Department of
Emergency Medicine, Newark Beth Israel
Medical Center, Saint Barnabas Health Care
System, Newark, New Jersey, USA.
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.
