What do you do?

nursetlm, ADN · Jan 9, 2020

My principal would then be calling the parent to advise that it needed to be brought in.

mainecoonRN92, BSN, RN · Jan 9, 2020

I have had issues like this, and at the end of the day, it is probably in your best interest to get admin involved.

Also make sure you are documenting your requests for the medication from parents.

SchoolNurse91, BSN, RN · Jan 9, 2020

Is it a financial issue? Insulin is super expensive.

ARN · Jan 9, 2020

type 1 mom here. I know the manufacturer recommends that you throw out an open vial after 28 days, however, insulin is expensive. even with insurance. they can't guarantee its potency, bacteria could form etc. is the reason for this rule.

what manufacturers recommend and often what type 1 diabetics have to do to get by are two different things.

I know as nurses we want to be by the books. we need to be to protect our licenses. however sometimes we also need to look at what our patients/students needs are as well (within reason).

I do not throw away my sons insulin if it is still effective (we aren't seeing unusually higher numbers without any other explanation/and it is not cloudy). I use it up until its gone. I keep his opened vial in the fridge until I need to use it/giving time for it come to room temp. now that he uses an insulin pump we go through about a vial a month and a lot gets wasted when we change his pods (omnipod). when he was mdi one vial lasted a long time for him.

insulin for a diabetic is like liquid gold. its sacrilegious to throw it away.

Can you work out a plan with mom to send in a new vial each month and you send back the open vial to her? so she can use at her discretion the opened vial? just an idea.

find out the reason she won't send you a new vial.

Diabetes is very very very very very expensive. between cgm, pump, insulin, strips, lancets, ketosticks, glucagon.....you get the point. we also have to throw in asthma and food allergies on top so inhaler, epi pen. not just one set. but mulitple of all of these things since my son isn't responsible enough to carry around his own supplies yet.

unfortunately this forces me a nurse and a mom to conserve and stretch out our supplies in whatever way I can that I still deem safe for my son. I make sure his epi is up to date but as he has used his inhaler less and less I can't justify buying new ones when there are still doses on the old ones that seem to be working ok. I can't justify throwing out insulin that is still working just fine and not causing my child any infection issues. we extend his cgm sensors by restarting them and trying to get 14 days vs the 7 that the manufacturer has fda approval to recommend is use for. before I became a mom of a type 1 I would have followed the books on these things to the T because I am rule follower. T crosser, I dotter. But as a mother of a child with multiple chronic illness I do what I have to do to make sure I can afford everything he needs.

sorry for the long reply. I know you have your students best interest at heart. yes 30 or 60 day insulin is better than no insulin.

I hope you can work a resolution out with the parent that you feel comfortable with.

JenTheSchoolRN, BSN, RN · Jan 9, 2020

1 hour ago, kelleyk1991 said:
Is it a financial issue? Insulin is super expensive.

This. And even when covered by insurance with a family that can afford to replace, shortages happen. I've had students that have "diabetes" buddy friends and borrow from each other when this happens (both taking same short-acting insulin). Not great, but also not great when you're out and order is arriving in three days.

I'd still give it while waiting as well in your case.

But, this did just remind me to request a new bottle for one of my students that I draw from nearly every day, so thank you! I do keep it refrigerated (the temp is not regulated well in my office) and it is isn't expired or cloudy, but it is time to start with a new bottle. I do send the home the old bottle usually, because honestly, parents can choose to still use it if they'd like.

amoLucia · Jan 9, 2020

(Not a school nurse here.)

To ARN - You wrote a very heart-felt, gut-honest letter that I think the mass majority of us never ever thought about. Not even thinking about its School Nursing application per se, cost affects such a large population of medication-dependent pts (myself included). It almost is like a sin to waste meds when there's still some leftover.

Like stupidly wasting food when hunger affects so many, again, it's like an obscene sin to toss out foodstuffs past the stated expiration date.

You said 'sacrilegious'; I feel it too, like a sin.

There's got to be something to do about it.

I've said it before - KUDOS to you school nurses.

BeckyESRN · Jan 9, 2020

48 minutes ago, ARN said:
insulin for a diabetic is like liquid gold. its sacrilegious to throw it away.
Can you work out a plan with mom to send in a new vial each month and you send back the open vial to her? so she can use at her discretion the opened vial? just an idea.

This is what I've done with a few of my diabetic kiddos. I explain to parents that I cannot keep an "expired" vial because it would be my license on the line if we were to get audited, but I'm happy to send it home (usually in the student's lunch box).

The cost of diabetic supplies and medication is unbelievable. The amount of hoops these parents have to jump through to, literally keep their child alive, is so sad.

KeeperOfTheIceRN, ADN · Jan 9, 2020

2 hours ago, kelleyk1991 said:
Is it a financial issue? Insulin is super expensive.

Until today, I had not heard any response from the parent as to why they hadn't brought one in. I just continued doing what we were doing and periodically sent another email or letter home.

@ARN, thank you very much for your post!! I am truly sensitive to the financial burden that those who live with diabetes have to face. I don't have personal experience with it, but I know its an arm and a leg for all of the supplies I genuinely want to help this family as much as I can. They are a newly diagnosed T1D, only about 4 months in.

I did finally hear back from mom today (the first time since we've started contacting her about the new bottle) and explained the WHY part of it (manufacturer's recommendation, bacteria, breakdown etc. etc.) BUT! I also explained that she could take the bottle we currently have and keep it at home for use there. I hadn't actually spoken to her about any of this as she never returned phone calls and never responded to emails or letters home. I had no idea on where they fell on all of this. But I did explain that I wasn't trying to inconvenience them or anything, I just needed to keep things "by the book" for legal reasons, especially since I'm not on this campus all of the time. Once we actually talked and I was able to explain things, she said she'd get a fresh bottle to the school and take the other one home. Again, thanks for your input on this! I'll definitely keep it in mind with any other diabetic families that come to my school!

ARN · Jan 9, 2020

I’m a bit on edge today as I update my sons insurance info with the pharmacy and durable medical equipment company.

The pharmacy auto filled my sons 3 month insulin supply. Denied since they ran his old insurance. So this is what I would pay out of pocket. Of course there are assistance programs out there but this price is gut wrenching. Not everyone qualifies for them and not everyone knows about them. They have to get samples at their endo. They have to ration insulin. They have to get otc R insulin which may not work well for them. They may not know how it works. There have been many deaths in the type 1 community due to the issue of cost. Dka that could have been prevented. Complications that could have been prevented.

So now I wait for them to do a prior auth because it’s a different insurance company. I’m not sure how they will pay but we will figure it out. Just sharing the financial side with you all.

ARN · Jan 9, 2020

7 minutes ago, KeeperOfTheIceRN said:
“They are a newly diagnosed T1D, only about 4 months in.”

Hopefully her communication will improve. My kiddo is 7 so I talk to the nurse frequently and we are on texting status now ? plus we work in the same district so she knows where and how to find me ?.

4 months in she is likely still very overwhelmed with it all. You get a crash course and really have to figure a lot out on your own. Not everyone is as motivated or knows where to even begin with learning all there is to know about T1D, what the school nurse needs...etc etc.

i am so glad you were able to talk to her and make a plan ?

JenTheSchoolRN, BSN, RN · Jan 9, 2020

3 minutes ago, ARN said:
Hopefully her communication will improve. My kiddo is 7 so I talk to the nurse frequently and we are on texting status now ? plus we work in the same district so she knows where and how to find me ?.

This is how me and one of the parents of my HS diabetic students works. Only parent that actually has my personal cell vs my google number - a nurse themselves and doesn't abuse it. The student's CGM data stream can be wonky so we can poke both and forth about highs as we give this student space to adjust themselves as part of the college transition. (Within reason, of course because teens are teens sometimes...)

OP, if you don't have a Google number, I recommend. Turned it around for me when it came to parent communication. All my Google phone number texts forward to my work email as well - I've been able to open some long thought lost communication panels with parents this way :).