Complex care confronts schools
It’s 7:30 on a Monday morning at Bethany Elementary School in Beaverton, Ore., and Nina Fekaris is crouching on the playground, busily picking up peanut shells left from a weekend community party.
Fekaris, a nurse for over 20 years in the Beaverton School District, checks her list of students with peanut allergies to make sure they are kept inside the school building and out of harm’s way until all of the shells are picked up.
Just before school begins at 8, a teacher visits Fekaris in the nurse’s office to request a vision test for one student and a dental referral for another. Soon a stream of children with diabetes or ADHD begins arriving for sugar screenings or daily doses of their medication.
“You need a nurse in the building,” Fekaris emphasizes. “We’re a safety net.”
These scenes play out daily at nurse’s offices and school clinics nationwide, especially as the number of children with life-threatening allergies, asthma and other chronic medical conditions increases. According to the National Center for Educational Statistics, 15 to 18 percent of K12 students have a chronic health condition. Three million of those have diabetes and more than seven million have asthma, says the Centers for Disease Control and Prevention (CDC).
The incidence of children with food allergies rose from 3 percent in 1997 to 5 percent in 2011. And the incidence of students with skin allergies increased from 7 to 13 percent, according to the CDC.
“The school nurse’s role has really expanded since I started 23 years ago,” says Christine Tuck, the director of health services at Seaman USD 345 in Topeka, Kansas. “We have a lot more students with special needs.”
During the past school year, Seaman USD nurses administered almost 26,000 doses of medication, from Adderall to ibuprofen, for a range of conditions—compared to fewer than 24,000 doses dispensed six years ago, Tuck says. Nurses also performed 6,138 blood sugar checks on diabetic students.
Although the National Association of School Nurses (NASN) recommends a maximum 750 students per nurse, that organization reports that half of school nurses face considerably higher ratios. NASN found in the same 2013 survey that half of the nurses had to cover more than one school, and some as many as 10 buildings.
In recent years, several large districts have shed nurses because of budget crunches. Since 2008, the Los Angeles USD cut its nursing staff by 13 percent, although the 2014-15 budget promises to restore some of those positions. In 2011, the Cleveland Metropolitan School District cut 55 percent of school nurses, leaving only 28 responsible for almost 100 schools.
And that same year, Philadelphia eliminated almost 100 school nurse positions. Those reductions made national headlines over the past year when two elementary students who became seriously ill at schools without nurses on site died.
Districts are pursuing a range of solutions to these mounting health care challenges. Training of school nurses and other health care personnel has been expanded to meet students’ complex medical needs.
In Beaverton, Ore., nursing leaders have recruited office staff and classroom teachers to administer medication and monitor blood sugar levels. And many districts from South Carolina to Oregon are seeking funding assistance from outside resources, such as local health care organizations and Medicaid.
School nursing has come a long way in Florida’s Brevard County Public Schools. “When I started more than 15 years ago, we didn’t have nurses in individual schools,” says Pamelia Hamilton, the county’s school health coordinator.
“We trained the front office staff to pass meds.” In those days, Hamilton and about half a dozen fellow registered nurses covered 90 schools, spending slivers of time at each.
The district budgets $3 million annually to the growing health needs of its students. It has placed 130 licensed practical nurses and healthcare technicians—most of whom come from area hospitals and perform all nursing functions—at each of the district’s 90 schools, resulting in an exemplary 450-to-1 ratio of students to the full-time health care providers. If necessary, these workers consult with the RN assigned to their school.
Some of Brevard County’s larger middle and high schools have more than one provider on site, and the remaining LPNs and technicians are assigned the entire day to individual students with serious conditions from epilepsy to breathing problems.
What’s helped make this large-scale deployment successful is a training regimen that prepares the LPNs and technicians to deal with children’s health problems, Hamilton says. They attend a three-day orientation during the summer, and then work alongside a school nurse for several more days.
“They learn the intricacies of caring for youngsters. For instance, the typical blood pressure of a 5-year-old is different from that of an 18-year-old,” Hamilton says.
Involving the community
The Beaverton School District has 12 nurses covering 43 schools. Fekaris is responsible for four and seldom gets to spend more than one day a week at each, leaving her to find effective health care alternatives.
“I do a lot of delegating and staff training,” Fekaris says. “The school secretaries dispense medications, and for diabetic students, they help count carbs, measure insulin doses, and can give emergency glucogen shots.” Fekaris provides annual training for injecting glucogen, which is a one-and-a-half hour session, and epinephrine, a two-hour session.
Ferakis also trains teachers who volunteer to help test and track students’ blood sugar in the classroom several times a day. And she doesn’t stop there. “We try to teach the kids to give themselves the insulin injections, even at the elementary school level,” she says.
In several Beaverton elementary schools, 10 percent of the student body have serious allergies—everything from shellfish and peanuts to eggs and bee stings—that can result in life-threatening anaphylaxis, Ferakis says. In those schools, she trains all teachers and staff to recognize symptoms—hives, vomiting and difficulty breathing—and to administer shots with an EpiPen.
Annie Sheetz, who served for 25 years as the director of School Nurse Services for the Massachusetts Department of Health, suggests a higher tech solution to cope with ever-increasing caseloads.
“You have to have a districtwide medical data system,” that tracks trends from the prevalence of obesity to the rate of students returning to class after visiting the nurse’s office,” she says. If too many kids are being sent home, Sheetz continues, nurses can analyze the numbers to see if more could have been kept in school.
SNAP Health Center, a school health management software program developed by Professional Software for Nurses and Student Tracking and Record Solution (STARS) software, provide access to student records, including medications, frequency of clinic visits, individual treatment plans and immunizations. The software also speeds up paperwork, including generating student reports and letters to parents.
Sheetz also recommends greater involvement by the central office. “The superintendent needs to sit down with the district’s nurse leader and ask, ‘What are you seeing out there?’ If you’re seeing a lot of kids overweight, a computerized tracking system will show it.”
At that point, the district could consider a range of responses, from starting an anti-obesity program to getting kids moving more and changing the lunch menus.
School nurses can somewhat negate the funding trend by billing Medicaid for providing care to students from covered families. The process involves submitting a claim that details each medical service and procedure the student has received. “I’ve been billing Medicaid for years,” says NASN President Carolyn Duff.
Public-private partnerships also can play a role in containing district costs. Duff, who works as a nurse for the Richland County Public Schools in South Carolina, points to a partnership between Austin ISD in Texas and local providers Seton Health Care Family and Dell Children’s Hospital.
While those organizations contract with districts to provide 70 full- and part-time RNs and 50 full-time health assistants to cover the district’s 113 schools, Seton and Dell officials note that a portion of the service they provide is designated “in kind,” at no expense to Austin ISD. As a result, the district is devoting barely 0.5 percent of its 2014 FY budget to student health services.
In contrast, the same services in Dallas ISD—which does not have that kind of public-private partnership—take up almost 1.5 percent of the district’s 2014 budget.
“It really isn’t possible for school districts to meet their educational goals for students without providing quality school health services,” NASN’s Duff says. “The two go hand-in-hand.”
Ron Schachter is a contributing writer.