Asthma Management in Educational Settings - Implementing System Change

for School Nurses

Robin Evans-Agnew, RN, MNRobin@alaw.org

History

Washington Asthma Initiative: “To mobilize individuals and communities throughout

the state to improve the prevention, diagnosis, and management of asthma in order to decrease its individual and societal burdens."

Access to inhalers and “zero tolerance” NAEPP asthma care in schools publication Successful partners: Boeing, CSHCN, OSPI,

SNOW, Mary Bridge, Childrens Hospitals, DOH K-20 presentation on world asthma day 2001 GlaxoSmithKline grant for Spokane project

Kaiser work group report December, 2001

School health services: National Recommendations*

Full time SN all day every day for each school ID and track all students with asthma Use asthma action plan Assure immediate access to medications Use standard emergency protocols Assure access to care for consulting physicians Provide intensive Case Management for

students with 10+ absences

* CDC, 2002. www.cdc.gov/healthyyouth/healthtopics/asthma

Addressing asthma within a coordinated school health program*

1. Support systems

2. Health services

3. Asthma Education

4. Environment5. P.E.6. Community

efforts

Family/community involvement

Physical education

Nutrition services

Healthy school environment

Health services

Counseling/psych/ social services

Health education

Health promotion staff

The AMES Manual: Contents

1. Asthma Basics

2. Working With Parents and Students to Manage the Students asthma in the School Setting

3. Creating a Safe and Supportive School Environment for the Student with Asthma

4. Resources

5. Appendices

Spokane Implementation Study

Can an intensive implementation of the Ames manual increase the number of children on effective case management?

Real – time, practice-based studyConvenience samplingStudy period: February – May 2002Implementation team

Methods

Data Children of concern with asthma (COCA)

selection Absences Asthma Care planning

How asthma friendly is your school survey (HAFYS)

Number of children with asthma in school setting School staff and other personnel trainings Process evaluations AMES evaluations

Methods

Study group: 23 nurses, 55 schools, 80 cases Control group: 22 nurses, 48 schools, 73 cases Attrition rates (study: 1 incomplete, 2 opted out,

control: 1 incomplete, 6 opted out) Confidentiality/Consent Study Group:

Two trainings on AMES and implementation strategies Incentives for staff training: extra training, spacers/Peak

flow meters, camp scholarships Control group:

AMES manual only

Methods: Data collectionControl NursesStudy Nurses

Training

Training

February

May

COCA, HAFYS, Process, manual evaluation

COCA, HAFYS

Results: Demographics

Elementary school Urban, suburban, and

rural differences Nurse: student ratio Nurse coverage area

Intervention Con Total

CV 81 101

Number of students 32 48 73 153

Age (average) 9.4 9.0 10.4 9.6

Grade (average) 3.6 3.3 4.7 3.9

Intervention Cont

CV ESD 81 101

Number of schools* 10 45 48

Number of students 5185 25669 11874

Number of students with asthma

465 2359 390

Rate of students with asthma (%)

9.0 9.2 3.3

Number of nurses available 9 10 15

Nurse: students w/asthma 51.7 235.9 26

Results: Asthma Action PlansFigure 1. Children of Concern With Asthma: Change in Care planning before and after

intervention

54%

42% 40% 38%35%

31%

15%

71%

59% 57%54%

48%

36%

14%

75%

86% 84%

71%

77%

56%

48%

00%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Care Plan Secretary Teacher PE Teacher Principal Play Aide Bus Driver

Staff members plan is shared with

Study in WinterStudy in SpringControl in spring

Results: Absences

Mean Monthly Absences, Children with Asthma, Spokane Area Schools, 2001 -

2002

0

0.5

1

1.5

2

Sept - Dec Jan - May

Control

Study

Results: Asthma Friendly Schools

Figure 2 : How Asthma Friendly Is Your School Survey Scores

0%

20%

40%

60%

80%

100%

120%

Med

icatio

n us

e

Tobac

co fr

ee

PE opt

ions

Self c

arry

Mod

ified

activ

ities

IAQ

Reduc

e irr

itants

Teach

scho

ol st

aff

Emer

genc

y pla

n

Nurse

Ava

iabl

e

Teach

stud

ents

Study-Feb

Study-May

Control

Qualitative Results:

Training (study:control – 297:80)

• Using training PowerPoint

• Using the manual sheets• Identify early symptoms• Teachers, students,

childcare staff, aides, kitchen staff, bus drivers

• Passive education systems (staffroom notebook)

• Using incentives

Qualitative Results:

Self knowledge• More educated-Have more tools• Increased my awareness of importance of good asthma

management• “I take it much more seriously”• “Better understanding of asthma and how it effects my

students”• “I knew I needed to learn more and this helped me learn

the easy way”• “Better use and understanding of peak flow”

Qualitative Results: other

Care plans Communication Case finding Other Barriers

Materials Time Confidentiality/nursing

practice

Qualitative Results: Behavior change

100% of study group nurses agreed the project had “changed or increased” their behaviors regarding asthma

Nurse goals: Student quality of life

“keep students safe” “to decrease absences”

“better management of asthma “to complete emergency plans” making sure “all appropriate people get plans”

“to increase asthma awareness” “more interaction with students, staff, bus drivers, parents, &

physicians” “improve staff awareness” : preparation of staff for a severe

attack “more involvement with parents” improving school systems

Qualitative Results: the manual

“I think the manual is very easy to use and is very well organized. I plan to use it extensively.

Thank you for this wonderful guide.”

Conclusion

LimitationsEntrée

Strategies for collaboration with school nurses Consent of leadership Participatory activities Training and education Access to relevant resources Openness to innovation

Ability to collect absence data

Areas of concern

IAQ/irritant issues All student education and awarenessNurse coverage for chronically ill students

Credits

Wenjin Li, MD, University of Washington

Paul Williams, MD, NW Asthma and Allergy

Lyndia Vold, MPH, Spokane County HD

Implementation Team: Carol Johns, MSN, RN Cheryl Funke, RH Kathy Reed-MvKay, RN Linda Bordwell, RN Julie Schultz, RN Cindy Thompson Trry Reid