School-based asthma program crucial to address gap in pediatric care

Based on the latest CDC data from 2013, more than 8.6% of school-aged children have asthma. Meanwhile, there is currently no standardized national program for the management, prevention and treatment of asthma within schools, an environment where most children spend the majority of their waking hours.

Photo courtesy of the Geffen School of Medicine at the University of California, Los Angeles

A program to address this discrepancy in care is in development through a partnership between the American Academy of Asthma, Allergy and Immunology (AAAAI) and the National Association of School Nurses (NASN). The program seeks to enhance communication between primary care providers, allergists, school nurses, parents and school faculty by creating a circle of support and promoting the best possible asthma care within schools. In addition, this school-based asthma management program is intended to provide an individualized asthma action plan in order to empower immediate asthma care decisions in schools.

Improperly managed asthma can lead to school absenteeism and, in turn, result in decreased academic performance. In 2013, there were 13.8 million missed school days among children, aged 5 to 17 years, with asthma, and 49% of children with asthma reported missing at least 1 day of school, according to the CDC.

To better understand how integrating asthma care within schools can benefit pediatric patients, Infectious Diseases in Children spoke to allergy experts, school nurses and pediatricians about how a school-based program would function, the barriers to implementing such a program, the limitations of current asthma care within schools, and what makes schools the ideal setting for addressing pediatric asthma care.

Identifying the need for asthma care in schools

Typical asthma treatment for children involves use of a daily preventive inhaler, consisting of either an inhaled corticosteroid alone or in combination with a long-acting beta agonist. According to Kristin C. Sokol, MD, MPH, of the division of allergy and inflammation at Beth Israel Deaconess Medical Center, educating children and their caregivers on proper use of inhalers, as well as having medication available at all times, drastically decreases asthma-related morbidity. Therefore, asthma care in school settings represents a crucial part of most children’s asthma management.

“Asthma is a chronic disease that is common in childhood,” Sokol told Infectious Diseases in Children. “It has been shown that kids experience less asthma exacerbations when they take their medications consistently and correctly. Asthma exacerbations can happen anytime, but especially when kids are active and playing, or when they are exposed to irritants — like strong perfumes or cleaning chemicals — and allergens — like dust mites, cockroaches and pollens.”

Beth Mattey, MSN, RN, NCSN, president of NASN, said triggers may also be found in schools, which makes schools an important partner in managing asthma care for children.

“Kids spend up to 8 hours a day in school, and that is where they spend a majority of their time,” Mattey said in an interview. “So, we know how important it is to address asthma for kids in the school environment.”

Getting treatment to the children who need it most, however, can be difficult because policies tend to vary across the nation, often getting bogged down in the milieu of bureaucracy or by simple oversight, according to Natasha L. Burgert, MD, FAAP, a pediatrician at Pediatric Associates Kansas City.

“Access and availability of proper health care for kids with asthma varies from region to region, from school district to school district, and I would even argue within the school districts,” Burgert told Infectious Diseases in Children. “Access and availability of proper health care for the kids with asthma really varies.”

These variabilities in children’s access to asthma care within schools, along with the variabilities in district policies for how students with asthma receive care, led Robert F. Lemanske Jr., MD, immediate past president of AAAAI, to spearhead an initiative to develop school asthma management plans that include a school-based asthma emergency treatment plan. The projected program would would apply to all students who present with asthma symptoms but do not have a documented and updated personalized asthma action plans available for access by the school nurse or personnel.

“The basis for development of school asthma management plans is that there isn’t a standard asthma action plan — that was one of the problems,” Lemanske told Infectious Diseases in Children. “I have worked with a nurse practitioner for the last 10 years or more, who was a previous school nurse in the Madison [Wisconsin] community, and she made me aware of the fact that there’s a lot of kids with asthma that are in the schools.”

According to Gary S. Rachelefsky, MD, of the Geffen School of Medicine at the University of California, Los Angeles, and an Infectious Diseases in Children Editorial Board member, the AAAAI initiative started as a simpler idea and evolved into a standardized school-based program after the dire need for asthma management in schools was identified. However, Lemanske noted, the process was more difficult than he initially imagined.

“I initially wanted to see if I could do something simple and work out a mechanism by which we could get an asthma action plan for every student with asthma in the schools in the United States,” Lemanske said. “I thought that would be a slam dunk, but it turned out to be a much more difficult process.”

The goal was to simplify the process of getting asthma action plans into schools in response to the confusion caused by the sheer number of different asthma action plans currently in use, according to Rachelefsky.

“The effort started in part because there must be a thousand action plans, maybe even more,” Rachelefsky said. “Our first initial effort was to have an action plan that would be more generic and more adaptable to every situation for the children with asthma and design it in a way that’s easier to transport to other cities, other doctors, to have some uniformity.”

These preliminary efforts prompted a summit between the AAAAI, NASN and other stakeholder organizations, through which a comprehensive school-based asthma management program could ultimately be developed, Rachelefsky noted.

School-based asthma management in action

According to Lemanske, there are a number of key components critical to ensuring a seamless and effective integration of an asthma management program into schools throughout the United States. These components include improved methods of communication among clinicians, families and school personnel; providing educational materials regarding asthma symptom presentation and treatment; and detailed guidelines for addressing environmental triggers both at school and in the home that can lead to a loss of asthma control.

An individualized asthma action plan is a single-page document that breaks down an individual’s daily asthma management routine. Stepping up asthma therapy is denoted by “zones,” which are typically in order of severity based on the colors green, yellow and red. For example, green zones mean a child is doing well and should continue usual daily treatment; yellow zones recommend therapy options for mild to moderate exacerbation; and red zones suggest emergency intervention in response to severe exacerbation. Although asthma action plans all contain these basic elements, Rachelefsky said their design, complexity and availability can differ greatly, which can make them difficult to use in schools.

“General action plans should not be used in the school setting,” Rachelefsky said. “The forthcoming school-based program is intended to be an individualized asthma action plan, as well as other interventions through the school setting.”

Although many organizations, including the Global Initiative for Asthma, recommend the use of asthma action plans, professionals and patients continue to underuse them, according to research by Nicola Ring, PhD, MSc, of the School of Health Sciences at the University of Sterling, Scotland, and colleagues. As a result, Burgert is concerned about the effectiveness of a standardized school action plan.

“An asthma action plan in itself is just a piece of paper,” Burgert said. “There are a lot of other attributes that make an action plan work. In my experience, it is difficult for me to think of a consistent pattern of instances when filling out all of these papers appropriately prevented an office visit or prevented a school day lost. I cannot say with great confidence a standardized form can create this kind of effectiveness.”

However, Sokol said that when implemented correctly, asthma action plans can be effective tools.

“Asthma action plans can be lifesaving,” Sokol said. “I think that it is vitally important to have a plan in place in multiple locations for a child with asthma — the child’s home, the grandparents’ home, with a baby sitter or nanny, and especially at school, particularly for children who have had severe asthma exacerbations in the past.”

Outside of implementing an action plan, a school-based asthma management program should seek to offer a comprehensive asthma education plan for nurses, teachers and school staff. According to Sokol, this is the critical element to a successful school-based program.

“Education of nurses and other personnel is key,” Sokol said. “In the moment of an emergency, the most important thing is that the nurses and other adults in the school (teachers, coaches, etc.) have been trained in the proper recognition of an asthma attack and the proper administration of an asthma inhaler or nebulizer.”

School-based programs should also focus on identifying asthma triggers within each school and developing a plan to reduce their prevalence, because schools are rife with asthma triggers that can exacerbate symptoms, according to Rachelefsky.

“There are a lot of triggers for asthma besides exercise in schools,” he said. “The action plan will identify what schools should do about asthma triggers, including buses, certain cleaning materials, some paints, as well as activities like mowing the lawn outside of classrooms or having construction on the premises while the kids are in school.”

Developing a community of support

The greatest challenge to successful asthma management within schools is poor communication among children, parents, clinicians, teachers and school nurses, according to research by Lisa C. Cicutto, PhD, MSc, of the clinical science program at the University of Colorado.

According to Mattey, school nurses are in a unique position to ameliorate this communication breakdown and ultimately be the most effective players in school-based asthma management for a number of reasons, foremost their understanding of the complexities of asthma.

“School nurses understand the physiology behind it. We understand the problems that asthma can cause and the frequency with which kids miss school due to asthma,” Mattey said. “We have studies that show that when a student’s asthma is case-managed by school nurses, their attendance improves.”

Mattey further explained that school nurses also are in the best position to educate and communicate with all other members of a child’s support team.

“School nurses are that bridge between health and education and represent a key member of the team,” Mattey said. “We want school nurses to be an integral part of the plan because not only can they educate the kids and their families, but also the school community. We can share information that will help the families and providers keep a child under control with their asthma and that is the bottom line. We want children’s asthma to be under control.”

Lemanske agreed that school nurses are an integral part of school-based asthma management, and stated that better bidirectional communication between school nurses and pediatricians is needed.

“School nurses are in a unique position to be able to care for children, and an important part of that is to establish a communication structure between the clinician and the school nurse, because the clinician is writing the orders and doing the clinical management to get the treatment plan into the school,” he said.

According to Mattey, opening electronic medical records to school nurses could be a solution to this problem.

“More and more school nurses are using electronic health records,” she said. “Some areas of the country are able to use electronic health records to share information. In Delaware, we have the Student-Health Collaborative project with the Nemours Foundation through which nurses can access the student’s medical health record with parent permission. That’s happening more across the country and will help eliminate the barriers.”

Burgert noted that asthma support must extend beyond the school to allow children’s asthma needs to be effectively met.

“A good deal of kids spend many hours in school, but if they’re going home and their parents smoke and they have dust mites and cockroaches all over their home, this makes me challenge the effectiveness of [focusing most resources on] school time,” Burgert said. “In addition, I am concerned that school-based programs might increase the fragmented care that children with chronic conditions often receive. The communication with a child’s medical home will be critical to make care full-circle.”

Barriers and limitations

Research by Jason S. Egginton, MPH, of Mayo Clinic in Rochester, Minnesota, and colleagues found that while action plans may solve several school concerns about asthma support, the plans are not effectively reaching schools. Furthermore, barriers in communication do not currently allow for sufficient information sharing between schools and families.

According to Mattey, a logistical disconnect sometimes prevents action plans from reaching personnel within schools.

“We always have a problem with getting action plans from families, whether it doesn’t come from the provider or gets lost in the child’s book bag or that families do not understand the need for the action plan,” Mattey said. “If there is a standard form and everyone is expecting that form to be there for the child with asthma, then that is really very helpful.”

Lemanske said that mismatched districtwide policies can sometimes cause a disconnect in communication and management of asthma.

“The problem that many states have is that they don’t have one uniform plan within the state,” he said. “It is partitioned into school districts and what works in district A may not be supported in district B. We are working on being able to harmonize this and come up with a uniform plan, but this is all down the road.”

Another issue with enacting standardized school-based asthma care programs nationally, is that they may add to the mounting stack of paperwork already required from clinicians by schools.

“I’m already filling out two to three sheets of paper per student for schools without these programs,” Burgert said. “School nurses want to know in detail what the student asthma plan would be, what medications they are on, and what they should do.”

Mattey hopes that a standardized school program will simplify this process and make things easier for all parties involved.

“The school-based asthma management program developed by Lemanske and other stakeholders kind of condenses three or four forms into one form, so it would be easier for providers to use the form and then it will have all of the information that school nurses need,” Mattey said. “The new form includes the HIPAA and the FERPA compliance, the doctor’s orders, the action plan and the steps to take in case of the emergency. All of the forms are on the one form, and it is much easier for providers, and it is much more compact for schools.”

Looking forward

The School-Based Asthma Management Program Act (H.R. 4662), co-sponsored by Reps. Phil Roe, MD, R-Tenn., and Steny H. Hoyer, D-Md., is currently going through Congress in an effort to incentivize participation in school-based asthma programs. The bill will allocate existing federal asthma control grants to participating states by amending the current bill to include a provision to stock asthma medication in the case that a child’s own medication is not available and to implement school-based asthma management programs. Lemanske said the school based asthma management program that is being developed addresses all of the components of the proposed bill and therefore will hopefully be the “go-to” school-based program when the bill passes.

“Not if, but when, this bills gets passed through Congress, then I think we have an incredible opportunity to disseminate, implement and sustain the program over time,” Lemanske said.

According to Burgert, targeted approaches that identify areas where school-based care is needed most may be a more effective plan than broad nationwide policies.

“It would be really nice, that instead of approaching global policy, for some epidemiologists to use data sets to find targeted absenteeism or hospitalism rates. We need to use information available to determine specific areas of need, defining where resources can be best utilized,” Burgert said. “I am challenged when these programs with excellent intent become sidelined because so many of the resources go to places where they aren’t necessarily needed.”

However, she also said that school-based programs are important for advancing the conversation of pediatric advocacy.

“This is a really important discussion,” Burgert said. “This is one of our most common chronic issues in kids, and tackling this challenge is really important. I hope this program will continue the dialogue and open discussions needed to determine what is going to work best in every community.”

Lemanske thinks that their new program will address these issues through practical trial, and through continuous updates.

“I am hoping that this will, in the next 4 or 5 years, become the standard plan that people are going to turn to because it has everything that the schools are going to require,” Lemanske said. “We have a steering committee, and we have administrative support from AAAAI that will help us keep the office moving forward — keep the program updated on a year-to-year basis — and keep the toolbox up-to-date.”

According to Mattey, successfully integrating asthma management into schools nationwide will require all stakeholders to cooperate.

“It is a team effort,” Mattey said. “I think that is one of the most important messages that we need to get out. We all need to coordinate our care, so that we are all on the same page, and we are all communicating about the student, so that they have the best care possible.”– by David Costill

• References:
• CDC. Asthma. Most recent asthma data. http://www.cdc.gov/asthma/most_recent_data.htm. Accessed April 6, 2016.
• Cicutto L. School-centered Asthma Programs. In: Leung DYM, eds. Pediatric Allergy: Principles and Practice. 3rd ed. Edinburgh, Scotland: Elsevier; 2015:329-335.
• Egginton JS, et al. J Sch Health. 2013;doi:10.1111/josh.12107.
• Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. GINA; 2015. Accessed April 04, 2016.
• Ring N, et al. BMC Family Pract. 2015;doi:10.1186/s12875-015-0352-4.

• For more information:
• Natasha L. Burgert, MD, FAAP, can be reached at kckidsdoc@gmail.com.
• Robert F. Lemanske Jr., MD, can be reached at 750 Highland Ave, Madison, WI 53726.
• Beth Mattey, MSN, RN, NCSN, can be reached at bmattey@nasn.org.
• Gary S. Rachelefsky, MD, can be reached at gary@rachelefsky.com.
• Kristin C. Sokol, MD, MPH, can be reached at ksokol@bidmc.harvard.edu.

Disclosures: Burgert, Lemanske, Mattey, Rachelefsky and Sokol report no relevant financial disclosures.