Responding to school health crises: students with chronic health conditions may need monitoring on a daily basis and assistance with health emergencies.

Today's school administrators face an increasing array of duties. One of the potentially most serious responsibilities is student health services. It is estimated that 20 percent to 30 percent of all school-aged children in the United States have a health condition that may require monitoring.

One out of five students could have an asthma emergency; an increased number of diabetic students need assistance with blood sugar monitoring, carbohydrate counting and possible insulin administration at school; and students with severe allergies may need assistance with emergency epinephrine injections if exposed to shellfish, peanuts or other allergens.

Students with chronic health conditions may need specialized treatments during the school day, special diets at lunch, have activity limitations or need to be monitored for special behavioral or health emergencies. The speed and accuracy with which teachers, office staff and ultimately the site administrator respond to a student health crisis has far-reaching implications.

Monitoring students with chronic health conditions is the traditional role of the school health nurse, but due to high student/school nurse ratios, school nurses are often not available to monitor chronically ill students on a daily basis or to assist with normal health emergencies.

According to a survey by the California School Nurse Association, untrained and unsupervised staff administer first aid and medications to students in 83 percent of California schools. School districts face legal, financial and administrative issues when staff members perform medical procedures without proper training.

The courts have repeatedly found school districts responsible for training staff about asthma recognition, use of asthma medications, and procedures when an asthma emergency occurs. Other conditions with life-threatening potential include seizures, diabetic coma caused by low blood sugar, and severe allergic reactions to things such as bees and peanuts. All of these conditions may necessitate the administration of emergency injections or medications by school personnel before calling 911.

Most CPR/first aid programs do not provide information on monitoring students with chronic health conditions. In California, few administrative programs provide any health-related information. Educators who work in the classroom may not know current first aid practices unless site administrators have incorporated them into the school's staff development programs.

Survey says teachers unprepared

A survey of 60 new teachers in a medium-sized school district in California found that 71 percent of beginning teachers had students with chronic health conditions in their classrooms, with asthma the No. 1 condition identified. In addition, 20 percent of teachers said they had experienced a medical emergency in the classroom, but only 35 percent felt prepared to monitor students with the potential for health emergencies.

The teachers overwhelmingly said they needed information on health-related issues beyond what was covered in their teacher education programs. To address the problem, the district instituted a unique, three-pronged approach to health emergency training. Components included developing an Emergency Protocols Handbook to serve as a resource and training guide, instituting a new hire orientation in health areas for all new district staff, and establishing a no-cost CPR and first aid certification program for all school site staff as part of professional development.

The Emergency Protocols Manual

The first step was to determine what health information the district felt all school personnel needed to know. After reviewing the types of health conditions commonly seen in the school setting, district nurses wrote an Emergency Protocols Handbook that would become the basis for professional development at individual schools and the foundation for the new hire orientation.

The handbook includes components on handling medical emergencies in the school setting, accessing emergency services, documenting accidents and illness and the district medication policy. In addition, information is included about the most commonly seen school health emergencies and the emergency medications for these conditions. School districts are required to train school site staff in blood borne pathogen prevention and child abuse reporting mandates; therefore, these components were added to the handbook.

At many district schools the Emergency Protocols Handbook has been incorporated into teachers' and coaches' handbooks and is part of the California State Beginning Teacher Support training materials.

A new hire orientation on health issues

The second step was to institute a mandatory new hire orientation in health areas for all new district employees to provide a baseline of knowledge in the district in emergency procedures and policy.

Conducted by district nurses and using the Emergency Protocol Handbook as a guide, new hires review district policy and procedures on how to recognize and handle emergencies and access emergency care. The mandated blood borne pathogen and child abuse training is also incorporated. In addition, all new district personnel are given information and discuss the symptoms of asthma, seizure, diabetic and severe allergy emergencies and emergency medications.

Cardio-pulmonary and first aid training

The final step was to establish a training program that provides American Red Cross certification in cardio-pulmonary resuscitation and basic first aid at no cost to all district employees. Classes are scheduled on district in-service days, weekends and at regular intervals during the month in order to reach as many school personnel as possible. Schools are encouraged to schedule training for all personnel, including administration, teachers, front office staff, yard duty, coaches and after-school program staff. By training as a team, staff are encouraged to problem-solve emergency situations unique to their setting.

In addition, certification in American Red Cross cardio-pulmonary resuscitation and first aid is offered to all district departments. Emergency training is individualized to meet the needs of the department. All district maintenance, custodian, food service and bus drivers have received training. Other departments receiving training include after-school program personnel, preschool staff and front office staff.

Opportunities to train staff

Every school administrator has the responsibility to make sure his or her school is safe for students and staff, and to recognize and provide life-saving measures if an emergency occurs. If there is a seizure on the playground, does your staff know how to recognize and care for the emergency, monitor the health condition, and call 911 quickly? If a student stops breathing, do you have personnel who can perform CPR quickly and effectively? Can your staff recognize a severe allergy, asthma or diabetic emergency and successfully administer lifesaving medications?

There are many training opportunities that can be offered at a school site. Emergency training and management of health conditions can be included into school site orientations, professional development and teacher handbooks. Workshops and in-service for teachers on health issues can be provided by inviting district nurses or community agencies such as the American Lung Association or American Red Cross.

It is important to make sure current emergency procedures and protocols are in place at your school, and that staff are aware of and can demonstrate competency in obtaining emergency assistance. Encourage staff members to obtain basic first aid and CPR training and assist them in maintaining training.

Avoiding a nightmare

A major health emergency that leads to disability or even death poses a real nightmare for any school administrator. The accompanying liability poses a different--but just as real--nightmare. A school administrator is the first line health and safety advocate for all students.

With the rising number of students with chronic health conditions, administrators are very likely to face health crises at their schools. How teachers, staff and the administrator respond has far-reaching implications for the entire school community.

One day at school ...

* A California student comes to the school office with severe asthma symptoms. As front office staff frantically attempt to assemble the asthma nebulizer machine to administer the necessary medicated breathing treatment, the student collapses and dies. A lawsuit later finds the district negligent.

* A recently diagnosed kindergarten diabetic student needs help from the classroom teacher monitoring his blood sugar three times a day and counting carbohydrates at lunch. If his blood sugar goes too low and he collapses in the classroom, the teacher is expected to administer an emergency injection in the classroom and call 911.

* An evening custodian experiences symptoms of cardiac arrest in the school parking lot. His fellow team members recognize the symptoms and quickly call for life-saving assistance. He survives.

Patricia Gomes coordinates district health services programs and Mary Smith is a district nurse and family nurse practitioner in Central Unified School District in Fresno. Both Gomes and Smith are part-time faculty for CSU Fresno and University of San Diego. They can be reached at [e-mail]. or [e-mail].