January 30, 2012
MEDICATION AND BLOOD GLUCOSE TESTING IN SCHOOL
By: Judith Lohman, Assistant Director
You asked for summaries and copies of state laws and State Department of Education (SDE) regulations and guidelines concerning (1) requirements for school staff to give students, and for students to give themselves, medicine at school and (2) blood glucose self-testing in school by student with diabetes. You also asked whether injections for diabetes are allowed in school and, if so, whether they have to be administered only by the school nurse. Finally, you asked whether the SDE guidelines on blood glucose self-testing restrict the locations where student self-testing can occur or establish any other restrictions on such testing.
The law and SDE regulations specify when medicine may be given or taken in school. They allow a school nurse to give students any kind of medication, including controlled drugs, in school under certain conditions. The nurse must administer the medicine according to a written authorization from a doctor, dentist, optometrist, advanced practice registered nurse (APRN), or physician assistant. She must also have written permission from the student's parent or guardian. If the school nurse is absent, the school board may allow certain other qualified, trained school staff members to give students certain kinds of medicine.
School boards that allow school staff other than the school nurse to give medicine or students to give themselves medicine in school must adopt written policies and procedures for doing so. The procedures must comply with state law and regulations and be approved by the school medical advisor or another licensed physician. School staff who give medicine to students must be properly trained. They may not give students “investigational” drugs (drugs being investigated for federal approval) or controlled drugs under any circumstances.
School boards must also allow students with medically diagnosed chronic conditions, written authorization from qualified prescribers, and their parents' written permission, to carry and take medicine from asthma inhalers or, for allergies, from automatic prefilled cartridge injectors known as epipens, if they are capable of doing so. A board may also allow students with other conditions to give themselves medicine in school under certain circumstances.
The law requires school boards to let diabetic students test their own blood glucose levels in school if a physician's or APRN's written order states the student needs to self-test and is capable of doing so. The education commissioner must consult with the public health commissioner and adopt guidelines for policies and practices for students' glucose self-testing.
The law and SDE regulations on giving medicine in school appear to allow a school nurse, but not other staff, to administer diabetes-related injections. Qualified school staff other than the nurse may administer injections only through a cartridge injector to students with medically diagnosed allergic conditions requiring prompt treatment to avoid serious injury or death. The definition of a “cartridge injector” used in both the law and regulations limits their use to delivering epinephrine in a standard dose as an emergency first aid response to an allergic reaction.
SDE's guidelines on students' glucose self-testing do not, in themselves, limit where students may perform self-tests. Instead, they recommend that the individualized health care plan (ICHP) for a diabetic student designate appropriate locations. Under the guidelines, the ICHP is developed by a team consisting of, at least, the school nurse; appropriate teachers; the student's parents or other family members; and the student him or herself, if appropriate. Once the self-testing locations are designated, the guidelines and the accompanying agreement on self-testing among the student, parents, and the school specify that the testing must occur only in those locations.
ADMINISTERING MEDICATION IN SCHOOL
By law, the school nurse or, in her absence, any other licensed nurse or certain other qualified school personnel may administer medicine to students at a school pursuant to the written order of an authorized prescriber and with the written permission of the child's parent or guardian. Medications may be given only as allowed by law and under regulations the education commissioner must adopt, in consultation with the commissioner of public health (CGS § 10-212a)
As required by state law, the SDE adopted detailed regulations on giving medicine at school. The regulations require local and regional school boards to decide (1) who may give the medicine (i.e., a licensed nurse only or, in her absence, other authorized school staff) and (2) whether students, other than those with asthma or allergies, will be allowed to give themselves medicine.
Boards must also establish specific written policies and procedures for giving medicine in school. The policies and procedures adopted must be (a) approved by the school district's medical advisor or another licensed physician and (b) reviewed and, if necessary revised, at least every two years.
This report summarizes only the provisions of SDE's regulations relating to (1) medical providers who may order medication for students at school; (2) school personnel, who, in the school nurse's absence, may give students medicine and under what circumstances; and (3) the types of medicine they may give. The regulations also establish requirements for (1) training school personnel who give medicine; (2) handling, storing, and disposing of medicine; (3) documentation and recordkeeping; (4) reporting and handling errors; and (5) the school nurse's responsibility for supervising the administration of medication to students and implementing the required medication policies and procedures (Regs. of Conn. State Agencies, §§10-212a-1 to 10).
Medical Providers Who May Issue Medication Orders
Both the law and regulations require a school nurse or other school staff to give medicine to students, and students to give themselves, medicine only under a written order from a physician, advanced practice registered nurse (APRN), physician assistant, dentist, optometrist, or podiatrist. Physicians and dentists can be licensed in any state but the remaining practitioners must be licensed in Connecticut (CGS § 10-212a (a) (1)). Connecticut-licensed podiatrists may issue medication orders covering school staff only for intramural or interscholastic athletic events (Regs. of Ct. State Agencies, § 10-212a-1(3)). They may also issue written authorizations for students to give themselves medicine (CGS § 10-212a(c)).
Qualified School Staff Who May Give Medicine
Each school board must determine whether it will allow anyone else to administer medicine when the nurse is absent, and if so, under what circumstances. The law and regulations allow a board to designate any or all of the following to give medicine:
1. another licensed nurse, including one providing services at a school-based health clinic (who may give medicine only to students enrolled in the clinic), as long as the nurse is employed by, or providing services under the direction of, the school board;
2. a principal;
3. any teacher;
4. a licensed athletic trainer;
5. a licensed physical or occupational therapist;
6. a coach of intramural or interscholastic athletics;
7. a school paraprofessional, under certain conditions (see below); or
8. the director or his or her designee of a state-funded school readiness program or a before- or after-school program offered in a public school building by the school board or a municipality (CGS § 10-212a).
A school paraprofessional may give medicine only to a specific student who has a medically diagnosed allergy that may require prompt treatment to protect the student from serious harm or death. The medicine can include a standard dose of epinephrine delivered through an automatic prefilled cartridge or other injector (epipen) as an emergency first aid response to allergic reactions. The paraprofessional may give medicine only with the (1) joint approval, and under the general supervision, of the school nurse and medical advisor and (2) written permission of the student's parents (CGS § 10-212a(d)).
A principal, teacher, or occupational or physical therapist may give a student medicine if he or she is a full-time board employee. A coach who does so must have a coaching permit issued by the State Board of Education. All staff authorized to give medicine must be trained according to requirements specified in the regulations (Regs. of Ct. State Agencies, § 10-212a-1(35)).
School staff who give medicine according to the law and regulations are immune from civil damages for negligent acts or omissions in doing so. The immunity does not extend to gross, willful, or wanton negligence (CGS § 10-212a).
Virtually all types of medications, including controlled substances, may be administered in school. Schools that administer controlled drugs must keep the same records of drugs as a hospital and must store the drugs according Department of Consumer Protection regulations (CGS § 10-212a(b)).
Under SDE regulations:
1. a qualified school principal, teacher, or licensed occupational or physical therapist may give (a) oral, topical, or inhalant medicine and (b) epipen injections to students with medically diagnosed allergies that may require prompt treatment to protect against serious injury or death;
2. coaches and athletic trainers may give inhalant medicine and epipens, but only (a) during intramural or interscholastic athletic events and (b) to select students who cannot administer the medicine to themselves, as determined by the school nurse;
3. a specific paraprofessional may give medicine, including epipens, to a specific student only when needed to promptly treat an allergic reaction;
4. school readiness and before- and after-school program directors or their designees can give (a) oral, topical, intranasal, or inhalant medicine and (b) epipen injections to students with medically diagnosed allergies that may require prompt treatment to protect against serious injury or death; and
5. school readiness and before- and after-school program lead teachers or school administrators can give oral, topical, intranasal, or inhalant medicine but not epipen injections.
None of the above are permitted to administer “investigational drugs,” which SDE regulations define as new drugs that have applied for Food and Drug Administration (FDA) approval and that are being tested and evaluated for efficacy, safety, and side effects as part of the FDA approval process (Regs. of Ct. State Agencies, § 10-212a-2).
Controlled drugs may be administered in schools and school readiness and before- and after-school programs only according to board of education policies.
Self-Medication by Students
A school board must allow a student with a verified chronic medical condition and who is capable of doing so, to take emergency medicine, including rescue asthma inhalers and epipens for allergies. A board may also allow students to give themselves other medicine in school.
In either case, a student may take medicine him or herself only if:
1. the medicine's authorized prescriber gives a written order for self-administration;
2. the student's parent or guardian has given written permission;
3. the school nurse assesses the student's competency, considers self-medication safe and appropriate for the student, documents her conclusion on the student's cumulative health record, and has an appropriate plan for the self-medication that includes its general supervision (but the district cannot use these conditions to prevent a student from carrying and giving him or herself inhalers or epipens for medically diagnosed allergies);
4. the school principal and appropriate teachers and staff are told the student is taking medicine him or herself; and
5. the student brings the medicine to school and keeps it in his or her control according to the school board's policy on student self-medication (Regs. of Ct. State Agencies, §10-212a-4).
A student cannot give him or herself controlled drugs, except in extraordinary situations, such as an international field trip, and then only (1) with the advance approval of the school nurse supervisor and the school medical advisor and (2) after development of an appropriate plan for doing so (Regs. of Ct. State Agencies, 10-212-4 (g)).
BLOOD GLUCOSE SELF-TESTING IN SCHOOL
A school board must allow a student with diabetes to test his or her own blood glucose levels in school if the student has an order from a physician or APRN saying he or she needs the testing and can do it him or herself. The law also requires the education commissioner to consult with the public health commissioner and adopt guidelines for school district policies and practices concerning the self-testing. The guidelines cannot be considered regulations (CGS § 10-220j). The education commissioner issued the guidelines on February 6, 2004 (Circular Letter C-19, Series 2003-2004).
According to the guidelines, students with diabetes should have individualized plans addressing their health and safety at school. The plan can be either a Section 504 plan (accommodation plans for students with disabilities developed under § 504 of the federal Rehabilitation Act of 1973) or an Individualized Health Care Plan (IHCP) that includes an Emergency Care Plan (ECP).
The guidelines recommend that school districts have policies on student blood glucose self-testing that address:
1. the process for developing each student's IHCP, including the members of the plan team, which should include at least the school nurse, appropriate teachers, the student's parents, and the student him or herself, if appropriate;
2. communication among the school, student, and the student's family and health care provider, including with respect to (a) documenting the student's needs, (b) required permissions and authorizations, and (c) how frequently communication occurs;
3. appropriate locations for self-testing that take into account (a) the student's needs, competence, and independence, (b) the safety of the student with diabetes, other students, and school staff, and (c) self-testing accommodations during field trips and athletic events, and in unusual situations such as school lockdowns and closures;
4. safety concerns, including disposal of lancets and other blood-exposed items according to Occupational Health and Safety Administration (OHSA) Universal Precaution Standards, and procedures for (a) carrying and storing testing items and (b) identifying signs of high or low glucose levels and what to do in those instances;
5. making sure appropriate school staff, including custodians and bus drivers, know of the plan, about diabetes in general, and the importance of timely treatment; and
6. procedures for evaluating, at least annually, the plan's effectiveness, testing locations, student competency to self-test, and changes in the school environment.
The guidelines include the following appendices:
1. a list of things to be included in student IHCPs and ECPs;
2. a list of responsibilities for team members creating the plans;
3. a checklist for the school nurse to monitor and make recommendations on the student's self-testing, including whether the student understands what locations are appropriate for self- testing;
4. a sample agreement between the school and the student and his or her family, including a requirement that, once appropriate locations are determined, self-testing be performed only in those locations; and
5. general instructions for self-testing, with the caveat that the student follow the instructions given by his or her own health care provider.
Limitations on Student Self-Testing
While the guidelines do not, in themselves, limit a student's self-testing, they advise that such limitations be part of an ICHP for the student. The guidelines state that the ICHP should specify the locations for self-testing, while the attached Sample Agreement Concerning Blood Glucose Self-Monitoring, to which a student and his or her family subscribe, states that “self-monitoring shall be performed in the designated location(s).”
The guidelines also advise that, if testing is taking place outside the school health office, the school nurse complete a self-testing check list, a sample of which is appended to the guidelines. The sample includes a criterion that the “student understands what locations are appropriate for blood glucose self-monitoring.” It also provides space for the nurse to enter her conclusions about whether the student is capable of self-testing. If the nurse concludes that the student is not, the sample provides space for her to suggest steps that “will help the student move toward independence.”