HOT TOPICS IN HOT TOPICS IN SCHOOL NURSINGSCHOOL NURSING

Essex CountyEssex County

School Nurses AssociationSchool Nurses Association

September 23, 2008September 23, 2008

Lorraine M. Chewey, Ed.D (C) R.N., C.S.N.Lorraine M. Chewey, Ed.D (C) R.N., C.S.N.

Coordinator, School Nurse Certification ProgramCoordinator, School Nurse Certification Program

New Jersey City UniversityNew Jersey City University

Practice IssuesPractice Issues• The Infamous Epinephrine Law The Infamous Epinephrine Law

ChangesChanges– N.J. S.A. 18A:40-12.5N.J. S.A. 18A:40-12.5– An Act concerning the administration of An Act concerning the administration of

epinephrine for certain students, epinephrine for certain students, amending P.L. 1993, c. 308.amending P.L. 1993, c. 308.• aka P.L.2007 Chapter 57aka P.L.2007 Chapter 57• AKA S79, A961, AKA S79, A961, • Associated clarifications/amendments - Associated clarifications/amendments -

A4371, A4617, S2753A4371, A4617, S2753• http://www.njleg.state.nj.us/2006/Bills/AL07/5

7_.HTM

• Approved March 16, 2007Approved March 16, 2007

Practice IssuesPractice Issues•Significant changes:

– Terminology - pre-filled auto injector mechanism (no longer EpiPen)

– Student does not need to have documented or known anaphylaxis, only written certification from the physician that the student has asthma or another potentially life-threatening illness, or is subject to a life threatening allergic reaction.

Practice IssuesPractice Issues• Significant changes (Continued):Significant changes (Continued):

• Bill 3865 Clarifies that a Bill 3865 Clarifies that a dual order dual order written by a physician or APN for written by a physician or APN for the administration of epinephrine the administration of epinephrine and an antihistamine DOES NOT and an antihistamine DOES NOT PROHIBIT the school nurse from PROHIBIT the school nurse from delegating another employee of a delegating another employee of a school district to administer school district to administer epinephrine when the school nurse epinephrine when the school nurse is not present.is not present.

• http://www.njleg.state.nj.us/2006/Bills/A4000/3865_R1.PDF

Practice IssuesPractice Issues• Significant changes (Continued): Significant changes (Continued):

– Removal of the sentence in PL 2003 Removal of the sentence in PL 2003 which stated “And does not have which stated “And does not have the capability for self-the capability for self-administration of the medication”administration of the medication”

– Interpreted to now mean, even Interpreted to now mean, even students with a written order to students with a written order to self-administer epinephrine, must self-administer epinephrine, must have a delegate.have a delegate.

Practice IssuesPractice Issues

• Significant changes:Significant changes:– The school nurse The school nurse SHALL SHALL [Changed [Changed

from ‘may’] designate, in from ‘may’] designate, in consultation with the BOE, consultation with the BOE, additional employees additional employees [formerly [formerly ‘another employee’] ‘another employee’] who volunteer who volunteer (Added) to administer……… when (Added) to administer……… when the nurse is not physically presentthe nurse is not physically present

Practice IssuesPractice Issues

• Significant changes Significant changes (Continued): (Continued): – Each BOE shall develop a policy Each BOE shall develop a policy

for the administration of for the administration of epinephrine via a pre-filled auto-epinephrine via a pre-filled auto-injector mechanism to a pupil for injector mechanism to a pupil for anaphylaxis anaphylaxis in accordance with in accordance with the guidelines established by the the guidelines established by the DOE.DOE.

Practice IssuesPractice Issues• The policy The policy shall requireshall require::

– Placement of epinephrine in a Placement of epinephrine in a secure secure but unlockedbut unlocked location easily location easily accessible by the school nurse and accessible by the school nurse and designees to ensure prompt designees to ensure prompt availability in the event of an availability in the event of an allergic emergency at school or at a allergic emergency at school or at a school-sponsored function. school-sponsored function. (Newly (Newly added from PL 2003)added from PL 2003)

– Location shall be indicated on the pupils Location shall be indicated on the pupils emergency care planemergency care plan..

Practice IssuesPractice Issues• The policy The policy shall require shall require

(Continued)(Continued)::– Back-up’Back-up’ epinephrine epinephrine shallshall also be also be

available if needed.available if needed.– The school nurse or designee to be The school nurse or designee to be

promptly available on site and promptly available on site and at at school sponsored activities school sponsored activities

– TTransportation to the emergency room ransportation to the emergency room by emergency personnel, by emergency personnel, even if even if symptoms have resolved,symptoms have resolved,

Practice IssuesPractice Issues• The school nurse The school nurse SHALL SHALL

determine that:determine that:a. Designees have been properly a. Designees have been properly trained using trained using standardized standardized protocolsprotocols established by the established by the DOE in consultation with the DOE in consultation with the DHSS (as mentioned previously).DHSS (as mentioned previously).

b. Parents consent in writing to b. Parents consent in writing to the administration by designees.the administration by designees.

Practice IssuesPractice Issues• The school nurse The school nurse SHALL SHALL determine determine

that:that:c. Board or CSA informs parents in c. Board or CSA informs parents in writing that the district and its agents writing that the district and its agents shall have no liability as a result of shall have no liability as a result of injury arising from the administration of injury arising from the administration of the epinephrine to the pupil. the epinephrine to the pupil.

d. Parents sign a statement d. Parents sign a statement acknowledging that they acknowledging that they indemnify and indemnify and hold harmlesshold harmless the district and its the district and its employeesemployees

e. Permission is e. Permission is renewablerenewable every school every school yearyear

Practice IssuesPractice Issues

• The DOE, in consultation with the The DOE, in consultation with the DHSS shall require trained DHSS shall require trained designees for students enrolled in a designees for students enrolled in a school who may require the school who may require the emergency administration of emergency administration of epinephrine for anaphylaxis when epinephrine for anaphylaxis when the school nurse is not available. the school nurse is not available.

Practice IssuesPractice Issues• Nothing in this section shall be Nothing in this section shall be

construed to prohibit the emergency construed to prohibit the emergency administration of epinephrine to a pupil administration of epinephrine to a pupil for anaphylaxis by the school nurse or for anaphylaxis by the school nurse or other employees designated when the other employees designated when the pupil is authorized to self administer pupil is authorized to self administer Epinephrine, or when there is a Epinephrine, or when there is a coexisting diagnosis of asthma, or when coexisting diagnosis of asthma, or when a prescription is received from a licensed a prescription is received from a licensed health care professional for epinephrine health care professional for epinephrine coupled with another form of medicationcoupled with another form of medication

Practice IssuesPractice Issues• The DOE, in consultation with the DHSS, The DOE, in consultation with the DHSS,

appropriate medical experts, and appropriate medical experts, and professional organizations representing professional organizations representing school nurses, principals, teachers, and school nurses, principals, teachers, and the food allergy community, the food allergy community, shall shall establish establish and disseminate to each BOE and disseminate to each BOE & CSA of a nonpublic school,& CSA of a nonpublic school, guidelines guidelines for the development of a policy by a for the development of a policy by a school district for the school district for the management of management of food allergies in the school setting and food allergies in the school setting and the the emergency administration of emergency administration of epinephrineepinephrine..

• All underlined text is newly amended to PL 2003All underlined text is newly amended to PL 2003

Practice IssuesPractice Issues• The BOE or CSA of a nonpublic school, in The BOE or CSA of a nonpublic school, in

consultation with the parents / guardians consultation with the parents / guardians of children enrolled who may require the of children enrolled who may require the emergency administration of epinephrine emergency administration of epinephrine for anaphylaxis, shall develop a district or for anaphylaxis, shall develop a district or school plan that outlines procedures to be school plan that outlines procedures to be followed to reduce the potential for followed to reduce the potential for student exposure to allergens.student exposure to allergens.

• The school nurse shall work with the The school nurse shall work with the parents/guardians of affected students to parents/guardians of affected students to develop the plan which shall be updated develop the plan which shall be updated annually.annually.

Practice IssuesPractice IssuesTraining ProtocolsTraining Protocols• In an effort to assist the certified school In an effort to assist the certified school

nurse in in recruiting, and training nurse in in recruiting, and training additional school employees as additional school employees as volunteer designees to administer volunteer designees to administer epinephrine for anaphylaxis when the epinephrine for anaphylaxis when the school nurse is not physically present, school nurse is not physically present, the DOE and the DHSS shall jointly the DOE and the DHSS shall jointly develop training protocols in develop training protocols in consultation with the NJSSNA.consultation with the NJSSNA.– Now available @:Now available @:http://www.state.nj.us/education/students/safety/health/epi.pdf

Practice IssuesPractice Issues• The certified school nurse, in The certified school nurse, in

consultation with the BOE or CSA of a consultation with the BOE or CSA of a nonpublic school shall recruit and train nonpublic school shall recruit and train volunteer designees who are volunteer designees who are determined acceptable candidates by determined acceptable candidates by the school nurse within each the school nurse within each building as building as deemed necessary by the nursing deemed necessary by the nursing services plan.services plan.

• All underlined text is newly amended to PL 2003All underlined text is newly amended to PL 2003

Practice IssuesPractice Issues• No school employee, No school employee, including a school including a school

nursenurse SHALL be held liableSHALL be held liable for any for any good faith act or omission consistent with good faith act or omission consistent with the provision of this statue, the provision of this statue,

• Nor Nor SHALLSHALL an action before the New an action before the New Jersey State Board of Nursing lie against a Jersey State Board of Nursing lie against a school nurse for any such action taken by school nurse for any such action taken by a person designated in good faith by the a person designated in good faith by the school nurse pursuant to this statue.school nurse pursuant to this statue.– Good faith shall not include willful misconduct, Good faith shall not include willful misconduct,

gross negligence, or recklessness.gross negligence, or recklessness.

N.J.A.C. 6A: 16-1.4 (a) N.J.A.C. 6A: 16-1.4 (a) Programs to Support Programs to Support Student DevelopmentStudent Development

• Establishes school health policies and Establishes school health policies and procedures procedures

• Each district BOE Each district BOE SHALLSHALL develop develop and adopt written policies, and adopt written policies, procedures, mechanisms or procedures, mechanisms or programs.programs.

N.J.A.C. 6A: 16-1.4 (a) N.J.A.C. 6A: 16-1.4 (a) Programs to Support Programs to Support Student DevelopmentStudent Development• Policies/Procedures must govern;Policies/Procedures must govern;

1. Care of ill or injured students1. Care of ill or injured students

2. Transportation and supervision of 2. Transportation and supervision of students deemed in need of students deemed in need of immediate medical care.immediate medical care.

3. Isolation, exclusion and readmission 3. Isolation, exclusion and readmission of any student or employee suspected of any student or employee suspected of having a communicable disease.of having a communicable disease.

N.J.A.C. 6A: 16-1.4 (a) N.J.A.C. 6A: 16-1.4 (a) Programs to Support Programs to Support Student DevelopmentStudent Development• Policies/Procedures must govern;Policies/Procedures must govern;

4.4. Provision of health services including Provision of health services including immunization,immunization,

administration of medication, treatment of administration of medication, treatment of asthma, medical examinations, nursing asthma, medical examinations, nursing services and emergency medial situations.services and emergency medial situations.

5.5. An annual An annual Nursing Services PlanNursing Services Plan that that details the provision of nursing services based details the provision of nursing services based upon student need.upon student need.

6.6. Administration of medication to students Administration of medication to students under written order of the school physician or under written order of the school physician or medical home.medical home.

N.J.A.C. 6A: 16-1.4 (a) N.J.A.C. 6A: 16-1.4 (a) Programs to Support Programs to Support Student DevelopmentStudent Development• Policies/Procedures must govern;Policies/Procedures must govern;

7. Emergency administration of epinephrine to 7. Emergency administration of epinephrine to a student for anaphylaxis.a student for anaphylaxis.

8. Provision of medical and nursing services to 8. Provision of medical and nursing services to meet requirements for health history, medical meet requirements for health history, medical examination, and health screening as an examination, and health screening as an alternative for students who do not have a alternative for students who do not have a medical home.medical home.

9. Provision of nursing services to non-public 9. Provision of nursing services to non-public schools located in the school district.schools located in the school district.

10. Comprehensive substance abuse prevention, 10. Comprehensive substance abuse prevention, intervention, and treatment referral programs.intervention, and treatment referral programs.

New LegislationNew Legislation

• N.J.A.C. 6A: 16-1.4 (b)N.J.A.C. 6A: 16-1.4 (b)• Each district BOE Each district BOE SHALLSHALL develop develop

and adopt policies & procedures and adopt policies & procedures that fulfill the rules and regulations that fulfill the rules and regulations of the NJ DHSS, the NJ DA, and local of the NJ DHSS, the NJ DA, and local boards of health which include the boards of health which include the following requirements:following requirements:

New LegislationNew Legislation

1.1. Exclusion of any student for failure to Exclusion of any student for failure to meet requirements for immunization meet requirements for immunization against communicable disease.against communicable disease.

2.2. Exclusion of any person if the person Exclusion of any person if the person has uncovered weeping skin lesionshas uncovered weeping skin lesions

3.3. Procedures for sanitation and Procedures for sanitation and hygiene when handling blood and hygiene when handling blood and bodily fluids.bodily fluids.

New LegislationNew Legislation4. Assurance that any student with HIV or 4. Assurance that any student with HIV or

AIDS, or who lives with or is related to AIDS, or who lives with or is related to someone with HIV or AIDS is not excluded someone with HIV or AIDS is not excluded from general education, transportation from general education, transportation services, extra-curricular activities, athletic services, extra-curricular activities, athletic activities, assigned to home instruction, or activities, assigned to home instruction, or classified as eligible for special education classified as eligible for special education for reasons of HIV infection.for reasons of HIV infection.

5. Creation of 5. Creation of wellness policieswellness policies, and local , and local nutrition policynutrition policy

6.6. Ensure accessibility Ensure accessibility to NJ Family Care to NJ Family Care program for students who are knowingly program for students who are knowingly without medical coverage.without medical coverage.

New LegislationNew Legislation

• 6A:16-2.1 Health Services Policy 6A:16-2.1 Health Services Policy and Procedure Requirementsand Procedure Requirements

• The treatment of asthma in the The treatment of asthma in the school setting which SHALL include, school setting which SHALL include, but not be limited to the following:but not be limited to the following:

• A requirement that each school nurse A requirement that each school nurse SHALL be authorized to administer asthma SHALL be authorized to administer asthma medication through use of a nebulizer.medication through use of a nebulizer.

N.J.A.C. 6A: 16-1.4 (a) N.J.A.C. 6A: 16-1.4 (a) Programs to Support Programs to Support Student DevelopmentStudent Development• A requirement that each school nurse receive A requirement that each school nurse receive

training in airway management and in training in airway management and in the use the use of nebulizer and inhalers consistent with of nebulizer and inhalers consistent with nationally recognized standards,nationally recognized standards, including, including, but not limited to, those of the National but not limited to, those of the National Institutes of Health and the American Academy Institutes of Health and the American Academy of Allergy Asthma and Immunology.of Allergy Asthma and Immunology.

• A requirement that each student authorized to A requirement that each student authorized to use use asthma medication orasthma medication or a a nebulizer nebulizer SHALL have an Asthma Action Plan (AAP)SHALL have an Asthma Action Plan (AAP) prepared by the student’s medical home prepared by the student’s medical home and submitted to the CSN.and submitted to the CSN. The AAP shall The AAP shall identify triggers and information to be identify triggers and information to be included in the IHP.included in the IHP.

New LegislationNew Legislation

• Each public and nonpublic school in Each public and nonpublic school in the state the state SHALLSHALL have and maintain have and maintain for the care of students at least one for the care of students at least one nebulizer in the office of the school nebulizer in the office of the school nurse or a similar accessible nurse or a similar accessible location pursuant to N.J.S.A. location pursuant to N.J.S.A. 18A:40-12.718A:40-12.7

Physical ExaminationsPhysical Examinations

• N.J.A.C.6A:16-2.2N.J.A.C.6A:16-2.2• Each student medical examination Each student medical examination

SHALL SHALL be conducted at the medical be conducted at the medical home of the student.home of the student.

• If the student does not have a medical If the student does not have a medical home, the school district home, the school district SHALLSHALL provide the examination at the school provide the examination at the school physician’s office or other comparably physician’s office or other comparably equipped facility.equipped facility.

Physical ExaminationsPhysical Examinations

• For the purposes of the physical For the purposes of the physical examination required in (h)1 examination required in (h)1 (athletic physicals), the (athletic physicals), the student’s student’s parent may chooseparent may choose either the either the school physician or their own school physician or their own private physician.private physician.

Physical ExaminationsPhysical Examinations

• Each school district shall ensure that Each school district shall ensure that students receive medical examinations:students receive medical examinations: 1. Prior to participation on a school-1. Prior to participation on a school-

sponsored interscholastic or intramural sponsored interscholastic or intramural athletic team or squad for students enrolled athletic team or squad for students enrolled in any of grades 6-12in any of grades 6-12 Within 365 days prior to the first practice Within 365 days prior to the first practice

sessionsession SHALL include a health history questionnaire , SHALL include a health history questionnaire ,

completed and signed by the parentcompleted and signed by the parent

Physical ExaminationsPhysical Examinations The report of health findings of the medical The report of health findings of the medical

examination examination SHALL be documentedSHALL be documented on the on the

Athletic Preparticipation Physical Examination Athletic Preparticipation Physical Examination

FormForm approved by the Commissioner of approved by the Commissioner of

EducationEducation The medical report The medical report SHALL indicateSHALL indicate whether a whether a

student is allowed or disallowed to participate in student is allowed or disallowed to participate in

the required sports categories and be completed the required sports categories and be completed

and signed by the original eamining physician, and signed by the original eamining physician,

advanced practice nurse or physician’s assistant. advanced practice nurse or physician’s assistant.

Physical ExaminationsPhysical Examinations

Each student whose medical examination was Each student whose medical examination was completed more than 60 days prior to the first completed more than 60 days prior to the first

practice session practice session SHALL provide a health history SHALL provide a health history updateupdate of medical problems experienced since the of medical problems experienced since the last medical examination, completed and signed last medical examination, completed and signed by a parent.by a parent. Each school district Each school district SHALL provide written SHALL provide written notification,notification, signed by the school physician to the signed by the school physician to the parent stating approval of the student’s parent stating approval of the student’s participation in athletics based upon the medical participation in athletics based upon the medical report, or the reasons for the disapproval of the report, or the reasons for the disapproval of the students participation.students participation.

Physical ExaminationsPhysical Examinations

• N.J.D.O.E. Athletic Pre-Participation N.J.D.O.E. Athletic Pre-Participation Athletic Physical Examination Form Athletic Physical Examination Form and Health History Questionnaire and Health History Questionnaire are available online at:are available online at:

– http://www.state.nj.us/education/http://www.state.nj.us/education/districts/ppeq.pdfdistricts/ppeq.pdf

Physical ExaminationsPhysical Examinations

2. Upon enrollment into school2. Upon enrollment into school– Each school district SHALL require parents Each school district SHALL require parents

to provide examination documentation of to provide examination documentation of each student within 30 days upon enrolling each student within 30 days upon enrolling into school.into school.

– When a student is transferring to another When a student is transferring to another school, each school district SHALL school, each school district SHALL ensurethat student documentation of entry ensurethat student documentation of entry examination is forwarded to the transfre examination is forwarded to the transfre school district.school district.

Physical ExaminationsPhysical Examinations

• Upon enrollment into schoolUpon enrollment into school– Students transferring into a NJ school Students transferring into a NJ school

from out-of-state or out-of-country, from out-of-state or out-of-country, may be allowed a 30-day period to may be allowed a 30-day period to obtain examination documentation.obtain examination documentation.

Physical ExaminationsPhysical Examinations

3. When applying for working papers3. When applying for working papers– The school district is responsible for the The school district is responsible for the

administration of medical examinations administration of medical examinations for a student pursuing a certificate of for a student pursuing a certificate of employment.employment.

– A statement of physical fitness SHALL be A statement of physical fitness SHALL be signed by the school physician unless the signed by the school physician unless the parent elects to obtain the exam at the parent elects to obtain the exam at the student’s medical home.student’s medical home.

Physical ExaminationsPhysical Examinations

4.4. For the purposes of a comprehensive For the purposes of a comprehensive child study team evaluation; andchild study team evaluation; and

5.5. When a student is suspected of being When a student is suspected of being under the influence of alcohol or under the influence of alcohol or controlled dangerous substancescontrolled dangerous substances *If a student is reported to the CSN, *If a student is reported to the CSN, as being suspected of being under the as being suspected of being under the influence as noted above, the CSN SHALL influence as noted above, the CSN SHALL monitor the student’s vital signs and monitor the student’s vital signs and general health status for emergent general health status for emergent issues and take appropriate action issues and take appropriate action pending the medical examination.pending the medical examination.

ScreeningsScreenings• Height, weight, and B.P. – Height, weight, and B.P. – Annually Annually for k- for k-

grade 12grade 12• Visual acuity – Visual acuity – BienniallyBiennially for k- grade 10 for k- grade 10• Auditory acuity – Auditory acuity – Annually Annually K- grade 3, grades K- grade 3, grades

7, and 117, and 11• Scoliosis – Scoliosis – Biennially Biennially for students ages 10-18for students ages 10-18• Screenings SHALL be conducted by a school Screenings SHALL be conducted by a school

physician, school nurse, physical education physician, school nurse, physical education instructor, or other personnel properly trained.instructor, or other personnel properly trained.

• The school district SHALL provide for notification The school district SHALL provide for notification of the parent of any student suspected of of the parent of any student suspected of deviation from the recommended standard.deviation from the recommended standard.

Evidence-Based PracticeEvidence-Based Practice

• Evidence-based practice (EBP) in Evidence-based practice (EBP) in nursing is an approach to health nursing is an approach to health care practice that enables nurses to care practice that enables nurses to provide the highest quality care provide the highest quality care based on the best evidence based on the best evidence available to meet the needs of their available to meet the needs of their patients patients (Melynk, Fineout-Overholt, 2005).(Melynk, Fineout-Overholt, 2005).

Evidence-Based PracticeEvidence-Based Practice

• Where does the “evidence” come Where does the “evidence” come from?from?– Research studiesResearch studies– Case studiesCase studies– Clinical and Research Expert opinionsClinical and Research Expert opinions– Scientific principles, collected, analyzed Scientific principles, collected, analyzed

and condensed into practice and condensed into practice recommendations by experts in the fields recommendations by experts in the fields (Adams & McCarthy, 2007).(Adams & McCarthy, 2007).

Evidence-based PracticeEvidence-based Practice

• Five critical steps of Evidence-based Five critical steps of Evidence-based practice include practice include (Melynk & Fineout-(Melynk & Fineout-Overholt, 2005):Overholt, 2005):

1. Asking the burning clinical question:1. Asking the burning clinical question:– Utilizing PICO format Utilizing PICO format

» Patient populationPatient population» Intervention of interestIntervention of interest» Comparison intervention or status; and Comparison intervention or status; and » OutcomeOutcome