With millions of New York and New Jersey students returning to school in September, school nurses are geared up to manage the many chronic illnesses they face. One of the most common of these ailments is asthma.
According to a December 2006 article in the Centers for Disease Control and Prevention’s “Advance Data From Vital and Health Statistics,” prevalence of childhood asthma was more than 9.8% in New York and between 8.6% and 9.7% in New Jersey. To better manage these children, city, state and healthcare organizations have teamed up to offer guidelines for school nurses to follow.
As a joint project between the New York City Department of Health and Mental Hygiene and New York City Department of Education, the Office of School Health identifies asthma as a leading cause of missed school among children, and it is the most common cause of hospitalization for children ages 14 and younger. The department’s asthma initiative offers programs geared toward managing the chronic ailment. Its Managing Asthma in Schools program improves coordination of care for children with asthma in public elementary schools.
Implemented in 2005, the program provides guidelines, resources and tools to identify and provide case management for students with asthma, said Kathleen Mulholland, RN, administrative public health nurse for the Office of School Health. “Nurses identify students with asthma through new admission physicals, medication administration forms and primary care provider referrals for students with suspected asthma,” she said. “They obtain PCP orders on medication administration to administer rescue medication in school.”Teresa Wilson, RN
A collaborative effort between the American Lung Association, the department of health and other New York City organizations, Open Airways for Schools is another asthma management program designed to teach children about asthma, its warning signs, triggers, medications and how to manage asthma and advocate for themselves. “All nurses assigned to elementary schools are trained to conduct OAS for third-, fourth- and fifth-grade students,” Mulholland said.
“The nurse’s goal is to identify all students in the school with asthma, ensure they have continuity of care, link them to health insurance if lacking and obtain medication administration forms for rescue medication in school,” she said. “Students use the rescue medication in school and return to class when symptoms subside. If the nurse’s assessment of respiratory status identifies symptoms continue to increase, the nurse determines whether an EMS call is required.”
The curriculum of six, 40-minute lessons is offered for free to students during the school day. The program teaches children with asthma basic information that will help them control their own asthma more effectively, eliminate the likelihood of hospital visits and reduce absences. New York City school nurses have trained more than 12,000 students in the program, Mulholland said.
The Montefiore School Health Program in the Bronx provides comprehensive multidisciplinary services in 19 Bronx elementary, middle and high schools. The Montefiore program has begun initiatives to help school children in the Bronx, according to Montefiore School Health Program medical provider Teresa A. Wilson, RN, MS, NP-BC. “Community health specialists are instituting no smoking around the schools, removing afflicting cleaning solutions from the school environment and are involved legislatively to institute no idling in front of schools,” she said.
Montefiore’s program is designed as a full-service clinic that includes a team of medical providers, mental health professionals and community health specialists, Wilson said. The nurses implement the plan of care, reinforce treatment regimes, facilitate educational sessions and distribute educational material throughout the school year to all asthmatic students and their families.
“Asthma action plans are completed by the medical providers and sent home to the parents,” Wilson said. “These reinforce the plan of care that will assist the parent in identifying when their child is having an exacerbation and how to proceed effectively.” During the school day, aerosol (nebulizer) treatments, oxygen and oxygen saturation monitoring — and other emergency medications — are available in all of Montefiore’s school-based Bronx clinics. Spirometry testing also is used in one of the clinics.
Each team identifies asthmatic children in the school and schedules them for annual and intermittent health assessments. “This is a time when the medical providers review [the children[‘]s] asthma classification and plan[s] of care,” Wilson said. “Throughout the year, other students are identified with new onset of asthma and the medical providers diagnose, classify and prescribe medications as needed.”
Asthma is triggered in school settings by a number of environmental factors, Wilson said, such as extremely hot or cold temperatures, humidity, dust, chalk, perfume or afflicting cleaning solutions and by an increase in activities during gym or recess. “They also get ill from exposure to other ill children in the classroom, consumption of allergic foods while attending school and increased anxiety which children experience in conflicting relationships or during exams,” she said.
To help minimize risk factors in the home, Montefiore medical providers refer families to the Healthy Nest program, which provides environmental assessments for potential triggers.
N.J. school nursesThe Pediatric/Adult Asthma Coalition of New Jersey’s toolkit consists of six requirements school nurses must meet before applying for the Asthma Friendly School Award.
In New Jersey, the Pediatric/Adult Asthma Coalition of New Jersey, part of the American Lung Association in New Jersey, works with more than 70 partners to provide resources and tools to help individuals manage their asthma. The coalition offers four training programs for school nurses as part of the requirements for its Asthma Friendly School Award, said Teresa Lampmann, coordinating manager.
“This initiative was designed to implement system change throughout the state to shift schools from a reactive response to a proactive response in managing asthma in the school setting,” Lampmann said. “The programs were also developed to support the New Jersey law requiring school nurses to have airway management training and school faculty to have asthma training.”
According to Lampmann, PACNJ wanted to create a standardized asthma education program based on the National Heart, Lung and Blood Institute guidelines for best practice in managing asthma, to be delivered statewide. “Currently, we have nearly 600 schools that have qualified for the PACNJ Asthma Friendly School Award including Newark, the largest urban school district in the state,” she said.
New Jersey law requires students permitted to carry an inhaler in school to have an asthma treatment plan on file in the school nurse’s office. The PACNJ asthma treatment plan was initiated statewide in 2001 and provided to New Jersey school nurses to distribute. “The purpose of the asthma treatment plan is to be a communication tool between the family, school nurse and healthcare provider so they work as a team to manage the student’s asthma,” Lampmann said. “It also met the requirements of the New Jersey law and was endorsed by the New Jersey Department of Health and Senior Services and later the New Jersey Department of Education.”
Based on the results of a 2005 PACNJ-conducted school nurse survey, the asthma treatment plan was revised and now includes a list of all asthma medication, how much to take and when to take them, Lampmann said. “This allows the physician to check off the information rather than write in the prescription and makes it easier for the family to read and understand,” Lampmann said. “We then made it available free to download from the PACNJ website in eight languages and it is available as a fillable form in English and Spanish that will print just the items checked. It serves as physician’s orders for the school nurse.”
In the trenches
New Jersey school nurse Wendy Lamparelli, RN, BSN, CSN, MSEd, said school nurses address asthma management in many ways. “We pick up on asthma diagnosis before a child has an attack or crisis when we review the health history upon entry to our school or upon enrollment,” she said. “We send letters home, call parents and inquire as to the severity, last attack and whether meds are needed in school. Sometimes asthma is indicated on a health history but by the time the child reaches high school [he or she has] outgrown it.”
There also are other ways to manage asthma, Lamparelli said, such as identifying potential triggers. “I requested the carpet in my office be removed,” she said. “I have approximately 25 children with asthma and will be asking for the carpet to be removed in all classrooms over time.”
Even with precautionary measures, the occasional crisis may occur, but is rare, Lamparelli said. “If this happens, it is usually because the child has a chronic asthma condition and the information and medication and treatment plan had never been discussed,” she said. “Or sometimes the parents may think the child has not had an attack in a while so they stop planning for it.”
Lamparelli, a certified school nurse who works with high school and elementary school students in the Hackensack, N.J., school district, is familiar with the coalition’s work. “The asthma coalition has a set step-by-step manual on how to take on asthma triggers in schools and make them more asthma friendly,” she said.
Realizing the importance of such initiatives, Lamparelli has begun projects to help other school personnel identify and react if a child has an attack. “I have recently spearheaded a project in my district where I can upload a step-by-step plan for the teacher to follow in an emergency,” she said. “I feel very positive about that.”
For information on PACNJ’s Asthma Treatment Plan, visit www.pacnj.org. For information on NYCDOHMH’s asthma programs, visit http://home2.nyc.gov/html/doh/html/asthma/asthma.shtml.