Ann Bartlett, often the source for many of my blog topics, recently sent me an article from the San Francisco Chronicle "Court Limits Who Can Inject Diabetic Students." In the article, Mr. Egelko, a staff writer, noted in early June, a state appeals court struck down California school regulations that allowed trained school staff members to give insulin shots to children who were unable to do so on their own. (For actual decision, see this.) In addition, they noted that state law required the caregiver to be a nurse. According to Mr. Egelko, the ruling overturned a 2007 agreement between the California State Department of Education and the American Diabetes Association. According to the ADA/CA state agreement, schools were required to train non-nursing staff members to check blood sugars and administer insulin if children are either too young or unable. Why? California (and now many other states) do not have enough nurses to care for children with diabetes.
According to the article, the California Nurses' organizations filed a suit indicating that state law allows school employees without a doctor's or nurse's license to inject insulin only in emergency situations. Apparently the law's definition of "emergency" does not encompass lack of nursing supervision to chronic shortages.
Mr. Egelko also aptly notes that state law allows injections by the student, student's parent, or a parentally designated relative or friend. It is clear that these provisions show that glucose monitoring and insulin injections require no special knowledge and can be given safely by trained school staff. As of this writing, only the Supreme Court may intervene when the overturned law takes effect in 30 days. Appeals are clearly being considered to overturn the ruling.
(I would be very interested to know what our newest Supreme Court justice, Sonia Sotomayor, has to say about this wrinkle since she went to school as young child with type 1 diabetes.)
The American Diabetes Association issued the following statement in response:
The American Diabetes Association expresses extreme disappointment in this ruling, which prevents non-medical school personnel from volunteering to administer insulin to California schoolchildren who are not yet able to self-manage their disease. Children with diabetes are in danger as a result of this ruling, because there are not enough nurses or other licensed healthcare professionals available in California's schools to administer the insulin that young students with diabetes must have in order to be safe at school. We want to emphasize that the opinion does not say that non-medical school personnel should not be permitted to administer insulin, or cannot do so safely, but only that they are not permitted to do so by currently enacted California law. Indeed, diabetes experts agree that permitting trained non-medical school personnel to administer insulin is in the best interests of these students.
"Every child with diabetes has a right to be medically safe at school and the right to the same educational opportunities as his or her peers." commented Nash M. Childs, PE, Chair of the Board of the American Diabetes Association. "Today's ruling goes against those basic rights. We will continue to fight for fairness and safety for children with diabetes and all those affected by the disease."
As of this writing, the ADA and JDRF are actively working to negate this ruling.
This issue is a "hot button" topic and is a universal concern of all parents with school-aged children regardless of their child's ability to be independent. All schools do not adhere to the same ADA policy and states vary with the degree of independence accepted. Indeed, the irony is often that too much independence may be allowed especially when children are low and allowed to go to the nurse's office alone. (I will never understand this....). In the Capitol area, some public schools allow more leeway than others. Clearly, the degree of diabetes independence is often based on the availability of a school nurse. Many public school systems have a traveling nurse who visits a school once or twice weekly with trained staff to help in their absence.
Is it then to be expected that a parent/caregiver must leave their place of employment to administer insulin or check a blood sugar level?
The fact that there is the lack of qualified school personnel to care for a child with special needs such as diabetes poses unique difficulties for the diabetes team. If the school refuses to allow a staff member to be trained to test blood sugars and administer insulin, what are the child's rights? Where does the Americans with Disabilities Act fit in? What about implementation of the 504 plan? My current understanding is that once the 504 plan is in place, public schools are required to adhere to the right of the child to check blood sugars and either administer insulin independently or with the help of a trained individual. Quite simply, in my opinion, it is unreasonable for my diabetes team to have to choose an insulin regimen solely for the convenience of the school system due to lack of qualified staff. Our toolbox is thus limited to conventional split mixed insulin: 2 or 3 shots/day to avoid the routine administration of bolus insulin at lunch. What about glucose monitoring in a young child at school?
Due to the lack of staff to administer insulin, does this translate to transitioning all children and teens to insulin pump therapy to avoid multiple daily injections? Insulin pump therapy is not for everyone. I also do not wish to prescribe an insulin pump to children/teens who show little enthusiasm or will not perform the necessary self-care skills required for successful pumping. Let us hope that this ruling does not go viral into the other 49 states.
For another perspective, read what Type 1 mom, Beth, has to say: The Insulin Wars in California Schools: Type 1 Kids Coming Up Losers
Published On: July 06, 2010