Medications in Schools
Ann Marie McCarthy, PhD, RN, FAAN University of Iowa, College of Nursing
Help from my friends
Janet Williams Michael Kelly David Reed Daniel Clay Karen Farris Judith Igoe School Nurses in Iowa & Nationally Nursing, Pharmacy, & Education Students
Acknowledgements
“AH HA” MOMENTS !
Children are in Schools
Health Care is
Provided in Schools School Nurses Provide this Care
Early School Health Projects & Research
School Nurse Practice (NIC)
2 of 3 most common nursing interventions are related to medications
Pharmacy & Nursing students
Joint educational project
Medication Management in the Schools
What is known about medication administration in the school setting? How can we make the process safer and more efficient?
Current Social Context
Mainstreaming children with health problems Changing morbidities & treatments Improved survival of children with complex health conditions Increasing use of medications for children Parents relying on schools to share responsibility of care
Current Statistics
~ 50 million children in the US in K-12 ~ 100 thousand public schools in the US ~ 13 million children take medications in the USA in any 2 week time period ~57% of school districts have an RN ~35,000 school nurses ~ 1:1,350, ratio of school nurse to students (1:750 recommended)
Current Systems of Authority
Multiple layers Federal laws State laws Local school district Individual School Professional guidelines
Educational & Medical
School Medication Management Guidelines
Most include Physician order for prescription medications Written parental permission Medication at school in labeled container Stored in a secure location Written documentation
Research on Medication Management in Schools
Studies on: School Nurses Principals Families Day Care Trends
Study #1: Medication Administration in Schools
Purpose: to describe medication administration
Methods
practices of school nurses Design: Survey, descriptive Subjects: 649/1,000 (~65%), randomly selected from school nurses who were members of the National Association of School Nurses
Results: Subjects
Primarily female (99.7%),
Middle-aged (M=47.9) 23 years as an RN 11 years as a school nurse Education level 50% BSN, 22% MS/MA
Results: Medications
Children receiving medication during a typical day 5.6%
Most common medications:
ADHD medications Nonprescription medications Asthma medications 3.3% 1.5% 1.1%
Results: Nonprescription Medications
60.0
%40.0
30.0 20.0 10.0 0.0 Available Order
50.0
Creams Tylenol Cold Meds Ibuprofen GI Aspirin
Results
Written guidelines Store medication in locked cabinet Self-administration allowed Secure container available for meds that need refrigeration Standing order for Epipens Transfer of medications Documentation of side effects 98% 80% 76% 36% 34% 23% 21%
Results: Delegation
76% of these school nurses use UAPs to help dispense medications UAPs who dispense medications
Secretary Health Aide Teachers Other Parents Students 66% 40 38 38 18 16
UAP education, 2 hours or less
58%
Principal delegates medication administration “in loco parentis” School nurses comfort with UAPs
Very/moderately comfortable Uncomfortable/very uncomfortable No response 45% 33% 18%
Results: Errors
Medication error in the last year Types of Errors
Missed dose Not documented Overdose/double dose Administered, no authorization Wrong medication
49%
80% 30% 23% 21%
20%
Contributing factors
Use of UAP, number of children
Conclusions
Concerns with:
Delegation Storage of medications Self administration policies Transportation of medications/field trips Side effects of medications Nonprescription medications Decreasing Medication Errors
Study #2: Research with Principals
Purpose: to describe medication administration
from the principal’s perspective
Methods
Design: Cross sectional survey Subjects: 396/850= 46.6% 75.5% Principals 16.7% School Nurses 7.8 % Others
Results
Responsibility
Overall: Daily: School Nurse 34% Principals 41% School Nurse 76% Others 24%
Policies
Pill count: 22%, Principals 30.6%, Nurses 15.6% Policy for Medication on field trips: Principals 80% School Nurses 64% Allow Self medication: 50%
Results
Types of Medication Errors
Missed dose: medication not provided to school, Missed dose: student did not go to the office Missed dose: staff did not notify student Medication administered at wrong time Medication administered but not documented Medication administered without authorization
Results
Reasons Contributing to Medication Errors Poor communication with families Increased numbers of children on meds Poor communication with healthcare providers Increased variety of medications Staffing levels inadequate Students on similar medications Stolen medication: 14-21% in middle & high school
Conclusions
Concerns with
Role of principal vs school nurse Confusion over self medication practices Transporting medications Understanding “missed dose” Factors contributing to errors communication and range of meds
Study #3: Changes in Medications in Schools
Purpose: to look at the changes in medications in
schools from 2000-2003 (post Concerta)
Methods
Design:Survey, descriptive Subjects: 338/1,000 (~34%), randomly selected from school nurses who were members of the National Association of School Nurses
Results: Prescription Meds
only 172 (50%) had data from both years 2000
Mean # of Students on ADHD Meds on prescription meds
on nonprescription meds
2003
Mean # of Students
8.7 18.1 5.9
2.7 10.7 8.0
90% of the school nurses agreed/strongly agreed
that they have seen a decrease in Ritalin use
Results: Prescription meds
In the late 1980’s, a study in Illinois schools reported 58 different meds This study, ~200 prescription medications listed
ADHD, psych meds
Results: Non-prescription
Medication
Analgesics
Mean # of students (range)
6.2 (0-120)
Cough/cold GI
Alternative
1.1 (1-40) 1.2(0-52)
0.1 (0-10)
Schedule of administration
(% of nurses giving meds at each time)
100 80 60 40 20 0
am 2n m m m m am 8a 9a pm 2p 3p 10 11 -1 78-1 1234p m
%
10 -
9-
11
12
Conclusions
Decrease in number of children on ADHD & prescription medications in schools Increase in number of children on nonprescription medications in schools Increase in the number & range of medications in schools Medication administered throughout the day
Recommendations
Consistent guidelines
All states/school districts require
Safety concerns/System issues
Delegation, storage, field trips, self administration, epi-pens Practice changes (2 containers, inhalers for school)
Recommendations
Improved communication
Between primary provider & school nurse Between parents & school Between pharmacist & school nurse
Need for ongoing collaborations
References
Farris, KB, McCarthy, AM, Kelly, MW, Clay, D, Gross, J. (2003). Issues related to medication administration in Midwestern schools. Journal of School Health, 73 (9), 331-337. Kelly, M., McCarthy, A.M., & Mordhorst, M. J. (2003). School nurses experiences with medication administration. Journal of School Nursing, 19 (5), 281-287. McCarthy, AM, Kelly, MW,& Reed, D (2000). Medication administration practices of school nurses. Journal of School Health, 70(9):371-376. Pavelka, L., McCarthy, A. M., & Denehy, J. (1999). Use of interventions by school nurses. Journal of School Nursing, 15 (1), 29-37. Sinkovits, H.S., Kelly, M. W., & Ernst, M.E. (in press). Medication administration in day care centers for children. Journal of the
American Pharmacists Association.
Funding
Midwest Nursing Research Society/ Glaxo Wellcome Research Award Center for Advanced Studies Spelman Rockefeller (CASSPR) Grant, The University of Iowa
Thank You!