Rebecca King RN, CSN, MSN, MEd School Nurse Liaison WVDE-Office of Healthy Schools Changing the Way We Do Business: Working SMARTER not HARDER?

Rebecca King RN, CSN, MSN, MEdSchool Nurse Liaison

WVDE-Office of Healthy Schools

Changing the Way We Do Business: Working

SMARTER not HARDER?

Hats Off To…

Objective #1:

• Participants will be knowledgeable of the vision for school health service initiatives at a national, state and local level.

WV Department of Education

WV State Board of Education(Promulgate educational rule for PreK-12,

adult vocational, institutional education facilities and the school for the deaf and blind)

State Superintendent of

Schools

WVDE Offices

Deputy Superintendent

RESA OEPA

Coordinated-School Public Health Partnership

The West Virginia Story…

Coordinated School-Public Health Structure

2011 RESA-RSWS Focus

• Work Plan – Local Wellness– Bullying (S3 high schools)– Substance Abuse (SBIRT)– Suicide Prevention (ASPEN)– Teen Pregnancy (HEAP, PREP grants)– Physical Activity (Let’s Move)– Nutrition (current WVDE-OCN

initiatives)– Tobacco Prevention (Quit Kits)

What’s on the books?• SN ratio of 1:1500 K-7 (W.Va. Code §18-5-22)

• WVBE Policy 2422.7-Standards for Basic and Specialized Health Care Procedures in the School Setting

• WVBE Policy 2422.8-Medication Administration (Prescribed and OTC)

• WVBE Policy 2423-Communicable Disease Control (HIV & Comm. Dx Inservices)

What’s on the books?

• WVBE Policy 5200- Certification…Authorization, Permit, Full Certification, Short or Long-Term Substitute and PPST

• Asthma laws-W.Va. Code §18-5-22b

• Diabetes laws- W.Va. Code §18-2K-1

• High Acuity Funding-W.Va. Code §18-5-22

• School Nurse National Certification- W.Va. Code §18A-4-2b

Top 5 Medical Diagnoses/Procedures2010/11 School Nurse Needs Assessment

Medical Diagnoses In-School Specialized Health Care Procedures

Asthma Inhalers for Asthma

Behavioral Disorders Emergency Medications

Anaphylactic Reaction Long-Term Medications

Obesity Special Diets per Federal Form

Mental Disorders (Depression, Bipolar, Schizophrenic, Suicidal)

Seizure Management

Close 5th places…..Ear, Nose and Throat/Migraine or Severe Headache/Seizures

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

238 8522147

4213

11491

16145

2010/11 Student Medical Diagnoses

Series1

School HealthEfficiency

• Multidisciplinary Team (SN, LPN, Aides, Health Clerk/Secretary)

• Utilization HealthCheck examination for new school enterers…No mass school screenings

• Evidence-based practices and policies (BMI, Scoliosis, Screenings, Lice, Prevention Programs, etc.)

• SBHC with full array medical, dental and mental

Model

• YOUR County

WVDE-Healthy Schools at http://wvde.state.wv.us/healthyschools/quicklinks.html.

NationalSchool Nurses to Student Ratio

1:750 Well child

1:225 Chronic conditions

1:125 Complex conditions

1:1 as needed for multiple disabilities

What does the Student to School Nurse ratio look like on paper?

1340 + 150 + 10 + 2 =750 225 125 1

1.66 + .66 + .08 + 2 = 5.28 nurses

Multidisciplinary Approach

1340 + 150 + 10 + 2 =750 225 125 1

1.66 + .66 + .08 + 2 = 2 RNs 1 P/T LPN 1 clerk

NASN Research Priority

• Identify school nurse delivery models (school nurse caseloads, credentials, experience, etc.) necessary for quality nursing care

• School nurses must identify and measure outcomes expected as a result of quality school nursing care

School nurse sensitive outcomes

• Identify factors that measure the impact of nursing care over and above other factors

• Outcomes “sensitive” enough to distinguish between the effects of family and community and the effects of the quality and the quantity school nursing interventions on child, family and school community outcomes

Health Care Reform• WV children with increased insurance

coverage• Expansion of Primary Care Center

services and funding (currently serving 1 in 5 West Virginians)

– School-Based Health Services • Dental• Mental Health• Family Planning

Helping us move to full-service communities/schools

Objective #2:

• Participants will be familiar with evidence-based practice recommendations in school health and challenged to fully utilize them in daily practice.

WHY EBIs…so students can get safe, quality standardized care

Prioritize

• Immunizations, Immunizations, Immunizations

• HealthCheck, Parent and Provider Education, HealthCheck, Common language, HealthCheck, Medical home concept

• Evidence-based Practice and Programs

Talk the Talk and Walk the Walk

• Know the data and the research, STOP the routines and start utilizing the facts to make school health programming and procedure decisions!

BMI…• USPSTF recommends Medical

provider screening for 6 -18 year old with comprehensive weight management program. Inclusive of counseling, diet, physical activity and behavioral interventions which are beyond our scope as nurses.

BMI…

• CDC (2007) recommends surveillance only not census or population-based screening by school personnel.

• Health and physical education including modeling school meals and physical activity for schools.

• Medical home management.

Acanthosis nigricans (AN) Markers…

• CDC is aware that some groups are interested in AN screening of children in school settings to identify those at high risk to develop type 2 diabetes. Although some studies have observed that half the children with type 2 diabetes had AN, insufficient evidence exists for us to conclude that having AN will lead to type 2 diabetes. Therefore, at this time, CDC scientists strongly discourage AN screening of children in school or community settings.

Acanthosis nigricans (AN) Markers…

• While AN is a reliable and independent marker of hyperinsulinemia, the extent to which AN predicts the development of type 2 diabetes is unclear. In this study, none of the 233 students screened had hyperglycemia.

• CDC scientists are not aware of any systematic guidelines for clinical detection of AN or a uniform AN case definition. The repeatability, reliability, and validity of AN screening, relative to expert diagnosis (gold standard), is unknown. This makes it impossible to meaningfully interpret AN screening results. Therefore, the utility of using AN as a screening tool for diabetes prevalence or as a predictor of developing diabetes is currently unknown.

Acanthosis nigricans (AN) Markers…

• Those adolescents who have AN can be stigmatized by the screening process and subsequent identification. We are also concerned that if AN status becomes a part of adolescents' medical records, it might jeopardize their future insurance benefits.

• Most importantly, there are now no known interventions or protocols to treat those who have AN. There is some evidence that those with AN might benefit from physical activity. Because improved physical activity benefits everyone in school or communities, it makes sense to encourage physical activity for all children, regardless of AN status.

• Medical home screening.

Acanthosis nigricans (AN) Markers…

• Given the absence of a uniform case definition and intervention protocols for those with AN and considering the risk of stigmatization for those with AN, CDC scientists believe that it is not ethical or cost-effective to mass screen children for AN. CDC recommends that state diabetes control programs consider an alternative primary prevention approach and use available resources to improve physical activity and nutrition in schools and communities.

Scoliosis Screenings...• Affects only 2-3% of entire US Population.

Do the math.• USPSTF did not find GOOD evidence to

support this screening for early detection.• Accuracy of current screening test

(forward bending or scoliometer) is VARIABLE.

• Only a small amount (minute) of the nationally 2-3 % cases actually have health benefits more cases are not clinically significant.

Scoliosis Screenings...

• USPSTF found idiopathic scoliosis detected through screening leads to MODERATE HARM…concluding that harms of screening out weigh the potential benefits.

Dental Screening…

• By West Virginia Dental Laws, this is outside of the scope of a nurse.

• We do individual “oral health assessments” based on an individual complaint NOT massive screenings.

Massive Screenings• Are massive screening conducive to

accurate screenings?• Do they detect a high population of

needs?• Can you do a diagnosis, treat or

referral to a specialist?• Is the medical home an unneeded

entity in a child’s life?• Do you coordinate health services and

share health information with them?

Massive Screenings

• Outdated• Lack of supportive research to show

need or true gaps in birth up to three year old screenings and medical home care.

• The concept of surveillance and screening in a medical home is continuity of care.

WHY?

• PreK is the new enterer with approximately 15, 000 (71%)students entering last year leaving only 6,000 new enterers in kindergarten.

• Follow PreK rule under WVBE…HealthCheck and now Superintendent’s Interpretation from 2007 which is rule for 6,000 kindergarten enterers.

• Prioritize your time stop rescreening!

Objective #3:

• Participants will be provided with the current status of school nursing and school health services in the state of West Virginia (changing of the guards, current data and trends, national certification and continued recruitment, working toward full-service schools, etc.).

Retirements

• School Nurses• Principals• Health Services Directors• Superintendents• Offsite PreK collaboratives

WV Data• Lack of preventive care.• Adolescents without well-child visits

and immunizations.• Poor oral hygiene and health.• 17% increase in teen pregnancy

population.• Below proficiency on HEAP scores

throughout the state.• Leading in Asthma, Obesity, Hepatitis

B and C, prescription drug abuse, etc.

Developing a Collaborative Team• Completing Electronic Data Entry

(Immunizations required on WVEIS, Ipad Grant requires HealthCheck data, High Acuity funds require HCP for certain specialized health procedures, medication logs, sick bay). PreK Child Accomplishment Summaries.

• Increasing the use of WV Statewide Immunization Information System (WVSIIS)…feeding into WVEIS.

Developing a Collaborative Team

• Capitalization of funding sources…what are they?

• Training of staff to recognize early signs and symptoms of communicable diseases, provide fluoride rinse programs, health promotion programs, enhancing health and physical education, physical activity, nutritional programs, relationships with hospitals, programming to assist school health, filling in the resource gaps, etc.

Developing a Collaborative Team

• Ensuring children receive annual Well Child visit and Dental exam for continued health promotion and prevention practices

• Incorporation of nursing students (LPN to NP and Doctorate in the school setting) and others.

• Developing MOUs/Contracts for a county medical director (Primary Care Centers, School-Based Health Centers, Private) or Medical Advisory Board

Developing a Collaborative Team

• Ensuring children receive annual Well Child visit and Dental exam for continued health promotion and prevention practices.

• Developing and maintaining working relationships.

• Developing supports at the RESA

• Developing a seamless health and medical record with the most influential people working together for the best of each student.

Full Service School

• School which provides for the whole child with integration of the eight components of school health through medical, behavioral and dental services, parent supports and services in the school, community supports…Making your school friendly with a whole child, family and community focus.

Become Nationally Certified

• Ensures leadership skills, quality care, efficiency, annual professional development and evidence-based practice.

How do we get there?

Strategies• Know legislative rule, state rules and county

policy.• Know your nursing practice act and the role

of LPN and UAPs.• Support the Medical and Dental Home

concept to move West Virginia towards preventive health.

• Validate immunization records and follow provisional enrollments through to completion.

• Make adolescent vaccinations and well-child visits YOUR priority NOT an AFTER THOUGHT!

Strategies• Follow and implement evidence-based

practice. Obtain a medical consultant or form medical advisory board for your county’s school health services program.

• Form collaborative teams/ relationships with public health.• Form collaborative teams/initiatives with

medical, dental and behavioral health providers/communities.

Together we serve the WHOLE CHILD

THANK YOU!

Have a WONDERFUL Thanksgiving!

Rebecca King

WVDE-Coordinator

School Health

and Coordinated School-Public Health

[email protected]

304.558.8830