Kathy Karsting - New School Health Program Manager

Kathy Karsting, RN, MPH, became the new School Health Program Manager for Nebraska Department of Health and Human Services  on November 16, 2006. Kathy comes to DHHS with over twenty years’ experience in school and community health nursing, most recently serving for eight years as Health Services Coordinator for Lincoln (NE) Public Schools.

Kathy’s nursing background includes public health nursing, Peace Corps service, medical surgical nursing, hospice-home health, and public health administration, as well as school health. Kathy has a Master’s degree in Public Health Administration from the University of Minnesota, with an emphasis in public health nursing. In 1992-94, Kathy was health services director for Northwest Community Action in Chadron, followed by four years in rural northeast Colorado as nursing director for the Northeast Colorado Health Department In 1998, Kathy returned to Nebraska to work with Lincoln Public Schools. Kathy lives in Lincoln with her two daughters, Claire and Sara, aged 12 and 10, and husband Doug, a fourth-generation Nebraskan from Blue Hill in Webster County.

Kathy brings to the school health position a love for working with nurses; a commitment to policies, programs, and systems that support the well-being of all children and families; and a great appreciation for the role schools play in the lives of all Nebraskans. “I am thrilled to be part of the DHHS system in promoting perinatal, child, and adolescent health. The opportunities to advance the practice of school nursing in our state, to support school health programs, and to lend expertise to how schools provide healthy and safe environments to children, are tremendously exciting to me. I urge school nurses and others to contact me and let me know your views on what DHHS can do for you to help you make a difference in the lives of children you know!”

School Nurses Making the Connection on Pandemic Flu

An audience of approximately 25 school nurses and a few administrators met in Kearney at ESU 10 on Dec. 1 to review a Pandemic Flu Action Kit for Schools, unveiled by a partnership of three public health districts: Two Rivers Public Health Department, Loup Basin Public Health Department, and Central District Health Department. The 1/2 day activity provided an opportunity not only for school nurses to meet together to think about pandemic flu (and all-hazards) preparedness, but also to hear from public health representatives about community-wide pandemic flu planning in the region.

As national-level planning proceeds and with it federal directives to states, it seems more and more likely that schools would be affected in major ways in pandemic response scenarios. An article in the Dec. 20 edition of the e-journal from Center for Health and Health Care in Schools, “School Closings Seen Likely in Influenza Pandemic,” reported increasing attention is being given to community containment interventions to reduce spread of illness in a pandemic situation. According to President Bush’s Assistant for Homeland Security and Terrorism, Frances Townsend, guidance will be released in January on interventions such as school closure and cancellation of public gatherings to promote social distancing. http://www.healthinschools.org/Educators-and-Families/Parents/Learn-Now/Pandemic-Flu-Planning-Checklist.aspx

As health care professionals with first-hand knowledge of the schools and the children and families we serve, it is imperative that school nurses take a role in community-wide pandemic flu planning. Connect with your administrators and share examples and tools developed for school settings. Find an example of a planning overview for schools posted at www.answers4families.org. For additional samples, contact Kathy Karsting, RN, at kathy.karsting@dhhs.ne.gov. Connect with your local health department and make use of their technical and professional assistance. Schools are an essential part of community infrastructure, and local health authorities need your expertise too. Find a directory and map of local health departments at http://www.dhhs.ne.gov/puh/oph/lhd.htm

When thinking about school preparedness, don’t overlook that effective community response also requires individual and family preparedness. How prepared are you? Find more resources and information to guide you at www.pandemicflu.gov. Get connected!

MRSA In Schools

The Newsletter for School Health Professionals

METHICILLIN-resistant Staphylococcus aureus (MRSA) is becoming more of a concern for school health professionals and educators. Once strong ly associated with hospital-acquired infection, health care providers and epi demiologists now find that MRSA may also occur as a result of exposures in the community, exposures not associated with hospital experience. The majori ty of community-acquired MRSA infections involve the skin or soft-tissue, and affect a younger and healthier population than associated with hospital-acquired MRSA infections.(1,2) MRSA infections have also been seen emerg ing in pet populations throughout the world, and recent evidence suggests MRSA infections may be transmitted between people and their pets (3).

MRSA is significant to school nurses. We work with students with needs for health care procedures at school, including those with wounds or stomas. Upon learning a student has been diagnosed with MRSA, multi-disciplinary school teams can become alarmed and raise many questions for the school nurse. What are the implications for the educational team and for students with whom the infected child may come into contact? Should MRSA be the basis for exclusion from school?

On another front, also alarming to educators and others may be the diag nosis of MRSA in an otherwise “well” setting, student athletics for example, when a wrestler or football player is diagnosed with MRSA.

Providing calm and knowledgeable leadership to the school community, the school nurse can be a vital asset in assuring: safe infection control prac tices at school; proper medical evaluation, treatment, and clearance of the infected student to return to school; medical privacy for affected individuals; case-finding; and education and reassurance for the school community.

The child who is ill and determined to have active infection needs to be treated and followed until medically cleared by the physician to return to school. Yet a person may also be colonized with MRSA. In this case, MRSA is present on the body, but there are no clinical symptoms of illness. The school nurse must be astute in gathering sufficient information to accurately discern between the two. Epidemiologists suspect an increasing number of persons in the general population are colonized with MRSA. (Remember Staphylococcus aureus is after all a part of the normal flora of the healthy person’s skin and nares.) It is not appropriate or necessary to exclude the clinically well individ ual who happens to be colonized with MRSA.

Once given medical clearance by their treating physicians, children who are colonized with MRSA should be allowed to attend school. Draining wounds or stomas should be covered. Consistent with developmental and cognitive abilities, the child should be instructed in good hand-washing and keeping the area covered while at school. Teachers should be instructed to observe that wounds remain covered and to assure good handwashing practices are a part of the daily classroom routine for all, as well as routine cleaning procedures. In early childhood settings, additional consideration may need to be given to avoid shared exposures to body fluids or secretions through toys or related to toileting/diapering activities. If treatments or procedures are provided to the child, personal protective equipment should be worn as appropriate, followed by good handwashing.

In student environments such as athletic venues, students should be instructed to wash skin thoroughly after exposures to shared common surfaces, especially where the skin has experienced friction rubbing, such as wrestling mats or tight-fitting shared head gear. All shared surfaces, such as mats and shower areas, should be cleaned thoroughly before use. Wounds should be kept covered and progress in healing monitored by school personnel.

In school health offices in otherwise undiagnosed persons, MRSA may potentially present in the form of boils, impetigo, or infected abrasions. The school nurse has an important educational role with both student and parents/guardians about adequate supervision and care of all wounds, and recommending medical attention when needed. Signs and symptoms of staph and other skin infections include: redness, swelling, warmth around the area; red streaks extending away from a wound; increased or throbbingp pain; and fever.

In summary, preventing spread of MRSA requires the basic infection control measures and precautions involving body fluids that should be practiced universally in all class rooms and other school environments at all times:

• Handwashing!
• Covering draining wounds and orifices, and contain ment of body fluids
• Identification and referral of non-healing or infected wounds
• Proper use of personal protective equipment to pre vent direct contact with potentially infectious body fluids
• Decontaminating surfaces that have been in contact with body fluids
• Proper disposal of contaminated materials
• Handwashing!

MRSA is an emerging health concern in child care and school settings, and the school nurse must stay alert to pre sentations of MRSA in the school population, and up-to date information as it develops about the epidemiology of MRSA in community settings, including schools.

RESOURCES TO LEARN MORE ABOUT MRSA:

The Maryland Dept. of Health and Hygiene has developed a set of guidelines for schools: http://www.cha.state.md.us/edcp/guidelines/guidelines.html
Guidelines for schools from the Indiana State Dept. of Health: http://www.in.gov/isdh/dataandstats/epidem/2004/sep/guidelines.pdf
Two excellent slide presentations on Community-Acquired MRSA on the Pennsylvania Dept. of Health Website:http://www.dsf.health.state.pa.us/health/cwp/view.asp?a=178&q=248839

REFERENCES

Fridkin SK et al, Methicillin-resistant Staphylococcus aureus disease in three communi ties. N Engl J Med. 2005 Apr 7; 352(14):1436-44.

Community-Associated MRSA Information for Clinicians. Centers for Disease Control and Prevention

Viatale CB et al, Methicillin-resistant Staphylococcus aureus in cat and owner. Emerging Infectious Diseases. 2006 Dec; 12(12);1998-2000. www.cdc.gov/eid .

Attack on Asthma Ed Committee Revises Curriculum

The Attach on Asthma Nebraska (AOAN) education subcommittee met in Kearney on December 14 under the leadership Susan Puckett, RN, AOAN Board Member education committee chair, and Andrea Holke, AOAN Executive Director. The goal of the session was to review and update the educational guidelines to reflect progress implementing the emergency medication protocol for breathing emergencies, as required in Nebraska schools by Title 92, Chapter 59, Regulations for School Health and Safety.

Three key areas of discussion emerged during the session: local EMS (emergency medical services), confidentiality and privacy issues, and best practices in asthma management at school. Local EMS personnel may or may not be aware of the epinephrine-albuterol protocol in their area schools, and may or may not be equipped to administer epinephrine themselves. Julie Smithson, AOAN board member and EMS coordinator with NE Department of Health and Human Services (DHHS) for the South Central region of the state, clarified that the medical director for each ambulance entity determines whether the ambulance will carry epinephrine for administration. Training is available for EMS personnel approved by their medical directors. School nurses are encouraged to invite local EMS personnel to their inservice activities for school employees, and to be advocates in their communities for EMS capacity to administer epinephrine in the event of life-threatening anaphylaxis or asthma.

In order to assure that the information requested by AOAN on the Emergency Report Form is consistent with FERPA (the federal Family Educational Rights and Privacy Act) requirements for protection of educational information, Kathy Karsting, RN, School Health Program Manager at DHHS, will seek additional information and report back to the committee at the next meeting.

School personnel need to be educated about how to implement the emergency protocol correctly, but they also need to be aware of strategies that help their students with asthma or anaphylaxis avoid a life-threatening breathing emergency. Such strategies include: trigger identification and avoidance; correct recognition and treatment of early symptoms such as chronic cough and poor sleep; current medical management and access to controller medications in addition to rescue supplies. The group recommended including a separate section in the curriculum on “best practices in asthma management at school” to better identify these important preventive measures.

The education subcommittee meets again on January 4 in Kearney. Contact Susan Puckett at susan.puckett@kearneypublic.orgor Andrea Holke at andrea@attackonasthma.org for additional information or with suggestions for the educational curriculum.

School Immunization Records – Sharing Only By Consent

Nebraska schools are not permitted to share immunization records without specific written parent/guardian consent and authorization to do so. The only exceptions are: FERPA (the federal Family Educational Rights and Privacy Act) allows educational records to be shared between an educational institution where a student has been in attendance, and another educational institution where a student is enrolling, without specific parent/ guardian consent. And once the student reaches the age of majority, 19 years, the student becomes the consenting party for release. At that time the release of records still requires consent, but the consenting party changes from parent to the student who has reached the age of majority.

Immunization laws in Nebraska allow immunization providers to share immunization records on their patients without specific written consent to do so. The only providers or entities permitted to share without specific consent are: physicians, advanced practice registered nurses, physician assistants, pharmacists, licensed health care facilities, public immunization clinics, local public health departments, and DHHS (per NRS 71-541). Parents/guardians may prevent such disclosure by signing a nondisclosure form at the provider location.

In practical terms for school health personnel and others, this means that schools may not share immunization records with doctor’s offices, clinics, or other providers, or with summer camps or employers of the students, or any other parties other than schools in which the student is in the process of enrolling, without first obtaining written consent from parent/guardian to do so.

The immunization laws in Nebraska are found in Neb.
Rev. Statutes Sections 71-539 through 71-544.
Unauthorized disclosure by child care program, school, or institution of higher education is a Class III misdemeanor in Nebraska.

Find the sections in NRS 71 by going to: http://uniweb.legislature.ne.gov/legaldocs/view.php?page=index_statutes.

Answers 4 You

The Internet is changing school nursing practice. Available in nearly all school settings, and nearly as pervasive in American homes, we can sit and wait to see what the Internet will bring us next - or we can take command of our practice and actively explore the ways the Internet can serve our needs and our aspirations to bring health and success to every child in school! With Answers4Families, Nebraska’s school nurses have an opportunity to shape a valuable Internet tool specifically to improve the quality of our professional impact on education and health of children, adolescents, and families.

Many of us are familiar with the list serve for school nurses supported by Answers4Families. If you are not using this resource, stop reading now and go to the Website to sign up for the discussion group: 

Answers4Families also offers educational tools. Ask Rx provides a link to the Nebraska Pharmacy Association and pharmaceutical expertise. Ask an Expert, a monthly feature, allows users to pose questions of interest to experts in a wide array of professional fields applicable to school nursing. Suggest an expert or a field you would like to have featured! Most recently, Answers4Families introduced an interactive tutorial on the use and development of the Individualized Family Services Plan, or IFSP, for young children with special needs. Look for this tutorial by searching on IFSPweb. What topics would you like to propose for interactive tutorials at the site? Health Screening methods? Exposure Control plans for Schools?

Answers4Families offers a bank of resources for families. From the site, you can link directly to the Nebraska Resource and Referral System. Looking for resources for the family with a young child with diabetes? A family needing access to financial resources for their child with a disability? Resources for adaptive technology specific to a student’s disabilities? Try the NRRS!

Answers4Families gives school nurses opportunities to create new resources to face new challenges. Current knowledge and resources on such perplexing conditions as methamphetamine use, pandemic influenza or other topics can be placed at our fingertips.

Finally, there is the School Nurse web page itself at Answers4Families. The Website is being renovated and revised to provide better navigation on topic areas – check it out! Have you ever wondered what you did with that nugget of particularly valuable info that came off the list serve? Find it again on the list serve archives! Five years of dialogue and information exchange are available with a few clicks of your mouse.

There’s a lot of talent behind the scenes at Answers4Families, most notably Charlie (Charlotte) Lewis. Charlie and her team at the UNL Center on Children,Families, and the Law bring us this resource. The School Health Program at Nebraska Health and Human Services, Office of Family Health, provides a financial contribution to make the school nurse Web page and list serve available to school nurses in Nebraska and support our practice.

Help unleash the power of the Internet to enhance your school nursing practice, and send a note to the list serve to share what you want to see in future developments!

Web Page and Resource Links