. It is a medical device, which would require orders from the prescribing doctor to have. So unless the mom gets an order dictating the nurse can do that maintenance (not to mention has received specific training on that device), she shouldn't feel obligated.

I also agree that at this point, the student should be working towards independence. The diabetic I had was still a bit nervous to change his pump site without me when he was in 6th grade, but he ran the show - I just stood by for encouragement and reinforcement of clean technique, placement etc. I would document that this care was done by the student with my assistance.

For reference, in my area, a typical diabetic order set for a pump includes the type of insulin, the basal rate and whatever carb correction ratio for boluses. It would include instructions to call the Pedi Endo if the pump failed and no replacement was available, or whatever - they would then give us specific verbal orders for the SC insulin injections (sometimes these would be included, but with how fancy pumps have become, I think there's more to it, especially if the basal rate is variable). The order set also typically gives authorization for the school nurse to perform pump & CGM sensor maintenance, dictates when to do a fingerstick instead of relying on the CGM, when to check ketones, and what to do with all of that information. They also include an emergency direct phone number for us (and families) to call the Pedi Endo provider office and get to speak with a nurse without going through the call center.

So, with that last bit in mind, if the nurse has contact info for this student's endocrinologist, I might bring these issues to their attention. Continue to call in Mom to do the change every time until the orders come through, and maybe even call the Pedi Endo every time. They might get so annoyed by the lack of compliance/independence that they call the family in for a meeting to discuss.

tlessman · Sep 17

I agree thank you so much! We are asking for a release to talk with endo today at this next meeting.

Home Health Columnist / Guide · Sep 17

k1p1ssk said:

Mom/Admin can't just throw pump maintenance into an IEP or 504 - Nurses follow orders from Doctors, not parents. If you do not have orders to perform the change (it may be referred to as pump "maintenance"), then I think you legally can't change the pump. It is a medical device, which would require orders from the prescribing doctor to have. So unless the mom gets an order dictating the nurse can do that maintenance (not to mention has received specific training on that device), she shouldn't feel obligated

Agree 100%. As camp RN, I had NO orders for insulin pump mgmt or diabetic mgmt for the 3 campers + staff-- everything handled by Camp Director who was IDDM since childhood and camp Pediatrician -their mom at their "diabetic porch". So when an issue occurred, that's who I called.