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HISTORY:
Life threatening events occur in schools due to a variety of conditions, including preexisting health problems, unintentional injuries, natural disasters, allergic reactions, cardiac arrest, and violence. School districts are accountable for developing prevention programs and for ensuring effective responses to urgent and emergent health problems of students, staff, and visitors in the school community (Hootman, 2001). Adequate provision of school health services includes a professional nurse authorized to determine appropriate administration of medication, medically trained staff, and immediately accessible supplies to ensure effective assessment and management of acute events in all schools. Medications can be a vital part of a rescue response.
DESCRIPTION OF ISSUE:
An emergency event in schools is a serious situation that arises suddenly to threaten well-being and safety (Schwab & Gelfman, 2001). School nurses and other school staff are increasingly called to provide emergency care in schools for students and faculty, including at school-sponsored extracurricular activities both on and off campus. The incidence of diabetes, asthma, and severe allergic reactions to foods and insect stings is increasing in children (American Academy of Allergy, Asthma, & Immunology (AAAAI), 2004; American Diabetes Association (ADA), 2003; Centers for Disease Control & Prevention (CDC), 2004; University of Maryland, 2004) increasing the likelihood that serious medical reactions may occur at school. With the advancement of technology and scientific research there has been an increasing availability of and reliance on medications for responding to these acute conditions. As a result, various advocacy groups are encouraging the availability of "rescue medications" in schools. The most commonly recommended rescue medication is epinephrine. Other rescue medications may include albuterol, glucagon, diazepam rectal gel (Diastat) and oxygen.
The federal mandates of IDEA and Section 504 of the Rehabilitation Act obligate schools receiving federal funding to provide certain medical services, including appropriate medication administration to students. State laws, however, generally govern the administration of medication in schools. Medication administration is a complex process and carries responsibility for safe administration practices to avoid untoward health risks such as over and under dosage, side effects, toxic effects, and harmful drug interactions. Subsequently, medication administration is clearly the function of licensed physicians and nurses and is not usually delegated to unlicensed persons except when administrative mandates specifically permit others to carry out this function (Hootman, 2001). Nurse practice acts in some states prohibit delegation of medication that is injected because this is an invasive procedure and errors can cause significant harm (Schwab & Gelfman, 2001). The primary intent of such legislated regulation is to ensure that medication is safely administered and that risks for negative side effects are minimized. For the safety of children needing "rescue medication" at school the school nurse should plan for ongoing assessment and for developing and maintaining an Individualized Health Care Plan and Emergency Care Plan.
Some schools have a health care professional, generally a school nurse, on site at all times. Other schools have only intermittent school nursing service. Some small or remotely located schools have no access to a school nurse or other medical professional. Some states’ statutes (e.g., Texas, Oregon, Nebraska, and West Virginia) allow for unlicensed staff (e.g., principal, classroom assistants, nursing aids, teachers) to receive training, recognize signs and symptoms of urgent/emergent conditions (e.g., anaphylaxis and hypoglycemia) and administer rescue medications when trained, delegated, and supervised by the school nurse. The availability or lack of availability of a school nurse strongly impacts the response that schools can safely provide for administering rescue medications. It has yet to be determined in states allowing delegation of medication if this sets standards in those states for schools and thereby a responsibility that training must be provided as well as stock emergency medication.
Nurse practice acts are in place to protect the public from harm. The nurse practice act in some states prohibits the delegation of medication by a sole route such as injection or prohibits all medications, no matter the route of delivery. The restraint upon medication administration in schools is most often due to a desire to protect persons from harm at the hands of unqualified persons. Safe administration involves in-depth knowledge, including the right technique, dosage parameters, side effects, and contraindications for use. Continuous education by the professional is needed to sustain and enhance competency in medication administration. Subsequently, repeated retraining is essential for assistive personnel involved in medication administration. Besides setting boundaries for the scope of nursing practice, nurse practice acts set expectations within the scope and standards of professional practice. Minimally, school nurses have accountability to assess, diagnose, plan, intervene, and constantly survey the environment and client for each known potential emergency situation. Only within this process can the nurse determine if delegation and or medication administration is safe given the student’s history, the features of the prescribed medication, and the potential for untoward side effects. The assessment aspect of the nursing process cannot be delegated to unlicensed personnel.
Opinions are diverse regarding what equipment and services should be available for rescue events at school. In the past, school systems’ accountability for responding to emergencies and urgent health problems primarily focused on first-aid measures. Today school district responsibilities include planning for and addressing complex medical and nursing needs of students, including emergency conditions such as anaphylaxis, hypoglycemia, and airway obstruction (Hootman, 2001). There are no nationally accepted recommendations for minimal emergency equipment, including medications, regardless of whether a school nurse is consistently present or not (Bobo, Hallenbeck, & Robinson, 2003). Multiple factors (e.g., legal concerns and mandates, district policies, resource allocation, equipment maintenance, training needs, time required for EMS to reach the site, as well as ethical and financial considerations) influence decisions about having emergency equipment and rescue medication available at school. Schools are not required by legislation to provide emergency medication for individual students (Hootman, 2001). (One exception is Nebraska that requires a nebulizer, premixed albuterol, and epinephrine (Epi pen) in each building.)
However, advocates are encouraging that schools be accountable for having stock rescue medications immediately available for the individual who has left his/her rescue medication at home or who cannot afford a second prescription for the school and for the undiagnosed person experiencing an unanticipated life threatening/urgent event at school. Legal mandates and costs must be considered. Schools must have access to a licensed medical provider willing to provide standing orders and to assume liability for any untoward events. With many schools facing declining educational budgets, some educational advocates are concerned about the use of educational funds to purchase medication. Schools have been cautioned about the potential for precedent setting and/or charges of discrimination should they not be able to equitably treat each financially needy situation (Hootman, 2001). Further complicating the decision is the issue of providing rescue medications on field trips and other school-sponsored events and of managing multiple, simultaneous off-campus events.
RATIONALE:
School nurses alone have the educational background, knowledge, and licensure that provide the unique qualifications necessary for directing the administration of medications in the school setting. Schools that do not have school nursing service are a particular concern. Medication and emergency policies in school districts must be developed for the safety of all students and staff. As the school staff member most involved with medication administration, the school nurse must have input into school district policies and procedures relating to rescue medication administration. These policies must be developed considering the safety of all students and staff. The school nurse should also be an integral part of the legislative process before any changes or modifications to a state’s current laws are undertaken.
In life threatening and urgent situations, there must be ready access to appropriately trained rescue staff as well as to pertinent rescue medications and supplies. Families have been historically responsible for providing medication needed for their child’s special health needs. Now some national health organizations, including the American Heart Association, American Academy of Pediatrics, and American College of Emergency Physicians have recommended that there should be essential minimal emergency equipment for schools with a school nurse. They consider albuterol, epinephrine, and oxygen, in accordance with state laws and pharmacy and nurse practice act specifications, part of the essential equipment (Bobo, etal., 2003).
School nurses bring emergency preparedness skills and possession of knowledge about the special health needs of students in emergency situations. School nurses can best determine the need for rescue medications in schools. Assessment, education, and planning are essential to establishing and maintaining a safe school environment. School nurses should be key members of program development for emergency preparedness. School nurses’ knowledge of existing school health programs and current health trends should be used in prioritizing and planning emergency response plans for the school community, including the provision of rescue medications.
School nurses have the expertise to provide necessary training for unlicensed assistive personnel. However, emergency responses can only be practiced by unlicensed persons in simulation. Thus, it is very difficult to have these persons fully trained and ready to function safely. Retraining must be done frequently to sustain adequate skill level. School nurses must be involved in the ongoing supervision and training of unlicensed assistive persons to assure an appropriate emergency response.
CONCLUSION:
It is the position of the National Association of School Nurses that school districts should provide school nursing services. School nurses can evaluate the need for rescue medications and provide student assessments, individual health /emergency plans, and supervision of unlicensed assistive personnel for the appropriate management of students’ health problems as well as management of rescue medications.
Before deciding which rescue medications, if any, to provide, the following areas should be studied:
- Individual school, school district, and community needs for emergency response
- State laws, school district policies, and nurse practice acts regarding parameters of medication administration in school settings
- Factors related to safety, effectiveness, and cost of the rescue medications
School districts that determine a need to provide one or several rescue medications should consider the following before routinely stocking any medications:
- The ongoing commitment of a school medical advisor for consultation, medical oversight, and writing of prescriptive orders (within state regulations and federal guidelines) for agreed-upon rescue medications
- The inclusion of the school nurse as a vital member in all aspects of program development and implementation
- Consistent funding resources to maintain an adequate medication supply and related expenses for training, equipment maintenance, liability expenses, and medical and nursing supervision
- The availability of an adequate pool of staff to whom administration of rescue medications can be delegated within the parameters of the state nurse practice act
- The commitment to developing policy and procedure that is kept current and supports safe program implementation and maintenance, and that respects the limiting parameters of delegation for medication administration
- The commitment of time and resources to develop well-defined emergency plans, including procedures for safe medication administration and storage, such as monitoring expiration dates and routine checking of inventory for immediate availability and functionality of supplies.
References/Resources:
American Academy of Allergy Asthma and Immunology. (2004). Position statement. Anaphylaxis in schools and other child-care settings. Retrieved March 9, 2004 from http://www.aaaai.org/media/resources/academy_statements/position_statements/ps34.asp
American Academy of Pediatrics (2003). Policy statement. Guidelines for the administration of medication in school. Pediatrics, 112 (3), 697-699.
American Academy of Pediatrics. School health training kit. Consulting with schools on health issues. Retrieved December 31, 2003 from http://www.schoolhealth.org/trnthtrn/section2/section2d.html
American Academy of Pediatrics. (2001). Policy statement. Guidelines for emergency medical care in school. Pediatrics, 107 (2), 435-436.
American Academy of Pediatrics, Committee on School Health. (2001). The role of the school nurse in providing school health services. Pediatrics. 08(5), 1231-1232.
American Diabetes Association (2003). Diabetes fact sheet. Retrieved May 12, 2004 from http://www.diabetes.org/diabetes-statistics/national-diabetes-fact-sheet.jsp
Baker, V. O., Friedman, J. & Schmitt, R. (2002). Asthma management, Part II: Pharmacologic management. Journal of School Nursing, 18(5), 257-269.
Barrett, J. C. (2002). Teaching teachers about school health emergencies. Journal of School Nursing, 18 (6), 316-322.
Barrett, J. C., Goodwin, D., & Kendrick, O. (2002). Nursing, food service, and the child with diabetes. Journal of School Nursing, 18 (6), 150-155.
Blum, M. (2001). Are school nurses using the recommendations of the diabetes control and complications trial in the care of students with diabetes? Journal of School Nursing, 17(6), 138-143.
Bobo, N., Hallenbeck, P., & Robinson, J. (2003). Recommended minimal emergency equipment and resources for schools: National consensus report. Journal of School Nursing, 19 (3), 150-155.
Centers for Disease Control and Prevention (2004). Asthma. Retrieved May 12, 2004 from http://www.cdc.gov/od/perfplan/2000/2000xiiasthma.htm
Gaudreau, J. M. (2000). The challenge of making the school environment safe for children with food allergies. Journal of School Nursing, 16(2), 5-10.
Harrigan, J. (2002). Overview of school health services. Castle Rock, CO and Scarborough, ME: National Association of School Nurses.
Hazinski, M. F., Markenson, D., Neish, S., Gerardi, M., Hootman, J., Nichol, G., etal. (2004) Response to cardiac arrest and selected life-threatening medical emergencies: The medical emergency response plan for schools. A statement for healthcare providers, policymakers, school administrators, and community leaders. Pediatrics, 113(1), 155-168. Available: http://www.aap.org/policy/erplanschool/04.pdf
Hootman, J. (2001). School nursing practice: Professional performance issues. In N. C. Schwab & M. H. B. Gelfman, Legal issues in school health services: A resource for school administrators, school attorneys, and school nurses. North Branch, MN: Sunrise River Press.
National Association of School Nurses. (2003). Position statement. Medication administration in the school setting. Available at http://www.nasn.org/positions/medication.htm
National Association of School Nurses. (2003). Position statement. Preparing for school emergencies. Suggested emergency equipment and resources. Available at http://www.nasn.org/positions/emergencies.htm
National Association of School Nurses. (2002). Position statement. Using assistive personnel in school health service programs. Available at http://www.nasn.org/positions/assistive.htm
National Association of School Nurses. (2001). Position statement. School nurse role in care and management of the child with diabetes in the school setting. Available at http://www.nasn.org/positions/diabetes.htm
National Association of School Nurses. (2000). Position statement. Epinephrine use in life-threatening emergencies. Available at http://www.nasn.org/positions/Epinephrine.htm
National Association of School Nurses. (2000). Position statement. The use of automatic external defribrillators in the school setting. Available at http://www.nasn.org/positions/autoexterdefib.htm
National Association of School Nurses. (1999). Position statement. The use of asthma inhalers in the school setting. Available at http://www.nasn.org/positions/inhalers.htm
National Association of School Nurses. (1998). Position statement. Emergency care plans for students with special health care needs. Available at http://www.nasn.org/positions/emer_care.htm
National Association of School Nurses & American Nurses Association. (2001). Scope and standards of professional school nursing practice. Washington, DC: American Nurses Publishing.
Neuharth-Pritchett, S. & Getch, Y. Q. (2001). Asthma and the school teacher: The status of teacher preparedness and training. Journal of School Nursing, 17 (6), 323-328.
Reutzel, T. J. & Patel, R. (2001). Medication management problems reported by subscribers to a school nurse listserv. Journal of School Nursing, 17 (3), 131-139.
Sander, N. (2002). Making the grade with asthma, allergies, and anaphylaxis. Pediatric Nursing, 28 (6), 593-596.
Schwab, N. C. & Gelfman, M. H. B. (2001). Legal issues in school health services, A resource for school administrators, school attorneys, and school nurses. North Branch, MN: Sunrise River Press.
Sichereer, S. H., Furlong, T. J., DeSimmone, J., & Sampson, H. A. (2001). The U.S. peanut and tree nut allergy registry: Characteristics of reactions in schools and day care. Journal of Pediatrics, 138(4), 560-565.
University of Maryland (2004). What children get asthma? Retrieved May 12, 2004 from http://www.umm.edu/patiented/articles/what_children_get_asthma_000005_4.htm
Adopted: July 2004 |