The Preparedness of Schools to Respond to Emergencies in Children: A National Survey of School Nurses

OBJECTIVES: Because children spend a significant proportion of their day in school, pediatric emergencies such as the exacerbation of medical conditions, behavioral crises, and accidental/intentional injuries are likely to occur. Recently, both the American Academy of Pediatrics and the American Heart Association have published guidelines stressing the need for school leaders to establish emergency-response plans to deal with life-threatening medical emergencies in children. The goals include developing an efficient and effective campus-wide communication system for each school with local emergency medical services (EMS); establishing and practicing a medical emergency-response plan (MERP) involving school nurses, physicians, athletic trainers, and the EMS system; identifying students at risk for life-threatening emergencies and ensuring the presence of individual emergency care plans; training staff and students in first aid and cardiopulmonary resuscitation (CPR); equipping the school for potential life-threatening emergencies; and implementing lay rescuer automated external defibrillator (AED) programs. The objective of this study was to use published guidelines by the American Academy of Pediatrics and the American Heart Association to examine the preparedness of schools to respond to pediatric emergencies, including those involving children with special care needs, and potential mass disasters. METHODS: A 2-part questionnaire was mailed to 1000 randomly selected members of the National Association of School Nurses. The first part included 20 questions focusing on: (1) the clinical background of the school nurse (highest level of education, years practicing as a school health provider, CPR training); (2) demographic features of the school (student attendance, grades represented, inner-city or rural/suburban setting, private or public funding, presence of children with special needs); (3) self-reported frequency of medical and psychiatric emergencies (most common reported school emergencies encountered over the past school year, weekly number of visits to school nurses, annual number of "life-threatening" emergencies requiring activation of EMS); and (4) the preparedness of schools to manage life-threatening emergencies (presence of an MERP, presence of emergency care plans for asthmatics, diabetics, and children with special needs, presence of a school nurse during all school hours, CPR training of staff and students, availability of athletic trainers during all athletic events, presence of an MERP for potential mass disasters). The second part included 10 clinical scenarios measuring the availability of emergency equipment and the confidence level of the school nurse to manage potential life-threatening emergencies. RESULTS: Of the 675 questionnaires returned, 573 were eligible for analysis. A majority of responses were from registered nurses who have been practicing for >5 years in a rural or suburban setting. The most common reported school emergencies were extremity sprains and shortness of breath. Sixty-eight percent (391 of 573 95% confidence interval (CI): 64-72%) of school nurses have managed a life-threatening emergency requiring EMS activation during the past school year. Eighty-six percent (95% CI: 84-90%) of schools have an MERP, although 35% (95% CI: 31-39%) of schools do not practice the plan. Thirteen percent (95% CI: 10-16%) of schools do not identify authorized personnel to make emergency medical decisions. When stratified by mean student attendance, school setting, and funding classification, schools with and without an MERP did not differ significantly. Of the 205 schools that do not have a school nurse present on campus during all school hours, 17% (95% CI: 12-23%) do not have an MERP, 17% (95% CI: 12-23%) do not identify an authorized person to make medical decisions when faced with a life-threatening emergency, and 72% (95% CI: 65-78%) do not have an effective campus-wide communication system. CPR training is offered to 76% (95% CI: 70-81%) of the teachers, 68% (95% CI: 61-74%) of the administrative staff, and 28% (95% CI: 22-35%) of the students. School nurses reported the availability of a bronchodilator meter-dosed inhaler (78% 95% CI: 74-81%), AED (32% 95% CI: 28-36%), and epinephrine autoinjector (76% 95% CI: 68-79%) in their school. When stratified by inner-city and rural/suburban school setting, the availability of emergency equipment did not differ significantly except for the availability of an oxygen source, which was higher in rural/suburban schools (15% vs 5%). School-nurse responders self-reported more confidence in managing respiratory distress, airway obstruction, profuse bleeding/extremity fracture, anaphylaxis, and shock in a diabetic child and comparatively less confidence in managing cardiac arrest, overdose, seizure, heat illness, and head injury. When analyzing schools with at least 1 child with special care needs, 90% (95% CI: 86-93%) have an MERP, 64% (95% CI: 58-69%) have a nurse available during all school hours, and 32% (95% CI: 27-38%) have an efficient and effective campus-wide communication system linked with EMS. There are no identified authorized personnel to make medical decisions when the school nurse is not present on campus in 12% (95% CI: 9-16%) of the schools with children with special care needs. When analyzing the confidence level of school nurses to respond to common potential life-threatening emergencies in children with special care needs, 67% (95% CI: 61-72%) of school nurses felt confident in managing seizures, 88% (95% CI: 84-91%) felt confident in managing respiratory distress, and 83% (95% CI: 78-87%) felt confident in managing airway obstruction. School nurses reported having the following emergency equipment available in the event of an emergency in a child with special care needs: glucose source (94% 95% CI: 91-96%), bronchodilator (79% 95% CI: 74-83%), suction (22% 95% CI: 18-27%), bag-valve-mask device (16% 95% CI: 12-21%), and oxygen (12% 95% CI: 9-16%). An MERP designed specifically for potential mass disasters was present in 418 (74%) of 573 schools (95% CI: 70-77%). When stratified by mean student attendance, school setting, and funding classification, schools with and without an MERP for mass disasters did not differ significantly. CONCLUSIONS: Although schools are in compliance with many of the recommendations for emergency preparedness, specific areas for improvement include practicing the MERP several times per year, linking all areas of the school directly with EMS, identifying authorized personnel to make emergency medical decisions, and increasing the availability of AED in schools. Efforts should be made to increase the education of school nurses in the assessment and management of life-threatening emergencies for which they have less confidence, particularly cardiac arrest, overdose, seizures, heat illness, and head injury.