Hello everybody. Welcome to today's one-hour panel discussion and webinar, Back to School, Bringing Diabetes Devices into the Classroom. We're glad you've joined us. You have an excellent program that we're going to share with you today. My name is Dr. Stuart Weinzimmer. I will be co-moderating today's webinar. To share a little bit about myself, I am a professor of pediatrics at the Yale University School of Medicine and a clinical professor at the Yale School of Nursing. I care for children with type 1 diabetes. I'm a pediatric endocrinologist and I've been working with diabetes technology for over 20 years. And I am also co-moderating. My name is Henry Rodriguez. I'm a pediatric endocrinologist as well. I'm a clinical director of the USF Diabetes and Endocrinology Center and a professor of pediatrics here at the University of South Florida in Tampa. My professional focus has been on the prevention and management of type 1 and type 2 pediatric diabetes. I'm a longtime ADA volunteer and I've had the privilege of serving as co-chair of the ADA Safe at School Working Group for several years. I'm a member of the ADA National Advocacy Committee and Legal Advocacy Subcommittee and my advocacy efforts on behalf of children, adults, and families affected with diabetes include long-standing collaboration with multiple school nurse organizations. I'm also an ardent supporter of diabetes camps. Thank you, Henry. So let's introduce the presenters for today's session. Dr. Christine March is an assistant professor of pediatrics at the University of Pittsburgh School of Medicine and an attending physician in the Division of Pediatric Endocrinology at the University of Pittsburgh Medical Center Children's Hospital of Pittsburgh. Dr. March is a health services trained investigator who conducts community partnered research using mixed methods. Her academic interests are focused on the care delivery and utilization by children and adolescents with type 1 diabetes with a specific focus on optimizing school-based management of type 1 diabetes. Currently she's funded by an NIDDK Career Development Award to develop and pilot a school-partnered collaborative care model for children with type 1 diabetes. The goal of this research is to develop a usable intervention which more comprehensively connects medical and school health care teams to help children with diabetes and their families achieve individualized goals. In addition to partnering with local school nursing organizations, she sits on both the ISPAD Diabetes in School Steering Committee and the American Diabetes Association Safe at School Working Group, contributing to national and international advocacy efforts and guidelines for children with type 1 diabetes to ensure that they have access to equal opportunities in school. Our other panelist is Crystal Woodward. She's the Managing Director of ADA's Legal Advocacy Program and the Safe at School Campaign that's based at the Association's home office in Arlington, Virginia. She's considered a national authority on the rights of students with diabetes and has spoken at conferences and forums throughout the United States and internationally on how to effectively advocate on behalf of students with diabetes, training hundreds of patient advocates, attorneys, and health care professionals. As a parent of a child with diabetes, Crystal began her advocacy as a volunteer for the ADA when she and another parent advocate teamed up to lead the passage of the first state diabetes school legislation in the country. And they successfully pursued a with the Office of Civil Rights and the Department of Education, resulting in a settlement that is a nationwide model for safe and effective school diabetes care. Crystal has contributed to many journal articles and diabetes publications and is a member of the Virginia Diabetes Council that serves on Diabetes Youth Advisory and Community Boards. Before we get started, I'll remind everyone that we will be collecting questions during our panelists' presentations. I'd encourage you to use the Q&A prompt at the bottom of your screen, and we will be leaving time at the end to address those questions. And so I'll now turn it over to Christine and Crystal. Thank you very much for those kind introductions for both of us. And we are thrilled to be able to be here today to talk about something that is near and dear to our hearts, and that is bringing diabetes devices into the classroom. We have no conflicts of interest to share. And first, as a disclaimer, we want to mention that we are ensuring that we provide accurate and current content. But certainly what we're sharing today doesn't substitute for individualized legal, medical or other expert advice that may be needed. And so if any of those questions do come up, we would encourage you to seek specific advice from an independent attorney or other professional organization. So just to outline what we're going to do today, we'll begin with Crystal talking about some of the legal protections for children with diabetes in school, how that is incorporated into different kinds of written accommodations plans, and also the resources that are available for school personnel, parents and us as medical providers. And from there, we'll shift gears and talk more about the experiences and expectations with device use in school, and some of the ongoing challenges that students may face, and recommendations for us as medical providers for how we can help support families through those challenges. And with that, I will turn it over to Crystal. Thanks so much, Christine, for that. And thanks for joining us today or whenever you are attending to this webinar, we hope you find it helpful and informational. And thank you, Henry, for that kind introduction. As Henry said, I am the Managing Director of the ADA's Legal Advocacy Division, which includes our Safe at School initiative. And with Safe at School, what we really do is we marry the laws, both federal and state, with the science and medicine to ensure that students with diabetes get the care they need at school. So the first item I wanted to briefly cover is the topic of legal protections for students with diabetes. As providers, it's important that you understand the relevant federal and state laws that provide these legal protections for our students with diabetes. And these laws also place legal obligations upon schools and other institutions to provide appropriate diabetes care to students and to make sure these students are treated fairly. Next slide. So there are federal and state laws that provide legal protections for students with diabetes. Here we have the three main laws that we look to for these protections. The Americans with Disabilities Act, or ADA, not to be confused with the American Diabetes Association. We have Section 504 of the Rehabilitation Act of 1973, or as most of you probably know it as Section 504. We have the Individuals with Disabilities and Education Act, known as IDEA or IDEA. In addition to these three main federal laws that provide protections to students with disabilities, including diabetes, there are state laws that come into play. And in particular, there are state laws or safe at school laws in 34 states, plus the District of Columbia, that have statutes in place that support the provision of care to students with diabetes, and who offer the source of authority on who may provide that care at school. Is the provision of care limited to just the school nurse or licensed healthcare provider? Or are there statutes that enable and permit non-clinical school staff to be trained to provide this care? And I'm talking when I say care, I'm talking about all aspects of diabetes care, insulin and glucagon administration, monitoring CGM, being familiar with nutrition requirements, and of course, having the training and education to recognize and treat hypo and hyperglycemia. We're only going to touch on these laws today. But please, please, for more information, you can go to our website at diabetes.org slash fed laws, or diabetes.org slash safe at school with just a wealth of information and explanation there. Next slide, please. As I mentioned, the first of these federal laws, the Americans with Disabilities Act, or ADA, and there are various provisions under these laws that have different imposed legal obligations upon different kinds of entities. So under Title II, the ADA applies to schools and childcare programs operated by a state or local government are conducted on public school grounds, such as an afterschool program. Title III of the ADA applies to what's called places of public accommodation. So in this law, places of public accommodation can be state or government owned venues or centers, but also businesses that are generally open to the public that fall into one of 12 categories, such as hotels, restaurants, movie theaters, grocery stores, banks, and other service establishments, bus depots, museums, parks, schools, daycare facilities, recreation facilities, and doctor's offices even. So just to give you a better idea of the scope of the ADA, the following entities do have obligations under ADA to accommodate people with disabilities, including diabetes, a preschool, secondary, undergraduate, or postgraduate school, other places of public education or private education, a daycare center, a senior citizen center, homeless shelter, food bank, adoption agencies, and other social service center establishments. But of course, today, we are focused on schools and not these other establishments. But I just wanted to give you an idea of the broad scope of this law. Of note, religious entities are generally exempt from the provisions of the Americans with Disabilities Act. Next slide, please. So most of you are probably familiar with the term Section 504. And this is the second law that I mentioned. 504 obligates public and private schools receiving federal funds, including religious operated schools, if they receive government money. So that's an important distinction. So under both ADA and Section 504, the term disability is defined. And disability is a mental or physical impairment that is limited by a major life activity. And I know that's a lot of words, but essentially, that means a mental or physical impairment that's substantially limited by eating, walking, caring for oneself, performing manual tasks. And there were some amendments to the Americans with Disabilities Act quite some time ago, which actually added the major life activity of endocrine system to that definition. So endocrine in diabetes does fall under one of the protected categories of both ADA and Section 504. So the rules are similar to ADA. And what generally happens on the ground is that schools will gather with what's called a 504 IEP team. They will bring teachers, guidance counselors, school nurse, and maybe other school staff together along with the parents to determine if the child is eligible under Section 504. And you're probably going to say, Crystal, you just told us that the endocrine system is one of those major life activities. That's true. But the way the federal regulations are currently written, the federal regulations require individual assessment. So this group comes together, theoretically, at the beginning of the school year or just after a student with diabetes has been diagnosed. And this group is responsible for determining if indeed the student is eligible for services under 504 ADA, or the next law I'm going to briefly talk about, IDEA. The answer to that is usually yes, for a student with diabetes. And then the team will put their heads together and develop a Section 504 plan, IEP, or other written accommodations plan. Next slide, please. So basically, these two laws, ADA and Section 504, prohibit discrimination on the basis of disability. So why am I even talking about discrimination in the school context? Well, just know that if a student is unable or refused appropriate care at school, that student cannot safely access that school environment. And when the student cannot safely access that school environment, the school's failure to provide that care and those services, that constitutes discrimination under these two laws. And that is prohibited by ADA and Section 504. I already explained how diabetes fits into the disability definition. So just know that once a student is qualified for services under these laws, that the plan is developed to include provisions of reasonable modifications in the policies, practices, and the procedures to ensure that the student with diabetes is given equal and meaningful access to the school setting, whether it's during school day, field trips, after school activities, a school dance, after school PTHS club. Those modifications should be put in place for both during the school day and at all school-sponsored extracurricular activities. Next slide, please. And then we have another federal law called the Individuals with Disabilities Education Act. We call this the special education law, because under this law, it must be demonstrated that the student's diabetes or another disability adversely impacts the student's ability to learn and to make academic progress. But sometimes just having diabetes is enough. When a student has fluctuating, a lot of fluctuating BGs or is out of school, absent from school due to diabetes, sometimes this will qualify students for what's called an individualized education program or an IEP. And with the Individuals with Disabilities Education Act, a couple of advantages. One, the schools get extra funding to implement this law, but also the regulations, the federal regulations attached to IDEA are a little stronger and a little clearer. Most students have not, not all students with diabetes should qualify for services under Section 504. And then a subset of those students will qualify for services under IDEA. We often get the question, if a student is IDEA eligible, does that student need both a 504 plan and an IEP? And the answer to that is no. Both are not needed. Just the IEP would be needed, rolling in those provisions that are needed in order for the student with diabetes to be healthy and to prosper. Next slide, please. So in addition to federal laws, there are state laws and regulations. Every state has these laws, which impact who may and who may not provide care to students with diabetes, mainly through the state's Board of Nursing Regulations. That's where we look to find out what the law is. And earlier in this presentation, I talked about the 34 states and the District of Columbia who had passed special Safe at School laws. In those 34 states and the District of Columbia, there are exceptions to these regulations in that these laws do permit non-clinical school staff to be trained to care for children with diabetes. Unfortunately, there's often no statewide policy. Rather, policies determine school district by school district and kind of bizarre, but even some schools within the same school district have different policies. Some states have developed school diabetes management guidelines. You can find those on our website. Some states have passed school diabetes care legislation or change regulations or passed what we call safe at school statutes. Just know that regardless of state and local laws, the requirements of federal laws must be met. Always. Always. So what do I mean by that? If your patient attends school in a state where only a school nurse is legally allowed to provide diabetes care, then it is the legal obligation of that school to make sure the school nurse is available all of the time, you know, to treat, recognize, treat lows, available on field trips, available for after school activities. So you can see how non-clinical school staff having the legal ability to be trained and provide care, how that really enhances the ability of the school nurse to provide care. But again, not all states permit non-clinical staff to provide this care, but you can find out which states do and do not by going on ADA's website. And again, to learn more about your state's laws relevant to diabetes management at school, you can go to diabetes.org slash safe at school. Next slide. I spoke about section 504. This is the first page of the association's template 504 plan. 504 plan is a written document. It's a written agreement between the family and the school where the school and the family agrees upon those services or modifications, also called reasonable accommodations. The plan is developed to align with the student's DMMP or provider's orders. The regulations require the student to be individually assessed, so the plan must be individually developed to meet these needs. So I would encourage you to encourage the parents and guardians of your patients to request a 504 plan for their child. This plan is also available in Spanish on our website, so you can take note of that. Next slide. And then these are just some examples of reasonable accommodations that would be rolled into those 504 plans or IEPs. Students can't be left behind and prevented from attending the field trip just because the school doesn't have a school nurse to go along. It is the obligation of the school nurse or other non-clinical staff to provide that care to the student. Students can't be required to chaperone or accompany their child on a field trip as a condition of the child's participation in the field trip or the extracurricular event. Again, schools are responsible for providing this care. Teachers and supervisory staff need to know where supplies are kept. If they're not kept with the student, the student should be provided with Wi-Fi access and access to their smart device. The school nurse and staff should provide needed care and support to students participating in medical clinical trials. And the last slide on this topic, please. And these are some examples here of accommodations for CGM. Of course, the DNMP should be individualized. The school nurse and trained staff need to have an understanding and be knowledgeable about the functionality of the CGM, understand what it means when an alarm sounds, and how to react and respond to that alarm. It should be clearly indicated what the expectations are for recognition and responses to alarms and trends, trend errors, and actionable communications when those should occur, should address remote monitoring during the school day and during those other school-sponsored activities. Again, students should be provided with access to school Wi-Fi and their smart device. And then remote monitoring, if needed, can be done by the parent and or the school, depending upon the need identified in the DNMP, and also the conversations and decisions that are made between the parent and school nurse. So there should be a conversation there. And then the parent or school may provide a device to link the CGM sharing app in accordance with the DNMP. And then we just, ADA has a wealth of free resources available for providers, for families, for school nurses. Next slide. Here is the Diabetes Medical Management Plan that I referenced earlier. This plan is, was developed by ADA's Safe School Working Group. This group is an advisory committee of pediatric diabetes providers from across the country. This plan is currently under revision, so we're very excited that we're going to be able to present a new and improved plan later this summer. The plan includes orders for new technology, diabetes treatment therapies. It's a form to be filled out by the parent and provider. Each has their own sections. There's a single page for insulin dosing orders. The foundation for this plan, or this plan is the foundation for 504 IEP, or Other Written Accommodations Plan, and there on our website, we have supplemental supportive resources for the DNMP that go into a little bit more detail on how to fill out the DNMP. This form is also available in Spanish on our website. Next slide. And then we have our school guide. This is one of our key resources developed, again, by our Safe School Working Group. Key audiences for this guide, school nurses, administrators, staff, child care providers, families, diabetes providers, and policy makers. This particular version, which came out in 2022, contains expanded sections on type 2 diabetes, diabetes technology, treatment therapies. The roles of school staff members and psychological and social development. This guide can be used alone or in conjunction with ADA school training modules to train school personnel, and we're really proud of this guide. And it has been very favorably accepted and highly utilized by all of these populations. Next slide. Another key resource we have that's available for free, this is our school diabetes training curriculum that can be used by diabetes educators and our school nurses to train non-clinical school staff in all aspects of diabetes care. Again, it's free from our website, and we are always, always updating these resources in an effort to keep them current. Next slide. And then we have our continuous glucose monitoring guidance that was last updated in April 2024. That's the version you see on our website. And we are about to offer another update this month, so be on the lookout for that. But this guidance provides general information on CGM use at school. It denotes the benefits of CGM use. There are recommendations for data sharing, monitoring, and error management, and also recommendations for a backup plan in the event of CGM failure. Next slide. And then in this past six months, we at the ADA have created a seven-part webinar series for school nurses where they can receive CE credit. I just wanted to bring this to your attention and ask that you share with school nurses when you talk to them. Just let them know ADA has these wonderful webinars available on ADA's website for free. They're one-hour webinars. They're worth one hour of free CEU credit. So please let your school nurses know. Let your parents know. Ask parents to share this information with the school nurses. Next slide. And this is just a list of other resources that the ADA Safe at School Working Group has produced. We have our CGM guidance. We have a new childcare statement. There are case studies for school nurses. We have an overview of insulin concentration for school nurses to help them understand, you know, the different syringes and doses. Emergency lockdown prep and guidance and tips. Tips for school nurses. And there's the URL where all of these wonderful resources can be found. So thank you again for attending this webinar today. And now I will turn the program back over to Christine. Thank you so much, Crystal, for that wonderful information. So now we're going to move on and talk a little bit more about some of the experiences of using these devices in the school setting from different perspectives. And a lot of the data on this topic has been qualitative. And so I'm going to be sharing with you some representative quotations that really will communicate the ideas and the themes. So to begin, we need to reflect on how the influx of these devices has been a fairly recent and robust change. This study looked at the change in device use for patients at the Barbara Davis Center from 2016 to 2020 in relation to their health outcomes. And here I'm just showing the prevalence of device use not related to outcomes. Now, even though this was only four years different, there were certainly some significant shifts in device use, particularly for glucose monitoring. For example, 67% of subjects in 2016 were using traditional blood glucose monitoring, which decreased to only 25% of patients in 2020. And for CGM, this went from 34% in 2016 to 75% in 2020. There's less of a change in insulin pump use, which stayed somewhere between 60 to 65%. And there was an increase in AID systems to about 30% in 2020, though that number is certainly expected to continue to increase. Now, as we all know, these devices are really now considered standard of care. And the most recent ADA guidelines emphasize that CGM should be offered as soon after diagnosis as possible. And AID systems should be offered to all patients if they can use the device safely based upon their individual circumstances, desires, and needs. The ADA standard of care also calls special attention to the use of these devices in school. In their guidance, they state that students must be supported at school in the use of their diabetes devices. Now, children spend nearly eight hours per day in school. That means that about a third of their diabetes care during the week is delivered there. And we've already reviewed the legal framework to support this from Crystal. But what is the experience of school staff as they have become acquainted with this technology? So, if we go back to the early 2000s, the published experiences of school nurses highlighted fear with this new technology, at the time being insulin pumps. School nurses described insulin pumps as a scary bird with hidden dangers that needed to be checked and double checked. And at the time, it was estimated that only about 6 to 10% of youth with type 1 diabetes were using insulin pumps. So, that apprehension was largely related to a lack of education and experience. And with hands-on practice, the school nurses in this study began to feel that they learned this new language and developed close bonds with their students who use the technology and their families. Now, similar experiences can be said of CGM, though later. In a qualitative study we did with 40 school nurses in Pennsylvania, they frequently described that this technology just kind of showed up at their doorstep before they really even knew what it was. And many also described concern about whether or not they could really trust this new technology. Now, things have certainly changed since this time, and for the better, as everyone has gained more experience. And as these devices become standard of care, several groups have paid attention to how these translate to the school setting in particular. And the current expectation is that school nurses or other trained staff need to have comprehensive skills with these devices. So, we now have multiple papers addressing the competencies, checklists, and basic education about these technologies, which are either specifically catered towards school staff or are using language that is also appropriate for school staff and other stakeholders. And as Crystal mentioned, the ADA Safe at School Working Group is very active in this area. In addition to the school guide, we have many documents which specifically address topics related to these technologies in varying degrees of detail. Now, there are several mixed method studies that are looking at the experience of using CGM in the school setting from the perspective of parents, students, and school nurses, and they highlight that there are true benefits to using these devices in school. School nurses have recognized that these devices seem to increase student efficiency and independence in the health office. It is faster to check a sensor reading or give an insulin bolus via a pump, and that enables kids to get back to the classroom or to the lunch, to their peers faster. School nurses also perceive that these devices are helping to foster more independent skills at a younger age, and as school nurses view an important part of their job is to help foster independent skills in children, this is something they really have a finger on the pulse as to how it's happening. Additionally, many nurses feel that the CGM in particular is a safety net with its alarm features that allows them to catch highs or impending lows or actual lows in a new way so they can intervene sooner, and this has translated to less worry on both the part of parents and school nurses. Several parents have called attention to how remote monitoring gives them peace of mind while their child is away from them, such as in school, and school nurses appreciate that having more information at their fingertips as to where the student's blood sugar is can help them do their job better. Now, there are some ongoing challenges, or perhaps we could call them hurdles, to using this technology in school in the best possible way, and the first relates to the pace that the new technology is coming out and how school nurses are able to learn to use them. Now, as an example of this, I recently presented to school nurses in Pennsylvania, and I polled them to see what percent of their students with diabetes are using AID systems, and somewhat surprisingly, over 50% of the nurses said that few or none of their students were using AIDs at this time. Now, that could be because they really aren't seeing it yet, or perhaps they aren't recognizing that some of their students on pumps actually have this technology. Either way, it suggests to me that schools will continue to experience change, and we need to help them with that. So, in thinking about general school nurse readiness to engage with diabetes devices, we were interested in their confidence to use these devices in addition to their diabetes knowledge, and we tested a scale to measure school nurse confidence with diabetes devices with over 300 school nurses in Pennsylvania. We found a lot of variability in what they described for different kinds of skills. So, this graph is showing you the mean score on a one to five Likert scale with one being the least confident and five being the most confident, and school nurses reported very high degrees of confidence with skills that pertain to oversight, education, and counseling, which are demonstrated here. So, for example, recognizing a pump site failure, assessing a student's knowledge with their own pump or their CGM, helping a teacher learn to manage alarms in the classroom, knowing when to test with a meter. Again, these are all skills that may translate across different types of management regimens because they're related mostly to education and counseling. Now, in contrast, when it came to specific skills with the devices, school nurses generally reported a lower or more moderate degree of confidence. So, for example, you can see here knowing how to override a pump to give a manual bolus, being able to check the history of the insulin pump settings, suspending insulin delivery, setting a temporary basal rate, knowing how to review the CGM tracing, understand what the alarms mean, and interpret the trend arrows. Now, these are all things which may fall under a school nurse's purview, as Crystal was describing, and so these are things that they also need to be getting some ongoing training with. Now, we looked at how different school nurse characteristics related to overall diabetes device confidence, and the most significant factors, which are not surprising, is having some prior training or having prior experience with students who are using devices. Interestingly, it's not correlated with the age of the school nurse, their degree, how many years they've been in school nursing, their student caseload, or their general diabetes knowledge. So, this highlights the importance of continuing education for nurses and other staff, and this is very important in the context of high school staff's turnover, particularly with school nurses that we have been seeing since the pandemic. Now, how are school nurses learning to use these devices? Well, the training seems to be a patchwork. A lot of this is happening on the job through informal mechanisms, which can include learning from parents, doing individual web searches, or talking to other school nurses. And while it may be ideal to learn from a parent directly so they can get some individualized education related to that student, there could be some information that gets lost in translation and what works for one student may not be totally applicable for the next student. More formal training may be harder to come by. And when surveyed, about half of school nurses reported having some form of formal training, about a third getting it from a medical center, and then a little bit less from device reps or other organizations like school nursing organizations. And when we've surveyed medical providers about their experiences with diabetes care in schools, many reported that they do offer some kind of training to school nurses, but that can vary. In some cases, an in-person or virtual workshop, maybe ongoing webinar series, but it could also just be simply some handouts attempting to provide some education. So there are indeed barriers for school nurses in accessing the trainings at present. Part of the problem is that you may need a membership. There could be a fee associated with a training. So for example, many of the school nursing organizations, you need to have a membership. Training may not be updated frequently enough, especially with how quickly some of these new devices are hitting the market. We need to be thinking about training that gets updated annually. It can be really hard to schedule and block out time. Full-day activities are often not an option for nurses, and summertime activities can work, but many nurses work other jobs or even take vacation. And for nurses who are not connected to an academic center, their patients meaning they don't go to an academic center, they may have less ability to access training that we are giving. And so school nurses in more remote areas may be a little bit more unable to access this. So given this patchwork approach, some centers are trying more creative solutions, and I wanna call attention to a few of those here. The first is the Project ECHO, which is being led by Alison Pollack, and her program is called Diabetes in School Health or DISH. This program is active in several states, Washington, Wisconsin, Montana, and I believe a couple others, but this is essentially a tele-mentoring model where school nurses can come together, learn about some new topics in diabetes and also discuss cases. Some centers are inviting school nurses to device training, which is a fantastic way to get in-depth training on a device, though not always feasible. Many places are giving school nurses access to the electronic health record, and though that may not necessarily offer a lot of training, it can help answer many questions and improve communication. In some places, they have diabetes resource nurses. So in Colorado, for example, these are publicly funded individuals who are there to help ensure that schools have the resources and education they need. And in others, for example, at our center, we have a newly funded school nurse navigator not just for diabetes, but also diabetes can go into school districts and help with communication and education. And again, just mentioning that many places do take advantage of the wonderful resources available through the Safe at School program. Now, the second challenge I wanna highlight is related to using and responding to CGM in the classroom. Now, with the legal protections in place, ideally, these should not be issues, but from a few papers, and I think many anecdotal reports from our patients, we've learned that there can still be hurdles to overcome. And the first is that there may be physical barriers. There's a lot of concrete and cinderblock in schools, and this can interfere with connectivity and contribute to sensor signal loss. And those students may have access to the Wi-Fi as determined in their 504. Sometimes the Wi-Fi is too slow to be able to share data. A second problem is that some school nurses just don't trust the device. They may wanna verify with a glucometer or calculate the insulin dose for a student on a pump, even if they're not instructed to do so in the DMMP. And this can add to confusion if we're regularly trying to compare sensor and glucometer readings or insulin dose calculations with an AID. Now, teachers can be an asset or a major roadblock. Now, because of the nature of school systems and certain rules within them, teachers' initial reaction may be to be unsupportive of technology, particularly when it comes to cell phones. So one student actually described how his cell phone would regularly get taken away if a teacher he didn't know as well saw him with his phone, and he had to wait until the end of a school day to get it. Another student in this study talked about how the teacher would call her out when her CGM would alarm in class, which sort of focused all eyes on her in a very unwanted way. Now, this ties into the continual need to educate school staff, and school nurses, parents, and students have all expressed this in the studies. It can be exhausting because it feels like it's never ending. Again, in this study, an 11-year-old child expressed that once one teacher started to understand it, he'd have to go to the next teacher, and it would be the same thing all over again. Another problem is that alarms can be disruptive, and students tend to feel this more, I think, than their parents or their teachers. One student mentioned that their device kept ringing, and they just left it there like that in class. His teacher then had to have a talk with him about how that was interrupting the class, even if it was on silent mode, and this is something that comes up quite a bit. Additionally, this can attract unwanted attention from peers, whether it's real or perhaps perceived, but students feel like when that device goes off, they just feel bad because it's, you know, they're that person over there kind of distracting everyone. And lastly, parents can bypass the school nurse or school staff and communicate directly with their students. They may text them with instructions for diabetes management, and many parents perceive this as being less disruptive, but it can be, but it may not be if it's done frequently, and this student mentioned that it just gets annoying. My parent does it a lot. I have to stop what I'm doing and check my phone. It's just one more thing for this person to manage. Now, all these pitfalls highlight examples of where it's going wrong, but of course, in reality, there are many people that are doing this well, and we can get involved by helping to advocate for good planning among all these parties and promoting best practices. So for example, we should talk to the parent and the patient about what alarms really need to be set in school. I had one patient recently who had turned on her high repeat to every 15 minutes, and her CGM would sometimes go off continuously after lunch. That's obviously unnecessary and just contributing to struggles. It is worthwhile to think about setting different profiles, which could be done on the G7 now, or using the schedule feature to time which alarms are set when. And certainly, alarms should be personalized to that individual student, but here are some suggestions for which ones should most likely be turned on versus turned off, just depending on student needs. Now, we also need to advise parents to determine a good communication plan prior to the start of the school year, ideally, and be thoughtful about who is going to be approaching that student during the day and for what reason. We may need to help with providing some resources or handouts for other teachers and staff, reminding them about 504. We also wanna think about those accommodations that need to be in a 504, that is going to reflect our medical orders. And also, talk to parents about empowering their youth to know how to silence their own alarms, which is especially important in the world of emergency lockdowns. As some groups had previously kind of told parents to tell their children to take their alarms off in that situation or take off their device, we don't necessarily wanna do that, we just wanna silence them. And the last challenge I wanna talk about today relates to remote monitoring by parents and school nurses. Now, remote monitoring by a caregiver, usually a parent, is beneficial for children with type 1 diabetes. And that's very clear for young children who cannot perform any tasks independently, but there is still some benefit for older children and adolescents too. And these figures look at time and range and time above range for children using CGM who had no followers in blue versus at least one follower in orange. And in this retrospective analysis of CGM data, the children between six and 12 and 13 to 18 years of age with at least one caregiver following them had statistically higher time in range and lower time with glucoses over 250. So having a caregiver following their CGM suggests some active co-management of the diabetes, and that's beneficial even for teens who might otherwise self-manage. Now, when it comes to school nurse remote monitoring, there's not necessarily clear evidence either way. This is a topic that has caused some controversy recently, it's coming up a lot in the news, particularly after a court case in four school districts in Connecticut four years ago. Now, parents and school nurses have expressed some mixed opinions on whether or not they want this and it would be helpful. We're gathering some data currently from parents and they have described it in different ways. So some parents see it as an opportunity for co-management that increases their reassurance that their child is safe at school, and they see it as a break where they can kind of take some time off during the school day and transfer that responsibility to the school nurse. Others have described it as potentially being unnecessary, burdensome, or intrusive. So for example, this parent here had shared that they can easily monitor those alarms from home with what they do, and when the nurse was remotely monitoring, actually they would just get double the phone calls, which was seen as burdensome. And then in terms of the intrusiveness, that may relate more to teenagers who don't necessarily want another person with eyes on them if it's not needed. And parents have also reported that some school nurses who are monitoring on a personal device have called them overnight or on the weekend when it was not during school time. School nurses have also shared some mixed perspectives. Some school nurses really love to remotely monitor from their health office as it allows them to be the first line of defense, and they found ways to integrate it into their workflow so it is highly effective. And I would say I've never talked with a school nurse who does remote monitoring who doesn't like it. But there are still some school nurses who view this as an unreasonable request in the realm of all of their other responsibilities, and they worry about the liability if they miss an alarm and what that could mean. And these are concerns that need to be addressed as this practice potentially becomes more commonplace. Now, as over 80% of our patients are moving to CGM soon after diagnosis, this is going to come up more and more. And the ADA Safe at School Working Group acknowledges that this is becoming a routine practice in some, but not necessarily all states, and this should be encouraged for students who need it. At present, it's not been considered a universal expectation. It adds a new layer of supervision, and so it needs to be an individualized decision for each student with diabetes and should be incorporated into their diabetes medical management plan. And certainly different factors may influence that need from those students. So as this is going to come to our attention as medical providers, it's helpful to have a framework in mind for how to discuss this with your patients. So first thinking, how is it going to help the student? So for example, any student who's young, who has no hypoglycemia awareness, perhaps students who are nonverbal, perhaps students who have a history of hypoglycemic seizure, these are all children who may benefit from remote monitoring by a school nurse or other trained school staff. In general, school staff shouldn't be asked to use their personal device to monitor, and so I would make sure this is communicated. And school nurses can follow multiple students on one device. So ideally it should be provided by the school district or the school, but parents can also, and sometimes do provide devices. I would encourage the parents to work with the school nurses to set very clear expectations. This is going both ways. So when is the school nurse gonna be monitoring during the school day and after school activities? Maybe, but not on the weekend, not overnight. It needs to be clear that the school nurse may not be able to do constant vigilance. And parents, I think, don't necessarily do that or perhaps expect that. In one of the studies that looked at parent use of CGM, while their child was in school, the majority actually reported that they had certain times that they would look at the device, including perhaps just when it alarmed. So the shame should really apply to school nurses. In addition, we need to discuss what alarms are going to be set on that school nurse device and what is the plan in terms of how we will respond and whether or not that needs to involve additional communication between the school nurse and parent. And we need to remind parents that the student should still have their device on them. We all have limitations and the school nurse may not be able to monitor the device if they've run to an emergency to assist a student having a seizure, who broke a leg, whatever it might be. And if the student still has their device on them in the classroom, there is still a way to help get them to the support they need if they need to respond to an alarm. So before we conclude, I do wanna again take a moment to reference the CGM guidance document that we put out. And as Crystal mentioned, a new version of this should hopefully be coming out in the next month. And this QR code would take you directly to the existing document. And to summarize, school nurses should support students with type 1 diabetes in their use of diabetes devices. Nurses and other staff are going to need ongoing education and training. And we as healthcare providers should be one of the multiple sources that helps fill in these gaps. Providers can certainly help to counsel parents and students on best practices for using CGM in the classroom to try to minimize any disruptions that could affect learning. And providers also should help counsel parents about school nurse or staff remote monitoring for their patients and be indicating in medical orders whether it's medically necessary. And with that, I wanna thank you for your attention today. And Crystal and I are more than happy to take any questions you may have. So Crystal and Christine, I think thank you immensely for this really valuable information. And for our attendees, I wanna remind you, if you haven't already, we have a couple of questions here for, sorry, a couple of minutes here for questions. So please use that Q&A function there on the bottom of your screen if you have questions you'd like to pose to our panelists. I'll start off with one, and this really is open to both of you. So the question is, particularly for those providers maybe that aren't quite so adept with these technologies, what's the best manner that they can provide a direction on diabetes technology use to school staff? Crystal, do you wanna go first? You want me to? No, you go ahead, Christine. Yeah, okay. So I would encourage those providers to go to the ADA Safe at School website and potentially lean on some of the guidance documents and training that we have put together. And so we can absolutely share some general best practices and general education for what these devices are, how they should be used in school, and what are typical expectations for school staff in using them. So that would probably be one of the first best steps. And then I think, I know I should say that like Dexcom, for example, has put out some resources as well that are school facing, and so that would be another avenue that they could use. And don't forget about the parents and families. They're using these devices every day. So certainly the parent, and having been and still am the parent of a child with diabetes myself, it was important for me to do that individualized training for my child. So certainly consult with the parent and get their input and use them as a resource, if not their own expertise, but to connect the school nurse with a resource and training resources. Well, I guess both of you would probably agree that maybe the first step would be to use that diabetes medical management plan as a guideline to start that conversation. We have one more question here. We've just got a minute. The question is, can trained staff also respond to alarms, or does it have to be a nurse? If the nurse has to leave, couldn't others be past the device? And it's mentioned that even our parents miss alarms sometimes, but the alarms go off every five minutes. I think Christine, you had mentioned that. So does it have to be a nurse? No, definitely not. Particularly as Crystal was saying, in many states they have these provisions non-clinical staff who are able to participate in diabetes care. They have to undergo training. And part of that relates to glucose monitoring. And so they are very capable of responding to alarms. Well, thank you, Christine. We're at the top of the hour. So I wanna thank everybody for attending. Obviously, Christine and Crystal, thank you so much for your expertise. I wanna thank all of our attendees for joining us today. We hope to see everyone at another ADA webinar in the future. And this concludes our presentation. Thank you, Dr. Weinzimmer. Thank you. On behalf of the Diabetes and Youth Interest Group, this was a terrific session. We appreciate all the time you spent with us and we'll see you in Orlando. Thank you. Thanks, everyone. Bye-bye.

diabetes devices

classroom

school staff training

type 1 diabetes

CGM

school setting challenges

ADA Safe at School program

collaboration with parents

school nurses role

diabetes management in schools