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

2. History 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 K-20 presentation on world asthma day 2001 GlaxoSmithKline grant for Spokane project

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

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

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

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

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

8. Methods 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:  Two trainings on AMES and implementation strategies  Incentives for staff training: extra training, spacers/Peak flow meters, camp scholarships Control group:  AMES manual only

9. Methods: Data collection Control NursesStudy Nurses Training February May COCA, HAFYS, Process, manual evaluation COCA, HAFYS

10. Results: Demographics Elementary school Urban, suburban, and rural differences  Nurse: student ratio  Nurse coverage area InterventionConTotal CV81101 Number of students324873153 Age (average)9.49.010.49.6 Grade (average)3.63.34.73.9 InterventionCont CVESD 81101 Number of schools * 104548 Number of students51852566911874 Number of students with asthma 4652359390 Rate of students with asthma (%) 9.09.23.3 Number of nurses available91015 Nurse: students w/asthma51.7235.926

11. Results: Asthma Action Plans

12. Results: Absences

13. Results: Asthma Friendly Schools

14. Qualitative Results: Training (study:control – 297:80) Using training PowerPoint Using the manual sheets Identify early symptoms Teachers, students, childcare staff, aides, kitchen staff, bus drivers Passive education systems (staffroom notebook) Using incentives

15. Qualitative Results: 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”

16. Qualitative Results: other Care plans Communication Case finding Other Barriers  Materials  Time  Confidentiality/nursing practice

17. Qualitative Results: Behavior change 100% of study group nurses agreed the project had “changed or increased” their behaviors regarding asthma Nurse goals:  Student quality of life “keep students safe” “to decrease absences”  “better management of asthma “to complete emergency plans” making sure “all appropriate people get plans”  “to increase asthma awareness” “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

18. 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.”

19. Conclusion Limitations Entrée  Strategies for collaboration with school nurses Consent of leadership Participatory activities Training and education Access to relevant resources Openness to innovation Ability to collect absence data

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

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