Bette Carr, MSN, RN, NCSN School Nursing and Health Services

1. School Nurse Summer InstituteEpilepsy, Seizures, and Continuous Quality ImprovementIdentifying potential barriers to implementation of seizure care in the school setting Bette Carr, MSN, RN, NCSNSchool Nursing and Health Services Wisconsin Department of Public Instruction

2. Disclosures • The speaker has no disclosures or conflicts of interest.

3. Objectives • Participants will be able to identify potential barriers, as well as resources, for implementation of seizure procedures.

4. Barriers What do you feel was the biggest barrier this past year in providing appropriate health services to students with seizures or epilepsy?

5. Barriers • School nurse knowledge and confidence levels • Parent and provider requests • Training of others • Privacy issues • SAFETY

6. Federal and state laws ADA IDEA Section 504

7. Nurse Practice Act

8. Barriers: School nurse knowledge and confidence • Lack of certainty on: • What seizures look like for this child • Medications, doses, routes, and side effects • Timeliness of EMS services • Whether I have the knowledge to train others • Delegating seizure monitoring and medication administration to others

9. Resources • Professional development that includes research-based information • Network with other school nurses • Refresh your assessment skills • Spend time with the student and family • Preparation of seizure curriculum for others • Preparation of individualized health care plans for students

10. Resources • Communicate with the health care provider (HCP) any concerns that you might have regarding the student or plans • Use resources that you have available to you: • Medical advisor • Webcast training • Other districts or nurses in your area • Epilepsy Foundation • WASN/NASN

11. Barriers: Difficult requests • Health care provider requests: • Orders that are outside your comfort zone • Non-FDA-approved medication routes • Parents request: • That 911 not be called • That the child remain in school after emergency medication has been given • That they will not sign a release of information

12. Resources • Plan ahead! • Request a meeting and develop a care plan • Encourage the health care provider to be part of the planning • Involve your medical advisor if needed • Encourage the family to sign a release and explain that the release can be very specific to the seizure disorder care

13. Resources • Plan ahead! • Let the family and health care provider know that the school wants to be prepared to provide the safest care possible for their child • Is a 504 Plan needed? • Involve your supervisor or director if needed

14. Barriers:Training of others • Leadership skills • Preparation of a curriculum and protocol • Preparing an individualized care plan • Deciding who to train-developing a team of responders • Obtaining time to train • Documenting those who have been trained • Periodically reviewing the plan

15. Resources: • Curriculum: • Recognize when urgent care is needed • How to access that care • How to handle an emergency • Know how to respond to the child • CPR, seizure recognition • NASN program • Epilepsy Foundation information

16. Resources • Protocols from other districts • Protocols from health care providers • Discussing specific situations with your medical advisor • WI Department of Public Instruction website • WISHeS website

17. Barriers: Privacy issues • Protection of the student’s privacy • Health information sharing • Classroom or school setting event management • Prevention of bullying

18. Resources • Be prepared and share a plan with the teachers on how to provide for a student’s privacy during a seizure: • If allowed by the family, discuss the child’s condition with the class ahead of time and let the students know what is expected of them • Remove the other students from the area • If giving rectal medications have a packet made up with a sheet or other physical barrier for privacy • Use other adults as a barrier if needed

19. Barriers: Safety • Concern for child’s safety • Fear of doing something wrong • Recognizing postictal somnolence vs. medication sedation • Sufficiently trained staff • EMS services readily available

20. Resources: • Planning and reviewing • Practice plan • Check with local health care provider for changes in care plan • Have parents video record what the child’s postictal and post-medication behavior looks like

21. Healthy Learner Model 2006 Healthy Learner Model: Special School District #1, Minneapolis Public Schools Related Services

22. School Nurse stories • Mary • Marc

23. Mary • Student: Wyatt, 13-year-old • Health condition: epilepsy, tonic-clonic seizures • Treatment: taking Valproic Acid 15ml b.i.d. • Emergency medication: Diazepam 10 mg rectal gel • Order states: • Administer Diazepam 10mg rectally for seizures lasting greater than 2 minutes, call parent, and stay with student until the parent arrives to pick up the child.

24. Mary • Questions: • What do Wyatt’s seizures look like? • Has Wyatt ever received emergency medication? • What was his reaction to the medication? • Is he fearful of getting it at school in front of his peers? • Is the nurse in the building and available to assess? • Is the Unlicensed Assistive Personnel (UAP) capable of monitoring the student? • How long will it take for the parent to arrive? • How long will it take for EMS services to arrive if there are problems?

25. Mary • Resolution: • Draft a care plan that takes into account the answers to the questions • Have parent sign release and communicate with the HCP • Train the staff that work with the student • Prepare an emergency kit that includes all necessary items and a barrier • Make decisions on whether care can safely be given without EMS services being called

26. Marc • Student: Anna, 5-year-old • Health condition: autism, complex-partial seizures • Med at school: taking Carbamazepine 100mg 2 chewable tablets at noon • Emergency medication: Midazolam 1ml intranasal MAD (mucosal atomization device) • Order states: • Administer Midazolam 0.5ml in each nostril for seizures greater than 5 minutes or for 3 or more seizures in 24 hrs lasting less than 5 minutes. Call 911after use.

27. Marc • Questions: • What do Anna’s seizures look like? • Has Anna ever received emergency medication? • What was her reaction to the medication? • Is the nurse in the building and available to assess the seizures? • Is the Unlicensed Assistive Personnel (UAP) capable of monitoring the student’s repeated seizures? • How long will it take for EMS services to arrive once called?

28. Marc • Resolution • Draft a care plan that takes into account the answers to the questions • Have parent sign a release and communicate with the HCP • Train the staff that work with the student in recognizing seizures and in timing of the seizures

29. Summary • Perceived barriers: • School nurse knowledge and confidence • Difficult requests • Training of others • Privacy • Safety • Overcoming these barriers: • Increase knowledge and skills which increases confidence • Improve communication between student-family-health care provider-school nurse-staff

30. References • Austin, J., Kakacek, J., & Carr, D. (2010). Impact of training program on school nurses’ confidence levels in managing and supporting students with epilepsy and seizures, Journal of School Nursing, doi: 10.1177/1059840510380206 • O’Dell, C., O’Hara, K., Kiel, S., & McCullough, K. (2007) Emergency management of seizures in the school setting, Journal of School Nursing, doi: 10.1177/10598405070230030601 • O’Dell, C., & O’Hara, K. (2007). School nurses’ experience with administration of rectal diazepam gel for seizures, doi: 10.1177/10598405070230030701 • Price, V., Murphy, S., & Young Cureton, V. (2004) Increasing self-efficacy and knowledge through a seizure education program for special education teachers, Journal of School Nursing, (20)1, pp. 43-49 • Wisconsin Department of Public Instruction, School Nurse Websitehttp://sspw.dpi.wi.gov/sspw_schlnurse