medication administration practices in schools and daycares michael w. kelly, pharmd, ms michael w....

Medication Administration Medication Administration Practices in Schools and Practices in Schools and

DaycaresDaycares

Medication Administration Medication Administration Practices in Schools and Practices in Schools and

DaycaresDaycares Michael W. Kelly, PharmD, MSMichael W. Kelly, PharmD, MS

College of PharmacyCollege of PharmacyThe University of IowaThe University of Iowa

Why are medications used in schools?

• Treatment of children with chronic conditions– Mainstreaming of children with health

problems– Improved survival of children with complex

health conditions– Increasing use of medications in children

• Parents rely on schools to share responsibility of care

Who are using medications in schools?• ~46,500,000 children in K-12 in US• ~87,400 public schools in the US• ~13,000,000 children take medications

in the US in any 2 week time period• ~1,000,000 children took

methylphenidate in school in 1998• ~4-6% of children receive medication

on a typical school day

Why is this an issue?• Change in role of the school nurse

– ~57% of school districts have a nurse– Nurse to student ratio ~1:1,350– 2 of 3 most common school nurse interventions related to

medications– Use of unlicensed assistive personnel

• Multiple layers of authority– Federal law– State law– Local school district procedures– Individual school procedures– Professional guidelines

Why is this an issue?• Medication use is widespread in

schools• Administration of medicationsis

often carried out by non-licensed individuals

• Potential safety issues

Our study group• Ann Marie McCarthy• Nursing, Pharmacy, and Education

students• David Reed• Daniel Clay• Karen Farris

Study #1

“Medication Administration in the School Setting”– Purpose:

• To assess current practices of school nurses in administering medications in school

– Design:• Survey, Descriptive

– Subjects:• Random sample of 1,000 school nurses who were

members of the National Association of School Nurses

McCarthy AM, Kelly MW, Reed D. Journal of School Health. 2000;70:371-376

“Medication Administration in the School Setting”

• Survey– 62 primarily closed-ended questions across areas of

interest with space for comments• What medications are dispensed in schools?• Are guidelines for administering medications used by the

school nurse?• How widely are Unlicensed Assistive Personnel (UAP) used?• How is medication stored in the school?• Are dispensed medications documented?• What procedures are used in dispensing prescription and

non-prescription medications• What type of medication related consultation is used by

school nurses?

“Medication Administration in the School Setting”

• Results– 649 usable responses returned– Primarily female (99.7%)– Middle-aged (mean = 47.9)– 23 years experience as RN– 11 years as school nurse– Education level 50% BSN, 22% MS/MA

“Medication Administration in the School Setting”

• Number of children cared for– 0-1,000 50%– 1,000-2,000 28%

• Number of buildings responsible for– 1 building 41%– 2 buildings 31%– >3 buildings 26%

“Medication Administration in the School Setting”

• Medications dispensed– 5.6% of children receive medication during

a typical day• ADHD medications 3.3%• Nonprescription medications 1.5%• Asthma medications 1.1%• Analgesics 0.9%• Anti-seizure medications 0.6%

– Medications more common in elementary

“Medication Administration in the School Setting”

0.0

10.0

20.0

30.0

40.0

50.0

60.0

Available Order

Creams

Tylenol

Cold Meds

Ibuprofen

GI

Aspirin

Nonprescription medications

“Medication Administration in the School Setting”

• Guidelines– Written guidelines 98%– State guidelines 92%

• Orders for administration of medication– Prescription medications

• Parent form 97%• Provider order 94%• Prescription label accepted 24%

– Non-prescription• Parent form 96%• Provider order 71%

“Medication Administration in the School Setting”

• Medication storage– Stored in locked cabinet in health office

80%– Secure container available in refrigerator

36%– Dispense from original pharmacy container

97%– Transfer medications to other container

23%

“Medication Administration in the School Setting”

• Personnel Dispensing Medications– 76% of these school nurses used UAPs– Description of UAPs

• Secretary 66%• Health Aide 40%• Teachers 38%• Other 38%• Parents 18%• Students 16%

“Medication Administration in the School Setting”

• Issues surrounding UAPs– Education

• Taught by school nurse 85%• Developed by school nurse 64%• Two hours in length or less 58%

– Are school nurses comfortable using UAPs?• Very or moderately comfortable 45%• Uncomfortable or very uncomfortable 33%• No response 18%

“Medication Administration in the School Setting”

• Self-administration– Self-administration allowed 76%

• Asthma inhalers and other asthma drugs• Insulin

– Junior/Senior High School75%

– Elementary 47%

– No Supervision 34%– Keep own medication 37%

“Medication Administration in the School Setting”

• Errors in Medication Administration– Medication error in the last year

49%– Types of errors

• Missed dose 80%• Not documented 30%• Overdose/double dose 23%• Administered, no authorization 21%• Wrong medication 20%

“Medication Administration in the School Setting”

Variable Estimated Effect

95% CI P value

Use of UAP 3.1 2.01-4.81 <0.001

# of Children 1.32 1.18-4.81 <0.001

Storage 0.71 0.49-1.02 =0.06

Education 1.56 1.10-2.22 <0.01

Self Management

1.13 0.75-1.70 =0.55

Contributing Factors to Medication Errors

“Medication Administration in the School Setting”

• Positives– Response rate– Medication use rate– Guidelines– Authorizations

• Negatives– Side effects not

documented– Storage– Delegation– Self administration– Errors

Clinical Implications•Need for consistent guidelines

•There are safety concerns

•Need for improved communication

Study #2

“Issues of Medication Administration and Control in Iowa Schools”– Purpose:

• To assess medication administration practices from the principals perspective

– Responsibility– Policies– Errors

– Design:• Cross sectional survey, Descriptive

Farris KB, McCarthy AM, Kelly MW, Clay D. Journal of School Health. 2003;73:331-337.

“Issues of Medication Administration and Control in Iowa Schools”

• Participants:– 850 randomly selected Iowa

principals (of 1,700)– Response rate 396/850 = 46.6%

• 75.5% Principals• 16.7% School nurses• 7.8% Other

– Schools of all grade levels

“Issues of Medication Administration and Control in Iowa Schools”

• Survey– 53 primarily closed end questions

• Based on previous survey• Sections

– Written guidelines– Medication administration processes and policies– Training requirements for medication

administration– Errors and causes of errors– Field trips– Demographics

“Issues of Medication Administration and Control in Iowa Schools”

• Who is ultimately responsible for medication administration?– Overall

• Principal 41%• School Nurse 34%• Unsure 13%• Other 4.3%

– On a day-to-day basis• School Nurse 76%• Other 24%

“Issues of Medication Administration and Control in Iowa Schools”

• School has written guidelines– Prescription Medication 97%– Non-prescription Medication 95%

• 22% of Schools use “Pill Counts”• Self-medication

– Allowed 50%• High schools more likely to allow

– Observed 83%– More common when a school nurse was available

• Missed dose was most common error

“Issues of Medication Administration and Control in Iowa Schools”

Never 1-2 Times >3 times Not sure

Med not supplied by parent 15.7 38.4 28.5 14.9Missed because of student 24.7 36.1 24.3 13.6Missed because of staff 47.7 32.5 5.8 12.4Wrong time 55.8 23.5 2.8 15.7Not documented 66.7 16.7 2.8 12.1Admin without authorization 84.8 3.8 0.8 9.3Given wrong medication 85.6 4.3 0 8.8Extra doses 86.6 3.3 0 9.6

Percent of Respondents Reporting Medication Errors in the Past Month

“Issues of Medication Administration and Control in Iowa Schools”

Disagree/ strongly disagree

Neither Agree/ strongly agree

Family does not communicate medications changes to school 18.2 17.4 55.0

Increased numbers of children onmedications

25.5 21.2 44.0

HCPs do not communicate changes in medications to school

30.3 26.5 33.6

Increased variety of medications prescribed to children 33.8 27.5 29.2

Inadequate staffing levels 42.9 19.2 29.1

Students are on same or similar medications 42.4 27.3 21.5

Percent of Respondents Reporting Reasons Contributing to Medication Errors

“Issues of Medication Administration and Control in Iowa Schools”

Disagree/ strongly disagree

Neither Agree/ strongly agree

Meds not labeled appropriately 64.4 13.9 12.6

Staff - not enough med and med administration training 61.6 21.0 9.4

Inconsistent day-to-day Process of med administration 68.2 14.9 7.8

Inconsistent documentation ofmedication administration 66.4 16.9 7.3

Students ask for wrong medication

71.4 17.7 2.3

Guidelines inadequate 69.5 16.2 1.8

Percent of Respondents Reporting Reasons Contributing to Medication Errors

“Issues of Medication Administration and Control in Iowa Schools”

Age of Student Stolen Medications Sold or Traded

Preschool & Elementary (n=56) 8.9 1.8Elementary only (n=97) 6.2 1.0Elementary & Middle School (n=20) 0 0Middle School only (n=62) 14.5 21.0Middle and High School (n=26) 11.5 15.4High School only (n=57) 14.0 15.8

Percent of Respondents Reporting Occurrences of Stolen, Sold or Traded Medication

“Issues of Medication Administration and Control in Iowa Schools”

• Clinical implications– Ultimate responsibility still unclear– Effects of self administration– Causes of medication errors– Diversion

Study #3

“Medication Distribution Trends in Schools”

• Purpose– To look at trends in medication use in

schools • Change from late 2000 to 2003• Change in medications used for ADHD• Change in administration time• Generate a list of medications administered

“Medication Distribution Trends

in Schools” • Methods

– Design• Anonymous mail survey, descriptive• Initial survey followed in 3 weeks by a second

– Subjects• A random sample of 1,000 school nurses who

were members of the National Association of School Nurses

“Medication Distribution Trends

in Schools” • Survey

– Subjects asked to supply information for the month that the survey was filled out and 3 years prior• Total number of students • Total number receiving prescription and

non-prescription medication• Number receiving individual agents for

the treatment of ADHD

“Medication Distribution Trends in Schools”

• Survey– Subjects asked to supply information

for the month the survey was filled out ONLY• Psychiatric conditions, asthma, seizure

and bladder/bowel management• List of all drugs administered in the

school

“Medication Distribution Trends in Schools”

• Survey– Assessed respondent perceptions on

• Change in methylphenidate use with release of Concerta®

• Any recent increase in immediate release methylphenidate

• Whether changes in medications are communicated to school

• Changes in the number of medication times

“Medication Distribution Trends in Schools”

• Results: Subjects– 338 Usable surveys returned

• 153 after first mailing• 185 after second mailing

– 154 had records for 2000 and 2003– 94% of the surveys were filled out by

school nurses• 83% held BSN/MSN/MPH degrees• Mean age 50 years, All female

“Medication Distribution Trends in Schools”

• Results: The Schools– 44 States and District of Columbia– 94% public– Level of student

• Elementary 198 (63%)• Middle/Junior High 99 (31%)• High School (26%)

“Medication Distribution Trends in Schools”

• The Students– Ethnic

• 66.8% White• 15.2% African-American• 12.8% Hispanic• 3.1% Asian • 1.3% American Indian/Alaska Native• 0.3% Native Hawaiian/Other Pacific IslanderResults

– Socioeconomic profile• 38.2% of schools had fewer than 25% of their students

in the free school lunch program • 21.2% of schools had 70-100% of their students in the

free school lunch program

Changes in Medications Administered, 2000 to 2003

2000Mean # of Students in a Typical Day (SD)

2003Mean # of Students in a Typical Day (SD)

In the designated school building

633.07 (516.46) (Range 0-5,200)

658.63 (541.29)(Range 0-5,100)

Receiving prescription medication *

18.09 (18.32)(Range 0-160)

8.72 (11.02)(Range 0-525)

ADHD Meds

Ritalin* 8.75 (8.26) 1.93 (2.60)

Adderal* 2.86 (3.73) 1.55 (2.65)

Concerta N/A 1.05 (4.02)

Dexedrine 0.87 (1.30) 0.29 (0.54)

Catapress 0.48 (1.01) 0.29 (0.71)

Welbutrin 0.23 (0.53) 0.14 (0.43)

Metadate 0.13 (0.59) 0.17 (0.53)

Receiving nonprescription medication

5.82 (9.68) 7.63 (23.98)

N= 177 schools with data for both years* p < .0001, Sign Rank Test

Prescription Medications, other than ADHD, administered in schools in 2003

Medication Number of

Schools*

Percent (%)

Asthma Treatments

Albuterol inhaler (Ventolin/Proventil) 260 87.0

Theophylline (TheoDur/SloBid) 7 2.3

Psychiatric Medications

Antipsychotics(Zyprexa, Seroquel, Geodon, Risperdal, Haldol)

75 24.1

SSRI Antidepressants (Paxil, Prozac, Zoloft, Celexa, Lexapro, Luvox)

49 15.8

Benzodiazepines (Valium, Xanax, Klonopin)

19 6.1

Tricyclic Antidepressants (amitriptyline, nortriptyline, imipramine, desipramine)

18 5.8

* Number of respondents varied from 200-311 for these items

Prescription Medications, other than ADHD, administered in schools in 2003 (Continued)

Medication Number of

Schools*

Percent (%)

Seizure Medications

Valproic acid, divalproex (Depakote) 69 22.2

Carbamazepine (Tegretol) 46 14.8

Phenytoin (Dilantin) 15 4.8

Bladder/Bowel Management

Oxybutinin (Ditropan), Tolterodine (Detrol), Polyethylene glycol (Miralax)

27 8.7

Nonprescription Medications

Analgesics (Aspirin, Acetaminophen, Ibuprofen) 207 68.3

Cough/cold products (Benadryl, Robitussin, Sudafed)

115 37.7

Gastrointestinal agents (Antacids, Zantac) 82 26.9

Alternative remedies (High dose vitamins, Herbals)

16 5.3* Number of respondents varied from 200-311 for these items

Psychotropic Medication Use

Medication Mean use per school

Range

SSRIs 0.49 0-34

Tricyclic ADs 0.09 0-3

Antipsychotics 0.45 0-13

Albuterol MDI 6.66 0-200

Albuterol MDI – PRN

1.26 0-64

Valproic Acid 0.74 0-100

Carbamazepine 0.23 0-8

Phenytoin 0.06 0-4

Nonprescription Medication Use

Nonprescription Medication Class

Mean use per school

Range

Analgesics 6.16 0-120

Cough/cold 1.12 0-40

GI agents 1.18 0-52

Alternative remedies 0.09 0-10

18 different Nonprescription medications are being given

Less common prescription medications administered in one or more schools grouped by

therapeutic class.

Therapeutic group with examples Unique

medication

named

Number of

students receiving

the medicatio

n

Gastrointestinal medicationsProton pump inhibitors, antacids, enzymes

20 49

Allergy/AsthmaAntihistamines, inhalers

19 37

Antibiotics/antiviralsCephalexin, amoxicillin

15 29

Antiseizure medicationsGabapentin, lamotrigine

11 39

Analgesics/migraine therapiesSumatriptan, aspirin/butalbital/caffeine

10 23

Hormonal/deficiency disordersSomatriptan, l-carnitine, levothyroxine, oral contraceptives

9 12

Renal disease/transplantationTacrolimus, Bicitra, PhosLo

8 8

Antianxiety agents/antipsychoticsBuspirone, mesoridazine

8 13

Less common prescription medications administered in one or more schools grouped by

therapeutic class.

Therapeutic group with examples Unique medicat

ion named

Number of

students receiving

the medicatio

n

Diabetic agentsMetformin, glucagon

5 63

CorticosteroidsPrednisone, presnisolone

5 7

Attention deficit disorder drugsMethylin, atomoxetine

4 43

AntidepressantsVenlafaxine, mirtazepine

3 6

AntihypertensivesPropranolol, bumetanide

2 5

Epinephrine injectionEpiPen

1 27

OtherHydroxyurea, baclofen, modafinil

7 7

Total 128 368

Variety of Medications Administered

• 7 ADHD drugs• 28 Prescription drugs in lists provided• 8 Nonprescription drugs in lists

provided• 128 “Other” prescription medications• 20 “Other” nonprescription medications

Total = 191 unique agents

Patterns of Medication Administration

• High school students– Administered fewer medications– Administered fewer ADHD medications– Administered more nonprescription meds

• Elementary students– Administered more asthma medications

Patterns of Medication Administration

• Small schools (<365 children)– Administered more medications– Administered more ADHD medications– Administered more Asthma medications

• Higher socioeconomic schools– Administered fewer medications– Administered fewer ADHD medications– Administered more nonprescription meds

Patterns of Medication Administration

• No difference across geographic region

• Children in private schools (n=17) were more likely to be given nonprescription medications

Percent of School Nurses Reporting Times Medications are Administered in Schools In 2003

0102030405060708090

7-8a

m

8-9a

m

9-10

am

10-1

1am

11-1

2pm

12-1

pm

1-2p

m

2-3p

m

3-4p

m

%

Results

• Perceptions– Is there a decrease in methylphenidate

administration?• 91% Agree or Strongly agree

– Is there a recent increase in the use of immediate release methylphenidate?

• 21% Agree or Strongly agree– Is failure to communicate medication changes a

problem?• 53% Agree or Strongly agree

– Has there been an increase in the number of administration times?

• 28% say YES

Limitations

• Sampling school nurses is convenient but misses schools without nurses

• Low response rate– Botched mailing– Lack of good records

Conclusions

– School nurses are responsible for more students

– Prescription medication administration is decreasing• ADHD medications in particular• Accompanied by an increase in the variety

– Nonprescription medication administration is increasing

– Medications administered throughout the day– Record keeping may be a problem

Recommendations• Schools must identify reliable sources of drug

information• Nurses need to share their expertise with less

trained assistants• Schools should review policies to identify ways to

increase information from families and health providers

• Physicians need to be aware of the complexity of medication use in the schools and act to reduce it

• Pharmacists can provide convenient dosages and containers and assure school is receiving relevant drug information

Future Research

• Measurement of the medication administration process

• Refinement and standardization of guidelines

• Quantify the impact of medication errors in schools