Running head: BEST PRACTICES FOR ASTHMA CARE GUIDELINES 1

Best Practices for Implementing Asthma Care Guidelines

Among School-Aged Children

Amber Blankenship

Western Washington University

Nursing 402: Translational Research for Evidence-Based Practice

Christine Espina, DNP, MN, RN

March 13, 2017

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Abstract

Poorly controlled asthmatic symptoms continue in school-aged children due to a lack of

knowledge by the child and parent, as well as a lack of resources for school nurses. Due to this

inadequate control, asthmatic children often miss school. Frequent absenteeism can lead to poor

academic performance and create social strain with peers. School nurses can provide care to

limit school days lost and allow the child to lead a more normal life. Many nurses report

challenges as simple as identifying those diagnosed with asthma and communicating with

families and primary care providers. This review appraises asthma care guidelines and their

effects on children, kindergarten through fifth grade, and school absenteeism. After careful

search via CINAHL and PubMed using keywords, studies were identified to support the use of

asthma action plans with co-interventions including educational opportunities for stakeholders,

case management, and addressing environmental needs. These studies provide evidence to

support the claim that implementing asthma care guidelines will reduce the number of school

days missed. This review addresses the need for case management to help families address

socio-economic essentials for healthcare and quality of life; as well as, improve team

collaboration between the school nurse, community provider, and family by improving asthma

awareness within the community. These two interventions are the foundation to a globally

successful implementation of these guidelines.

Keywords: Asthma, attendance, asthma care guideline, Asthma Action Plan, school-aged

children.
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Best Practices for Implementing Asthma Care Guidelines

Asthma is a reactive airway disease which causes inflammation and muscle constriction,

leading to decreased airflow and available oxygen to vital organs. This disease affects both

adults and children alike. In 2015 it was estimated that 6.2 million children of the US population

suffered from asthma. In 2013 approximately 13.8 million lost school days reported were related

to asthma (American Lung Association, 2017). If poorly controlled, asthma can be debilitating,

decreasing abilities to participate in activities similar to peers. If properly managed through the

appropriate use of medications and avoiding triggers, a quality of life may be preserved.

Children spend an average of eight hours per day, five days per week at school.

Consequently, having poor control of asthmatic symptoms during school hours places these

students at greater risk for exacerbations, hospitalizations, and even mortality. It is vital that

symptoms be recognized and managed. Multiple asthma care guidelines have been developed to

address symptom control and provide both staff and student support during exacerbations. Will

school-age asthmatic children, kindergarten through fifth grade, 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

This paper aims to review available research to identify best practices and up-to-date

guidelines for managing childhood asthma within the school environment. This review will

assess the implementation of such guidelines and evaluated their effect on student attendance.

Methods
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An online literature search was initiated employing the Western Washington University

OneSearch database using terms Asthma action plan AND attendance OR absenteeism AND

school-aged children." Close to 2000 articles populated. Inclusion criteria were abstracts

referencing asthma programs and attendance records, full-text access, peer-reviewed journals,

and studies published after 2012. Articles dating before 2012 were included if studies were

relative and of an essence. Exclusion criteria were studies focusing on medication brands or

explicit socio-economic demographics.

Search was then routed to Google Scholar, PubMed, and CINAHL databases where

search criteria, attendance OR absenteeism were removed and further studies were identified.

Intra-article citations were evaluated. These citations directed search to the National Association

of School Nursing (NASN) and National Heart, Lung and Blood Institute (NHLBI) websites,

where current best practice guidelines were visited. A peer-reviewed journal, The Journal of

school Nursing, provided by community mentors, contributed one literature review.

Findings and Synthesis

Findings

Based on the Evidence Hierarchy, these articles provide strong, high-level research

evidence: a systematic review, two randomized control trials (RCT), and a quasi-experiential

study. Two qualitative studies, although provide a lower level of evidence, illustrate

phenomenology and processes. Research also identified two literature reviews to include in this

discussion.

Absenteeism
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This search identified four studies which provided strong evidence addressing asthma

care and school attendance. Three of these studies clearly supported improved attendance records

after the implementation of an asthma action plan (AAP) coupled with other co-interventions. A

third study elicited no direct statistical changes on school attendance in the asthmatic student

population. However, on closer review, this same study noted differences in absentees between

asthmatic students who received care in the health office, and those who did not. This study,

completed by Splett, Erickson, Belseth, & Jensens is a randomized control trial (RCT) which

focused on care coordination with medical providers, developing AAP, the creation of resource

nurse positions, staff training, and student education. (Splett et al., 2006). A second RCT

implemented case management to assist with screening, family referrals, and collaboration with

medical providers. This study provided strong evidence illustrating a decrease in school days

missed of approximately two days (Moricca, Grasska, BMarthaler, & Weismuller, 2013). Liptzen

et al. developed and trialed a step-up program which encompassed case management, screening,

collaboration and student and staff education. This study illustrated improved outcomes and

supported a decrease in absentees (Liptzin et al., 2016). The fourth article examined an

assortment of care plans and their effects on symptom control and attendance. This study also

reported an improvement in attendance (Zemek, Bhogal, & Ducharme, 2008).

Screenings and case management

The National Heart, Lung, and Blood Institute (NHLBI) and the National Association of

School Nurses (NASN) provide evidence-based guidelines supporting nurse case managers

(Schantz & Maughan, 2015) (National Heart, Lungs, and Blood Institute, 2014). Although these

previously researched guidelines provide the strongest level of evidence, this review identified
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three studies providing further substantial evidence to support recommendations. Each

supported case identification using a nurse case manager as an agent for implementation. The

Splett et al study monitored students visits to the health office. Those students who had more

than one visit per week with asthmatic symptoms qualified for further assessment by case

management. If merited, parents were contacted and referred to a community care provider for

follow-up (Splett et al., 2006). The second and third study used questionnaires to screen students

at risk. Students parents fill out these questionnaires upon school enrollment and every three

months throughout the academic year (Lipzin et al., 2016). Case managers then contact families,

explain results, and make appropriate referrals. These nurses act as a liaison for collaboration

between family, school, and primary care providers (PCP); as well as address family needs,

providing education and resources.

Collaboration and asthma action plan

NHLBI guidelines acknowledge the need for access to medications and a partnership

with families and community providers, to ensure a plan is in place for prevention and crisis

management. (National Heart, Lungs, and Blood Institute, 2014). In both qualitative studies,

Nurses expressed communication challenges with families, and a lack of provided asthma action

plans. In one study nurses reported an approximate 28% of asthmatic students had an AAP

(Borgmeyer, Jamerson, Westhus, & Glynn,2005). Of these same nurses, 72% agreed or strongly

agreed that AAPs provided a guidance tool and improved in the nurses self-confidence in caring

for these students. One study addressed AAP with built-in consents for medication administration

and acknowledged the need for systems for community providers to share AAP with the school
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district. The results of this study exhibited more AAP on file, more medications were available

during a crisis, increased knowledge by all stakeholders (Splett et al., 2006).

Education

Each study addressed education for student, family, and staff. The step-up program provided

evidence-based asthma education titled Open Airways for School (OAS)(Liptzin et al., 2016).

This six, forty minute-session program educated students, 3rd through 5th grade, on proper

inhaler use and basic disease knowledge. On evaluation, students were shown to have improved

inhaler technique and symptom management. A second study addressed education for school

staff following National Institutes of Health (NIH) (which equates to NHLBI) guidelines. A half

day training was provided and regularly reinforced (Splett et al., 2006).

Discussion and Synthesis

There is a significant amount of information available regarding asthma interventions and

asthma action plans implemented during school hours. However, there are few studies which

provided a consistent recipe of co-interventions for implementation. Two of three studies clearly

confirmed an improvement in attendance after guidelines became enacted; whereas a third study

indirectly affected the number of days missed. Evidence-based guidelines from NHLBI and

NASN agree. These three studies with national guidelines provide the strongest level evidence

to support the implementation of an asthma action plan coupled with co-interventions. All studies

appraised coordinated other interventions to augment and support AAP; though each study had

differences, common themes surfaced overall. These topics included policy development, case

identification, education, case management, and addressed barriers perceived by school nurses;

many of which mirror those of national institutions such as the NHLBI and National Association
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of School Nurses (NASN) (Schantz & Maughan, 2015) (National Heart, Lungs, and Blood

Institute, 2014).

Asthma action plans

An asthma action plan, prepared and tailored by the child's pediatrician promotes control

of the disease, avoids exacerbations, and maintains a quality of life for the student. With a proper

action plan in place, staff [nurses, teachers, and administration] have the tools needed to help

these students participate in activities with their peers and maintain a quality of life; yet many

school nurses claim to have few AAP on file. This lack of AAP is a compromise to student

safety. A student must have access to their medications. Although students are permitted to carry

their inhalers, until they demonstrate proper use, there is need for assistance. Without an action

plan, schools lack consent to share health information if an emergency were to occur (Cicutto,

Gleason, & Szefler, 2014).

Case identification and collaboration

There is a need to improve communication between parents, nurses, and primary care

providers (PCP). A major concern for nursing is that they are not always aware of which students

have asthma, or who have undiagnosed asthmatic symptoms; despite surveys and phone calls as

these are not always returned (Nadeau & Toronto, 2016). Nurses report a disconnection with

parents; possibly related to distrust due to misunderstanding of school nurse level of education,

or due to management preferences (Nadeau & Toronto, 2015). Naturopathic remedies have gain

popularity and communities, like the one here in the Bellingham school district, prefer these

practices. Due to HIPPA law's, PCP's are not allowed to share information with school boards,
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unless permitted by the parent, as action plans are establish between the parent and provider, a

process needs to be implemented to share this information with the school district.

Staffing and case management

School nurses are spread thin and often have multiple schools to visit. In the Bellingham

school district, each nurse has 1500 students each, despite a recommended ratio of one nurse to

750 students by NASN and acknowledged by U.S Department of Health and Services

(Dolatowski et al., 2015). Due to a lack of available time, these nurses are unable to address

student needs thoroughly. Our research revealed strong evidence supporting positions for case

management. Many families may not have access to healthcare; a case manager provides insight,

skill, time to address concerns and make referrals as needed; as well as provide a bridge of care

serving the important role of liaison between all stakeholders, assuring full collaboration.

Education

Creating awareness for each stakeholder addresses many barriers discussed. Research

supports implementation of OSA to provide a foundation of knowledge for the student who can

then share with family. As the family gains experience and has a sense of support from the

school, miss-trust towards the nurse, improves. Substantial evidence supports staff education. If

a child has an AAP in place, ancillary staff can follow the plan as written; however, providing

staff with tools can assist with prevention. An understanding of their role and early symptom

recognition avoids a delay of care and improves outcomes for these students; as well as provide

support for case identification. Further education will allow staff to address other environmental

needs such as dust, plants, and perfumes, which may act as triggers for the student.

Recommendations
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Nurses report communication with both parents and primary care providers to be the

most frustrating challenge (Nadeau & Toronto, 2016). It is believed that the cause of these

communicational barriers is related to a decreased asthma awareness in selected populations

(Cicutto et al., 2014). Education should then be provided to improve knowledge of students,

family, and ancillary staff. Evidence-based programs such as OAS have been proven

fundamental for students. Nursing interventions, which provide general educational

opportunities for all staff and families, lead to less asthma exacerbations, as evident in the Step-

Up study. This increased awareness will also help to build trust in school nursing practice by

community members.

In a perfect world, a care manager would be available to assist families in obtaining

insurance coverage, access to primary care, and address educational needs. Case management

positions may not be realistic for current school budgets. However, the evidence is strong enough

to support a recommendation to implement a study investigating costs related to Emergency

Room visits by uninsured families, versus the cost to employ a case manager. Looking further at

potential downstream affects, if children are frequently missing school, which leads to decreased

academic performance and increased dropout rates, a reliance on social systems is promoted

which will indirectly increase the cost to the community.

Implications for Practice

Applying the above two recommendations will improve access to care, health literacy,

and parent compliance to care plans. These factors will increase the number of asthmatic

students with asthma action plans, available medications, and provide direction for staff to
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improve student outcomes. However, the need for funding to establish case management

positions creates further challenges as previously discussed.

Conclusion

School nurses are stretched thin to provide care for hundreds of children, sometimes

dispersed between two or greater schools. A requisition testified by these nurses, is that of

accurately identifying asthmatic children, to provide appropriate interventions such as prevention

and crisis management. If properly managed, asthmatic children can lead healthy lives alongside

their non-asthmatic peers. Asthma care guidelines and asthma action plans will provide nursing

with the tools and knowledge to support these students. With support, students will have less

symptomatic days and fewer missed days of school, thus creating better opportunities to thrive

academically.

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