Health professionals. Children and families. Policy makers
Leeds Teaching Hospital Trust
Intensive diabetes management, multiple daily injection regimens and insulin pump therapy are increasingly being recommended for children of all ages. Due to the age and development, children with diabetes are not all able to give their own injections or take responsibility for them. In order to ensure children get the support they need to live a full school life, appropriate diabetes care and management from schools is crucial for the child’s short and long term health and optimum academic performance.
How this service improves
It is important to ensure that blood glucose level of children with diabetes are close to the normal range (4-8mmol, rising to no higher than 10mmol two hours after a meal) for as much time as possible in order to reduce the risk of developing long term complications.
The local education authority and Leeds Hospital Trust worked together to have effective policies in place to support school staffs play an important role by monitoring blood glucose levels and administering injections or using the insulin pump to deliver insulin for food for children with diabetes. In result of this, children have better control during the school day and improved concentration, general well being, and reduced risk of developing complications later in life.
Why this service is a good example of shared practice
The team’s philosophy is that responsibility and risk should be shared between the child and family, health and education. The team have shown that it is possible for school to inject and give insulin via an insulin pump during the school day.
The programme is eligible to all school staff. Full day training for all local education staff was offered in order to develop the skills and knowledge a school member will need to supervise or administer insulin via a pen or pump. However due to poor attendance the team now have to visit each school individually to deliver the training.
The training includes raising awareness to school staff of the need for more intensive diabetes management at school, practical demonstration of administering insulin and supervising, practice opportunity under supervision and independently.
A guide to manage diabetes during school hours and on trips was developed. The guidance included a brief explanation of why more intensive management of diabetes has become necessary for children and different documents are produced for each level of required supervision: administration of insulin by staff; supervision only; insulin pumps; injections using pen devices; procedure for administering insulin via pen device; blood glucose testing procedures; hypoglycaemia and hyperglycaemia recognition and treatment.
The guidance is agreed and signed by parents, the Children’s Diabetes Nurse Specialists, head teacher and school staff who has been specifically trained. A full range of insulin management plans were developed including multi injections or basal bolus regimen, as summarised below.
(1) Agreement for school staff to administer a flexible dose of insulin via injection or insulin pump:
All school staff are made aware of the pupils who have diabetes and are wearing an insulin pump or who administer insulin via injection. School staff will ensure that a trained member of staff is available every school day to give or supervise the injection and will inform the child’s parent/ carer immediately if a trained person is not available. The mobile numbers of the Children’s Diabetes Nurse Specialists are listed on the guidance as well. Training is given to key staff on how to treat a hypoglycaemic episode and know the location of the ‘hypo treatment box’. Key staff are encouraged to disseminate this information to all school staff and the offer of returning to speak to all staff at their convenience is offered.
Staff members who have agreed to give the lunchtime injection of insulin have all practiced with an insulin pen and demonstrated their competence to the children’s Diabetes Nurse Specialist. One of the Children’s Diabetes Nurse Specialists will supervise the first injection that is given to them and offer ongoing support and training to schools as needed. Parents will continue to attend until they indicate to school and the diabetes nurse specialist that they are ready to sign the agreement and share the responsibility with school. The nurse specialist will then assess competency and also sign the agreement.
Staff will check the child’s blood glucose level before the lunchtime bolus of insulin. They are aware of the target of 4-8mmol/L and will record this in the logbook. If the blood glucose is less than 4mmol/L (hypoglycaemia) they will require 50mls Lucozade OR 3 dextrose tablets followed by long acting carbohydrate e.g. plain biscuits once feeling better (or as per agreement with parents documented in health care plan). If they are unable to tolerate oral diet or fluids, then staff at school needs to administer Glucogel to avoid further deterioration. They must be conscious prior to administration of Glucogel – if in doubt, they should be placed in the recovery position and 999 should be dialled.
If the child has a hypoglycaemic episode just before lunch, the lunchtime injection should not be given until they have made a full recovery from this. If in doubt, the parent(s)/carer should be contacted prior to administration of the insulin injection as this could cause a further hypoglycaemic episode. The Diabetes Team should be contacted if unable to contact parent(s)/carer.
The child will have a dose of insulin at lunchtime calculated using the Carbohydrate and blood glucose scale. This dose is based on the carbohydrate content of his/her lunch and the blood glucose result. Parents will inform staff of the carbohydrate content of lunch or in an older child will write the amount and put in the child’s lunch box. Any changes will be made in writing to the school, normally by the parent(s)/carer. On occasions this may be done by the Diabetes Team, who will also notify parents. The maximum amount of insulin that should be administered as a bolus will also be noted on the child’s guidance.
High blood glucose levels (above 14mmols/l) need to be reported to parent(s)/carer at the end of the school day, unless the child is unwell or they are on an insulin pump, in which case parents/carer should be contacted immediately. The diabetes team should be contacted if unable to contact parent/carer. Blood glucose tests may be indicated at other times of the day, for example mid-morning or before PE.
(2) Diabetes medical management plan (Animas Insulin Pump/ Medtronic Insulin Pump/ Roche Insulin pump plan in development)
Staff are trained to respond in the event of a pump problem. At school/ nursery, a key worker is responsible for a child’s daily care and in case of emergency. In the absence of the key worker, an alternative named member of staff will be available. In cases of hyperglycemia, moderate to severe hypoglycaemia, when the set site needs to be changed and generally at times of uncertainty it is advisable to contact the parents.
Deliver a bolus for food during snack/ lunch time:
If there was going to be cake or treat at school on a particular day, school staff could let parents know to enable them suggest the appropriate carbohydrate amount to use.
Packed lunch will be clearly marked with the total or individual amounts of carbohydrate and a list of carbohydrate values of snacks are developed by the dietitian together with parents and school staff. If the child does not finish something staff will make a best guess of food eaten and make a note in the log book (including insulin that was delivered) of any of these estimates to allow parents make any necessary adjustments at the end of the session. A maximum bolus with food is agreed and recorded in the healthcare plan. A maximum bolus can also be set in the pump memory as an additional safe guard.
Local education authority, Leeds Hospital trust risk management team and parents have worked collaboratively to develop and agree these health care plans
Over 40 schools in Leeds are administering or supervising children take insulin in school and the service continues to roll out to more. Schools were initially concerned about implementing the new approach but good outcomes are now being reported such as improved concentration and mood. Plans to offer an annual study day on long term conditions such as diabetes, asthma and epilepsy as part of teachers “statutory training days” are now being revisited in collaboration with the local education authority in order to more effectively target school personnel, highlight the key issues and provide quality education and training
Parents have reported feeling more confident about the support their child receives from school and more optimistic they can achieve their full academic potential and improving both long and short term health.
Significant amount of dedication and commitment from all key stakeholders.
The Leeds Paediatric Diabetes Team including 4 Children's Diabetes Nurse Specialists and a consultant paediatrician.