Asthma affects more children than any other chronic disease, and is one of the most frequent reasons for school absence, hospital emergency visits and hospital admissions. For children with asthma SHS staff help to obtain physician-directed asthma action plans (AAPs) for all children with asthma. This is an important process because the primary care provider is the initiator of the plan, secures parental consent, and contacts SHS to provide continuity of care. SHS is currently participating with Dell Children’s Medical Center in a continuum of care quality improvement initiative that looks at how many students take their AAPs to school following hospital discharge.
The Texas Department of State Health Services estimates 8.2% of children in Texas have asthma, based on the Texas Behavioral Risk Factor Surveillance System (BRFSS, 2009). The prevalence rate for Central Texas, as represented by Health Service Region 7, exceeds the state rate at 9.3%. Asthma prevalence in Texas among African American children is estimated at 13.5%. Applying the 9.3% prevalence rate (for all ethnicities) to AISD, this would predict that about 8000 students have the condition. The prevalence rate varies by ethnicity and age of the child. School RNs manage 1530 students for asthma. Students being actively managed for asthma tend to be younger students. Older students case managed by SHS tend to have more severe asthma. Still, in AISD it is believed that a number of students with asthma have not been previously diagnosed. This is evident in the number of breathing difficulty incidents for students each year, who have no previously known diagnosis of asthma. SHS seeks to identify as many students with asthma as possible prior to any asthma exacerbation. When a student is seen in ER or admitted to the hospital for asthma, SHS works with Dell Children’s Medical Center to obtain AAPs for in-school management of the condition.
Breathing Difficulty Episodes and Outcomes
There were 4547 breathing difficulty episodes during SY 2011-12, a 32.9% increase in episodes over the prior year. Of the total episodes, 1303 were among students for whom there was no previously known diagnosis of asthma, and therefore no care plan. School nurses are dependent on parents to notify them of their student’s health conditions. For students who lack access to care, and who experience breathing difficulty in school, school nurses help link families to care.
Breathing difficulty episodes for students with a known diagnosis/care plan have increased 96.8% over the past two years, while those among student with no known diagnosis have decreased 4.5% over the same time period. This likely reflects a quality improvement initiative over the past few years to identify such students and get plans in place. Students without a known diagnosis/care plan that experience breathing difficulty are more likely to be absent than their counterparts whose asthma is actively managed in school, they are also less likely to return to class following an asthma exacerbation during school hours.
A quality improvement introduced in SY 2009-10 was to focus on getting care plans or asthma action plans in place for previously undiagnosed students to improve their health outcomes and reduce loss of educational time in subsequent episodes. The chart above reflects a two year decrease in the percent of breathing difficulty episodes among students previously undiagnosed for asthma. This likely reflects the results of efforts to target such students and implement care plans.
Of students experiencing a breathing difficulty episode in SY 2011-12, 83.8% of those with a care plan returned to the classroom, while only 62.9% of those without a plan remained in school. This stable pattern over several years reiterates the importance of targeting previously undiagnosed students and implementing care plans as a means to increase educational time and reduce a health barrier to learning.
In SY 2011-12, 1.0% of students with a care plan who experienced breathing difficulty required a medical referral, 0.1% involved EMS contact, and 0.2% were transported via EMS.
In contrast, 3.9% of students without a care plan required a medical referral following breathing difficulty, 1.5% required EMS contact and 1.4% were transported via EMS.
In essence, students without a known diagnosis and care plan were nearly 4 times as likely to need a medical referral, 15 times as likely to require EMS contact and 7 times as likely to be transported via EMS as were students with a diagnosis, care plan and medications in place.