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INNOVATION

Providing better asthma care for children in school

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A project provided children and young people with better care and support, and improved education and awareness for parents and teachers

Abstract

Assessing the needs of children, young people and families is a fundamental part of the school nurse’s role. This article describes a project in Doncaster that has enabled a partnership working with children, young people, families, school nurses and school staff aimed at providing improved services throughout the primary and secondary school day.

Citation: Schuller L (2015) Providing better asthma care for children in school. Nursing Times; 111: 40, 12-14.

Authors: Lynne Schuller is clinical lead Healthy Child Programme 5-19 and Gemma Faulkner is community staff nurse at Doncaster both at Rotherham, Doncaster and South Humber NHS Foundation Trust.

Introduction

Asthma is a serious long-term condition that can be life threatening, but children with asthma can lead entirely normal lives if they are supported by the adults who care for them (Department of Health, 2015). However, it can affect a child or young person’s education due to absence periods as a result of exacerbations of their condition (Asthma UK, 2012). Asthma is also known to have an impact on emergency care, accident and emergency and paediatric services, placing them under increased pressure in winter. My own experience with parents, schools and community services highlighted the lack of knowledge about asthma and evidence-based practice/care.

A pilot project, funded by Doncaster Clinical Commissioning Group resilience fund (winter pressure monies), was designed to reduce hospital admissions and school non-attendance associated with asthma, while improving self-care and the confidence of children and young people with asthma and their families.

As part of the project we conducted a literature search and identified award-winning guidance for schools developed by Shropshire, Telford & Wrekin NHS Foundation Trust school nurses (Shropshire, Telford & Wrekin Asthma Steering Group, 2006) and this provided an evidence base for our guidance which is outlined in Box 1.

Box 1. Summary of our guidance

The asthma guidance provides:

  • Summary of asthma, diagnosis and treatment options
  • Outlines needs for knowledgeable support in schools and the roles and responsibilities of staff
  • Identifies need for good record keeping, care planning and training, supported by school policy
  • Provides an emergency plan, care plans and documentation for inhaler use, and staff training

We then contacted a small cohort of 12 young people, 20 parents and all schools (99 primary, 18 secondary and 12 other providers) in our local area who shared individual experiences of asthma in the Doncaster area.

Developing the pilot service

We employed a band 5 staff nurse to work alongside me, a band 7 clinical lead. I managed the pilot, with responsibility for day-to-day management, developing the project management documents, controlling the budget and providing reports / feedback.

The first contact practitioner, paediatric liaison nurse, paediatrician and acute care paediatric nurse were recruited to support the project. Regular feedback was forwarded to the resilience fund as requested.

We visited Shropshire, Telford and Wrekin NHS Foundation Trust to learn more about their guidance. The Shropshire team outlined the difficulty in ensuring the beneficial changes gained as a result of following the guidance were sustainable after their project teams returned to substantive posts. It was vital that changes as a result of the guidance were embedded in practice.

Identifying children with asthma

We identified 79 children with an asthma diagnosis in the Doncaster school nurse caseload using a national Read Code. With an estimated 10% of all children having asthma, the realistic figure should have been approximately 3,000 and it was clear that there is under reporting.

These 79 children and young people were used as the sample group for the project. Parental questionnaires were sent out to the 20 parents of all the primary school children in the group. The questionnaire revealed that parents did not feel confident sending their children to school when they had minor ailments as they feared an asthma attack may occur.

Two focus groups lasting approximately 45 minutes were conducted with 12 young people in two secondary schools. They felt happy and in control of their asthma, but, using an asthma control test, we found they lacked control and had inadequate knowledge of their condition.

Many underestimated the importance of monitoring their condition or carrying their inhaler. The focus group identified a need for advice and education before they finished year six (ages 10-11 years) and transferred to secondary school.

Additionally, they identified a need to access online support, and believed an app would be beneficial.

All schools in Doncaster were asked whether they had an asthma lead, a directory of children with asthma, a policy and guidance.

The following was assessed:

  • Experience of teachers in the school to manage asthma;
  • Knowledge of teachers about asthma;
  • Confidence of treatment by school;
  • School attendance of children with asthma;
  • The level of commitment the school had to asthma (did it hold an up-to-date directory of students with asthma, did it have guidance and/or a policy in place, and did it access training?).

Schools had no guidance for staff and reported having little knowledge of asthma. The Department of Health published guidance on emergency use of salbutamol inhalers in school. This provided information on action to be taken in case of a child having an asthma attack. This is outlined in Box 3.

Box 3. Advice to schools on how to recognise an asthma attack

The signs of an asthma attack are:

  • Persistent cough (when at rest)
  • A wheezing sound coming from the chest (when at rest)
  • Difficulty breathing (the child could be breathing fast and with effort, using all accessory muscles in the upper body)
  • Nasal flaring
  • Unable to talk or complete sentences.
  • Some children will go very quiet.
  • May try to tell you that their chest ‘feels tight’ (younger children may express this as tummy ache)

Call an ambulance immediately and commence the asthma attack procedure without delay if the child:

  • Appears exhausted
  • Has a blue/white tinge around lips
  • Is going blue
  • Has collapsed

What to do in the event of an asthma attack:

  • Keep calm and reassure the child
  • Encourage the child to sit up and slightly forward
  • Use the child’s own inhaler - if not available, use the emergency inhaler
  • Remain with the child while the inhaler and spacer are brought to them
  • Immediately help the child to take two separate puffs of salbutamol via the spacer
  • If there is no immediate improvement, continue to give two puffs at a time every two minutes, up to a maximum of 10 puffs
  • Stay calm and reassure the child. Stay with the child until they feel better. The child can return to school activities when they feel better
  • If the child does not feel better or you are worried at any time before you have reached 10 puffs, call 999 for an ambulance
  • If an ambulance does not arrive in 10 minutes give another 10 puffs in the same way

Source: Department of Health (2015)

During the project the clinical lead shared the information gained with teaching staff and the local safeguarding leads at Doncaster’s local authority. Besides helping education partners to understand the aims of the project, this allowed the project team to share the guidance with those working in the schools. As a result of the meetings, two schools contacted the pilot team and requested further support as they had high numbers of children with asthma and high levels of non-attendance attributed to asthma exacerbations.

Meetings were undertaken with these schools and we developed the concept of a “beacon school” status. Schools were given intensive support so they could work towards achieving an “asthma-friendly” status (Box 2).

Box 2. Criteria for asthma-friendly accreditation

  • Adopting guidance on asthma for schools
  • Completing a directory of children with asthma
  • Buying an emergency inhaler, with spacers
  • Developing care plans for children and young people with asthma
  • Identifying an “asthma lead” - a member of staff who would take responsibility for the children and young people with asthma
  • Asthma leads receiving enhanced training that could be cascaded to staff
  • Ease of access to inhalers for all those with asthma in the school.

Perceived benefits

The initial benefits map outlined the following possible benefits:

  • Early identification leading to intervention and prevention of exacerbation;
  • Improved empowerment of children and families, providing them with greater control and leading to fewer acute episodes;
  • Improved partnership working to provide a supportive framework, improving education partners’ knowledge and ability to support young people with asthma;
  • The designated lead and community staff nurse, providing timely responses to education providers ensuring preventative work with children.

Initial benefits were achieved in the two beacon schools and further benefits were identified as the project progressed. Working with schools, having directories of young people with asthma, and ensuring parents have a designated lead in school and information is provided on primary school entry could improve outcomes for children and young people with asthma. The benefits are outlined in Table 1 (attached).

Results

As a result of the pilot the following steps have been achieved.

Asthma guidance has been adapted from the existing Shropshire, Telford and Wrekin guidance. This has been developed to provide a Doncaster focus, based on results of the questionnaires and focus groups. The guidance has been shared with education providers, in safeguarding leads’ meetings, with the CCG task and complete group, and with paediatric departments at the local hospital.

Baseline data has been formulated as a result of questionnaires completed by parents and schools, focus groups with young people and reviews of clinical records.

All young people who have asthma and are entering primary school in September 2015 will receive a parents’ information leaflet and a MyAsthma inhaler carry case for transporting an inhaler, spacer and emergency contact card.

Two “Beacon” schools have been identified and are working towards asthma-friendly accreditation, and schools have been supported to have an emergency inhaler on site.

Pupils with asthma, who are known to school nurses, have a long-term condition care plan, an asthma diagnosis noted in their school nurse clinical record and are placed on a stratified caseload.

Links have been made with acute care, offering improved communication and information sharing.

The CCG task and complete group has been provided with lessons learned from the project via the regular reporting to the resilience fund, along with membership of the group by the clinical lead. A community staff nurse has undertaken the asthma diploma, providing a greater evidence base within the school nursing team. Following the project we have developed the Doncaster Inhale asthma app which allows young people to self-monitor and self-manage their asthma. They can:

  • Monitor weather conditions;
  • Find out where to access support in emergencies;
  • Log their use of their reliever medication;
  • Download information for medical reviews;
  • Link to sites of interest.

Conclusion

This project has been successful in identifying baseline needs and has enabled the school nurse team to adopt evidence-based practice via the schools guidance.

Following identification of children and young people with asthma and gaps in care we are working closely with schools, parents and young people. There is engagement with the CCG and wider work provides support for children, young people and families within the Doncaster area. School nurses will continue to build on their initial findings by improving outcomes and strengthening the evidence base surrounding the need for support for this potentially vulnerable group.

Key points

  • Many schools have no record of their pupils who have asthma
  • Through education, school nurses can help improve education providers’ asthma awareness
  • Schools should have emergency inhalers and spacer devices on site
  • Improved awareness of asthma can help reduce pupils’ non-attendance at school due to asthma exacerbations
  • Education projects and an asthma app can help young people self-manage their condition
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