Improving asthma management in schools not only benefits pediatric patients' health, but improves attendance rates.
Melanie Gleason, MS, PA-C
When working with pediatric patients with asthma, ensuring that their care extends to their school is a challenge for allergists. By broadening the available asthma care, schools can improve asthma control, as well as reduce absences, and therefore increase academic performance.
The best way to guarantee that children with allergy and asthma are continuing to receive their care is to make certain that health education is paramount and proper in school systems—and usually, it is not.
“Many times, the school nurse is not in the building,” Melanie Gleason, MS, PA-C, said. “School nurses then delegate and supervise care to unlicensed and non-medical staff. That care can range from routine to emergency.”
In a presentation at the 2018 American Academy of Allergy, Asthma, and Immunology (AAAAI)/World Allergy Organization (WAO) Joint Congress in Orlando, Florida, Gleason, explained how allergists can tackle this challenge head-on by creating a school setting that is a promoter of health for their patients.
“The school setting is ideal for reaching the majority of children,” Gleason, a pediatric pulmonology PA at the Children’s Hospital Colorado, said. “There is potential for a significant impact. Children want to fit in and be ready to learn.”
Most schools, she noted, utilize either some type of health clinic, a site-based school nurse, and/or a consultative school nurse. The nurse, in these models, is oftentimes the health care provider that children will see most consistently, emphasizing the importance of their role in educating and promoting health.
The problem, however, is that these systems have weaknesses that impact pediatric patients that are in need. School nurses have identified that multiple barriers exist that are preventing the care that is needed—inadequate asthma management practices, inconsistencies in workforce knowledge and skills, not enough time, and competing priorities, among others.
“There is a lack of communication with the families and the providers,” Gleason said. “And asthma care plans and quick relief inhalers are simply unavailable.”
For clinicians, there is also a misunderstanding of the requirements for school orders, which tend to be “picky,” Gleason said, as school nurses cannot delegate tasks that necessitate their judgment or assessment. Unlicensed assistive personnel (UAPs) must then be able to understand and follow their orders to a tittle.
In Colorado, Gleason has been part of the state’s Step Up Asthma Program, started in 2009 to provide counseling and education about asthma in schools and the Building Bridges for Asthma Care initiative, started in 2012 intending to coordinate care for pediatric asthma patients with registered nurses and schools. The Step Up program has since expanded and has begun providing technical assistance.
Through the programs, Gleason said, their team has “identified students with asthma, begun to provide access to quick-relief inhalers, ensure school staff are prepared to manage asthma, reduced exposure to environmental triggers, provided self-management training, and coordinated care with the families and providers to ensure the successful management of asthma.”
The lack of family and child engagement is the biggest barrier for school nurses, so the Building Bridges initiative implemented the use of a “Caregiver Action Letter” which is sent to the parents of children with asthma, as well as providing an asthma self-management education to the students by evaluating their inhaler use and conducting an asthma control test.
Thus far, the program has seen a marked improvement in inhaler technique, which Gleason noted is essential to proper asthma management. From visit 1 to visit 3, there was roughly a 20% improvement in the number of children that removed the caps to their inhalers, a 40% improvement in the number of children that primed their inhalers, a 40% improvement in the number that exhaled, a 25% improvement in proper inhalation, and a 40% improvement in the number of children that held in their breaths.
The program has also worked to coordinate care with asthma specialists to open a line of communication between them and the school nurse.
“So far, the program has increased the availability of school asthma care plans from 5% to 85%,” Gleason said. “It has increased the number of registered nurses that are certified asthma educators, increased asthma self-care skills, reduced asthma burden, and importantly, improved school attendance.”
The impact on absenteeism has been noticeable. In Denver, there was a 26.5% decrease in school absenteeism in schools utilizing the Building Bridges program compared to those without (0.74; 95% CI, 0.64—0.85; P <.01), and in Hartford, there was a 21.8% decrease (0.78; 95% CI, 0.65—0.95; P = .01). Combined, the schools utilizing the program observed a 24.8% decrease in absences (0.75; 95% CI, 0.67—0.84; P <.01).
“With just 2 absences per month, children are likely to fall behind in school,” Gleason said. “If that is consistent across all 9 months of school, they’re likely to fail a grade. Improper management of asthma should not be impacting the education of our children.”
Gleason noted that facilitation of asthma management can be achieved by documenting the school and identifying the nurse, completing and updating forms, ensuring access to quick-relief inhalers. She also said that turning school absence excuses into useful letters addressed to the nurse can and will aid in asthma management.
Ultimately, she said, having open lines of communication are the key to improving asthma management in schools.
“To develop a system of communication, there need to be contact lists for school nurses,” Gleason said. “Additionally, schools should integrate electronic medical records into the workflow, families should designate someone as the point person to communicate with the school, and the school district’s health board needs to be involved.”
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