Managing Asthma in Minnesota Schools
Asthma has reached epidemic proportions in the United States. More than 24 million Americans currently have asthma, including an estimated 6.3 million children under the age of 18. This chronic, but manageable, disease affects 1 in 12 school-aged children in the United States. In Minnesota,1 in 14 school-aged children (7.1%) have asthma.
In K-12 schools, asthma has a sizable impact on the lives of students and staff. Consider these facts:
- Asthma is the leading cause of school absenteeism due to chronic illness in the USA. In 2013 children missed almost 14 million school days due to asthma each year.
- Asthma can affect a student’s academic performance. It can disrupt sleep and the ability to concentrate. It can also cause a child to miss out on important social interactions and school activities.
- Asthma can be life-threatening. An asthma episode can quickly escalate and can result in death if a student does not receive prompt and appropriate medical attention.
The good news is that asthma can be managed. Asthma can usually be controlled with the right medications, addressing environmental triggers of asthma and teaching parents and students how to self-manage asthma. But, asthma must be managed 24 hours a day, 7 days a week.
Because children spend a great deal of time in school, school staff can play a pivotal role in helping students manage their asthma. By working together along with parents/guardians, medical providers and the students themselves, we can devise strategies that ensure their health and safety helping them to get the most from their time in school. The result is a better, healthier learning environment.
About Minnesota Schools
Minnesota public schools (Pre-kindergarten through grade 12) operate as Independent School Districts (ISD) which are governed by locally elected school boards with a superintendent at the helm.
- Minnesota has around 329 independent school districts with another 168 charter schools and 475 non-public schools.
- Each school district is independent, meaning each district (or school for charter/non-public) determines its own budget, school personnel staffing levels and the discipline mix they’ll employ, overall school policies and procedures.
- Minnesota K-12 academic standards define educational achievement goals for Minnesota’s public school students across the state. Local standards must be developed by districts for health, world languages, career and technical education.
School Health Office
Not all Minnesota schools have a full-time licensed school nurse (LSN) on staff or in their school health office on a full-time basis. Minnesota Board of Nursing requires school nurses to be licensed and currently registered in Minnesota, and have, at a minimum, a Baccalaureate degree in Nursing, be registered as a Public Health Nurse and have a School Nurse License (LSN) from the MN Board of Teaching. In fact, the vast majority of schools in Minnesota share their LSN with other schools in their district or contract with local public agencies or other outside agencies to provide professional nursing services. Unlicensed support service staff like health aides and licensed practical nurses (LPN’s) help fill the gaps in service but LSN’s are tasked with managing increasingly complex medical conditions and chronic illnesses in addition to overseeing multiple school health offices.
Students with chronic health conditions like asthma, diabetes and life-threatening allergies have the potential to experience life-threatening emergencies in the school and during school-related activities.
Communication and Teamwork
School health staff are essential participants in the control and management of asthma. But they can’t do it alone. To be most effective, school health staff must work closely with students, parents/guardians, health care providers and other school staff. Good communication is vital when it comes to providing asthma education to school staff, and identifying, preventing and managing asthma symptoms in the health office and classroom.
The Centers for Disease Control (CDC) have developed a new student-centered care model - The Whole School, Whole Community, Whole Child, (WSCC) to address health in the nation’s schools. The WSCC model is student-centered and emphasizes the role of the community in supporting the school, the connections between health and academic achievement and the importance of evidence-based school policies and practices.
Working with Students
Any successful asthma care model should have the student as the center focal point. Schools should work in partnership with students to plan, set goals and implement their asthma self-management plan. Supporting student participation in self-managing their asthma sends the message that they have the ability to "manage" their asthma symptoms effectively. Supporting students by giving them the self-management tools they need to participate, also means identifying what their responsibilities are. For example, a student should:
- Complete and return all health related paperwork, questionnaires, medication updates, etc., to health staff.
- Follow district policies if they self-carry their medications and check in with health staff at regular, predetermined intervals to evaluate their asthma status.
- Report increasing (or decreasing) symptoms or changes in their asthma to health staff.
- Report changes in peak flow readings to the health staff.
- Understand how their AAP and/or medication care plan are used and when to request assistance.
- Be responsible for carrying and using their asthma medications at the proper time (e.g., pre-medicating before sports activities), self-administering them correctly and not sharing medications with others.
Even students in elementary school can learn simple self-management tasks like avoiding their triggers, taking their medications as prescribed, and using their rescue inhalers when needed. But every child who has asthma should receive appropriate age level asthma education with frequent assessment and management oversight by LSN’s while in the school setting.
- Asthma is well controlled (e.g. no asthma symptoms)
- Reaching their optimal performance and not missing school due to asthma
- Participates in all physical activities including on sports teams
- Asthma triggers are minimized/avoided
- Friends and peers treat him/her just like everyone else
- Has an asthma action plan that is up to date and always accessible
School staff can help students achieve these goals through good communication among parents/guardians, the child’s health care provider, the school's nurse/health staff, and other school personnel.
School health staff communicate with students by:
- Asking what the students’ personal goals are or what motivates them to be successful. For example, a child who gets short of breath while playing basketball may be more motivated to take their medication if they realizes they can be symptom-free while on the basketball court.
- Giving positive reinforcement and encouragement to a child who uses proper metered dose inhaler (MDI)/ medication administration technique. This sends the message that child is doing it "right" and encourages active participation by the child in managing their asthma.
- Using terminology and wording that is "kid"-friendly and age-appropriate. For instance: When referring to inhaled corticosteroids, use the term "control medications" instead. Or, use "quick-relief inhaler” or “inhaler that helps you breathe easier" instead of "bronchodilator" .
While this is by no means an all-inclusive list of communication techniques and responsibilities, health staff can understand how important it is to help the child actively participate in their own asthma management plan.
Working with Families
A child’s asthma can affect the dynamics of the entire family, so it’s important to understand what a family experiences when dealing with a chronic health condition like asthma. Families may not fully understand asthma and how to manage it properly. School health staff can help families by providing educational resources and materials about asthma and organizing training workshops for the school and community or by providing asthma education for the individual student and their family. Individualized education sessions could be offered during teacher conference days or during other school events.
Health staff have the opportunity to educate families regarding asthma triggers in the home and can help them create a healthy home environment. Since children who have asthma are extremely sensitive to their environment, an environmental assessment should be done in both the home and school environments. An assessment can help identify asthma triggers and identify solutions that minimize exposure to those triggers. Some local public health agencies offer asthma home based services that include a home environmental assessment and individualized asthma self-management education in the child’s home.
See Asthma Home Based Services section for more information or consult with your health care provider for resources available in your area.
Communicating with the student’s family and health care provider require tools that create an opportunity for collaboration - among school staff, like teachers, the parent or guardian and the health care provider.
- A written asthma action plan (AAP) is a tool developed by the health care provider in collaboration with the student’s parent/guardian. Health staff can encourage parents/guardians to participate in the asthma management process by asking their child’s provider to develop and share an individualized AAP (also called an asthma management plan) with the school; to write prescriptions for medication supplies that remain in the school health office; and by returning all required paperwork the school requires to help their child successfully manage their asthma.
- Parents/guardians should be notified when a student’s asthma symptoms are flaring up or when health staff have any related concerns such as when asthma related medication supplies are running low.
- Establishing an open, two-way line of communication with families promotes consistent and current information and can lead to successful asthma management for the child who has asthma.
Working with Health Care Providers
The triangle of teamwork and communication among the school, health care provider and parent/guardian, is crucial to successful asthma management. School health staff should consider this an integral part of their role. Many times school health staff may be the first to recognize symptoms that are consistent with asthma.
Evaluation and proper follow-up with referral to a health care provider opens the door toward establishing a collaborative relationship between school health staff, the health care provider and the parent/guardian. School health staff should obtain parental/guardian permission (release of information consents) prior to contacting and communicating with a student’s health care provider directly. This step in the communication process is important as staff work to build communication pathways with providers, clinic care coordinators and other health professionals who may be working with a student who has asthma.
The LSN/RN is the person responsible for establishing this network and other health staff can support this relationship by providing the LSN/RN with clear and concise observations. Information that is provided in writing is much easier to respond to and less likely to be misinterpreted. For consistency and accuracy, school health staff should use district-approved forms when documenting information or entering data into the districts electronic health record.
The health care provider can communicate with the school health office by:
- Providing written, complete and up-to-date Asthma Action Plans (AAPs). Note that schools/districts typically require a new or updated AAP every school year.
- Performing student self-carry assessments and documenting permission for
- that student to self-administer and carry their asthma inhaler.
- Communicating special student needs: i.e., if a student requires further education or support when taking medication or checking peak flow readings, or by clarifying specialized care plan instructions.
- Writing prescriptions so a student has proper medications while at school: i.e., a rescue inhaler and holding chamber/spacer should be available at school and at home.
- Promptly completing and returning assessments and paperwork provided by school health staff that comply with district policy and guidelines.
- Contacting and discussing the child’s asthma management plan with appropriate school health staff.
- Obtaining parent/guardian signatures on consent to release/share information forms between the clinic and school when the parent is present at the clinic with the student and ensuring that paperwork is returned to the school health office.
School health staff responsibilities when providing information to health care providers vary greatly depending on school district policy and guidelines, as well as professional licensure. Overall, health staff can assist the asthma management process by providing information in a timely and accurate manner and by using the parent/guardian as an informational conduit to the health care provider. Always include the parent/guardian in the communication triangle so they may participate and understand how well (or poorly) their child’s asthma is under control.
Minnesota Inhaler Law
There are legal requirements, statutes or laws that regulate how schools care for children with asthma and children with special needs. Minnesota statutes, laws and rules, are listed in the Minnesota Office of the Revisor of Statutes. Minnesota school medication administration laws, including our statewide inhaler law are available on the Revisors’ web-page and linked via PDF in the descriptors below. All three statutes should be reviewed to understand how Minnesota laws define how school health services are provided.
- 121A.21 School Health Services – Minnesota Statutes 2018 The School Health Services law states every school board must provide (health) services to promote the health of its students regardless of the size of the school or district. This statute defines the minimum health services staffing required for each district, and options for fulfilling those requirements.
- 121A.221 Possession and Use of Asthma Inhalers by Asthmatic Students - Minnesota Statutes 2018 Also called the Minnesota Inhaler (self-carry) law. School nurses or agencies providing nursing services must assess the student’s ability to carry their own asthma inhaler. This statute defines what processes the district and LSN must follow before a student can carry and use their asthma inhaler in the school or on the school grounds. This statute also clarifies what documents are required from the parent and health care provider in districts without a school nurse or school nursing services.
- 121A.22 Administration of Drugs and Medicine - Minnesota Statutes 2018 Students who want to self-carry and use their asthma inhalers in the school outside of the health office must have written permission from their parents and that information submitted every year. The school nurse still needs to evaluate the student’s ability and knowledge to handle managing their asthma.
Healthy children learn better
Poorly controlled asthma can affect a child’s ability to learn. It can disrupt sleep, the ability to concentrate, memorize, and, when not managed properly can prevent a student from participating in “normal” school activities. Children who miss school due to uncontrolled asthma not only miss classroom instruction, they also miss out on social interactions with other children, which can lead to fears of social isolation, rejection, and believing they are “different” from other children.
Students with poorly controlled asthma may feel drowsy, tired or anxious about taking medications. They may also experience side effects from medications, or be embarrassed when an asthma attack or flare up of symptoms prevents them from participating in school activities.
Asthma can be controlled
Asthma can usually be managed with the right medications and modifications to the home and/or school environment. Students who have asthma should be able to live healthy, active lives without symptoms.
Effective asthma management can result in:
- A supportive learning environment for students who have asthma.
- Reduced absences. Students having fewer episodes and symptoms are treated earlier.
- Reduced disruption in the classroom. Students have fewer symptoms when they and their caregivers follow their asthma action plan.
- Appropriate emergency care. School staff members are prepared to respond to emergencies.
- Students fully participating in physical activities. Physical education (PE) instructors and coaches know how to prevent exercise induced asthma (EIA).
- Increased classroom time. Students spend less time in the nurse’s office and away from class when asthma is well managed and under control.
Asthma Action (Management) Plans
The Asthma Action Plan (AAP) is a personalized, written tool that help students and staff manage an individual student’s asthma.
AAP’s come in a number of formats. The most common includes the green-yellow-red zone format and may be symptom or peak flow driven. Each zone has assessment measures and tailored instructions specific to that zone. Some students can benefit from using both symptoms and peak flow measurements to determine their current asthma zone. Use whichever indicator is more significant for that student.
For example, if a student is coughing, but blows a green zone peak flow reading (above 80% of that students personal best peak flow rate), that student may still be in the yellow zone, due to the presence of asthma symptoms. Once it’s determined what zone a student is in, follow that zones directions in administering medications and when to seek medical care.
- Green =GO (feeling good, no symptoms, peak flow between 80-100%). Children whose asthma is well controlled should be in this zone all of the time. By following the instructions in the green zone, students can often avoid slipping into the yellow or red zones. This zone also includes instructions for the control medications the child may take every day (if they require a daily controller medication), and it includes medication instructions for students who develop exercise-induced symptoms due to strenuous activity.
- Yellow = CAUTION (having some asthma symptoms, peak flow is 50-80%). A student may slip down into this zone if they forget to take their control medication (if prescribed) or if they’re exposed to asthma triggers. This zone provides specific instructions for rescue or quick-relief medication administration when the student is starting to have asthma symptoms. If action is taken while the students asthma is in the yellow zone, the student may avoid dropping into the more dangerous red zone.
- Red = DANGER (severe symptoms, peak flow less than 50%). A student with asthma symptoms or peak flow in this zone is an emergency. He/she needs immediate medical attention. Follow the instructions regarding emergency treatment and medication administration. If the student is struggling to breathe, give red zone medication and call 911, if there is no significant relief.
All students who have asthma should have a personalized AAP; especially students with persistent asthma (mild, moderate or severe). Some AAP’s include embedded consents within the body of the plan that promote the sharing of information (and consent to administer medication at school) between the school and health care provider. Be sure to consult your school district policy and guidelines about using an AAP with these specialized consents.
- MDH Asthma Action Plans - AAP templates that can be completed by your health care provider.
- MDH School Resources - School policies and templates (health office and environmental), educational and information resources, tools and forms for the school health office.
- American Lung Association – Improve Asthma Management in Schools Asthma materials for schools include school and community policy suggestions, assessment tools, action steps and learning modules for school personnel, the student and family.
- Practical Guidance for Schools & Districts – Enhancing wellness policies (PDF) This document provides guidance to schools and school districts on ways to enhance school wellness policies that include specific protections for students who have asthma.
- How Asthma-Friendly is your school? (PDF) National Heart, Lung & Blood Institute – Students who have asthma need proper support at school to keep their asthma under control and be fully active.
- Peak Flow Measurements The Johns Hopkins Medicine Health Library page provides a detailed description of what a peak flow measurement is, how it measures the amount and rate of air that can be forcefully breathed out of the lungs, how it relates to the green, yellow red zones in an AAP and who should use a peak flow meter to help manage their asthma.
- Whole School, Whole Community, Whole Child (WSCC) The Whole School, Whole Community, Whole Child, (WSCC) model is student-centered and emphasizes the role of the community in supporting the school, the connections between health and academic achievement and the importance of evidence-based school policies and practices.