ABN Update

1. ABN Update N Genell Lee, MSN, RN, JD Executive Officer

2. Objectives Identify changes to the Curriculum to Teach Unlicensed School Personnel how to Assist with Medications. Discuss case examples of substandard practice. Discuss case examples of illegal practice.

3. Curriculum Delegation rules moved from Chapter 610-X-6 to Chapter 610-X-7 so revision noted the new section Curriculum reviewed by ABN and approved at June 20, 2013 meeting Issues identified by school nurses considered

4. Handouts The handouts are the revised version; the slides will address where the changes occurred unless it is a minor change (use of hyphen, corrected spelling, etc.) Post-test will be changed as well Curriculum will be posted to the Board’s website

5. Sections • Section One: Introduction, no changes • Section Two: School Health—minor language change in most of section • On page 3, added section about lead or designated nurse doing comprehensive assessment of health needs of students and reporting that to superintendent. This is in school nurse law (statute).

6. Section Two: Health Serviees On page 9 forward, responsibilities of school nurses mentions free of distractions for unlicensed personnel; storage of emergency health plans on buses, for extracurricular activities; and field trips. Review of student health assessment records.

7. Section Two: More on Responsibilities Develops procedures for student specific routine and emergency procedures including assisting with medication while at school, during school-sponsored trips and activities, and during transportation to and from school and document in student’s IHP/EAP

8. Section Two: Health Services Page 12: medication assistant should notify school nurse if a new medication is received at school

9. Page 13: Orders Orders may be accepted by fax and email without requring a hard copy. Third parties: certified medical assistant can transmit orders to school nurse from doctor’s office but otherwise, should not accept orders from unlicensed school personnel

10. More on Orders PARENTS: is the parent giving you ‘orders’ or providing you with information? Example: Nemours Clinic in Pensacola and the “FIT” paper Example: child with diabetes inspidous Example: Order by MD vs LEA policy

11. Page 14: First Aid May keep first aid supplies including betadine, antibiotic ointment, etc without an order Instituting first aid is within scope of practice of RN and LPN and should occur in the school if needed Minor wounds: soap and water; if dressing changes needed, follow MD orders if they exist; if child has a band-aid and needs another one, not a problem

12. Field Trips and Other Extracurricular Activities The LEA determines how to handle OTC medicines Call from parent asking for clarification---school nurse was taking suit cases of OTC meds (up to 250 in some circumstances). Is that a logical solution to OTC for field trips? Discuss with LEA—superintendent, principal, etc—how you will handle this for OTC. What do you do if school nurse is not accompanying the field trip or football game or whatever the extracurricular activity is? Siblings: One bottle to be shared is okay

13. Page 15-16 Storage of medication, including controlled substances Refrigerated medications: stored in refrigerator by themselves (not with food) and has method of checking and documenting temperature Do not administer drugs that have been frozen!

14. SECTION THREE: COMMON HEALTH CONDITIONS Some deletions and additions of drugs for specific health conditions You can add medications for specific children in your schools when you do the training

15. Section Four: How to Assist Students with Medication Depending on Route One minor change: Don’t touch medicine with bare hands!

16. Section Five: Safety Need beginning and ending dates for for medications It is not recommended that school personnel administer any substance that could be construed as a drug or medication, including natural remedies, herbs, and nutritional supplements, without the explicit order of an authorized prescriber, parent authorization, verification that the product is safe to administer to children in the prescribed dosage, and reasonable information regarding therapeutic and untoward effects (pg 44)

17. OTC Meds LEA policy determines whether you need physician order for OTC; ABN does not require it School nurse should document details about the OTC meds

18. Repackaging Medications School nurse and unlicensed school personnel are not authorized to repackage meds (placing them from a pill bottle, for example, into an envelope wth the student’s name on it) Repackaging: to package again or anew; specifically: to put into a more efficient form

19. Disposal of Medications • Follow National Standards • Trash vs • Toilet vs • Bring Back programs • Burning

20. Page 50: Self-Administration Chronic health condition/illness is defined as “a physical, physiologic, developmental impairment; an anatomical, physiological or mental impairment that interferes with an individuals ability to function in the environment; one that is long-term (usually more than 3 months duration) and is either not curable or has residual features that result in limitations in daily living requiring adaptation in function or special assistance; a medical condition that interferes with daily functioning for more than three months in a year, causes hospitalization for more than one month in a year, or (at time of diagnosis) is likely to do either of these.” (Schwab & Gelfman, 2001).

21. Epi-Pen National movement to have an epi-pen available to use at school for someone with an anaphylactic condition that occurs at school Would be considered “stock” medication ABN does not object to having epi-pen in school for these one-time events Issues: who will prescribe; who will pay for it; and would the unlicensed school personnel give it?

22. Documentation of Training It is the school nurse’s responsibility to document training of unlicensed school personnel who are assisting with medications! No documentation: didn’t do it. Documented but didn’t do it: false documentation.

23. Some Situations to Consider • Kindergarten girl with itching and redness in perineal area. School nurse looked at it. Applied some sort of cream. • Problem: No documentation of assessment. • Problem: No phone call to parent. • Problem: “Cream” was not ordered nor was there documentation. • Problem: No communication with lead nurse

24. Parental Consent 1st grader self-catheterized. School nurse allowed nursing student to observe. Problem: child was asked if okay and while the child said ‘yes’, the child felt pushed into it. Problem: child was sensitive about having to perform the procedure and school nurse overlooked the anxiety Problem: What does a nursing student gain from observing this self-procedure? Problem: No communication with parent even though parent made it known that child was sensitive about issue.

25. Field Trip and OTC Meds Mother called and asked about OTC meds for field trip. Had called Superintendent, School Nurse, Board of Pharmacy, Department of Public Health, and finally ABN Problem: suitcases full of OTC meds for prior field trip Problem: Mother believed she was given the ‘run around’ about policy Problem: Decision made by LEA but told Mother it was the law

26. Medications School Nurse administered insulin that had been frozen. Problem: School nurse did not contact parent. Problem: School nurse knew the insulin had been frozen previously and now thawed. Problem: School nurse did not understand that freezing insulin can change the efficacy of the drug

27. Storage of Medications School Nurse written up 3 times for failure to keep medications secure. Problem: Student came in to health room and took another student’s medications. Problem: School nurse resisted locking up medications even after employment action. Problem: School nurse disciplined for failing to secure medications

28. Assessment 3rd grader sent to health room by teacher because of shortness of breath and wheezing (history of asthma). Problem: LPN School Nurse allegedly “assessed” child and sent child back to classroom. Teacher sent child back to health room 10 minutes later for continued SOB. LPN School Nurse gave child inhaler and then sent child back to classroom. Father called. Child admitted to hospital. HR 160 in ED, RR 36. Acute asthma attack. School nurse response: “I didn’t think the child was that sick.” NO DOCUMENTATION of any sort of assessment

29. Boundary Issue Anonymous email received by ABN that school system hired a school nurse that was not competent to provide care to a ventilator-dependent student Problem: Turns out it was another nurse who sent the email Problem: Interfering with a patient’s care can result in charge of boundary violation---the anonymous nurse did not get the job and therefore questioned the hiring of someone else and was communicating with parent

30. How can I stay current with procedures? Lead/designated nurse will have skills lab at Children’s of Alabama on July 26, 2013 Many hospitals and schools of nursing have simulation labs---talk with local area resources to see if training can occur in setting with simulation lab for things like replace G tube, ventilator management, etc. There is no ‘official certification’ requirement—must be able to demonstrate training (Organized Program of Study)

31. DOCUMENTATION Lack of documentation regarding medications being administered by school nurse Lack of documentation regarding carbohydrate count at mealtime for student Lack of documentation regarding communication with parent Lack of documentation regarding first-aid care If you didn’t do it, don’t document it! If you don’t document it, you didn’t do it!

32. Glucagon Pilot Started in July 2013 Specific to school-sponsored activities—camps, athletics, summer school, etc. Urban, suburban, and rural schools Focus: PREVENTION ABN and SDE will evaluate in Fall 2013

33. Curriculum Volunteers to tape so we can put the curriculum/teaching online? Do we put the demonstration of how to do things such as eye drops online? Focus on individual student needs part of training and that will not be online. Post-test will change. Be sure to document training!

34. Annual Survey SDE will conduct this next year but information is shared with ABN One of the few states that actually gathers data about health services Number of nurses important because latest information is Alabama has a low nurse:student ratio compared to other states

35. Illegal Practice Continuing to practice when license not renewed LPNs renew in 2013. Should check LPN licenses for renewed status before January 1, 2013. If LPN not renewed by January 1, 2013, should not be allowed to return to work until can prove licensure. Subscriber or license look up: close to real time updates during renewal

36. Citizenship/Legal Presence I am not a Communist! Must prove citizenship or legal presence in US in order to renew As of Friday, July 12, only 18% LPNs verified Sent an email via list serv to provide how to login and check if citizenship/legal presence verified

37. Conclusion • Joyce Jeter, Nurse Consultant for CE/Practice • Joyce.Jeter@abn.state.al.us • Peggy Benson, Deputy Director • Peggy.Benson@abn.alabama.gov • Genell Lee, Executive Officer • Genell.Lee@abn.alabama.gov • 1-800-656-5318 • www.abn.alabama.gov; “Nursing Practice” and then “School Nurses”