Diabetes Care Tasks at School: What Key Personnel Need To Know INSULIN BY PEN The American Diabetes Association’s Diabetes Care Tasks at School: What Key Personnel Need to Know is a training curriculum that consists of PowerPoint modules with corresponding video segments, pre-/post-tests and other helpful resources. This training is based on and should be used in conjunction with the 2016 “Helping the Student with Diabetes Succeed: A Guide for School Personnel”, a guide developed by the National Diabetes Education Program (NDEP), which is a federally sponsored partnership of the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention and over 200 partner organizations. Training participants should read the NDEP guide prior to this training in order to gain a full understanding of the requirements of appropriate school diabetes care. Participants should have a copy of the guide during this training and for future reference. The guide can be found on the web at http://www.ndep.nih.gov. Some key points about the overall training: Overall objective: The overall goal is to optimize both health and learning for students with diabetes by providing diabetes care training to school personnel about how and when to perform routine and emergency diabetes care tasks for students, under the supervision of a school nurse or another qualified health care professional. Completion of training will help prepare school personnel to perform diabetes care tasks, ensuring that health needs are addressed in times and locations when a nurse is not available. Rationale: The school nurse, when available, is the most appropriate person in the school setting to provide care for a student with diabetes. However, many schools do not have full- time nurses. Even for schools that do, the nurse may not always be available during the school day, during school-sponsored extra-curricular activities or field trips to assist with routine care and emergency care. Trained school personnel must be available to perform and assist the student with diabetes care tasks. August 2018

GOAL: OPTIMAL STUDENT HEALTH AND LEARNING Accurate and timely insulin dosing is a vital piece of a comprehensive plan. This training component was created specifically for school nurses and other qualified health care professionals to train non-medical school personnel. These components are: • Diabetes Basics • Diabetes Medical Management Plan • Hypoglycemia • Hyperglycemia • Blood Glucose Monitoring • Continuous Glucose Monitoring • Glucagon Administration • Insulin Basics • Insulin by Syringe and Vial • Insulin by Pen • Insulin by Pump • Ketones • Nutrition and Physical Activity • After-School Programs, Sports and Camps • Before- and After- School Care • Childcare • Psychosocial Aspects • Legal Considerations This unit is Insulin by Pen.

LEARNING OBJECTIVES Participants will be able to understand: Types of insulin pens Where on the body to inject insulin Preparation steps for insulin pen injection How to dose with an insulin pen How to inject with an insulin pen Participants will be able to understand: Types of insulin pens Where on the body to inject insulin Preparation steps for insulin pen injection Participants will be able to demonstrate: How to dose with an insulin pen How to inject with an insulin pen In addition to understanding insulin dosing and delivery using an insulin pen, it is important school staff who administers insulin to a student or assists a student with insulin administration understand the fundamentals of insulin action, dosing and delivery. These general concepts are covered in the unit entitled “Insulin Basics.”

METHOD OF DELIVERY Insulin injection Prescribed insulin therapy Prescribed as back-up plan if insulin pump malfunctions Prescribed for only certain seasons – determined by student, parent/guardian and provider Insulin pump Prescribed and intended year-round unless pump malfunction Prescribed and used for only certain seasons – determined by student, parent/guardian, and health care provider Insulin pens may be used for those on injections but also for those on insulin pump therapy during times of pump malfunction Method of insulin delivery is determined by the student, parent/guardian and provider and therapy may change. Some students may only ever use insulin injections while others may transition to insulin pump therapy, which will be discussed in another separate unit on insulin pumps. It’s important to be prepared that students on insulin pumps may still require injections during cases of pump or pump site malfunction. Some students on insulin pump therapy may also return to injections; see current DMMP for therapy.

INSULIN PENS Techniques for dosing and insulin delivery are similar for both types of pen devices - Prefilled pens - Reusable (cartridge) pens Both long-acting or basal insulin and rapid-acting or bolus insulin are available in pens Most students will only take rapid-acting or bolus insulin in school Regardless of whether a student uses a pre-filled or a reusable pen design, the techniques for dose preparation and insulin delivery are generally similar. Pre-filled pens Pre-filled pens contain a built-in, insulin cartridge. Because this device requires no loading by the student/parent/guardian, it is especially convenient and easy to use. Reusable pens With the reusable pen, an insulin cartridge is inserted into the pen's delivery chamber. Check the package insert for the specific guidelines for product expiration, as pens vary from vials. Injection basics with a pen: Once a disposable needle is screwed on to the pen and the pen is primed, pen is dialed to the appropriate dose, which can be seen in the device's display window and can be heard as audible clicks in many pen devices. The needle is inserted subcutaneously, and the plunger injection button is depressed to deliver the dose. The pen needle should remain in the subcutaneous tissue for 10 seconds after complete depression of the plunger.

INSULIN INJECTIONS Inject into fat layer under skin Rotate sites Insulin works best when it is injected into a layer of fat under the skin, above the muscle tissue. Rotating sites is important to insulin absorption. Common preferred sites are the abdomen, thighs, buttocks, and upper arms. Student should help choose injection site. Inject into fat layer under skin Rotate sites Student should choose site Common sites: abdomen, thigh buttocks, upper arms

INSULIN PEN: PREPARATION 1. Gather supplies. Verify insulin type pen device (with cartridge) pen needle alcohol wipe sharps container 2. Wash hands 3. Apply gloves 4. Have student chose injection site 5. Clean injection site 6. Screw on pen needle Here are the steps for administering insulin with an insulin pen device: Gather supplies: You will need the pen device (with insulin cartridge), pen needle, alcohol wipe, sharps container Wash hands Apply gloves Chose injection site Clean the area where you plan to give the injection Screw the pen needle onto the pen device

INSULIN PEN: DOSING 7. Prime: Dial “2” units. If the pen is being used for the first time, prime 4-6 units as per manufacturer’s instruction 8. Hold upright. Remove air by pressing the plunger. Repeat “Prime” if no insulin shows at end of needle 9. Dial number of units to be administered as per DMMP Dial “2” units 8. Holding the pen upright, needle end up, press the plunger at the base or bottom of the pen to remove air until a few drops of insulin come out of the end of the needle 9. Dial number of units to be administered as per DMMP Note: A brand new pen will need to be “primed” with 4-6 units until a few drops of insulin come out of the needle. The purpose of priming is to clear any air out of the syringe that could affect dosing. Priming should be done into the air and not at the student.

INSULIN PEN: INJECTING 10. Avoid injecting into muscle; if necessary pinch up the skin 11. Push the needle into the skin at 90 - 45° if necessary to avoid muscle 12. Release pinched skin 13. Push down on the plunger 14. Count to “10” 15. Remove and dispose of pen needle 16. Document time, dose, site, and blood glucose value 10. Pinch up the skin if necessary to avoid injecting into muscle 11. Push the needle into the skin at 90 into the chosen injection site. A 45° angled approach may be recommended for lean students to avoid intramuscular injection. 12. Release pinched skin 13. Push down on the plunger at the base or bottom of the pen 14. Count to “10” when using insulin pens 15. Remove and dispose of pen needle 16. Document time, dose, site, and blood glucose value The needle should be removed after each dose to prevent leakage of insulin from the pen. School personnel should allow the child to remove the needle if s/he is deemed competent to do so according to care plan agreements with the parent/guardian, student, and school nurse. If school personnel remove the needle, caution should be taken to carefully replace the outer cap of the needle without touching the outer cap itself.

Module 8 Pre – and Post – Tests: INSULIN BY PEN This tool may be freely duplicated and distributed for training purposes

Many pens contain a built-in insulin cartridge. True False Which is not a step to consider when administering insulin with a pen? Needle is screwed onto pen Insulin is drawn from vial Pen is primed Pen is dialed to appropriate dose Plunger injection button is pressed

American Diabetes Association WHERE TO GET MORE INFORMATION American Diabetes Association 1-800- DIABETES www.diabetes.org/safeatschool