Asthma Management in Schools

Steps for Schools

• Identify students with asthma through a review of health history and/or medication forms, and collect additional needed information  
  • Asthma-Friendly Schools Initiative Toolkit, American Lung Association 
    Step-by-step toolkit on building an asthma-friendly school, including a health history form and other resources on identifying and tracking students with asthma 
  • Asthma Intake Form, Colorado Department of Education 
    Information form to be completed by caregivers of students with asthma 
  • Missouri School Asthma Manual, Missouri Department of Health and Senior Services
    Comprehensive manual with numerous tools and forms

• Review school absence reports to identify students with frequent respiratory issues and elicit feedback from teachers to identify students with asthma symptoms 
• Flag students with asthma within the health section of the school’s records or identify another method to easily track students with asthma (e.g., spreadsheet, registry) 
• Notify teachers and other appropriate school personnel of students with asthma and provide training on how to recognize and respond to asthma emergencies (for resources, see education/training section) 
• Record and monitor key data for students with asthma, such as completion of needed forms, medication administration, absences, and acute episodes 
• Assess students’ level of control and need for more intensive case management based on quick-relief medication use, attendance, hospitalizations/ED visits, etc. 
  • Missouri School Asthma Manual, Missouri Department of Health and Senior Services
    Comprehensive manual with numerous tools and forms including information on assessing control 

• When storing records and communicating regarding student health conditions, follow confidentiality guidelines 
  • HIPAA and FERPA, National Association of School Nurses 
    NASN resources on HIPAA and FERPA, including a webinar and 2 radio broadcasts
  • Data Privacy in School Nursing: Part 1 and Part 2, The Network for Public Health Law 
    Overview of HIPAA and FERPA with FAQs from school nurses 
  • Data Sharing Guidance for School Nurses, The Network for Public Health Law 
    Overview of laws with questions and examples for setting up data sharing agreements 
  • Joint Guidance on the Application of the Family Educational Rights and Privacy Act and the Health Insurance Portability and Accountability Act of 1996 to Student Health Records, US Dept. of Health and Human Services and US Dept. of Education 
    Guidance with FAQs to clarify implementation of HIPAA and FERPA in relation to school health services 

How primary care providers can help

• Explain to families the importance of informing the school about the child’s asthma, turning in all school health forms, and providing the school with medications 
• Maintain blank paper and electronic copies of school district health forms for families to complete 
• Assist families that may need help with completing health forms and fax them directly to the school nurse/school health office 
• Ask families to sign a consent form to allow communication with the school about asthma management 
  
  • Sample HIPAA-Compliant Authorization for Exchange of Information, Connecticut State Department of Education 
    Consent form for schools and providers to share information 
• Notify the school of patients whose asthma is severe, requires special monitoring, or who may benefit from administration of daily controller medications by the school nurse
   

Steps for schools

• Ensure that students with asthma have a current asthma action plan on file. Start with students with a high level of severity 
  • SAMPRO™ Asthma Action Plans, American Academy of Asthma, Allergy, and Immunology 
    Asthma action plan for home and school, picture-based, and Spanish versions 
  • Asthma-Friendly Schools Initiative Toolkit, American Lung Association 
    Step-by-step toolkit that includes asthma action plans in English and Spanish and letters to caregivers 
  • Sample Asthma Action Plans, CDC
    Sample asthma action plans from several organizations 
  • State Policy Database, National Association of State Boards of Education
    Lists states with legal requirements related to asthma plans 

• As needed, develop an Individualized Healthcare Plan (IHP) for students with asthma. Partner with families and providers to set goals for asthma management 
• When developing asthma action plans and IHPs, consider asthma management during school-sponsored activities, field trips, before- and after-school care, and times when a school nurse is not present 
  • Field Trips: Guidance for School Nurses, Connecticut State Department of Education 
    Information on considerations related to field trips for students with special health care needs 

• Periodically evaluate students’ plans to ensure they contain current information (eg, medications, contact information) and that their needs are being met 
  • Is the Asthma Action Plan Working? A Tool for School Nurse Assessment, National Heart, Lung, and Blood Institute 
    Assessment tool to determine how well an asthma action plan is working 

How primary care providers can help

• Provide patients with asthma with an asthma action plan for use at school. If possible, send the plan directly to the school nurse/school health office in addition to giving a copy to the family 
• Include your office contact information on the asthma action plan 
• Respond promptly to questions from the school regarding the asthma action plan and provide any information needed for the development of an IHP or other management plan 
• Keep in mind that not all schools have a school nurse present at all times. Ensure that the asthma action plan and any other orders are written in a way that can be understood by trained school staff 
  
  

Steps for schools

• Maintain written emergency protocols with clear communication procedures and responsibilities 
  • School-based Asthma Management Program, American Academy of Asthma, Allergy, and Immunology 
    Toolkit that includes emergency treatment plan 
  • Management of an Acute Asthma Episode in the School, American Lung Association
    Protocol for managing asthma emergencies 
  • Management of Asthma Exacerbations: School Treatment Steps to Follow for an Asthma Episode in the School Setting When a Nurse is Not Available, National Heart, Lung, and Blood Institute 
    Sample protocol for responding to an asthma emergency when no nurse is present 
  • Management of Asthma Exacerbations: School Treatment Suggested Emergency Nursing Protocol for Students Who Don't Have a Personal Asthma Action Plan, National Heart, Lung, and Blood Institute 
    Sample protocol for nurses to manage asthma emergency when the student does not have an asthma action plan 
  • Code Ana, The Teal Schoolhouse 
    Online program to prepare schools to respond to medical emergencies 

• Train all staff on how to recognize and respond to an asthma emergency ​(see educate/train staff), including in students with no prior history 
• Assure immediate access to prescribed medications, including during field trips and school-sponsored activities (see manage medications) 
• Plan for access to medications during lockdowns, evacuations, and other disaster procedures 
• Consider maintaining stock albuterol if allowed within your state 
  • Albuterol in Schools, Asthma and Allergy Foundation of America 
    Map that shows which states have legislation or guidelines on stock albuterol 
  • Emergency Use of Stock Albuterol for the Student with Known Asthma in the School Setting, National Association of School Nurses 
    NASN position statement on stock albuterol 

How primary care providers can help

• Assist patients with obtaining emergency medications to keep at school 
• Volunteer to review school emergency protocols 
• Assist schools in training staff on recognizing and responding to asthma emergencies 
• Secure caregiver permission to communicate with the school to facilitate communication during urgent situations  
  
  • Sample HIPAA-Compliant Authorization for Exchange of Information, Connecticut State Department of Education 
    Consent form for schools and providers to share information 

• Work with the state or local school health services program lead to provide standing orders and other assistance to schools in maintaining stock albuterol (if allowed and needed within your state) 
• Advocate for stock albuterol in schools if not allowed within your state 
  
  

Steps for schools

• Develop and maintain written policies and protocols for asthma management within your district. Policies and protocols provide guidance for staff and communicate expectations for all stakeholders 
  • School Governance and Leadership: Asthma Wellness, AASA
    Magazine with information on asthma policies and procedures as well as liability
  • Practical Guidance for Schools and School Districts: Enhancing School Wellness Policies to Protect Student Lung Health, American Lung Association
    Guidance on enhancing school wellness policies to provide protections for students with asthma 
  • Sample Field Trip Medication Policy, American Lung Association 
    Sample policy on medication administration during field trips 
  • Sample School Policy for Asthma Action Plans, American Lung Association
    Sample policy for use of asthma action plans in schools 
  • Clearing the Air: An Asthma Toolkit for Healthy Schools, Massachusetts Department of Public Health 
    Includes numerous sample policies for school-based asthma management 
  • Model Policy on the Management of Asthma in Schools, Michigan State Board of Education
    Sample asthma management policy 

• Ensure that policies and protocols adhere to national and state laws and regulations, including state nurse practice acts 
  • Albuterol in Schools, Asthma and Allergy Foundation of America 
    Map that shows which states have legislation or guidelines on stock albuterol 
  • State Policy Database, National Association of State Boards of Education 
    Lists states with legal requirements related to asthma plans 

• Policies and protocols should address:
  • Routine and emergency management 
  • Medication administration and nursing delegation or administrative assignment, including provisions for self-carry and self-administration, standing orders, and stock medications 
  • Procedures for field trips, the bus, and before- and after-school activities 
  • Documentation 
  • Procedures for errors 
  • Use of written care plans 
  • Maintenance of a safe environment 

How primary care providers can help

• Educate school leadership about the importance of written policies and protocols 
• Volunteer to help develop or review district policies and procedures to ensure that they are comprehensive, aligned with best practice, and practical given available staffing and resources (see examples above) 
  
  

Steps for schools 

• Support self-carry of quick-relief medications for students who are able to self-administer 
  • Asthma Medication in Schools, American Lung Association 
    Includes issue brief, model policy, readiness assessment tool, online course, and other resources related to access to bronchodilators in school 
  • Metered Dose Inhaler Technique Checklist for School Nurses, American Lung Association 
    Checklist for assessing students’ inhaler technique 

• Ensure that medications are stored in secure yet easily accessible locations during the school day, during school-sponsored activities, and during field trips 
  • Sample Field Trip Medication Policy, American Lung Association 
    Sample policy to guide medication administration during field trips 
  • Guidelines for Provision of Health Services on Field Trips or Extracurricular Activities, Colorado Dept. of Education 
    Guidelines for health services during school-sponsored trips and activities 

• Work with families, providers, and insurers to obtain quick-relief medications for school use 
• Maintain documentation of medications stored, medications administered, medication errors, and medication authorizations 
  • Asthma-Friendly Schools Initiative Toolkit, American Lung Association 
    Step-by-step toolkit with numerous resources to build an asthma-friendly school, including medication authorization forms 
  • Sample Policies and Forms, Mass.gov 
    Sample medication orders, authorizations, logs, and policies 

How primary care providers can help

• Assess patient readiness to self-carry and provide recommendation to the school 
• Provide ongoing self-management education to patients 
• Respond to questions from the school regarding medications 
• Assist families in securing quick-relief medications (bronchodilators) to keep at school 
• Advocate for insurers to cover an extra quick-relief inhaler for at school 
• Write a prescription for a spacer for school in order to help families obtain coverage for the additional cost 
  
  

Steps for schools

Staff

• Define staff roles. At a minimum, all staff should receive basic information about asthma and how to identify and respond to emergencies 
  • Minimum Competencies for Asthma Care in Schools: School Nurse, Colorado Department of Education
    Detailed outline describing core competencies for nurses 

• Identify training needs through knowledge and skills assessments 
• In larger districts, consider having an asthma resource nurse who receives additional specialized training and has time allotted to answer questions and provide support to other nurses 
• Provide regular training and assessment on relevant skills and information, keeping in mind the prior knowledge and health literacy level of the audience 
  • School-based Asthma Management Program, American Academy of Asthma, Allergy, and Immunology 
    Toolkit that includes training resources for staff 
  • Asthma Basics, American Lung Association 
    Self-paced online learning module or in-person workshop for school nurses, teachers, coaches, and other school personnel to learn about asthma. Also available in Spanish 
  • Four Steps for Creating an Asthma-Friendly School, American Lung Association 
    E-learning course based on the Asthma-Friendly Schools Initiative Toolkit 
  • Ready? Set? Go with Asthma! Exercise-Induced Asthma, Asthma and Allergy Foundation of America  
    Education program to teach coaches, PE teachers, and others how to help children manage asthma 
  • Medication Administration in Missouri Schools: Guidelines for Training School Personnel, Missouri Department of Health and Senior Services 
    Detailed guidance on training staff to administer medications 
  • Missouri School Asthma Manual, Missouri Department of Health and Senior Services 
    Comprehensive manual with numerous tools and forms, including information on staff training 
  • Chronic Health Conditions Toolkit for Non-Medical Staff in Schools, Tennessee Department of Education
    Provides an overview of asthma and how to respond to emergencies for non-medical school staff
  • Stock Albuterol Inhaler Training for School Personnel, University of Arizona 
    E-learning course to train school personnel to administer stock albuterol (approved in Arizona) 
  • Medication Training, Wisconsin Department of Public Instruction 
    Training videos, tests, and skills check-off on quick-relief inhaler and nebulizer administration 

Students

• Provide coaching and education when interacting with students in order to support increased independence in self-management  
• Consider offering formal self-management education for students with asthma 
  • Kickin' Asthma, American Lung Association 
    Asthma education program for ages 11-16 that has shown statistically significant improvements in asthma control 
  • Open Airways for Schools, American Lung Association 
    Evidence-based asthma education program for elementary school children 
  • Iggy and the Inhalers 
    Asthma education program and materials for children that have been shown to be effective in increasing asthma knowledge 

Families 

• Consider offering asthma education programs for families
  • Asthma Basics, American Lung Association 
    Self-paced online learning module or in-person workshop for adults with asthma and caregivers who want to learn more about asthma. Also available in Spanish 

• Provide resources to support asthma management at home 

How primary care providers can help 

• Volunteer to assist with developing, reviewing, or delivering trainings (see resources above) 
• Recommend or provide patient education materials 
• Communicate with school nurses about children and families that may need additional education, such as newly diagnosed or poorly controlled patients 
• Advocate for adequate numbers of licensed school nurses in schools 
  
  

Steps for schools

• Assist families without a primary care provider and/or insurance with accessing health care 
  • Does Your Child Have Health Insurance? AASA 
    Toolkit to assist schools in identifying uninsured children and connecting them to coverage 
  • Health Insurance for Children: How Schools Can Help, CDC 
    Guidance for schools on connecting students with health insurance 

• Obtain consent from caregivers to communicate with students’ primary care providers (consider including in annual consent form) 
  
  • Sample HIPAA-Compliant Authorization for Exchange of Information, Connecticut State Department of Education 

• Notify caregivers (and primary care provider, if appropriate) of asthma attacks at school 
• Communicate with students’ providers and caregivers regarding frequent use of quick-relief medications, frequent absences, or other concerns 
  • Sample Form Letter to Physician, American Lung Association 
    Sample letter informing physician of concerns regarding a student’s asthma management 

• Identify local resources that can support students with asthma 
  • Parents for Healthy Schools, CDC 
    Collection of resources, including guidebook, presentation, e-learning module, and idea sheets for engaging parents in school health, including chronic condition management 
  • Partner Build Grow, The Center for Health and Health Care in Schools 
    Action Guide for sustaining school-based approaches to support cognitive, social, emotional, and physical health 
  • Nine Elements of Effective School-Community Partnerships to Address Student Mental Health, Physical Health, and Overall Wellness, Coalition for Community Schools 
    White paper on ways school-community partnerships can create positive health and academic outcomes 
  • Partnership Building to Support Students Managing Chronic Health Conditions, National Association of School Nurses 
    Webinar on how to create, strengthen, and sustain partnerships to support students with chronic health conditions to be safe, healthy, and ready to learn 

• Consider partnering with a local hospital, American Lung Association Chapter, public health department, nursing school, or community provider to provide education to staff, families, and/or students 

How primary care providers can help 

• Obtain consent from caregivers to communicate with the school 
  
  • Sample HIPAA-Compliant Authorization for Exchange of Information, Connecticut State Department of Education 
    Consent form for schools and providers to share information 

• Recommend community resources and partners that can support students with asthma 
• Consider serving as a consultant to the school district or participating on a school health or wellness committee 
• Complete the SAMPRO Practice Improvement Module from the American Academy of Allergy, Asthma, and Immunology on how to collaborate with schools in improving asthma care 
  
  

Steps for schools 

• Ensure adequate school nurse staffing 
  • Role of the School Nurse in Providing School Health Services, American Academy of Pediatrics  
    Policy statement outlining the importance of a school nurse in every school 
  • School Nurse Workload: Staffing for Safe Care, National Association of School Nurses 
    Position statement on appropriate school nurse staffing 

• Assure students have quick access to needed medications and supplies​ (see manage medications) 
• Implement needed accommodations​ as outlined in IEP and/or 504 plans 
• Reduce potential triggers in the school environment​ 
  • Provide a Healthy School Environment, American Lung Association 
    Guidance and tools on maintaining healthy indoor air quality 
  • Creating Healthy Indoor Air Quality in Schools, Environmental Protection Agency 
    Comprehensive set of resources including action kit, IAQ assessment mobile app, webinars, and guides 
  • Creating Asthma-friendly Environments and Promoting Access to Guidelines-based Care for Children with Asthma, National Association of School Nurses 
    Presentation on how to identify environmental triggers and implement evidence-based environmental interventions to effectively manage and improve health outcomes for students with asthma. CNE credit available 
  • Asthma Environmental Intervention Guide for School-Based Health Centers, Regional Asthma Management and Prevention 
    Guide to reducing exposure to environmental triggers for school-based health centers 

• Create a positive social climate that fosters acceptance, inclusion, and full participation for all students 

How primary care providers can help

• Educate school leadership on the importance of policies to protect indoor air quality 
• Work with families and schools to support full participation by students with asthma 
• Advocate for adequate school nurse staffing 
  
  

Steps for schools

• For students with poor control, consider having school nurses provide case management or additional services such as administering controller medications at school, conducting home visits, assisting with making appointments, connecting families with transportation assistance, etc. 
  • Asthma Case Management Form, American Lung Association
    Case management planning form for schools
  • Translating Strategies into Actions to Improve Care Coordination for Students with Chronic Health Conditions, National Association of School Nurses 
    White paper that proposes a common definition of care coordination and identifies actions for implementing effective chronic condition management in schools 

• Provide additional support and training opportunities to equip school nurses to identify issues relating to poorly controlled asthma and develop solutions 

How primary care providers can help

• In districts with adequate health services staffing, partner with school nurses, counselors, social workers, and school-based health centers to support case management and care coordination through the school and suggest services and supports that would be helpful to the students and families