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Development of Asthma Guidelines for School Age Children and its Effect on Absenteeism
Kristine Krumdiack
Abstract
Background: Asthma is one of the leading causes for school absenteeism and is one of the most
monitoring, action plans, education and school nurse case management have been successful in
many parts of the country in reducing these attendance rates and maintain heather youth.
Purpose: The purpose of this project was to demonstrate to the Bellingham school district, in
Whatcom County Washington. The importance of established asthma care guidelines, education,
monitoring and the impact that these have on reducing absenteeism. This project will also assist
the district with ideas for the implementation of such programs that are supported with evidence
based research.
Methods: Research literature for this project was obtained through searches on CINAHL,
PUBMED and Google Scholar. Data pertaining to children outside the age range and small
studies were excluded. A second exclusion criterial was placed for any articles that were
published before 2012. The search was expanded back to include certain studies from 2004. A
concept map was completed during the group portion of this project and helped focus the
Findings: The prevalence of asthma in young children is astounding. With it being the most
common cause for a child to miss school. School based asthma management programs,
implementation of asthma action plans combined with the presence of a nurse care manager has
a strong relation to the reduction of asthma related absences. The children have also been found
Implications: Some of the implications to this new practice includes the need for increased
staffing both temporary and long-term. The need for increased collaboration with healthcare
Development of Asthma Guidelines for School Age Children and its Effect on Absenteeism
Background
Fifteen elementary schools make up a majority of the Bellingham school district. All
fifteen are without a set plan for the care and management of one of the most prevalent
childhood illnesses, Asthma. Asthma is also the leading cause for absenteeism. With this
correlation and concern for the wellbeing of the children with in the district, who have asthma. A
need for a plan was the request of a few school nurses within this Bellingham school district.
For these nurses who have to divide their time between multiple schools and only being
present for a few days at each. Need to rely on the administrative staff and teachers to be able to
response to an emergency in the event that he or she is not present. For this reason, the push for
at least a step by step action plan for each child is in desperate need and should be handles in the
way that any other potentially fatal illness such as peanut allergies is handled.
The PICO question was established as Will school aged asthmatic children, grades K -
5, with a standardized asthma care guideline in place, have improved attendance records in
comparison to school aged asthmatic children without a standardized asthma care guideline
enacted?
Purpose
The main purpose of this project was to demonstrate to the Bellingham public school
district that there is a desperate need and evidence, that supports the use and implementation of
an asthma- management program. The population was students kindergarten thru fifth grade
within the Bellingham school district or similar districts in size. The suggested intervention was
to have asthma histories taken, contacting parents and providers, obtaining medications,
constructing asthma step plan, and school based education programs. The comparison would be
ASTHMA GUIDELINES FOR SCHOOL AGE CHILDREN 5
for school or students that did not have the interventions. The outcome would be the attendance
improvement and knowledge and management of asthma symptoms. With this program, there
would not only be young children and families that are able to understand and manage their
asthma better but absentee rates that are increased with worsening asthma symptoms will go
down. Lastly, would give the elementary school staff a reliable action plan in the event of an
Methods
The search for my literature began with PUBMED, Google Scholar and CINAHL. Using
key terms such as asthma care and school nurse. The second search used key terms such as
elementary schools and asthma action plans. To filter the research some criteria was placed
on the search such as peer reviewed, full text and published after 2012. Articles were excluded if
there was a small study size or if the study had not yet completed. Other exclusions were for
studies with school districts that are of a unproportionate size to the school district in question.
Some articles where retained that were outside of the publication date indicated but the findings
Overall the research we found was strong. It was narrowed down to ten studies. The
strongest of our evidence included four randomized controlled trials, two systematic reviews and
two quasi- experimental studies as well as practice guidelines that where provided to use by our
mentors.
In an attempt to organize all of the literature and direct the project a concept map was
created with the main points and focus of the PICO question in the center of the map. In making
this map it was easier to find connections and common themes among the studies with color
coding. This also made it easier to develop recommendations based off of the findings. For the
ASTHMA GUIDELINES FOR SCHOOL AGE CHILDREN 6
questions that arose during this process I was able to look into further or write down and ask our
Synthesis Review
Some common themes among the research was the implementation of asthma education
programs such as Open Airways sponsored by the American Lung Association. This program
is a school-based curriculum that is a fun and interactive way to educate and empowers children
to feel more confident in asthma self-management. When following programs such as this one
during the study where based off of the National Heart and Lung Association asthma guidelines
in which the four components are periodic physiology assessment and monitoring of asthma
symptoms, appropriate use of medication, patient education and control of factors contributing to
asthma. The students in this study again exhibited an increase in school performance.
Another theme that developed in the research was the use of an asthma tracking survey.
This survey would help nurses identify students with asthma by the completion of this parent
completed form that was given at the beginning of each school year (Moricca et al ,2012). An
assessment was then completed with information such as medication available at school,
severity, and peek flow. The nurses would follow up throughout the year with education, calls to
physician and parents. Again, showing a promising increase in asthma management and
control.
A common theme that was un expected was present in all of the research that I found and
that is the need for more nurses in the schools. With budgeting constraints, it is understood why a
ASTHMA GUIDELINES FOR SCHOOL AGE CHILDREN 7
lot of the schools have such a short contact with the school nurse but it was noted that the need
for the school nurse is there and it is strong (Liberatos et al, 2013). This might be a look into
Requirements
In order for the asthma program to be sustainable there were a few common factors that
seemed to be present. There was an asthma care plan in place for each student on hand located in
the childrens classroom. This care plan would give a non-medically trained individual step by
step instructions on how to respond to an asthma emergency based on the symptoms the child is
exhibiting (Maughan & Schantz, 2014). The other factor was the presents nurse case manager.
The duties of the case manager are to offer practice guideline support (Greener, 2014). They
assure the use and creation of the action care plan. Help in the healthcare navigation for the
families. As well as, coordinate referrals and education sessions for the students and staff.
Barriers
A number of barriers were identified within the literature. The first was communication
between school nurses and medical providers. All too often the primary care provided may have
an idea or plan for the medical care of the child and this information or severity of the asthma is
not communicated effectively. Second, was the lack of parental involvement and follow through
in relation to the asthma care provided at school. All too frequently a plan would be set into place
and when it would come time to review the plan the meeting or communication between nurse
and parent would cease to occur. Next, was the lack of time and resources available to all
stakeholders. Another barrier was the limited resources and availability of medication and
medical equipment. The last barrier in the research that was identified was it seemed to be hard
ASTHMA GUIDELINES FOR SCHOOL AGE CHILDREN 8
to track asthma related absences specifically due to the specific reason for the students absence
Recommendations
As the research suggests there is a strong need for a nurse case manager to be able to take
the time to follow up with calls to local providers and families as well as conducting the
educational sessions. Use of the screening tool at registration to identify individuals with asthma
is another way to fill that gap in communication and gives the school the ability to reach out to
all of the students as they are coming in to the school year and get a baseline for the student
health. The parents are already in the routine of filling out paperwork so this would be the time to
catch them before the year gets going. Action plan or established asthma management protocol
located in each childs class room with information such as triggers, demographic and emergency
step by step plans. As mentioned above, a school based education program for the children such
as Open airways sponsored by the American Lung Association would give the schools and the
nurses the tools they need to start this path to a more prepared school district.
The main purpose of this purposed change is practice for the school district is to improve
the attendance rates for the children in kindergarten through fifth grade who have asthma.
Staffing Increase
Some of the implications that may come from this change is that there will be a need for
an increase in staffing for both temporary and long term positons. One for the influx in students
at the beginning of the school year that will need to be evaluated and a care plan placed and the
long-term portion will be needed for the continued follow up for the case management role.
Healthcare collaboration
ASTHMA GUIDELINES FOR SCHOOL AGE CHILDREN 9
There will be a need for increased collaboration with the healthcare professionals in the
care for these children. From the first diagnosis and provision of the care plans in place to the
medication that will need to be prescribed in such case that the child should need during school
hours. This involvement form the healthcare professionals I believe will come quickly. If most of
the assessments and paperwork is provided to them at the beginning of the school year when the
children are getting the required checkups for school, then this will be a more convenient
method.
Increased Funding
As with any change there will be an increased need for funding, especially during the
implementation phase of this program. This funding need may be met by things such as
government grants or by applying for reimbursements with the increase in attendance rates.
Conclusion
At the end of this project we come back to the question: Will school aged asthmatic
children, grades K - 5, with a standardized asthma care guideline in place, have improved
asthma care guideline enacted? Evidence strongly suggests that, the implementation of an asthma
care plan in combination with school nurses as a case manager is the most effective way in
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