Asthma Management in Educational Settings Implementing System Change

Asthma Management in Educational Settings - Implementing System Change for School Nurses Robin Evans-Agnew, RN, MN Robin@alaw. org

History l 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 l K-20 presentation on world asthma day 2001 l Glaxo. Smith. Kline grant for Spokane project l l l

School health services: National Recommendations* l l l l 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 Kaiser work group report December, 2001

Addressing asthma within a coordinated school health program* Family/community involvement Physical education Nutrition services Healthy school environment Health services 1. Support systems 2. Health services 3. Asthma Education 4. Environment 5. P. E. 6. Community efforts Counseling/psych/ social services Health education Health promotion staff * CDC, 2002. www. cdc. gov/healthyyouth/healthtopics/asthma

The AMES Manual: Contents 1. 2. 3. 4. 5. Asthma Basics Working With Parents and Students to Manage the Students asthma in the School Setting Creating a Safe and Supportive School Environment for the Student with Asthma Resources Appendices

Spokane Implementation Study l Can an intensive implementation of the Ames manual increase the number of children on effective case management? l Real – time, practice-based study l Convenience sampling l Study period: February – May 2002 l Implementation team

Methods l Data ¡ Children of concern with asthma (COCA) selection Absences l Asthma Care planning l ¡ How asthma friendly is your school survey (HAFYS) l Number of children with asthma in school setting ¡ School staff and other personnel trainings ¡ Process evaluations ¡ AMES evaluations

Methods l l l 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: ¡ ¡ l 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 collection Study Nurses February Control Nurses Training COCA, HAFYS May Training COCA, HAFYS, Process, manual evaluation

Results: Demographics Elementary school l Urban, suburban, and rural differences Intervention 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 l ¡ ¡ Nurse: student ratio Nurse coverage area Intervention Total 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 Plans

Results: Absences

Results: Asthma Friendly Schools

Qualitative Results: l Training (study: control – 297: 80) • Using training Power. Point • 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: l 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 l l l 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: l l Student quality of life ¡ l l “better management of asthma ¡ l l ¡ “to complete emergency plans” making sure “all appropriate people get plans” “to increase asthma awareness” ¡ ¡ “keep students safe” “to decrease absences” “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 l Limitations l Entrée ¡ Strategies for collaboration with school nurses Consent of leadership l Participatory activities l Training and education l Access to relevant resources l Openness to innovation l l Ability to collect absence data

Areas of concern l IAQ/irritant issues l All student education and awareness l Nurse coverage for chronically ill students

Credits Wenjin Li, MD, University of Washington l Paul Williams, MD, NW Asthma and Allergy l Lyndia Vold, MPH, Spokane County HD l Implementation Team: l ¡ ¡ ¡ ¡ Carol Johns, MSN, RN Cheryl Funke, RH Kathy Reed-Mv. Kay, RN Linda Bordwell, RN Julie Schultz, RN Cindy Thompson Trry Reid