December 09, 2002
BLOOD SUGAR TESTING
By: John Kasprak, Senior Attorney
You asked for information on the testing of blood sugar levels by students with diabetes in school settings.
No statutes or regulations or uniform guidelines in Connecticut specifically address allowing students to test themselves in school settings for their blood sugar levels. A local school board would decide whether to allow such self-testing. The state has recently passed legislation addressing blood sugar monitoring of children in day care and camp settings by authorized staff. Regulations implementing these laws allow children to self-administer blood glucose tests under certain conditions, including written authorization from parents and a medical professional and direct supervision by a trained staff member. Generally, student blood glucose testing in schools would involve, in addition to the child, the school nurse and school medical advisor, teachers, parents, and possibly other staff. Also, determining the appropriate setting for the testing (e. g. the classroom, nurse's office, anywhere on school grounds) is an issue that has arisen and needs to be addressed in any local district's policy.
Current state law leaves the decision whether to allow school personnel to administer medication to students to local or regional boards of education. If a board decides to allow this, it must do so
within the parameters set out in statute and regulation. A decision by a local board to allow students to self-test their blood sugar levels would presumably follow similar procedures.
In the late 1990s, a student and her family sued a Connecticut school district under the federal Americans with Disabilities Act (ADA) because it did not allow her to test herself in a classroom setting. Instead, the school required her to go to the school nurse's office to conduct each test. The lawsuit was eventually settled out-of- court, with the student winning the right to conduct the blood testing in the classroom. (The student switched schools, but if she returns she continues to have the right to self-test under the agreement. )
Other states have passed legislation or adopted guidelines specifically addressing self-testing by students in schools. New Jersey legislation created a task force charged with developing guidelines addressing the needs of students with diabetes in the school setting. One of the guidelines, which are intended to be best practice standards and not mandates, recommends allowing students to test their blood sugar in school according to their individual health plan (IHP). In some cases, classroom testing would be appropriate.
A new law in Washington directs school districts to provide IHPs for students with diabetes and allow them to perform blood sugar tests. North Carolina legislation passed in 2002 requires the State Board of Education to adopt uniform guidelines addressing students with diabetes. The guidelines must be based on those of American Diabetes Association, which include allowing children to monitor their blood sugar anywhere necessary. Other states that have recently addressed aspects of this issue are Tennessee and Virginia.
BLOOD SUGAR TESTING BY STUDENTS IN CONNECTICUT
School Personnel and Administration of Medication
State law requires each local or regional board of education to appoint one or more school nurses or nurse practitioners. Such a nurse must be qualified according to state regulations. School nurses may also act as visiting nurses in the town, visit homes, assist in executing the orders of the school medical advisor, and perform other duties as requested by the board (CGS § 10-212).
While testing blood sugar levels is not "administering medications," state law on administration of medication may provide some guidance in addressing this issue. By law, a school nurse, or in her absence, any other licensed nurse, the school principal, or any teacher may administer medications to students at a school pursuant to the written order of a licensed physician, advanced practice registered nurse (APRN), physician assistant, or dentist and with the written authorization of the child's parent or guardian. The law allows administration of all types of medications, including controlled substances. (§ 10-212a).
The State Department of Education (SDE) has adopted detailed regulations covering administration of medicine in schools (see State Regs. , §§ 10-212a-1 et seq. ). The regulations state explicitly that schools are not required to administer medicine to students. Local school boards may decide: (1) whether schools under their jurisdiction may give students medicine; (2) who may give the medicine-licensed personnel only, or, in their absence, teachers and principals; and (3) whether students will be allowed to give themselves medication.
If a board chooses to allow medication, it must, with the advice of the school medical advisor and school nurse supervisor, establish specific written policies and procedures for doing so. The policies must be submitted to, and approved by, SDE. They must be reviewed and, if necessary revised, at least every two years. If the school nurse is absent, the regulations allow only school principals and teachers who are properly trained to give students medication. Such personnel may give oral, topical, or inhalant medicine and they may give injections only to students with medically diagnosed allergies that may require prompt treatment to protect against serious injury or death (Regs. § 10-212a-2).
Self-Medication by Students
Under the SDE regulations, a local board may allow a student to take medicine himself only if:
1. the authorized prescribe gives a written order for self-administration;
2. the student's parent or guardian has given written permission;
3. the school nurse considers it safe and appropriate, documents her conclusion on the student's cumulative health record, and has a plan for general supervision;
4. the school principal and appropriate teachers are told the student is taking medicine himself; and
5. the student brings the medicine to school and keeps it in his control according to the school board's policy on student self-medication (Regs. § 10-212a-4).
Individual School District Policy
As with self-medication, whether a student is allowed to self-test for blood sugar levels is a policy determination at the local school district level. The SDE does not have a detailed list of local school districts allowing students to do so. We have contacted the Connecticut Association of Boards of Education (CABE) for more information on local district policy. We will provide this when we receive it.
A student in the East Haddam, Connecticut school district filed a lawsuit under the Americans with Disabilities Act (ADA) after her school refused to allow her to test herself in the classroom. The school first required the child to go to the nurse's office for the testing. Then, she was allowed to test herself in class, based on a recommendation by a physician diabetes expert her family consulted. While in second grade, the school district apparently allowed the self testing in the classroom for three days, but then required her to return to the nurse's office for testing, arguing in part, that the student wasn't competent to do her own testing. But her parents pointed out that the child had performed over 3,000 tests to that point and physicians had written that she was competent to do so. Eventually, the family decided to sue under the ADA, filing in the U. S. District Court in New Haven in 1996.
The school district agreed to an out-of-court settlement that allows the child to regularly test her blood glucose in the classroom should she ever return to the East Haddam public schools (she apparently transferred to a parochial school in Old Saybrook; see "Testing in Class: A Connecticut Family Convinces a School District to Allow Blood Sugar Testing in the Classroom," Juvenile Diabetes Research Foundation International, Summer 2000 Newsletter).
CONNECTICUT LEGISLATION CONCERNING DIABETES
Connecticut has adopted diabetes-related legislation over the past few years addressing health insurance coverage, self-management training, and monitoring diabetes in children. But specific legislation allowing for students' self-testing of their blood sugar levels has not been adopted. More detail follows on these legislative enactments.
PA 99-284, which primarily addresses managed care regulation, also requires individual and group insurance policies to cover outpatient self-management training for the treatment of insulin-dependent, insulin-using, gestational, and non-insulin-using forms of diabetes. After a diabetes diagnosis, the policies must cover medically necessary training visits for: (1) up to 10 hours of initial training visits, including nutrition counseling and the proper use of equipment and supplies; (2) up to four hours of training and education after a doctor's subsequent diagnosis shows that a change in symptoms or conditions requires modification of the self-management program; and (3) up to four hours of training and education because of new techniques and treatments for diabetes. These benefits must be subject to the same terms and conditions as other policy benefits (see CGS §§ 38a-492e; 518e).
Testing in Youth Camps
PA 99-125 allows staff at youth camps to monitor glucose levels in campers with diabetes. It directs DPH to adopt regulations under which youth camp directors and staff can administer the monitoring tests (CGS § 19a-428). Regulations implementing this law specify that a child may self-administer a finger stick blood glucose test under the direct supervision of a trained, designated staff member upon the written authorization of the child's physician, physician assistant, or APRN, and the child's parent (see DPH Regs. § 19-13-B27a).
Insurance Coverage for Tests
PA 97-268 requires individual and group health insurance policies to provide coverage for laboratory and diagnostic tests to treat all forms of diabetes. The policies must cover (1) medically necessary treatment of insulin-dependent, insulin-using, gestational and noninsulin-using diabetes; (2) medically necessary equipment in accordance with a treatment plan; and (3) drugs and supplies prescribed by a licensed practitioner (CGS § 38a-492d; 518d).
Testing in Day Care Settings
PA 97-14 requires DPH to adopt regulations allowing child day care centers, group day care homes, and family day care homes to monitor the glucose levels of children in their care who are diagnosed with diabetes. Before they can conduct this monitoring, the facility must have a written order of a physician, dentist, APRN, or a physician assistant. The facility must also obtain the written consent of the child's parent or legal guardian (CGS § 19a-79(a); 19a-87c(b)). DPH regulations allow a child to self-administer a finger stick blood glucose test under the direct supervision of a trained, designated staff member. The child must have the written authorization of a medical professional and his parent or guardian (DPH Regs. , §§ 19a-79-13; 19a-87b-18).
New Jersey established a Task Force on Diabetes in the Schools in 1999. It was charged with developing guidelines on the most appropriate and effective means of providing for the needs of students with diabetes in the school setting. The guidelines had to include (1) a standardized but flexible system of procedures to enable a school to implement an individualized treatment plan for a student with diabetes; (2) basic procedures to ensure that a school works in conjunction with the student's parents and medical care providers; and (3) procedures to ensure that a student's diabetes care is integrated into the usual school routine to the greatest extent possible. These guidelines are not a mandate for the schools, but instead are meant to establish best practice standards for the care of children with diabetes in the school setting (Chapter 7, Laws of 1999).
The task force issued its report in January 2000 (Guidelines for the Care of Students with Diabetes in the School Setting, Task Force on Diabetes in the Schools, N. J. Department of Education; copy attached). The guidelines state that children with diabetes attending public schools should have an Individual Health-Care Plan (IHP), which includes an emergency health-care plan. The school nurse should be involved in developing the IHP, since the nurse will serve as the case manager who establishes the school treatment and emergency plans, coordinates the nursing care, and educates the school staff in monitoring and treatment of symptoms. The school nurse, under the guidelines, is responsible for consulting and coordinating with the student's parents and health-care provider to establish a safe, therapeutic environment.
The guidelines specifically address blood sugar (glucose) testing in the school. The report states,
"current technology is such that blood glucose is a minor invasive procedure. The values obtained from such testing are used to design and evaluate the diabetes treatment plan. The frequency of routine testing is determined by the student's health care team and may vary from student to student. Unscheduled or non-routine blood glucose tests must be done on an as-needed basis for students with diabetes who are suspected to be hypoglycemic (have a low blood glucose level) or hyperglycemic (have an elevated blood glucose level). "
The task force recommends that students be permitted to test blood glucose in school as per their IHP. For students requiring supervision, the blood glucose test should be performed in the nurse's office and traditional lancets are suitable, according to the guidelines. For students who are deemed sufficiently responsible, mature, and knowledgeable to perform tests in the classroom, the task force recommends using a non-reusable lancet. Also, universal precautions should be followed as required by federal regulations (see 29 CFR § 1910. 1030 PEOSH Bloodborne Pathogens Standard).
The North Carolina Legislature passed legislation in 2002 (Session Law 2002-103, SB 911), requiring the State Board of Education to adopt uniform guidelines for the development and implementation of individual diabetes care plans and local school boards to implement them. The guidelines must be based on those set by the American Diabetes Association (ADA), which recommend in part that: (1) school personnel be trained in the treatment of diabetes and hypoglycemia; (2) children be allowed to snack and monitor their blood sugar anywhere on school grounds, including in the classroom and on the school bus; and (3) students have access to glucagons at all times. Glucagon belongs to the group of medicines called hormones and is an emergency medicine used to treat severe hypoglycemia.
Under the law, the state board has until January 15, 2003 to adopt these guidelines, which school boards must implement in time for the start of the 2003-04 school year.
A copy of the law is attached.
A new law addresses accommodating children with diabetes in schools. The law, effective July 1, 2002, directs school districts to provide IHPs for students with diabetes, subject to certain conditions. One of these is that students must be allowed to perform blood glucose tests, administer insulin, treat hypoglycemia and hyperglycemia, and have easy access to necessary supplies and equipment to perform monitoring and treatment functions as specified in the IHP. School policies must give students the option (1) to carry with them the necessary supplies and equipment and (2) to do monitoring and treatment functions anywhere on school grounds including the classroom and at school-sponsored events (see Chapter 350 of the Laws of 2002, § 2, attached).
In Tennessee, existing law allows a local school board or a governing body of a private school to permit employees to assist students in the self-administration of medications. The assistance must be approved in writing by a parent, the student's condition must be stable, and the student must be competent to self-administer the medicine.
A 2002 law allows qualified school personnel to receive training by a registered nurse (RN) employed or contracted by a local education agency in administration of glucagons. School personnel so trained would be permitted to administer the shot in emergency situations to students based on their IHP. But if a school nurse is available and on-site, the nurse must provide this service. The school nurse is responsible for updating and maintaining each IHP.
The new law directs the state departments of health and education to jointly amend the existing "Guidelines for Use of Health Care professionals and Health Procedures in a School Setting" to reflect the appropriate procedures for use by RNs in training volunteer school personnel to administer glucagons. The guidelines must be used uniformly by all school districts that choose to allow school personnel to administer glucagons. Training to administer glucagons must be repeated annually. Finally, the law extends protection from liability to volunteers who provide these services and the RNs that provide the training.
A copy of the law (Chapter 808 of the 2002 Tennessee Public Acts) is attached.
In l999, Virginia adopted legislation (SB 899, Chapter 570) which required all Virginia public schools attended by a student with diabetes to have employees trained by a licensed medical professional to administer glucagons and insulin. Schools with 10 or more instructional and administrative staff must have two such full-time employees; smaller schools must have at least one. Training guidelines issued by the state Board of Nursing require all Virginia school districts to provide designated staff members with a four-hour diabetes training workshop conducted by a diabetes health care professional. A copy of the law is attached.
This law came about as a result of lobbying efforts by parents in Loudoun County, Virginia, and the American Diabetes Association (see attached document-Agreement, Loudoun County Public Schools).