Tylenol. Cold Meds. Ibuprofen. GI. Aspirin. %. Results. â Written guidelines. 98%. âStore medication in locked cabinet 80%. âSelf- administration allowed. 76%.
Acknowledgements
Help from my friends Medications in Schools Ann Marie McCarthy, PhD, RN, FAAN University of Iowa, College of Nursing
“AH HA” MOMENTS ! Children are in Schools Health Care is
Provided in Schools School Nurses Provide this Care
Janet Williams Michael Kelly David Reed Daniel Clay Karen Farris Judith Igoe School Nurses in Iowa & Nationally Nursing, Pharmacy, & Education Students
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
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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)
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
Study #1: Medication Administration in Schools Purpose: to describe medication administration practices of school nurses
Methods
Design: Survey, descriptive Subjects: 649/1,000 (~65%), randomly selected from school nurses who were members of the National Association of School Nurses
Current Systems of Authority Multiple layers Federal laws State laws Local school district Individual School Professional guidelines Educational & Medical
Research on Medication Management in Schools Studies on: School Nurses Principals Families Day Care Trends
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
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Results: Nonprescription Medications
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%
60.0
%40.0
Cold Meds Ibuprofen
20.0
GI
10.0
Aspirin Available
Order
Results: Delegation
Results 98% 80% 76% 36% 34% 23% 21%
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%
Results: Errors
Principal delegates medication administration “in loco parentis” School nurses comfort with UAPs Very/moderately comfortable Uncomfortable/very uncomfortable No response
Tylenol
30.0
0.0
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
Creams
50.0
Medication error in the last year Types of Errors
45% 33% 18%
Missed dose Not documented Overdose/double dose Administered, no authorization Wrong medication
Contributing factors
49% 80% 30% 23% 21% 20%
Use of UAP, number of children
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Conclusions Concerns with:
Delegation Storage of medications Self administration policies Transportation of medications/field trips Side effects of medications Nonprescription medications Decreasing Medication Errors
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 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
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 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
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
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Study #3: Changes in Medications in Schools
Results: Prescription Meds only 172 (50%) had data from both years 2000
2003
Mean # of Students
Mean # of Students
on ADHD Meds
8.7
2.7
on prescription meds
18.1
10.7
on nonprescription meds
5.9
8.0
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
90% of the school nurses agreed/strongly agreed that they have seen a decrease in Ritalin use
Results: Prescription meds
Results: Non-prescription
In the late 1980’s, a study in Illinois schools reported 58 different meds
Medication
Mean # of students (range)
Analgesics
6.2 (0-120)
This study, ~200 prescription medications listed
Cough/cold
1.1 (1-40)
GI
1.2(0-52)
Alternative
0.1 (0-10)
ADHD, psych meds
Schedule of administration (% of nurses giving meds at each time)
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
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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)
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
Recommendations Improved communication Between primary provider & school nurse Between parents & school Between pharmacist & school nurse
Need for ongoing collaborations
Funding Midwest Nursing Research Society/ Glaxo Wellcome Research Award Center for Advanced Studies Spelman Rockefeller (CASSPR) Grant, The University of Iowa
American Pharmacists Association.
Thank You!
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