Published online October 1, 2008
PEDIATRICS
Vol. 122
No. 4
October 2008, pp.
887-894
(doi:10.1542/peds.2008-2171)
Medical Emergencies Occurring at School
Council on School Health
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ABSTRACT
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Children and adults might experience medical emergency situations because of injuries, complications of chronic health conditions, or unexpected major illnesses that occur in schools. In February 2001, the American Academy of Pediatrics issued a policy statement titled "Guidelines for Emergency Medical Care in Schools" (available at: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;107/2/435). Since the release of that statement, the spectrum of potential individual student emergencies has changed significantly. The increase in the number of children with special health care needs and chronic medical conditions attending schools and the challenges associated with ensuring that schools have access to on-site licensed health care professionals on an ongoing basis have added to increasing the risks of medical emergencies in schools. The goal of this statement is to increase pediatricians' awareness of schools' roles in preparing for individual student emergencies and to provide recommendations for primary care and school physicians on how to assist and support school personnel.
Key Words: school • medical emergency • emergency care plan
Abbreviations: AAP—American Academy of Pediatrics • EMS—emergency medical services • CPR—cardiopulmonary resuscitation • AED—automated external defibrillator • EMT—emergency medical technician • IHP—individualized health plan • IEP—individualized education plan • ECP—emergency care plan
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RATIONALE
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Many schools lack a licensed health care professional on site to respond to individual student medical emergencies. Injuries are the leading cause of death and disability in the United States, especially among children, with 70% of injury deaths occurring in school-aged youth (5–19 years of age).1 It is estimated that 10% to 25% of injuries to children occur while they are in school.2 In addition to injury-related emergencies, status asthmaticus, diabetic crises, status epilepticus, sudden cardiac death, and other medical emergencies can occur in students and staff at school. The prevalence of children with special health care needs attending schools means that there now exists a pool of students with a broad range of medical conditions that may require special equipment, preparation and training of personnel, medications and supplies, and/or transport decisions and arrangements.3 This statement highlights the role of school personnel, the school health and safety team (school nurse, social worker, school resource officer), school physician, and primary care clinician in each step in the process of managing individual student emergencies occurring at school. It is important to note that there is a fundamental link between emergency readiness and disaster preparedness. Schools that are prepared for an emergency in an individual are more likely to be prepared for complex events such as community disasters. Disaster planning in schools is covered in a separate policy statement from the American Academy of Pediatrics (AAP), "Disaster Planning for Schools."4 It is helpful to view these 2 policies together to appreciate the full spectrum of school emergency planning.
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BACKGROUND
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The average school-aged child spends 28% of the day and 14% of his or her total annual hours in school.2 There are 72.3 million children younger than 18 years living in the United States (according to the 2000 US Census). The Maternal and Child Health Bureau of the US Department of Health and Human Services estimates that of this group, 18 million children and adolescents have special health care needs or a chronic illness. Children with special health care needs or chronic illness account for 25% of the pediatric patients seen in hospital emergency departments each year.3 Despite its critical importance, school emergency preparedness is frequently inadequate because of barriers such as geographic and physical facility conditions, staffing, staff education and training, and financial resources.
Schools across the nation vary tremendously in their degree of preparedness to deal with emergencies. A survey of schools in rural New Mexico found that schools, particularly in larger communities, were ill prepared to deal with emergencies in students or staff as assessed by evaluating equipment and emergency training (communities with populations of <200000 were more likely to have equipment available).2 Oxygen was available in only 20% of the surveyed schools, epinephrine was available in only 16%, artificial airways were available in only 30%, cervical collars were available in only 22%, and splints were available in only 69%. Annually, 67% of schools activate emergency medical services (EMS) systems for an emergency involving a student, and 37% activate EMS for an emergency involving an adult. EMS response time was less than 10 minutes for 84% of the schools.2
A national survey of 573 school nurses conducted by Olympia et al5 revealed that 68% of the school nurses managed a life-threatening emergency requiring EMS activation in the school year before the survey. Although 86% of the surveyed schools reported having a medical emergency-response plan, 35% of the schools had not tested it during a drill.
Regional statistics demonstrate that injuries are the chief complaint listed for two thirds of EMS dispatches to schools. Medical emergencies, such as breathing difficulties and seizures, account for one quarter of school calls to the EMS system.3 Compared with non-school–based EMS incidents, school-based EMS incidents are more often attributable to injury, are frequently related to a sporting activity, and are more likely to result in transport to a medical facility.6 Even in the case of children with special health care needs, approximately half of EMS responses are unrelated to the child's special needs and include traditional causes of EMS calls, such as an acute injury.1
Another critical factor in the preparedness of schools for emergencies is medical, nonmedical, and students' training. School medical emergencies can involve students, adults, staff members, or attendees of special events. Because injuries are the most common life-threatening emergencies encountered by children and adolescents inside or outside schools, teachers, school nurses, physicians, athletic trainers, coaches, and students should know general principles of first aid and cardiopulmonary resuscitation (CPR). In a survey of all high schools in Washington State, 80% of teachers thought that CPR training was important, yet 35% of the schools provided no CPR training for students.
The goal of this statement is to increase the pediatric clinician's awareness of the role that schools play in preparing for and responding to the individual student emergency. Recommendations and resources will be provided to assist primary care clinicians and school physicians in supporting schools in this role. The management of individual emergencies is linked to the preparation for large-scale community emergencies.4 Resources, linkages with EMS, and staff training are all vital to emergency preparedness. It is really the scale and terminology that distinguish the response to an individual emergency from the response to a disaster. The terminology of mitigation and prevention, preparedness, response, and recovery7 is generally not used for individual emergencies but reserved for large-scale disasters. However, in individual emergencies, the emphasis is less on prevention and more on preparedness and response. The following reflects the role that schools play in these aspects of individual emergency response.
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DESCRIPTION OF THE SCHOOL'S ROLE
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Readiness for Response
Any child can have a medical emergency in school. Children with special health care needs carry additional risks of emergencies related to their diagnoses. From injury to anaphylaxis to status epilepticus, schools are expected to anticipate and prepare to respond to a wide variety of emergencies.8,9
General Preparation
Ideally, schools develop emergency policies with input from the medical community—both EMS and community clinicians. These policies need to be flexible enough to accommodate different students' developmental levels. Integration of EMS into school emergency planning familiarizes them with the location and type of medical resources available at the school. This collaboration leads to the creation of policies and regulations that appropriately delegate authority, assign roles, distribute shared resources, and establish parameters for health care providers. The range of possible policies can vary from general emergency management to use of CPR and automated external defibrillators (AEDs) to life-threatening allergy management; these are discussed briefly below.
- Policies, regulations, and protocols are created to cover all aspects of school jurisdiction, from classroom to playground, school-based health centers (if one is available), before- and after-school programs, field trips, transportation, and athletic events. These are to be clearly stated and communicated to all school staff and parents. Table 1 provides some resources for the creation of such policies.
- Emergency data are to be collected on all children and include parental contact, health care provider contact, medical conditions, medications, allergies, and insurance. Information technology could facilitate the collection, storing, and transfer of these data.
- Protocols should include algorithms for determining levels of emergencies. Minor illnesses or injuries are to be distinguished from emergencies that require EMS activation.
- It is important that the EMS-activation process is clear to all staff. This process ensures accessible and appropriate transportation and care during transport to a hospital or other appropriate medical facility.10 Although EMS traditionally is thought of as emergency medical technicians (EMTs) and ambulances, it really encompasses prehospital through emergency department management. Therefore, in the event of a medical emergency within school jurisdiction, EMS include school nurses and school staff. Ongoing communication, review, and practice of procedures ensure achievement of this level of integration.
- Participation of physical facilities administrators in the planning ensures that the most efficient access routes to the school, as well as floor plans, are available to EMS.
- Clarity of school staff roles in an emergency is essential for smooth response. Ideally, the school nurse in each building should be the key person to develop and implement the emergency plan, because the nurse is the staff member who is most skilled and familiar with individual students' health issues and community resources. In the absence of a school nurse, members of the school health and safety team (social worker, school resource officer) are designated, trained, and empowered to make decisions concerning health emergencies. Names, telephone numbers, and locations of these designated and trained school personnel are to be provided to all staff members.
- The development of campus-wide communication strategies (2-way radios, pagers, cell phones) is key so that staff members are accurately informed and rumors are minimized, which is especially important in the event of an incident involving violence.
- Schools can determine if using trained students in an emergent situation is feasible within the constraints of confidentiality. These students may maximize limited resources by being used as runners, for mobilizing equipment, helping in evacuation, or providing escorts to response agencies not familiar with school grounds. It is important to define their role ahead of time, guarantee adequate training, include them in the plan, and practice executing the plan.
- Periodic drills with local EMS and hospital emergency departments are essential components of preparedness. This process allows schools to better understand their barriers to good EMS care, and in turn, EMS professionals get a preemergency look at school operations and physical structure, which allows problem solving to begin before any emergency or crisis.3
- The availability of sufficient supplies to address an individual emergency is of utmost importance. A complete emergency medical kit that is secure, carefully organized, and monitored by protocol should be accessible for use by authorized and trained school staff members who have volunteered to serve in an emergency.10 In 2003, a national consensus group that included the AAP was convened by the Emergency Medical Services for Children National Resource Center and the National Association of School Nurses and published a report titled "Recommended Minimal Emergency Equipment and Resources For Schools: National Consensus Group Report."11 This report is a valuable reference for putting together an emergency medical kit.1
- All equipment should be maintained and inspected at appropriate intervals. If an AED is available on site, an AED maintenance, testing, and repair program is to be incorporated into the AED emergency-response protocol.1
- Staff development and training is essential for responding to a medical emergency. Human resources policies and regulations may determine to what extent and capacity staff may respond to an emergency. However, there are certain basics in which all staff members can participate.
- It is important that universal precautions be discussed with the entire staff at the beginning of each year.
- Basic response to emergent situations is to be discussed with the entire staff. This discussion should include responses to large-scale emergencies and minor problems. Because parents have the right to limit medical information given to schools, it is prudent to give general response guidelines for seizures, fainting, bleeding, anaphylaxis, choking, and head trauma so that staff members can become more comfortable with initiating an emergent response even if they are not aware that the child has a medical concern.
- Some staff members may opt for more in-depth training, and it is recommended that at least 1 staff member, in addition to the school nurse, have CPR and first aid training.1
- Schools determine if a school staff member accompanies the student to the hospital. If a staff member is to accompany the student, the school must develop policy to clarify when the staff member assumes "in loco parentis" (in-the-absence-of-parents status).
- It is preferable that multiple back-up numbers for emergency contacts be available for each student's family.
Preparation for Children With Special Health Care Needs
- Students and staff members with chronic medical conditions or other special health care needs are more susceptible to medical emergencies and require schools to have a heightened sense of readiness. Students should have an updated individualized health plan (IHP) prepared by the school nurse with input from the family and the primary care clinician. The IHP contains information on medications, activity levels, dietary needs, equipment, transportation, and other accommodations. Using this information, the school can then plan for accommodations for daily classroom activity, field trips, and emergency needs of the student. The IHP can assist school teams in developing individualized education plans (IEPs) or 504 plans.
- Individual emergency care plans (ECPs), developed from information in the IHP, are to be copied and made available for transport with the child if he or she requires hospital treatment and/or management in the event of a community-wide disaster. The emergency information form, developed by the AAP and the American College of Emergency Physicians, is useful in developing both an IHP and an ECP.12 Unlike IHPs and ECPs, both a 504 plan and an IEP are formal, legal documents, which means that the school is legally bound to implement the elements of the plans. A 504 plan is an agreement between a student's legal guardian and a school district that the student will have full access to all school activities and will have his or her medical needs met.
- Any equipment or medication required for emergency management of a student or staff member (eg, evacuation chair or epinephrine autoinjector) is to be easily accessible.
- Staff who care for students with special needs should have an awareness of the illnesses and be trained to respond to emergencies (eg, seizures, asthma, diabetic ketoacidosis, hypoglycemia, sickle crisis) until a health care professional arrives. This capacity is especially important in the event of a community disaster in which the EMS, prehospital emergency-response system may not be readily available.
- As stated previously, some parents may opt not to disclose a child's disability to teachers out of concern about stigmatization. In these cases, basic awareness training to all staff at the beginning of the year is a prudent approach.
Policies and Procedures for Specific Emergencies
- Life-threatening allergic reactions, particularly related to food triggers, are increasing in schools.9,13 It is very important that schools have policies, procedures, and protocols for addressing the response to such incidents. School procedures must comply with state and local regulations for administration of epinephrine autoinjectors by nonlicensed personnel.
- Use of CPR and AEDs is a valuable addition to school emergency response.14,15 An AED program is to be covered by a school policy,16 and staff members who are trained for such use are to be able to respond effectively to first aid and cardiopulmonary emergencies. Sudden cardiac arrest has an estimated annual incidence of 0.7 to 1.0 per 1000 population17–20 and is responsible for >50% of all deaths attributable to cardiovascular disease in the United States. If no CPR is provided, each minute that defibrillation is delayed decreases the chances of survival for victims of sudden cardiac arrest attributable to ventricular fibrillation by 8% to 10%.21,22 High school athlete sudden death is rare. When sudden death of an athlete does occur, it is more likely to affect collegiate than high school athletes. However, sudden cardiac deaths in adult spectators have been reported, and schools need to prepare for them. Professional and collegiate sporting venues typically use emergency medical response teams for spectator care coverage.23,24 High school event coverage is less organized and typically falls under the responsibility of the athletic director or school administrators.17–20 Many national agencies that provide certified training programs exist. The American Heart Association's medical emergency-response plan for schools describes the core elements of such a program (Table 2).1,25,26
- Communicable-disease emergencies involve exposures for which there needs to be contact tracking and management. Protocols for varicella, pertussis, measles, methicillin-resistant Staphylococcus aureus, and meningococcal meningitis exposures are developed in conjunction with local health departments.
- Protocols for responding to specific emergencies (eg, head trauma, choking, lacerations) are helpful to school nurses or designated staff. The Illinois Emergency Medical Services for Children program has an online manual that provides algorithms for managing specific school emergencies.27
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TABLE 2 American Heart Association Medical Emergency-Response Plan for Schools2,23,24: 5 Core Elements of the American Heart Association Plan
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Response
Once policies and procedures are in place, the response follows the plan in an organized and efficient manner. - A staff member, ideally the school nurse, is to assess the situation and activate the appropriate protocol(s) and determine whether EMS needs to be activated.
- When EMS is activated, communication of school entry points to EMTs and a designated greeter to direct them to the emergency are of utmost importance.
- When possible, other students and staff members are removed from the scene.
- All emergency-response interventions should be promptly and accurately recorded and passed on to the EMTs.
- For children with special health care needs, the ECP is activated and information is to be prepared for EMTs.
- Any student who receives emergency epinephrine must be transported to the emergency department as recommended by the American Academy of Asthma Allergy & Immunology.9,13
- Parents, legal guardians, or designated emergency contact persons are informed ideally as quickly as possible about the child's injury or sudden illness at school after an emergency response and about actions taken to care for him or her.10 In addition, notification systems must be in place through a designated spokesperson to inform the school staff, students, the media, and the community at large of the outcome of an individual student's emergency situation in an appropriate manner that respects the student's confidentiality and dispels false rumors.
- The description and disposition of significant illnesses or injuries (including the illnesses or injuries for which a student, staff member, or visitor is released from school to visit a physician or hospital) are to be recorded on an illness and injury form. This information is also used to (1) identify patterns of injury, (2) prevent another such injury or illness, (3) inform parents of the nature and management of the injury, (4) share information with the child's primary care clinician (ie, medical home), local and state child fatality review teams charged with investigating death and near-death events, and/or EMS personnel, and (5) provide information for liability and insurance purposes.10
After the Event
- Ideally, the records developed are studied and used to provide feedback to staff, identify areas in need of improvement, and design education programs.
- After an emergency intervention, the ECP is to be reviewed and adjusted as needed.
- Mental health interventions, as appropriate, are preferably planned for all affected students.
- Necessary equipment and medications should be restocked.
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CONCLUSIONS
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School preparedness for an individual student medical emergency intervention heavily depends on a team effort that involves the school administration and its physician (if applicable), the individual school health and safety team and its nurse, the local community (EMS, local hospital/emergency department), and the student's medical home/primary care clinician. Continued and timely communication between the student's medical home and the school is the key to ensuring that updated IHPs, ECPs, 504 plans, and IEPs are established, when applicable. Some of the documents referenced in this statement can be used as communication tools. The primary care clinician should advise parents and caregivers, particularly for a child with a chronic illness, to be familiar with and support the school emergency-preparedness plan. In addition, medical home clinicians and school physicians can be the best advocates to help a school obtain needed life-saving emergency services for a student with a particular condition. The medical home clinician can play a key role in supporting the school's efforts in ensuring students' safety in school, particularly those with special health care needs.
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FACTORS THAT AFFECT SCHOOL EMERGENCY PREPARATION
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School administration preparedness for individual student medical emergencies must recognize and address: - system factors such as school district size, student/school nurse ratio, students' ages/grade levels, the complexity of student medical needs, prehospital level of training of school personnel, local emergency department capability, local readily available medical treatment facilities, and human and financial resources; and
- process factors such as protocols and procedures, continuous training and evaluation, and collaboration among the medical and educational homes and community services such as EMS, clinical and mental health support, and follow-up services.
Emergencies that occur in school can be either anticipated risks related to an individual student's medical condition or unanticipated events that occur in an otherwise healthy student or a staff member. The following recommendations are meant to assist primary care clinicians and school physicians in providing support to schools in their efforts to prepare for the individual student medical emergency.
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RECOMMENDATIONS FOR PRIMARY CARE CLINICIANS
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The medical home plays a key role in helping schools prepare for the individual student emergency. The following are key recommendations for primary care clinicians: - Communication: Maintain a strong, open, and ongoing line of communication with the school nurse and/or the school physician (when available) regarding the individual student's medical condition and current management in coordination with the parent/caregiver. This linkage informs the school nurse of any changes or updates to the student's IHP, ECP, 504 plan, or IEP when applicable. The emergency information form13 (developed by the American College of Emergency Physicians and the AAP) is 1 such tool that can be completed by the primary care clinician and may be used to communicate with the school nurse.13 Table 2 provides selected resources for general and disease-specific emergency care, action, and health plans that can be used by the primary care clinician in communication with the school nurse after obtaining parental permission. The school nurse plays an important role in developing and implementing health plans, activating physicians' orders, and interpreting physicians' instructions for staff, students, and families.
- Familiarity: Be familiar with the individual emergency plan and the disaster plan of the patient's school, the school resources, and staffing and provide advice on issues that might affect the student's disease management and outcome.
- Parent engagement: Advise parents to become familiar with the school's emergency plan and help them evaluate how the plan meets the needs of their children.
- Advocacy: Get involved with the school district's School Health Advisory Council and provide input on health-related policies that will affect individual patient care, including school wellness policies and emergency plans.
- Drafting health plans: Participate in the drafting of IEPs and 504 plans as needed. If a student with a particular special health care need or chronic disease has special education needs, an IEP may be developed by using the IHP as a foundation for details on the student's disease-management routine. To qualify for an IEP, a child must have an impairment that substantially affects his or her academic performance.24
- Orders: Provide a clearly written problem list, daily care instructions, accommodations, and orders for the use of emergency medications (eg, epinephrine autoinjector, albuterol) and the necessary current prescriptions to keep these medications and devices available in school for use in a particular student's emergency. This information is used by the school nurse to create the student's IHP and ECP.
- Be available to assess the individual student after an emergency and assist in a prompt and safe return to school and provide support to parents whose child sustained a medical emergency in school.
- Review the documentation and details of the student's school emergency, provide feedback, and provide instructions that amend the individual ECP as necessary.
- Communicate directly with the school physician (where available) as needed.
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RECOMMENDATIONS FOR THE SCHOOL PHYSICIAN
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The school physician, if one is available, is uniquely positioned to interact with schools in each of the previously mentioned steps and provide global and system-based recommendations related to individual students' medical emergency readiness as follows: - Assist administration and collaborate with the school nurse in the planning, development, training, implementation, review, evaluation, update, and approval of the school emergency plan and protocols for individual student emergencies,9 including medical emergencies and injuries that occur in school, after school, in transport, and on the playground.
- Ensure that the individual emergency preparation seamlessly links with the preparations for disaster planning.
- Be familiar with the spectrum of medical diagnoses of individual students in each of the schools in the district to effectively assist the school nurse in obtaining, interpreting, and implementing the IHP, ECP, IEP, and 504 plans for those students and to anticipate the schools' needs and resources to deal with anticipated emergencies.
- Assist in the development and periodic assessment of programs for emergency education, training, and retraining of school staff and designated volunteers in emergency procedures, including basic life support, first aid, AED use, and emergency medication administration.1
- Act as a liaison between the medical home and the school staff to ensure continued communication regarding a student's IHP, ECP, IEP, or 504 plan.
- Provide guidelines and recommendations on the contents of the emergency kit and ensure that the kit medications are safe, accessible, and in adequate supply9 (see the AAP policy statement "Guidelines for Emergency Medical Care in School"10 for a guideline for kit contents).
- Oversee school emergency drills in collaboration with the local EMS, hospitals, and community agencies.
- Establish a program for regular AED maintenance, testing, and repair when an AED is available in the school25 (see Table 2 for highlights of the elements of an AED plan).
- Oversee and manage the medical emergency-response actions on behalf of an affected student (if present in school during an emergency).
- After a student emergency occurs, review the records of the school's management of the medical emergency, its response and adherence to the emergency protocol, the adequacy of services provided, and the accuracy and completeness of data recorded to evaluate access to and quality of emergency services and materials, and make necessary recommendations for changes in the school's protocols, supplies, and individual student ECPs.
- Act as a liaison between the medical home and the local school of the student who sustained the emergency to ensure adequate communication, perform any needed changes/modifications to the student health plan, and assist the primary care clinician in ensuring the student's safe return to class after an emergency.
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COUNCIL ON SCHOOL HEALTH EXECUTIVE COMMITTEE, 2007–2008
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Robert D. Murray, MD, Chairperson
*Rani S. Gereige, MD, MPH
Linda M. Grant, MD, MPH
Jeffrey H. Lamont, MD
Harold Magalnick, MD
George J. Monteverdi, MD
Evan G. Pattishall III, MD
Michele M. Roland, MD
Lani S. M. Wheeler, MD
Cynthia DiLaura Devore, MD
Stephen E. Barnett, MD
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PAST COUNCIL EXECUTIVE COMMITTEE MEMBERS
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Barbara L. Frankowski, MD, MPH, Immediate Past Chairperson
Cynthia J. Mears, DO
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LIAISONS
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Alex B. Blum, MD
Section on Residents
Sandi Delack, RN, MEd, NCSN
National Association of School Nurses
Mary Vernon-Smiley, MD
Centers for Disease Control and Prevention
Robert Wallace, MD
Independent School Health Association
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STAFF
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Madra Guinn-Jones, MPH
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FOOTNOTES
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All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
* Lead author 
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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
The following policy statement has been revised:
-
Guidelines for Emergency Medical Care in School
Pediatrics 107: 435-436.
[Full Text]
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K. Kennedy
Statements sound alarm on importance of school planning for emergencies
AAP News,
October 1, 2008;
29(10):
1 - 1.
[Full Text]
[PDF]
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Council on School Health
Disaster Planning for Schools
Pediatrics,
October 1, 2008;
122(4):
895 - 901.
[Abstract]
[Full Text]
[PDF]
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ABSTRACT
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