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Diabetes Youth New Zealand National Diabetes Camping Guidelines Diabetes Youth New Zealand National Diabetes Camping Guidelines The Organisation and Management of Camps for Young People with Diabetes, and their Families Produced by Diabetes Youth New Zealand in association with the Starship Paediatric Diabetes Team and the Diabetes Nurse Specialist section of the New Zealand Nurses organisation, and supported by the New Zealand Society for the Study of Diabetes Diabetes Youth New Zealand National Diabetes Camping Guidelines These guidelines have been designed to ensure that the health and safety of young people with diabetes is maintained at all times during camp. These guidelines replace the May 1992 version. All Diabetes Youth New Zealand and Diabetes New Zealand Societies and Support Groups should follow these guidelines wherever possible and appropriate. It is strongly recommended that all other New Zealand groups organising camps for young people or families with diabetes also follow these guidelines. The information contained within these guidelines is provided for reference purposes and is not intended to be a complete manual or handbook, nor is it intended to provide absolute forms, policies or procedures for diabetes camps. Every camp must develop its own materials that address the safe and effective provision of services to children with diabetes in its own unique camp setting - these services must meet the regulations of local and national government/accrediting bodies. The information provided here is intended to guide the reader through the process. While every reasonable precaution has been taken in the preparation of these guidelines, the author and publisher assume no responsibility for errors or omissions, nor for the uses made of the materials contained herein and the decisions based on such use. This document does not contain all the information necessary for the total operation of a diabetes camp. As such no individual may solely rely on the information presented herein in forming a comprehensive diabetes camping program. Neither the author nor the publisher shall be liable for direct, indirect, special, incidental or consequential damages arising out of the use or inability to use the contents of these guidelines. By necessity, as research evidence and new treatment approaches emerge, this document will be reviewed and updated by DYNZ on a continuing basis. Feedback from all stakeholders is encouraged. Next Review Date: July 2012 Diabetes Youth New Zealand Diabetes Youth New Zealand National Diabetes Camping Guidelines Purpose of these Guideline Aims and Objectives of Diabetes Camping 1.3.1 Primary Aim of a Camp 1.3.2 Secondary Objectives of Camps 1.3.3 Additional benefits of camps 2. Camp Organisation and Management The Camp Committee Roles of the Camp Committee: Planning the Camp 2.2.1 Selection of camp site 2.2.2 Raising funds and working to a budget 2.2.3 Appointing Staff 2.2.4 Selection of campers 2.2.5 Defining specific objectives for the camp 2.2.6 Programme Development 2.2.7 Administration: Policies and Procedures 2.2.8 Camp Report 2.3.1 Objectives 2.3.2 Staff 2.3.3 Participants and their Selection 2.3.4 Rules and Regulations 2.4.1 General Objectives 2.4.2 Educational Objectives 2.4.3 Staff 2.4.4 Campers 2.4.5 General Rules for Family Camps On Site Facilities General Guidance and Camp Rules Safety Requirements 2.10 Motor Vehicles Used During the Camp Selection of Staff 3.1.1. Clinical Staff 3.1.2. Non-clinical Staff 3.1.3. Staff Ratios Roles and Responsibilities of Staff 3.2.1. Division of Responsibility 3.2.2. Expectations of Staff 3.2.3. Specific Responsibilities of the Camp Coordinator and Clinical Staff 3.2.4. Specific Responsibilities of the Non-Clinical Staff Diabetes Youth New Zealand National Diabetes Camping Guidelines 3.3.1. General requirements 3.3.2. Pre-camp Briefing for Clinical Staff 3.3.3. Pre-camp Workshops for Non-clinical Staff and Volunteers 4. Medical Care at Camp Medical Facilities 4.1.1. Off Site 4.1.2. On Site – the Medical Health Unit Medical Supplies 4.2.1. Diabetes Supplies 4.2.2. General First Aid Supplies 4.2.3. Kits for Outings 4.2.4. Other Supplies Blood Glucose Monitoring 4.3.1. Objectives of Monitoring 4.3.2. Monitoring In Practice Insulin Adjustment 4.4.1. General Guidance Management of Young People using Insulin Pumps 4.5.1 Basal Insulin 4.5.2 Bolus Insulin for Meals 4.5.3 Bolus Insulin for Blood Glucose Correction 4.5.4 Hypoglycaemia 4.5.6 Disconnection Management of Hypoglycaemia 4.6.1. Standard First-Response Treatment for Hypoglycaemia 4.6.2. Administration of Glucagon 4.6.3. Administration of Intravenous Glucose Management of Hyperglycaemia 4.7.1. Hyperglycaemia in the Context of Camps 4.7.2. Testing Ketone Levels 4.7.3. Treatment of Hyperglycaemia with Ketonuria or Raised Blood Ketones 4.7.4. Management of Hyperglycaemia and Sick Days Medical Care for Illness or Conditions other than Diabetes Applying for Camp 5.1.1. Registration 5.1.2. Legal Consent Selection Criteria 5.2.1. Inclusion Criteria 5.2.2. Exclusion Criteria On Arrival at Camp Education at Camp 5.4.1. General Objectives 5.4.2. Detailed Objectives What to Bring and WHAT NOT to Bring to Camp Diabetes Youth New Zealand National Diabetes Camping Guidelines Aims of Evaluation Methods of Evaluation 6.2.1 Collection of Data 6.2.2 Interpretation of Evaluation Data Implementation of Evaluation Data 7. References 8. Appendices Appendix 1 – Memorandum of Understanding for Group leaders, Camp assistants, Industry representatives Appendix 2 – Camp Registration Form: Youth/Teen camp Appendix 3 – Camp Registration Form: Family camp Appendix 4 – Sample Budget Appendix 5 – Guidelines for Hypoglycaemia for Campers using Insulin Pumps Appendix 6 – Photography Permission Form Diabetes Youth New Zealand National Diabetes Camping Guidelines Camping provides young people with diabetes and their families with a unique opportunity to share with and learn from others with diabetes. Every family with a young person with diabetes in New Zealand should be given the opportunity to benefit from the diabetes camping experience. These guidelines have been prepared by Diabetes Youth New Zealand (DYNZ) in collaboration with various special interest groups within New Zealand. The guidelines are supported by New Zealand Society for the Study of Diabetes (NZSSD). The document is based on previous guidance published by the NZNO Diabetes Nurse Specialists Group (1992). Purpose of these Guidelines These guidelines have been produced for the attention of all persons involved with diabetes camping, and are intended to be used in the conduct of educational and recreational camps for young people with diabetes in New Zealand. It is essential that all camps adhere to minimum standards of organisation and management, education, health and safety. These guidelines are intended to direct and advise, however it is acknowledged that local factors or preferences may lead to adaptations in practice. Aims and Objectives of Diabetes Camping 1.3.1. Primary Aim of a Camp The primary objective of holding a camp is to provide children and young people with diabetes with a fun but safe environment that allows them to learn about themselves and their diabetes, to reinforce current education, and to promote the further development of management and coping strategies. 1.3.2. Secondary Objectives of Camps  To provide an enjoyable recreational camping experience for young people with diabetes and/or families;  To provide a safe and healthy environment away from home, embodying the physical, social and emotional well-being of campers;  To enable young people with diabetes to meet and share experiences with others with  To encourage young people with diabetes to learn more about their condition, and how  To promote emotional adjustment to having diabetes, increase confidence, and to overcome any sense of isolation, stigma or pessimism;  To support young people in taking responsibility for their own wellbeing and mastering habits of resourcefulness, dependability, tolerance, originality and appropriate levels of Diabetes Youth New Zealand National Diabetes Camping Guidelines NOTE: In addition, individual camps are expected to have specific aims and objectives that are prepared by the camp committee during the planning stage for the given camp (see sections 2.2.5 and 2.2.6; also see section 5.4 for educational objectives). 1.3.3. Additional benefits of camps In addition to achieving the above objectives, camps bestow numerous additional benefits to children and young people with diabetes, their parents and families, and the health professionals who care for these young people at camp:  Many camps provide the opportunity for campers to take part in vigorous or unusual activities, where diabetes management can be demonstrated and positively reinforced;  Campers may gain confidence in dealing with diabetes away from the home setting – this benefit may also extend to an increase in confidence of the parents or caregivers;  Increasing self-reliance in young people with diabetes will tend to support regular attendance of camps, and further the benefit;  An increased confidence and ability to deal with diabetes away from the home setting may encourage participation in other independent activities, such as sleepovers and  Health professionals participating in camps gain an increased understanding of the day- to-day challenges facing children and young people with diabetes – this is an invaluable  Camps provide a respite for parents and caregivers from the daily stresses of dealing 2. Camp Organisation and Management The organisation of a camp should be initiated at least 9 – 12 months prior to the proposed The Camp Committee Each camp should operate under the authority of a local or regional Camp Committee. This body should consist of at least the following members:  Camp Coordinator – Person responsible for overall co-ordination of activities of camp committee, camp staff, site staff, campers, parents, and implementation of these  Clinical Advisors – Health professionals with expertise in diabetes who are able to advise on paediatric medical, nursing and dietetic aspects of the camp;  Financial Officer – Responsible for the budget, coordination of fundraising, collection of receipts and upkeep of detailed accounts;  Parent Representative. Additional committee members might include adult volunteers with a special interest in, or experience of, diabetes in young people. Diabetes Youth New Zealand National Diabetes Camping Guidelines Roles of the Camp Committee: Planning the Camp 2.2.1. Selection of camp site The chosen camp site is usually one that has been previously used for diabetes youth or family camps. See sections 2.5 – 2.9 for essential facilities and other requirements of a camp 2.2.2. Raising funds and working to a budget Funding should be sourced at least 12 months prior to the camp. The Camp Committee should consider fundraising possibilities on an ongoing basis. Some funding may be  Lottery Grants  Diabetes Youth New Zealand  Local Diabetes Societies  District Health Boards  Charitable Trusts  Income Support and other Government sources  Company sponsorship and/or donations  Service Clubs – e.g. Lions, Rotary Early application to the appropriate District Health Board(s) is essential to secure funding and medical supplies. A sample budget is included in Appendix 4. 2.2.3. Appointing Staff The health and safety of staff and campers is dependent on adequate staff numbers – both overall, and within specific professional or skilled areas. The exact staff required will depend on the nature of the camp and the age range and number of campers. Also see sections 2.3.2, 2.4.3 and 3.1.  Clinical Staff – Medical director, Diabetes Nurse Specialist(s), Dietitian(s), Registered nurse(s), Night nurse  Non-clinical Staff (Group Leaders and Camp Assistants) – Additional volunteers with experience of diabetes in young people Early application to the appropriate District Health Board(s) is essential for the release of necessary medical, nursing and dietetic staff. The appointment of all clinical staff should be confirmed at least 2 months prior to the start The following roles may also need to be appointed by the Camp Committee; alternatively these roles may be covered by camp venue or ‘site' staff: Diabetes Youth New Zealand National Diabetes Camping Guidelines  Recreation Officer  Transport Officer  Housekeeper  Cook The Camp Coordinator should clarify the roles assumed by Site Staff and appointed Camp Staff, and ensure that all Staff understand their responsibilities. NOTE: Security police checks are mandatory for all staff See section 3 for more detailed guidance on selection, training, and roles and responsibilities of Camp Staff. 2.2.4. Selection of campers Advertising should be initiated at least 6 months prior to the camp, with the close date no later than one month before the camp. The Camp Committee should consider the following national and local advertising options:  Diabetes Youth Times  Diabetes Youth New Zealand Website  Diabetes Youth New Zealand local or regional coordinator  Local Diabetes Clinic  Local Diabetes Society  Local Magazines and Newspapers or Newsletters The close off date for applications to be returned should be set at 6 weeks before the start Participants should be appointed in liaison with clinical staff. Campers should belong to a Diabetes Society or be accountable to a Diabetes Youth Committee in order that they are covered by Diabetes New Zealand indemnity insurance. More guidance on selection and approval of prospective camp participants can be found in sections 5.1 and 5.2. 2.2.5. Defining specific objectives for the camp In addition to the general objectives of camp (see section 1.3) each camp must have a defined scope and specific objectives that it wishes to achieve. These objectives should be written and borne in mind by all people involved with the camp, including campers themselves (especially in the case of a teen event (see section 2.3) or family camp (see section 2.4)). Educational objectives are covered in section 5.4. Evaluation of the objectives as the camp proceeds should occur in conjunction with evaluation of the programme and documented as appropriate (see section 6 for guidance Diabetes Youth New Zealand National Diabetes Camping Guidelines 2.2.6. Programme Development The programme must be designed to achieve the goals of the individual camp (see section 2.2.5). Ideally, a balanced mix of social, recreational and educational components will be Development of the programme will be the responsibility of the Camp Committee in consultation with the appropriate camp venue staff. Coordination with the Recreational Officer and Transport Officer will be necessary (NOTE: Some outings and transport will need to be booked well in advance). Other pertinent points to consider include the following:  Previous camp experience of staff members and camp participants  Age of campers, their skills and abilities  Specific skills or expertise of staff  Duration of camp  Time of year/season/weather  Available adult or group leader/assistant to camper ratio  Camp resources  Safety factors Coordination of staff skills is important in order to ensure an interesting and stimulating camp for the relevant age group. Some activities may be finalised during pre-camp training workshops (see section 3.3), when staff get together and are able to coordinate their skills and ideas. 2.2.7. Administration: Policies and Procedures A written statement of policies and procedures is required. These may include the  Specific objectives of the camp  Memorandum of Agreement for members of staff  A description of channels of communication and responsibility  Formal camper selection procedure  Medical protocols and procedures  The upkeep of camper records  Fire and general safety policies  Emergency procedures  Search & rescue for persons lost or missing  Reporting of incidents  General rules for campers; behaviour management 2.2.8. Camp Report On completion of each camp a written report should be compiled. This is essential for future reference and to inform planning of other camps. The report should include a formal evaluation of the camp (see section 6). Diabetes Youth New Zealand National Diabetes Camping Guidelines The report should be put together by the Camp Coordinator in collaboration with the Camp Committee and the Camp Staff. Input from all participants – clinical staff, group leaders and assistants, and campers themselves - ensures that a balanced report is produced. A copy of the final report must be sent to Diabetes Youth New Zealand and may also be required or requested by other funding agencies or diabetes societies. Teen events are usually both exhilarating and exhausting - for all of those involved. They provide specific challenges pertaining to the age group of the participants. Education should occur in an informal environment as described in section 5.4, with topics/activities appropriate and relevant for the given camp participants (in line with camp objectives, the young people themselves may participate in the development of a specific education program). NOTE: For teens it may be preferable to refer to campers as "camp participants". 2.3.1. Objectives  Essentially, the aims and objectives of Teen Camps are the same as those described for camps in general – see section 1.3.  Whilst safety is always the primary concern, it is essential that a certain amount of ‘space' is allowed for the development of the emerging adult, and all that that entails (i.e. acquiring confidence, independence, autonomy, and responsibility);  Specific individual and group objectives for the camp are often best defined with the involvement of the camp participants themselves;  The fostering of a team spirit is particularly important in teen camps – older camp participants, group leaders and camp assistants are encouraged to promote team spirit and to ensure that no one is left out or feeling isolated (the Camp Coordinator should be notified of any potential problems arising in this context). The staff required for a teen event may depend on the location and nature of the planned When considering staffing a camp, the Camp Committee should consider the following:  The type of event being held  The age range of the young people invited to attend  Additional related expertise of prospective staff  Prior knowledge of the teens and their medical and social background (see box)  Ability and sensibility of the young participants (see box)  Possibility/likelihood of potential misadventure  Accessibility of closest medical help/emergency services. 2.3.3. Participants and their Selection See sections 2.2.4 and 5.2. Diabetes Youth New Zealand National Diabetes Camping Guidelines 2.3.4. Rules and Regulations  General rules for the camp should be agreed prior to, or at the beginning of the camp. See sections 2.6 – 2.10.  If camp participants are under the age of 16 years, the Camp Coordinator is legally bound to have a consent form for that participant from their parent or legal guardian (see Appendix 2). This should provide the Camp Coordinator with ultimate responsibility for specific camp rules that are defined, and that should be adhered to during camp. It is recognised that family camps often differ when it comes to local, regional and national aims /objectives and organisation. These guidelines are intended to ensure that safety - regarding food, physical activities, clinical decisions and accidents - remains a principle concern for all. 2.4.1. General Objectives Family camps share the same aims and objectives as described in section 1.3. Additionally, family camps aim to include close family in the educational experience that tends to evolve on getting to know and learning from other people and families coping with 2.4.2. Educational Objectives Whilst the objectives described in section 5.4 should be noted, it should also be observed that family camps are about sharing and learning from each other and creating an environment in which all members are equal – i.e. diabetes should not single one family member out as being "special" or to have "special needs" (over and above the essential monitoring and insulin administration, and ideally these management aspects should be shared with others, as opposed to being concealed from others). Group/family sessions should not only be diabetes-focused; team-building events and activities that promote confidence-building should also be included. Although not mandatory, clinical and/or leadership staff are advantageous at a Family Clinical staff tend to have a more low-key role in Family Camps, since care of the individual with diabetes is usually assumed by the family. However, the "Clinical Staff" remain an integral part of the camp and usually have much to offer in terms of education from a more social/interactive perspective. Essential clinical staff may provide back-up for medical emergencies, should they arise. Diabetes Youth New Zealand National Diabetes Camping Guidelines Family Camps provide an excellent learning experience for health professionals, and those in training. The opportunity to learn about the challenges faced by individuals and families with diabetes should not be turned down by any qualified or would-be health professional in almost any speciality, given the prevalence of diabetes today, and that forecast for the future. The attendance of a Medical Director/Camp Physician at a Family Camp is not essential since medical care – in terms of day-to-day diabetes management - of the individual with diabetes is usually assumed by the family attending camp, or the person themselves. However the learning experience for the health professional may in fact be invaluable, so participation by physicians is still encouraged. The Diabetes Nurse Specialist may assume an educational role during camp – formal and/or informal educational approaches may be discussed with the Camp Committee during the planning stages. The dietitian may provide input during the planning stage in terms of providing a menu and liaising with cooking/kitchen staff to ensure that meal and snack times are appropriate. More formal educational sessions may be desired – this will depend upon the specific camp objectives (see section 2.2.5) and educational objectives (see section 5.4). Other staffing requirements may be fulfilled as described in section 3. A roster system may need to be established to ensure that essential chores (such as cleaning toilets, setting tables, washing dishes etc.) are shared out and completed satisfactorily. Selection of campers should essentially take place as described in section 5.2; however inclusion/exclusion criteria may be influenced by the prospective attendance of parents or guardians at camp. 2.4.5. General Rules for Family Camps  The young person with diabetes should be supervised by their own caregiver at all  Family members must be aware that physical contact with non-family members may be misconstrued; for this reason it is recommended that any physical contact be made only  Blood testing may be performed as per family expectations (although it is hoped that education may promote adequate testing – 4+ times daily - if this is deemed  Blood testing at supper time is mandatory;  All medical supplies should be supplied by the family. Also see sections 2.6 – 2.10. Diabetes Youth New Zealand National Diabetes Camping Guidelines NOTE: Whilst these guidelines are applicable for family camps, they may need to be adapted to suit local or individual camp requirements. Check with DYNZ if you have any queries (see inside front page for contact details). On Site Facilities The site should comprise a well-defined contained area. Essential facilities at the prospective camp site include the following:  Water supply  Toilets  Washing facilities  Sleeping units (cabins or tents)  Kitchen  Dining hall  Area to be used as Medical Health Unit (see section 4.1.2)  Recreation hall  Outdoor recreational area  Equipment for activities  Fire protection and sanitation  Civil Defence Kit  Telephone General Guidance and Camp Rules 2.6.1 No smoking, alcohol, or illegal drugs are permitted on the camp premises, or on 2.6.2 It is desirable to keep age groups divided into developmental stages, e.g. 8-10, 11- 12, 13-15, 15-18 years. 2.6.3 Lifting of bedwetters should be carried out according to guidance from the parent or guardian, with consideration to normal practice for the child. 2.6.4 Two adults must be present at all times when attending children during the night. 2.6.5 No persons other than those involved with the camp are permitted to stay on the camp premises overnight without prior arrangement through the Camp Coordinator. 2.6.6 If campers wish to drive themselves to camp then car keys must be surrendered on arrival. NOTE: it is preferable if parents or caregivers drop campers off and collect them at the end of camp. 2.6.7 Permission to take/use photographs of campers should be sought; see Appendix 6. Safety Requirements 2.7.1 All activities must at all times be supervised by a responsible adult who has a good knowledge of diabetes and particularly hypoglycaemia, its signs, symptoms and management. Also see section 4.6. Diabetes Youth New Zealand National Diabetes Camping Guidelines 2.7.2 The whereabouts of all campers and staff must be known - at least by the Camp Coordinator - at all times. Campers should leave the camp site only with the prior approval of the Camp Coordinator, and should preferably be accompanied by a responsible adult, or group leader. 2.7.3 Potentially hazardous camp activities (e.g. archery, horse-riding, swimming) must be under the direct supervision of a suitably qualified adult, capable of implementing safety standards and with training or experience in conducting the activity. 2.7.4 Staff must be aware that physical contact may be misconstrued and for this reason it is recommended that staff only touch camp participants in public. If a child is upset or troubled, refer to camp leadership or a camp parent. 2.7.5 Incidents must be fully documented - when a problem occurs (including bullying or alleged abuse) or a complaint of a serious nature is lodged by a camper, staff member, or visitor. A copy of the incident report should be retained on file for the Camp Committee, and a confidential copy should be sent to the Camp Coordinator, the National Youth Coordinator and the President of Diabetes Youth New Zealand (See inside front page for contact details). 2.7.6 Injury forms/reports are primarily the responsibility of the camp site, and will usually be designed around their own safety RAMS. If any child is injured at camp, the camp site staff must complete their own appropriate forms and should provide copies to the Camp Coordinator. Health and Safety Legislation - mandatory requirements:  Maintenance of a hazard register with known hazards;  Reporting of incidents to the organisation, recorded on an incident register;  Notification of Occupational Safety and Health (OSH) of serious harm as soon as possible and reporting within seven days. (You can send reports directly to OSH from the National Incident Database To notify serious harm, see www.osh.dol.govt.nz ); Reporting of fatalities to the police. 2.8.1 All camps must be equipped with fire-fighting equipment of the type and quantity approved by the local fire authority. 2.8.2 The staff of the camp must be familiar with the fire-fighting equipment and its use. 2.8.3 A plan of sleeping locations of both campers and staff should be on display. 2.8.4 There should be a written protocol for emergency evacuation. 2.8.5 It is mandatory that each camp have a fire drill including an evacuation brief and safety brief at the start of the camp. Diabetes Youth New Zealand National Diabetes Camping Guidelines 2.9.2 The Camp Committee should ensure that appropriate insurance will cover all aspects 2.9.3 Some circumstances are potentially covered by Accident Compensation Corporation 2.9.4 All camp attendees must be a financial member of Diabetes New Zealand, Diabetes Youth New Zealand, or local diabetes society to be covered by indemnity insurances held by Diabetes New Zealand. Subscription may be requested upon registration. 2.9.5 Insurance should cover any transportation vehicles used. Motor Vehicles Used During the Camp 2.10.1 Any vehicle used for transporting staff and/or campers must be maintained in a safe condition; it must be registered, insured, and have a current warrant of fitness. 2.10.2 Every vehicle used for transporting staff and/or campers must be equipped with a first aid kit plus any other appropriate emergency equipment/medical supplies (also see sections 4.2.2 and 4.2.3). 2.10.3 Open bed trucks or trailers must not be used to transport campers and/or staff. 2.10.4 The seating capacity of the vehicle must not be exceeded and seat belts must be 2.10.5 A back-up or support vehicle should be available in case of breakdown. 2.10.6 All drivers transporting campers and/or staff must hold a full driver's licence applicable to the type of vehicle being driven. 2.10.7 All drivers transporting campers and/or staff must obey the Road Code at all times. Selection of Staff The Camp Committee is responsible for appointing staff. The following staff members are essential for the safe and smooth running of the camp: 3.1.1 Clinical Staff - Medical Director/Physician, Diabetes Nurse Specialist(s), Dietitian(s), Registered Nurse(s), Night Nurse All clinical staff should have clinical experience of - and a specific personal or professional interest in - diabetes in children and young people. 3.1.2 Non-clinical Staff - (Group Leaders and Camp Assistants) - Additional Volunteers with Experience of Diabetes in Young People Ideal qualities sought in non-clinical staff and young adult leaders include the following:  good role model  show maturity and responsibility  aged 16 years or over  personal experience of diabetes Diabetes Youth New Zealand National Diabetes Camping Guidelines  holds a current First Aid certificate  willing to attend at least one workshop or meeting prior to camp  willing to have a police check conducted 3.1.3 Staff Ratios General - there should be at least one diabetes nurse(or doctor) and one adult/leader/assistant per 10 campers. Nursing staff - one Diabetes Nurse Specialist and one experienced Registered Nurse per 25 Night staff - there should be one night nurse and at least one night assistant. If the number of campers is in excess of 25, staff numbers must be increased accordingly. Staff ratios may be affected by age and experience of both campers and staff. These recommendations may be altered, should the Camp Committee deem this to be Roles and Responsibilities of Staff 3.2.1. Division of Responsibility Responsibility should be divided as follows:  Medical – activities carried out by clinical staff under supervision of the Medical Director and in liaison with the Camp Coordinator.  Recreational – activities carried out by all camp staff under supervision of the Recreation Officer and/or in liaison with the Camp Coordinator.  Household – activities carried out by Camp Staff and/or Site Staff under supervision of Housekeeper/Site Supervisor and/or Camp Coordinator. 3.2.2. Expectations of Staff It is desirable for each camp to have a written statement of personnel policies and practices as they affect both the camp and staff member; these may be based upon a memorandum of agreement (see Appendix 1). Staff members are expected to:  have read and understood the current version of these guidelines;  be fully aware of all specific camp policies and practices, rules and safety regulations (see section 2.2.7 and sections 2.6 - 2.10), and to comply with these at all times;  appreciate the specific aims and objectives of the camp, as defined by the Camp Committee (see section 2.2.5);  work creatively towards achieving educational objectives (see section 5.4). It is desirable that all Camp Staff – including group leaders/camp assistants – arrive at camp at least two hours prior to the arrival of campers. This enables Camp Staff and Site Staff to become fully acquainted and to confirm roles and responsibilities. Diabetes Youth New Zealand National Diabetes Camping Guidelines All staff must be fully aware of the signs, symptoms and management of hypoglycaemia. All Camp Staff and Site Staff (especially those supervising specialised activities) should be provided with a Hypoglycaemia Management Protocol (see Section 4.6). NOTE: It may be necessary to train Site Staff prior to camp, so that a basic understanding of hypoglycaemia, its causes and treatment, are understood in advance of the camp. 3.2.3. Specific Responsibilities of the Camp Coordinator and Clinical Staff Camp Coordinator The Camp Coordinator  is responsible for the overall coordination of the camp –in the planning stages, and during the camp itself;  must ensure there is clear communication between the staff;  should know the whereabouts of all staff and campers at all times. Medical Director/Physician It is essential that the camp have a physician in residence, with up-to-date knowledge of diabetes management, and who is actively involved in the camp. The physician will usually assume the role of the Medical Director during the camp. The Medical Director/Camp Physician  is responsible for the overall health of the campers;  will work closely with all members of the clinical team, with the camp coordinator, and with other staff, to ensure that optimum health is achieved for all campers during the  should ensure that the camp environment is conducive for the clinical staff to work together and communicate well with each other and the other members of staff;  must agree the clinical guidelines, policies and procedures to be used in the medical management of campers;  should be fully involved in the development of the educational program for the camp (see section 5.4), in line with the specific objectives for the camp (see section 2.2.5) NOTE: this should be completed during the planning phase of the camp in conjunction with the Camp Committee;  should be aware of the health status of all members of staff, as well as that of the In conjunction with the Diabetes Nurse Specialist, the Medical Director/Camp Physician is also responsible for:  maintaining camp medical records;  ordering and maintaining pharmaceutical supplies;  altering insulin doses (except where older youths take responsibility for their own insulin adjustment, as agreed prior to camp);  supervising the Registered Nurse(s);  implementing the education program in line with the specific objectives for the camp. Diabetes Youth New Zealand National Diabetes Camping Guidelines Diabetes Specialist Nurse The Diabetes Nurse Specialist will work closely with other members of clinical staff to oversee the following essential aspects of diabetes care for the campers:  supervision of insulin injections;  supervision of monitoring of blood glucose, and if appropriate, ketones;  provision of appropriate care for diabetes-related health problems that may arise during In conjunction with the Medical Director/Camp Physician , the Diabetes Nurse Specialist, may also be responsible for further duties as described in section 3.2.3.2. Registered Nurse The Registered Nurse will work closely with the Medical Director/Camp Physician and Diabetes Specialist Nurse, and under their supervision. Any general nurses that are not diabetes specialists, but have a special interest in diabetes, may require some pre-camp training. The Registered Nurse will assist the Diabetes Nurse Specialist as required. The Registered Nurse may be responsible for:  maintaining first-aid equipment in a designated area;  supervision of care for non-diabetes related conditions of campers, such as:  treatment of diarrhoea and/or vomiting;  dressings;  administration of non-diabetes related medications;  application of ointment/lotion.  initiating first-aid treatment as and when appropriate. The Night Nurse should always be accompanied by a responsible adult when performing regular night rounds. Campers should be checked at least every two hours. The duties of the Night Nurse are under the direct authority of the Medical Director/Camp Physician, and should include:  regular observation for hypoglycaemia;  testing of any young person that may be at risk of (see box) or thought to be currently experiencing hypoglycaemia (see section 4.6). Any episodes of hypoglycaemia should be treated and documented, as described in section Diabetes Youth New Zealand National Diabetes Camping Guidelines The Night Nurse should be aware of individual potential problems that may arise as a result of hypoglycaemia, or independently of hypoglycaemia, such as:  bedwetting  sleepwalking  nightmares Risk Factors for Nocturnal Hypoglycaemia  Known susceptibility to nocturnal hypoglycaemia;  Bedtime blood glucose test < 8.0 mol/L;  Previous nocturnal hypoglycaemia occurring at camp;  Severe or repeated hypoglycaemia experienced during the Each camp will ideally have an experienced dietitian fully involved with dietetic planning and ongoing supervision of meals and snacks. Campers with special food requirements should be brought to the attention of the dietitian well in advance of the camp. The dietitian may also be involved with educational aspects at camp (see section 5.4). 3.2.4. Specific Responsibilities of the Non-Clinical Staff Group Leaders and Camp Assistants The bulk of voluntary staff at camps will tend to fall into the category of group leaders and their ‘assistants'. Group leaders and camp assistants may be youth leaders (peer group leaders), adults with diabetes or a special interest in diabetes, or medical/industry representatives. Group leaders and camp assistants must be good role models, and have a good working knowledge and experience of diabetes. Specific responsibilities of group leaders will usually include the following:  To know the whereabouts of all of the group members at all times;  To establish a good rapport with the campers in the group;  To encourage a healthy team spirit within the group;  To attend daily camp meetings as appropriate;  To watch for the signs of hypoglycaemia in members of the group, and act accordingly (see section 4.6);  To report anything untoward to the Camp Coordinator and/or Medical Director Diabetes Youth New Zealand National Diabetes Camping Guidelines Group leaders and camp assistants are encouraged to enjoy themselves and have fun – this rubs off on the campers and positively influences the success of a camp. Group leaders should be able to take time out for their own socialisation as necessary (although this must be pre-organised with the Camp Coordinator and must be within certain guidelines i.e. no alcohol, illicit illegal drugs, or smoking). NOTE: Industry Representatives Industry reps are encouraged to participate in camps as group leaders/camp assistants; however they should be reminded that their role at camp is predominantly one of a supervisory nature. Direct promotion of any product(s) is not permitted, unless agreed beforehand with the camp director, and a specific time is set aside for this purpose. Recreational Staff The main role of the Recreational Staff is to organise appropriate development activities around set meal and snack times. Potentially hazardous camp activities must be supervised by suitably qualified or experienced people, who are able to implement appropriate safety standards should the NOTE: All activities should be supervised at all times by a responsible adult who can readily identify hypoglycaemia, and treat it confidently. The responsibilities of the housekeeper should include the following: - coordination of day-to-day care of clothes and bedding; - supervision of hygiene of toilet and shower facilities; - ensuring camper's hygiene standards are maintained e.g. by supervising hand washing - supervision of hygiene of washing-up area, ensuring frequent changing of washing-up water and tea towels as necessary. NOTE: The kitchen should be staffed by an experienced cook who is capable of organising kitchen staff to prepare the required food for the said number of people at the required times. Liaison with the dietitian may also be required. Camp Parents assist in the general smooth running of camp by helping campers that may need individual attention, for example: - at times when home sickness is experienced; - if there is conflict with other campers; - if the young person is feeling or experiencing social isolation. An additional role of Camp Parents is the supervision of settling at bedtime, in coordination with the other staff. Diabetes Youth New Zealand National Diabetes Camping Guidelines Camp Parents are an integral part of the staff and should ideally participate in all consultative meetings with the organising Camp Committee and Clinical Staff both prior to and during the camp. Transport Officer The Transport Officer is responsible for the safe supervision of campers (by prior arrangement) to and from the camp, and during the camp. Also see section 2.10. Financial Officer The Financial Officer: - should be part of the Camp Committee but does not necessarily need to be present at the camp itself; - is responsible for the budget, coordination of fundraising, collection of receipts and the upkeep of detailed accounts relating to the camp; - is required to contribute to the Camp Report (see section 2.2.8 and section 6). 3.3.1. General requirements The Camp Committee is responsible for ensuring that all of the Camp Staff undergo appropriate pre-camp training as necessary. Final agreement of the camp programme (see section 2.2.6) by Camp Staff and the Camp Committee may coincide with pre-camp training. Each individual member of staff should be issued with an up-to-date copy of these guidelines, along with the specific aims and objectives of the camp, and the appropriate memorandum of agreement (see Appendix 1), prior to the start of the camp. Any staff that will be attending camp for the first time must attend at least one pre-camp briefing or training session. 3.3.2. Pre-camp Briefing for Clinical Staff It is desirable that the Clinical Staff meet in advance of the camp in order to establish roles and responsibilities under the direction of the Medical Director. Education in pre-camp meetings should be supported with written information. This should include the following:  A copy of these DYNZ Camp guidelines  Aims and objectives of the camp  Plan for routine diabetes care. Education about diabetes  Procedures for insulin administration under supervision  Procedure for blood glucose/ketones testing including defined frequency of testing (at least four times daily – more often if unwell or hypoglycaemia suspected)  If feeling "hypo" or unwell, managment of "hypos" – prevention, detection and  Information regarding hyperglycaemia and ketones Diabetes Youth New Zealand National Diabetes Camping Guidelines  Procedure for documentation  Hygiene  Procedures for daily review of health and possible adjustments to regime. 3.3.3. Pre-camp Workshops for Non-clinical Staff and Volunteers Basic training in the principles of diabetes management may be necessary for non-clinical staff and volunteers. Some coaching in leadership skills may also be valuable, depending on age and experience. Roles and responsibilities of non-clinical staff, and general expectations of group leaders and camp assistants should be explained and clarified during pre-camp training workshops. 4. Medical Care at Camp The Medical Director is responsible for coordinating and overseeing medical care at camp. Medical management of campers should be sensitive and relevant to the needs of the young people. Any parental concerns should also be borne in mind. In addition to registers held by members of the clinical staff, a central medical register should be maintained. All medically associated activities and occurrences must be fully Medical Facilities Prior to camp, the nearest hospital, medical centre, pharmacy, and out-of-hours emergency primary care provider must be identified. The distance from these facilities may have a bearing on the resources that will be required on site during camp. Appropriate local medical personnel (paediatricians, primary care centres, and emergency departments) should receive prior notification of the camp – dates, venues, numbers of children, and medical staff in attendance. 4.1.2. On Site – the Medical Health Unit There should be a separate area at the camp that is designated the Medical Health Unit. This facility should be suitably organised and equipped to handle diabetes related and non- diabetes related medical problems (the latter are likely to be primarily of a First Aid nature). Blood testing equipment must be readily available in the Medical Health Unit. Additional requirements of the designated Medical Health Unit:  A sink, running water, and toilet facilities;  At least one bed; a means of isolation for a child with an actual or suspected communicable disease while transport home is arranged (this should occur within 6 hrs);  An area for medical records to be stored and updated;  A storage area for medical supplies, to include a refrigerator;  A private treatment area; Diabetes Youth New Zealand National Diabetes Camping Guidelines  There should be an Emergency Plan to hand;  Key emergency telephone numbers must be displayed close by a telephone. Money or a Telecom phone card must be immediately available if required to operate the telephone. [NOTE: Do not rely on a cell phone; coverage for 021 and 027 phones differs, and it may be necessary to have both. It is suggested that coverage be checked before camp and all staff notified of signal strengths prior to camp];  A list of local providers (see 4.1.1) and a map clearly defining their location should be displayed in the Medical Health Unit. The medical director and camp coordinator should agree a plan to transport sick or injured individuals to the nearest appropriate medical care facility. Information clearly defining the location of the nearest facility should be readily available. Medical Supplies There should be adequate medical supplies available for the treatment of diabetic and non- diabetic health problems. The quantities of supplies will depend on the number of campers and the distance from local providers. NOTE: All usual medication and supplies should be provided by the camper's family – this includes diabetes supplies plus anything required for any illness or condition other than diabetes. See section 5.5 for a checklist of medical supplies that would normally be brought to camp by the campers themselves. 4.2.1. Diabetes Supplies Personal diabetes supplies may be the responsibility of the camper but always ensure that there are adequate "spares" available.  Meters  Meter batteries  Test Strips  Finger pricking devices plus lancets  Record books or sheets  Cotton wool  Paper towels  Glucagon kits (at least 1 per 5 people with diabetes)  Ketone testing strips  Insulin syringes  Insulin pens & pen needles  Insulins, including pen vials  Insulin pump consumables  Insulin pump batteries  Glucose tablets (allow at least 30g per child)  Glucose powder  Emergency carbohydrate foods e.g. fruit juice, muesli bars  Secure and rigid sharps container(s)  50% glucose vials and 10% dextrose bags for emergency plus appropriate tubing and needles for intravenous administration. Diabetes Youth New Zealand National Diabetes Camping Guidelines 4.2.2. General First Aid Supplies  Adrenaline (1:1000 solution)  Hydrocortisone (1%)  Salbutamol Inhaler  Band Aids  Bandages  Dressing pads  Scissors  Adhesive Tape  Insect repellent  Antiseptic solution and cream  Antihistamine tablets and cream  Steri-strips  Plastic spray dressing  Laxative  Paracetamol tablets and syrup  Sun-block 4.2.3. Kits for Outings  Blood glucose monitoring equipment o Strips and meter(s) o Finger pricking device & lancets o Cotton wool/tissues  Wipes  Insulin & syringes  Container(s) for sharps  Glucose – tablets and powder  Glucagon kits  Emergency carbohydrate foods e.g. fruit juice, muesli bars  Whistle(s)  Sun-block  Insect repellent  Fully stocked First Aid kit (see below) Essentials for First Aid Kits  Band aids  Bandages  Steri-strips  Slings (component)  Antiseptic solution  Tourniquet  Antihistamine tablets & cream  Burn cream  Dressings  Scissors  Adhesive tape Diabetes Youth New Zealand National Diabetes Camping Guidelines 4.2.4. Other Supplies  Phone cards or coins for phone box  Torch  Batteries  Identity key rings or cards – for satchels  Mobile/Cell Phone [NOTE: Coverage for 021 and 027 phones differs, and it may be necessary to have both. It is suggested that coverage be checked before camp and all staff notified of signal strengths prior to camp.] Blood Glucose Monitoring 4.3.1. Objectives of Monitoring The general aim is to avoid hypoglycaemia and symptomatic hyperglycaemia, particularly Suggested pre-prandial targets: 4.0 – 10.0 mmol/L Suggested overnight range: 7.0 – 12.0 mmol/L Individual targets may be determined by the clinical team with consultation with parents NOTE: Tight blood glucose control is not the ultimate objective at camp, and it may result in recurrent hypoglycaemia. 4.3.2. Monitoring In Practice Frequency of testing and the degree of supervision required will depend on the age, experience and abilities of each individual camper. Active involvement in monitoring should be encouraged in all young people with diabetes. A minimum of 4 times per day - before meals and at nighttime – should form the basis of the testing routine for all campers. Monitoring requirements for each camper should be assessed by the medical team prior to camp. Those using a basal/bolus or insulin/carb ratio approach to diabetes management may also need to perform post-prandial tests. Those on an insulin pump may also require additional testing (also see section 4.5). An accurate meter must always be used for blood glucose measurements. If the child or young person is unwell and/or ketotic, intensive blood glucose monitoring – at least hourly – may be necessary until the person is stable. Ketone testing should continue until ketonuria is absent or blood ketone levels return to normal. See section 4.7. All test results should be recorded in the central medical register. Any action taken that is based on the test result must also be fully documented. Diabetes Youth New Zealand National Diabetes Camping Guidelines Insulin Adjustment 4.4.1. General Guidance Insulin adjustment must be individualised, and carried out in conjunction with the camper. Dosage adjustments should be agreed by the Physician, Medical Director, or Diabetes Nurse Specialist, unless it has been agreed prior to camp that the camper will be responsible for his/her own insulin adjustments. See section 4.5 for guidance pertaining to young people using insulin pumps at camp. Changes in activity levels and dietary intake will need to be taken into account. Other factors to bear in mind include previous level of fitness and metabolic control, the weather, emotional state of the camper (is the individual homesick or happy?), and the length of the Previous control should also be borne in mind when making adjustments to insulin dosage; a recent HbA1c level is useful in this context. Insulin adjustment should always be made in order to try to achieve the individuals' agreed blood glucose targets whilst minimising the risk of hypoglycaemia. The camp environment usually requires a reduction in insulin in order to avoid recurrent hypoglycaemia, and a ‘reduction protocol' may need to be agreed by the Medical Director in conjunction with the other clinical staff. Dosage and time of insulin administration must be recorded in the central medical register, and in the supervising clinical staff member's register. Management of Young People using Insulin Pumps Detailed records of basal and bolus insulin must be kept, with changes to the normal routine being fully documented in the central medical register, and in the supervising clinical staff member's register. 4.5.1. Basal Insulin  The usual formula for the proportional decrease to the insulin should be added as a 24 hour minus temporary basal at the start of camp. i.e. -30% .  This decrease is to be adjusted each day in consultation with medical staff as per the usual reduction protocol for all children (see Section 4.4).  The Diabetes Specialist Nurse should be the person responsible for setting the basal insulin each day. 4.5.2. Bolus Insulin for Meals  The usual insulin/carbohydrate ratio at mealtimes should be used until patterns show that this needs to be changed.  Note that children will be eating exercise snacks of 15 -30 grams of carbohydrate regularly throughout an active day WITHOUT a bolus being required; these are extra to normal meals that will be bolused for. Diabetes Youth New Zealand National Diabetes Camping Guidelines 4.5.3. Bolus Insulin for Blood Glucose Correction All blood glucose levels >13.5mmol/L should be followed by a blood ketone test - see  Children/young people on a pump should test before every meal and snack.  A correction bolus need only be given if the blood sugar is over target (usually 7 mmol/L) and there has not been any other bolus in the last 3 hours.  Any pump user with ketones should have correction done manually with an insulin pen  Overnight, pumpers should be tested routinely at midnight and a correction given if outside the target. If a correction is required at midnight, the child should be tested 4.5.4. Hypoglycaemia See section 4.6 and Appendix 5. NOTE: Some children may require a temporary decrease in basal insulin (i.e. -40%) for 1-2 hours after strenuous exercise. 4.5.5. Disconnection  Children should disconnect their pump for all contact or water based activities.  The pump should be given to the Diabetes Specialist Nurse, who is responsible for making sure it is reconnected at the end of the activity session. Management of Hypoglycaemia All staff must be confident and competent in treating a "hypo" without panic or hesitation. Some pre-camp training may be necessary to ensure that all staff – including site staff - understand the basics of hypoglycaemia, what causes it, what the signs and symptoms are, and how it should be managed. For young people using insulin pumps, also see Appendix 5 for the management of Hypoglycaemia should be confirmed by a blood glucose test giving a result of < 4.0 mmol/L. All episodes of hypoglycaemia must be documented with blood glucose test results accompanied by a full description of actions taken and/or treatment administered. Diabetes Youth New Zealand National Diabetes Camping Guidelines 4.6.1. Standard First-Response Treatment for Hypoglycaemia First-Response Treatment for a Hypo Give 10g glucose (3 vita or Dextrosol glucose tablets) 1 tablespoon glucose powder in 100ml fluid (e.g. water) 125ml tetra pack of juice (13g CHO) Re-test blood glucose; if still < 4.0 mmol/L, repeat glucose administration as per step 1, and wait a further 10 – 15 mins. NOTE: Do not give any food at this stage; giving food slows down the absorption of the glucose. When blood glucose level is above 4.0 mmol/L a mixed carbohydrate and protein snack can be given if meal-time is more than 15 minutes Monitor closely until stable. 4.6.2. Administration of Glucagon During camp, glucagon may only be given by the Medical Director or Diabetes Nurse Specialist, unless other members of staff have been fully trained in glucagon administration, and the Medical Director has approved this responsibility prior to the start of camp. Glucagon needs to be administered to treat hypoglycaemia if:  uncontrollable behaviour is exhibited For young children the dose may  the person is unable to swallow need to be calculated by weight –  the person is fitting refer to protocol if necessary.  the person is unconscious. Contact medical personnel as per Medical Director's prior guidance. NOTE: Be aware of the possibility of vomiting; lay the person in the recovery position if Once conscious or sufficiently awake treat as described in 4.6.1 (if behaviour allows). 4.6.3. Administration of Intravenous Glucose If necessary, glucose can be administered intravenously by a suitably qualified member of the clinical team. This responsibility must be previously agreed by the Medical Director/Camp Physician. Diabetes Youth New Zealand National Diabetes Camping Guidelines Management of Hyperglycaemia 4.7.1. Hyperglycaemia in the Context of Camps In the context of camps, hyperglycaemia can be simply defined as a blood glucose level above the desirable range. A blood glucose level above 15mmol/L is generally recognised as indication to test for ketones and may require close monitoring. A level of 15mmol that falls by itself after a few hours is usually not cause for concern, however if blood glucose levels remain high (persistent hypergycaemia) for a number of hours, the risk of diabetic ketoacidosis (DKA) is significantly high. 4.7.2. Testing Ketone Levels Blood ketone testing is superior to urine ketone testing. Blood ketone levels (β-hydroxybutyrate) < 0.6 mmol/L normal 0.6 – 1.5 mmol/L raised ketone levels indicate potential problem > 1.5 mmol/L high ketone levels indicate significant risk of DKA 4.7.3. Treatment of Hyperglycaemia with Ketonuria or Raised Blood Ketones Treatment of Hyperglycaemia with Ketonuria or Raised Blood Ketone Level Test urine for ketones – if ketones are present then the following guidance should be followed:  Allow person to rest  Give clear fluids to prevent dehydration (200 ml hourly)  Increase fast-acting insulin (Novorapid or Humalog) - approx 10% of total daily dose given 2 hourly - as required  Monitor blood glucose level hourly to identify the effect of treatment and monitor progress  Continue to test for ketones until clear from urine or blood level Follow the agreed Sick Day Plan (see section 4.7.4) if necessary. Diabetes Youth New Zealand National Diabetes Camping Guidelines 4.7.4. Management of Hyperglycaemia and Sick Days Prior to camp, the Medical Director/Camp Physician should work with the other Clinical Staff to agree a Sick Day Plan for campers. This should include guidance on:  frequency of testing blood glucose and blood or urinary ketones  insulin adjustment  food and/or fluid intake  when to request collection of young person by parents//guardians  when to refer to emergency care. Treatment of Hyperglycaemia and Sick Days Take at least the usual insulin dose. Test blood/urine for ketones – if ketones are present in the urine, or raised in the blood, then the guidance in section 4.7.3 should be followed. If blood glucose levels > 12mmol/L give sugar free clear foods. If blood glucose levels < 12mmol/L but the young person is unable to tolerate normal food intake, replace with fluids or soft foods to balance the effect of insulin 1 – 2 hourly:  1 glass (200 ml) ordinary lemonade (not sugar free or diet) or fruit  1 scoop ice-cream  ½ cup ordinary jelly Test blood glucose levels hourly. If unable to tolerate even fluids by mouth, intravenous fluids will be Observe for underlying cause – e.g. stress, infection. When blood glucose levels stabilise at near-normal levels return to usual insulin dosage and routine management. Medical Care for Illness or Conditions other than Diabetes There must be an agreed plan for the administration of medications required for illness or conditions other than diabetes, including acute medical problems or emergencies. All such medication should be given under supervision of the camp medical staff, and must be documented. Usual medical supplies should be provided by the camper's family; however some emergency and First Aid supplies should be made available on site (see section 4.2). Diabetes Youth New Zealand National Diabetes Camping Guidelines Applying for Camp Communication with families is important to ensure that accurate information about the child's health is obtained. There should be ample opportunity for parents/carers to discuss their child's health before, during, and after camp. 5.1.1. Registration All young people applying for camp will need to be reviewed by their health care team, before a place on camp can be confirmed. The registration form must cover the following:  Name, date of birth, residential address, and contact information for parents/carers  Usual diabetes health care providers  Up-to date insulin information  Type(s)  Usual timing and dosage  Recent HbA1c test result  Details of other medical conditions – e.g. asthma, epilepsy, allergies  Other medications  Duration of diabetes  Hypo information – usual signs & symptoms, any predisposition towards severe hypos that may including fitting  Previous attendance at camps – include dates  Family background/social history, including relevant information on domestic circumstances and/or situation at school  Existing behavioural problems (NOTE: major problems may disrupt the camp experience for other campers)  Other potential problems e.g. bedwetting  Details of usual meal plan  Immunisation status, plus details of any recent contact with infections such as chicken pox or vomiting and diarrhoea  Emergency contacts. See Appendices 2 and 3 for example registration forms, covering the essential aspects NOTE: It is essential that the clinical staff see all camp registration forms at least 2-3 weeks before the camp start date 5.1.2. Legal Consent An appropriate legally binding consent form must be signed by the parent or guardian – this should include consent for any necessary medical, surgical or anaesthetic care in an emergency, should this be required during camp. (See Appendix 2) Diabetes Youth New Zealand National Diabetes Camping Guidelines Selection Criteria The selection of campers should be made jointly by the Camp Committee and the Camp 5.2.1. Inclusion Criteria The needs of the entire group of camp participants must be considered, as well as the personal needs of a given individual. Thus, if one individual has the potential to disrupt the entire event, the inclusion of that individual should be carefully reviewed. Consider the following:  This to be a first camp experience  Newly diagnosed  Social reasons  Geographical (consideration to those in remote areas)  Age (consider giving priority to those who may not be eligible next year)  Exclusion from previous camps on account of numbers  Recommendation from young person's health professional. 5.2.2. Exclusion Criteria  Exceptional behavioural or medical grounds  On account of age or gender ratio. On Arrival at Camp Parents/guardians must be encouraged to bring their children to camp if possible. This is important - parents/guardians are given the chance to meet members of the clinical staff to discuss their youth's health, diabetes care, and current diabetes knowledge and management abilities. This in turn provides the opportunity to assure the parents/guardians that their youth's individual needs will be met. NOTE: Equally, at the conclusion of the camp, parents should be encouraged to collect young people and take the opportunity to discuss their camping experience with both clinical and non-clinical staff that have been spending time with the young person. Education at Camp Camps clearly illustrate the successful concept of diabetes education away from the formal setting. Much of the learning process occurs spontaneously in the environment created during general camp activities. Each camp provides new opportunities for all participants (including the staff) to learn more about living with diabetes, and the challenges that this presents. Camp staff may draw on creative methods of imparting and reinforcing diabetes knowledge – e.g. through the use of crosswords, quizzes, role plays. Diabetes Youth New Zealand National Diabetes Camping Guidelines Educational objectives should be aligned with both the general and specific aims and objectives of the camp (see sections 1.3 and 2.2.5). 5.4.1. General Objectives  To provide and reinforce diabetes knowledge and management skills in a camp setting;  To encourage independence and the development of self-reliance skills;  To reinforce that diabetes is a condition that can be controlled with proper self-care;  To foster a positive attitude towards having diabetes, promoting the fact that having diabetes does not limit the potential achievement of an individual. 5.4.2. Detailed Objectives Specific educational objectives should include the following:  The importance of blood glucose monitoring and control  The relationships between food intake, exercise and insulin  The factors relating to the development of hypo- and hyperglycaemia  Signs, symptoms of hypo- and hyperglycaemia  Management of hypo- and hyperglycaemia  Management of food intake  Blood glucose management during exercise/sports  The whys and wherefores of:  Injecting insulin  Blood glucose monitoring  Ketone testing. What to Bring and WHAT NOT to Bring to Camp The Camp Committee should compile a list of what to bring and what not to bring to camp. This will be appropriate to the type of camp and the age group of the campers. Evaluation of camps is an essential part of the process. Evaluation informs future camps and promotes the advancement of diabetes camps for young people across New Zealand. The Camp Committee should be able to use the results of a formal evaluation to make recommendations for future camps or events. The evaluation should be fully documented within the camp report (see section 2.2.8). Diabetes Youth New Zealand National Diabetes Camping Guidelines Aims of Evaluation  To provide feedback to the Camp Committee on the overall success (or otherwise) of the  To assess whether the objectives of the camp were achieved;  To inform future camp organisation. Specific aims of the evaluation should be drafted at the time of defining the objectives for the camp (see section 2.2.5). Methods of Evaluation The precise methods and timing of data collection for evaluation purposes should be decided during the initial stages of planning (section 2.2). 6.2.1. Collection of Data Evaluation of camps may include subjective and objective assessments, involving  campers  staff  parents  other caregivers Information may be gathered through  interviews  questionnaires  documented observation during camp  written reports by camp staff  written statements from campers 6.2.2. Interpretation of Evaluation Data Evaluation data may be interpreted in the light of  specific aims and objectives  age range of the campers  expectations of the campers  previous camps, especially if any of the aims or objectives were based on recommendations from previous evaluations Implementation of Evaluation Data The evaluation of each camp should be implemented in connection with the results of previous or other concurrent evaluations in order to benefit all of those involved in the organisation, management and participation of camps for young people with diabetes in Diabetes Youth New Zealand National Diabetes Camping Guidelines  Outdoor Activities – Guidelines for Leaders. SPARC, 2005.  Haddock, C., Outdoor safety – risk management for outdoor leaders, 2004.  Safety and EOTC. A good practice guide for New Zealand schools. Ministry of Education,  Health and Safety Code of Practice for State Primary, Composite, and Secondary Schools. Ministry of Education, 1998.  Worksafe at School. Ministry of Education, 2002.  Camping Standards – Guidelines for the conduct of camps for children and adolescents with diabetes. Diabetes Australia NSW / National Diabetes Camping Committee for Children and Adolescents, 2007.  Maslo and Lobato. Diabetes summer camps: history, safety, and outcomes. Paediatric Diabetes, 2008. DOI 10.1111/j.1399-5448.2008.00467.x  The Safe and Healthy Camp. Book User Friendly Resource Enterprises Ltd, 1998.  APEG: Clinical Practice Guidelines. Type 1 Diabetes in Children and Adolescents. March  American Diabetes Association. Diabetes Care at Camps. Diabetes Care Volume 27, Supplement 1. January 2004. Diabetes Youth New Zealand National Diabetes Camping Guidelines MEMORANDUM OF UNDERSTANDING Group leaders/Camp assistants/Industry representatives Thank you for coming on the children's diabetes camp. Without your valuable input, the children would not have this great experience. In order for everything to run smoothly and safely we have a Whilst on camp, you will be allocated to a group of children This group will consist of a nurse, team leaders and approximately 10 children. The nurse's main responsibility is to oversee all the blood glucose levels, drawing up and administration of insulin and treatment of hypoglycaemia and hyperglycaemia. The leader's responsibility is to assist the nurse in all these areas. ONLY A NURSE MAY GIVE AN INJECTION TO ANOTHER PERSON. Leaders' main responsibility is to be with the children during the day, and overseeing and assisting them with the activities. Please be prepared to help the children wash their hands, test and record their blood glucose levels, and observe the drawing up of insulin in children who are proficient. Each dose of short and then long acting insulin must be checked by nurse or leader. ONLY nurses will assist children to do injections. NO INSULIN INJECTIONS are to be given UNTIL THE NURSE GIVES THE OK. The nurse will make the decision about the timing of injections prior to meals. Please make sure the children do not give insulin until the right time. All these children are patients of medical teams on camp. They are on an individual regime that is tailored for them in their particular circumstances. Please do not take it upon yourself to make other treatment suggestions. You are not a health professional. Remember that everyone's diabetes is different. I accept and understand the responsibilities detailed above SIGNATURE: _ DATE: Diabetes Youth New Zealand National Diabetes Camping Guidelines CAMP REGISTRATION FORM: Youth/Teen camp GENERAL INFORAMTION: Name of child Age Diabetes Clinic Doctor: Hospital: _ Phone: _ Family Doctor/Practice: Phone: Al ergies: Date of diagnosis: Hospital admissions in past 12 months - Yes / No (if yes supply details) _ Any special needs / concerns: e.g. requires a caregiver, al ergies, bedwetting, sleepwalking, asthma, other (please detail) Has your child attended previous camps? Yes / No - if yes please supply details (relevant domestic or school details which wil help the camp team) List your child's usual sporting interests / physical activities: _ Gauge of child's fitness level (1= very fit, 2 = moderately fit, 3 = moderately unfit, 4 = very unfit) Can your child swim? Yes / No List any hobbies, crafts or activities your child enjoys / may enjoy: Are there any special fears or dislikes? _ Does your child get carsick? _ Emergency contact name and contact details: Diabetes Youth New Zealand National Diabetes Camping Guidelines DECLARATION BY PARENT OR GUARDIAN: I, …………………………………………… would like to apply for …………………………………… To attend the ………………………….to be held at ……………………. from …………………. I understand that (name of society), al health professionals and members of the camp team wil exercise al due care but wil not be liable for any injury to them or damage to their property. As the (name of society) is liable for any damage caused by campers on camp, I further indemnify the (name of society) if my child is found to be responsible for that damage. SIGNED……………………………… Parent or guardian Diabetes Youth New Zealand National Diabetes Camping Guidelines CURRENT INSULIN REGIMEN: Young Person's Name: Age: Pre breakfast dose Pre breakfast dose 30 unit syringes 50 unit syringes 100 unit syringes Pre tea / dinner Pre tea / dinner …………………. Inject ease used Evening / pre bed Extra's/adjustments usual y made. Give Diabetes Youth New Zealand National Diabetes Camping Guidelines Does your child give his / her own injections? Does your child draw up their own insulin/s? What injection site/s are used? Frequency of home blood glucose testing: Does your child require help with testing? Has your child had any episodes of Diabetic ketoacidosis / large amounts of ketones present within the last Has your child had any severe hypos requiring Glucagon within the last 12 months? Yes / No - If yes - what were the circumstances? Last HbA1c test result: _ What are your child's hypo symptoms? Does your child recognise hypo symptoms? What treatment does your young person prefer to use to treat hypos? Do you usual y adjust insulin and / or food for extra activity? If yes give examples Duration of Diabetes? _ Any comments relevant to management of his/her diabetes? _ Diabetes Youth New Zealand National Diabetes Camping Guidelines OTHER MEDICATIONS Is your child on any other medication? Yes / No - (give details if yes) Types/s: Dose/s: Times: Please note: Sometimes it is necessary in a camp setting to change a child's insulin dose or food intake to compensate for the change in activity level he / she wil experience. If you have any hesitation / concerns about this please contact your Diabetes Educator directly. Diabetes Youth New Zealand National Diabetes Camping Guidelines DIETARY INFORMATION: Young Person's Name: _ Age: Usual Dietitian's Name: Hospital Clinic: _ Please write an outline of usual foods / fluids in boxes below: If your child uses carbohydrate : insulin ratios please also write these below: MID MORNING SNACK: MID AFTERNOON SNACK: EVENING SUPPER SNACK: Does your child have coeliac disease? Does your child have any al ergies to food / drinks? Yes / No - If yes please specify (include symptoms): _ Please list favourite foods: _ Please list food dislikes: _ Any other comments: We try to provide meals that al young people enjoy but we may be unable to accommodate al dislikes. Please note that all information requested on these forms is essential in helping plan a safe camp. Thank you for completing in full, all aspects of the applications Diabetes Youth New Zealand National Diabetes Camping Guidelines REGISTRATION FORM: Family camp NAME OF PERSON WITH DIABETES:
(e.g. mum, brother, aunt, etc) Please note that families are responsible for their own health and welfare including the management of their diabetes. Al food wil be available including snacks and extras, but please bring al your own personal insulin, testing equipment , ketone stix, glucagen etc. SLEEPING Cabins (you may have to share with another family) FOOD Other than diabetes-related food, does your family have any other food preferences, e.g. Vegetarian, coeliac? If you have any queries regarding camp then please contact the Camp Coordinator. Diabetes Youth New Zealand National Diabetes Camping Guidelines This is a sample budget catering for young people between the ages of 8 and 13 with staff members (no paid staff). The fol owing items need to be considered when budgeting for a camp for young people. • Accommodation & food (the cost here wil vary considerably especial y if using Health camps) • Activities off site • Night Nurse costs Other costs (sample only) • Casual Meals • Medical Supplies • Hypo emergency foods e.g. Glucose Tablets • Telephone Cal s • Photocopying • Activities both on and off campus ? Obtain quotes Optional costs (samples only) • Certificates and Gifts (These costs and items to be decided by the camp committee) • Photos and developing (consent to publish MUST be obtained from parents) Many of the above items may be donated or sponsored but should be budgeted for to get a true cost of the camp. NOTE: If health professionals are brought in from outside your own area, you may need to pay them. It may also be necessary to pay for a night nurse or his/her expenses. Diabetes Youth New Zealand National Diabetes Camping Guidelines The fol owing points should also be considered • Check that any DHB funding is available. - Notify medical staff of proposed dates (try do this 12 months in advance) - Once the medical staff are confirmed book the venue and form a camp - Start to source funding as soon as possible. A letter may be needed to verify that the camp is taking place. - Initial expression of interest to camp; send out through DNS/Diabetes Youth NZ groups and Support groups four months before camp, to be received back 8-10 weeks before camp - After the selection of young people has been decided send out detailed applications to be received back six weeks before camp - This enables time for the medical staff to familiarise themselves with the young peoples' details. Diabetes Youth New Zealand National Diabetes Camping Guidelines Managing Hypoglycaemia in Young People on Insulin Pumps Hypoglycaemia DAYTIME PROTOCOL FOR PUMP USERS For use when child conscious and able to swallow BG ≤ 2.0 mmol/L BG ≤ 3.1 – 4.0 mmol/L 2 x 125 ml JUICE [26g fast acting CHO] [26g fast acting CHO] [13g fast acting CHO] RECHECK in 15 mins RECHECK i n 15 mins If still low then RETREAT If still low then RETREAT Once recovered give [15g long acting CHO] [15g long acting CHO] If still low after 2nd treatment, contact Medical Director or Diabetes Specialist Nurse immediately for advice. Diabetes Youth New Zealand National Diabetes Camping Guidelines Hypoglycaemia NIGHTIME PROTOCOL FOR PUMP USERS All children on pumps should have blood glucose levels tested at midnight. BG ≤ 2.0 mmol/L BG 2.1 – 3.0 mmol/L BG ≤ 3.1 – 4.0 mmol/L 2 x 125 ml JUICE 2 x 125 ml JUICE [26g fast acting CHO] [13g fast acting CHO] RECHECK in 15 mins RECHECK in 15 mins If still low then RETREAT If still low then RETREAT Once recovered give Once recovered give [15g long acting CHO] [15g long acting CHO] If still low after 2nd treatment, contact Medical Director or Diabetes Specialist Nurse immediately for advice. Diabetes Youth New Zealand National Diabetes Camping Guidelines PHOTOGRAPHY PERMSSION FORM If the camper is under 16 years old, please give date of birth of individual and name and contact details for parent/guardian: Name of parent/guardian: Contact number: _ I permit Diabetes Youth New Zealand to take/use photographs of myself/my child in Diabetes Youth New Zealand or Diabetes New Zealand publications and/or publicity material. SIGNATURE: _ DATE: (must be signed by parent/guardian if individual is under 16 years old) For DYNZ internal use: Diabetes Youth New Zealand National Diabetes Camping Guidelines

Source: http://www.diabetesyouth.org.nz/files/dynz-campguidelines-aug2010.pdf

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Cell Physiol Biochem 2015;37:651-665 DOI: 10.1159/000430384 © 2015 S. Karger AG, Basel Published online: September 08, 2015 Spaas et al.: Chondr ogenic Priming Enhances MSC Adhesion ed: August 04, 2015 This is an Open Access article licensed under the terms of the Creative Commons Attribution- NonCommercial 3.0 Unported license (CC BY-NC) (www.karger.com/OA-license), applicable to