November 2018 Sarah Blumenthal, MSN, RN, NCSN - Colorado ...

November 2018
Sarah Blumenthal, MSN, RN, NCSN

Transitions …
New School Year
Election Season
New School Health Leaders

Health and Wellness Unit
                  Sarah Blumenthal
 State School Nurse Consultant         Assistant Director of
• Guidance and Technical               Health and Wellness
  Assistance – Student Health    • Brain Injury
  and School Nursing
                                 • Title V – Abstinence Education
• Supervise Regional Nurse
  Specialists                    • School Medicaid
• Supervise CDE School Nurse
  Mentors

I’m one
of you!

Welcoming CDPHE Partners
Deborah Monaghan, MD, MPH
New CDPHE Public Health Consultant
deborah.monaghan@state.co.us

Kate Lujan, RN, MPH
Field Epidemiologist - Communicable Disease
Public Health Nurse Consultant
kate.lujan@state.co.us

Announcing soon…
                     Jane Weber

                                       Ann Burkett

Megan Murray       Tammie Chasteen

  Jody Stroh                      Anita Brodecky

Joni Heiden

Sharon Lindeman

            Jessica McDonald

 Nurses participating in School Health
  Professional Grant
 Nurses serving as mentors for induction
  requirements
 Nurses serving as School Medicaid
  Coordinators
 Nurses TBI Team Members
 NCSN Certification
 School Nurse Leaders

HB 18-1286 “Quentin’s Law”
Signed into Law: June 4, 2018
Essential Resources:
• Legal counsel for your organization
• Scope and Standards of Practice
• School Nurse Code of Ethics
CASN Position Statement

Per DEA:
Schedule I drugs have no currently accepted medical use in the
United States

At the September 12, 2018 meeting, the State Board of
Education approved notices of rulemaking for the
following rules: Student Possession and Administration of
Asthma, Allergy, and Anaphylaxis Management
Medications, 1 CCR 301-68.
The proposed rule change is technical in nature.
Technical rule change – these are typically initiated by
the Office of Legislative Legal Services and are usually
minor corrections to align with state statute or current
practice and do not result in substantive changes.

Wednesday, November 14, 2018
3:30 p.m. Rules for the Administration of Student
Possession and Administration of Asthma, Allergy, and
Anaphylaxis Management Medications, 1 CCR 301-68
The purpose of the rulemaking hearing is in response to:
HB 16-1373 directs school districts to adopt policies
regarding the administration of medical marijuana by a
primary caregiver to students with a medical marijuana
registry card.
 HB 18-1286 requires the state board to establish the
written documentation required should a district choose to
allow school personnel to administer medical marijuana to
a student.

6-25-18
First FDA approval for purified drug derived from
marijuana plant
https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm611046.htm

9-27-18
Department of Justice (DOJ) and Drug Enforcement
Administration (DEA) announces Epidiolex approved as
Schedule V of the Controlled Substances Act –(least
restrictive)
https://www.dea.gov/press-releases/2018/09/27/fda-approved-drug-epidiolex-placed-
schedule-v-controlled-substance-act

RX: Oral Solution
Used BID for seizure control
Uses cannabidiol (CBD) – non-psychoactive
Availability anticipated soon
Approximate cost: $32,500/yr.
• Indicated for tx of seizures associated with
    •   Lennox-Gastaut syndrome
    •   Dravet syndrome
    •   2 years of age or older

• Simplified
• Easier to follow
• Districts not required
  to use this plan, as
  long as statutory
  requirements are met

Major Changes:
• Severe Symptom List
  and Descriptions
• Treatment for Severe
  Symptoms
• Treatment for Mild
  Symptoms
• Give 2nd dose “if
  available”

NEW: Guidance to Districts
• Districts must include the new Allergy and
  Anaphylaxis plan in their notice to parents
• May accept an older or modified version as
  long as the form meets requirements in 22-2-
  135, C.R.S.

Colorado Board of Health       Who must report?
        Rule 6 CCR 1009-2          • Public Schools K-12
Schools and licensed child cares   • Private/Parochial Schools K-12

Aggregate immunization and         • Child care centers, preschools & Head
                                     Start programs with 10 or > children
exemption data
                                   Who does not need to report?
To CDPHE
                                   • School-age child care centers, family
Annually                             child care homes, drop-in centers, day
Submission Deadline:                 treatment centers, foster care homes,
                                     day camps and resident camps

      Dec 1, 2018                  https://www.colorado.gov/pacific/cdphe/school-and-child-
                                   care-immunization-data-reporting

• Allows a nurse to have one license, issued by the state
  of primary residence
• Allows practice in all states within interstate compact
• Nurse is subject to each state's practice
  laws/discipline
• All licenses issued to permanent Colorado residents
  will be compact licenses
• Those licensed in Co. AFTER 7-20-17 will have to
  undergo federal background check and fingerprinting
• If primary state residence changes, nurse must notify
  the CBON
• Colorado Board of Nursing: Nurse Licensure Compact FAQs

Colorado Driver’s License      Colorado Multi State RN License
Issued to qualified Colorado      Issued to qualified Colorado
Residents                         residents
Able to legally drive in other    Able to practice nursing in other
states                            NLC states
Must abide by the laws of the     Must abide by nurse practice
state you are in                  laws of the state you are in
If you break the law in another   If you break the law in another
state, you are subject to that    state, you are subject to that
state’s disciplinary actions      state’s disciplinary actions

Additional Pathways for SSP/School Counselor and SSP/School
Nurse - The Colorado State Board of Education has expanded the
rules for the issuance of a special services provider (SSP) license
to allow additional pathways for individuals to obtain a school
counselor or school nurse endorsement.

School Nurse (1 CCR 301-101 Rule 7.05) - Individuals who meet
the following requirements may receive an initial special services
provider license with a school nurse endorsement:
hold a valid Colorado RN license issued by the Colorado department
of Regulatory Agencies (or by a nursing compact state); and
have three (3) or more years' licensed nursing experience with
school-age children.

1 CCR 301-101
Rule 7.05 School Nurse (Ages Birth–21)
To be endorsed as a school nurse, an applicant shall hold an
earned bachelor’s or higher degree in nursing from an accepted
institution of higher education or have successfully completed 3
years of practical experience working with school aged children
and completed a nursing education program for a Registered
Nurse (RN) or …..BSN program…
…have successfully completed field experiences and a
supervised practicum as prescribed by the preparing
institution, including experiences with school age children in a
community health/public health or school setting.

• School districts, BOCES, and the Charter School Institute
  (CSI) are the only entities that can sign an induction
  certificate for a teacher or SSP
• It is allowable for a district, BOCES, or CSI to partner
  with a program, such as CDE’s School Nurse Mentor
  Program, or a similar program in a pediatric hospital, to
  ensure that inductees are also being supported by
  experts in their content area

• The district/BOCES/CSI needs to create the induction
  certificate for their school nurse

Every Student Succeeds Act
        Indicator            Measures
                               Science achievement and…
V. School Quality or Student
Success Elementary/ Middle     Reduction in Chronic
Schools*                       Absenteeism for
                               Elementary/Middle Schools
                               (Student engagement)

Colorado ESSA Plan

Truancy Rate: Calculated at the school level by dividing
the reported Total Student Days Unexcused Absences by
the Total Student Days Possible
Habitual Truant (Student Count): A student is counted
as habitually truant if the student has 4 unexcused
absences in one month and/or 10 absences in 1 school
year.
Chronic Absenteeism Rate: Students absent 10 percent
or more of the days enrolled in the public school year
during the school year. All absences are included –
unexcused, excused and suspensions.
CDE Student Attendance Fact Sheet
Attendance Works

Defined as missing 10% or more of a school yr. (approximately
18 days/yr.) or just 2 days/month
Colorado: 1 in 5 students are chronically absent.
Preschool students with good attendance develop good skills
and habits to prepare for kindergarten.
By 3rd grade, children missing too much of KDG and 1st grade
will fall behind in reading.
Chronic absenteeism in MS is a warning sign that students are
in a path to dropping out.
In 9th grade, attendance is a better predictor than test scores
that a student will leave before completing high school.

Robust Rubric Revision Process
2-Day Workgroup Commitment
Focus Group: School Nurse Standards and Elements
Additional Opportunity to Provide Feedback
• Online Platform
• Late Winter
• Early Spring
Measures of Student Outcomes: Samples for School Nurses
https://www.cde.state.co.us/educatoreffectiveness/nursesa
mpleoutcomemeasures

• Other Health Impaired (OHI) Guidelines
  submitted to ESSU March 2018
• CDE’s Exceptional Student Services Unit
  (ESSU) met to review and provide feedback
• CDE Stakeholders revised and submitted final
  revisions Oct 26, 2018
• Upon final approval, guidelines will be shared
• Trainings will be offered during Regional
  School Nurse Workshops

DURANGO - Wednesday, February 13, 2019
CHERRY CREEK - Tuesday, February 19, 2019
JEFFCO - Tuesday, February 26, 2019
PUEBLO - Wednesday, March 13, 2019
COLORADO SPRINGS - Friday, March 15, 2019
FORT COLLINS - Wednesday, March 20, 2019
LA JUNTA - Tuesday, March 26, 2019
GRAND JUNCTION - Friday, April 5, 2019
DENVER PUBLIC SCHOOLS - Monday, April 29, 2019
Registration available early December, 2018

178                    148
910, 280                             Districts
Students         School             Meet the
                 Districts         Definition of
                                     “Rural”
           109               148
       Districts        Rural Districts
      Meet the             Comprise
     Definition of       16% of Total
     Small Rural            Student
                          Population

School Year                        15-16                 16-17                  17-18

Districts                  56                     62                    76
Other                      5 charter/1 private    4 charter/1 private   7 charter/1 private

# Students                 527,330                706,290               668,754
Represented                58.65 %                78.04 %               73.46%
        Chronic Diseases                % of Students Represented in the Report

Asthma                                      5.5                   6.9        51,505 = 5.6%
Life Threatening                            2.7                   3.3        18,144 = 2.0%
Allergies
Diabetes – T1                              0.31                  0.32        1,975 = 0.20%
Seizures                                   0.74                  0.71        5,203 = 0.57%
Mental Health                               1.9                   1.9        18,620 = 2.0%
High Acuity                                0.27                  0.53         4,061 = 0.4%

YR      14-15         15-16        16-17         17-18
Total Students      65            71            96          131
Known Allergy
YES              49 (75%)     60 (84.5%)    83(86.4%)    98 (74.8%)
NO                  10            10           11            29
Unknown              5             1            1             4
Action Plan
YES              46 (70.8%)   60 (84.5%)    70 (72.9%)   86(65.6%)
NO                   17           10            25          43
TRIGGERS
Food             37 (56.9%)   43 (60.5%)   75 (78.1%)    71 (54.2%)
Insect               0            2            5             8
Exercise             0            0            0             0
Medication           0            1            0             3
Latex                0            0            0             0
Inhaled              0            1            0             3
Unknown          26 (40.0%)   18 (23.6%)   13 (13.5%)    29 (22.1%)

Epinephrine Cont.    14-15            15-16             16-17           17-18
Epinephrine
Total Students
                Reports71(cont)
               65                                          96             131
LOCATION of Event
Off School Grounds      1                2                 3               2
Classroom            39 (60%)       36 (50.7%)        42 (43.75%)      70 (53.4%)
Cafeteria              11               14                 23             21
Health Office           7                3                 7              13
Playground              3                5                 5               9
Bus                     0                0                 0               0
Other                   4                9                 15             15
Epi Pen Storage
Classroom                                                                  7
Self-Carry                                                                27
Health Office                                                          64 (48.8%)
Other                                                                     25
                                                 Administered by RN    48 (36.6%)
                                 Administered by Staff Other than RN   51 (38.9%)
                                             Administered by Student   13 (9.9%)
                      Administered by Other (Parent, Paramedic, EMT)   10 (7.6%)

Cigarettes used to be
considered medicinal !

State/Federal           Theoretical
    Laws                Framework

            School Nursing
               Practice
              Questions

State/District         School Nursing
 Policies &         Standards of Practice
 Guidelines           & Code of Ethics

“…authoritative
statements of the duties
that school nurses,
regardless of role, are
expected to perform
competently.”

 Includes Provisions from
 Code of Ethics for Nurses
 with Interpretive
 Statements – ANA

 Child Well-Being
 Diversity
 Excellence
 Integrity
 Innovation
 Leadership
 Scholarship
NASN: Code of Ethics
ANA: Ethical Issues in School Nursing

Comprehensive Text

Endorsed by NASN

Colorado Department of Agriculture: Under Colorado
State law any Cannabis with a percentage of THC above
0.3% is considered marijuana.
Hemp has a lower concentrations of THC and higher
concentrations of Cannabidiol (

Signed into Law: 3-30-17
(I) THIS PART 1 DOES NOT PROHIBIT A PERSON WHO HAS BEEN
    APPROPRIATELY TRAINED FROM DISPENSING AN OVER-THE-
    COUNTER MEDICATION TO A MINOR AS LONG AS THE
    PERSON HAS WRITTEN INSTRUCTIONS FROM THE MINOR'S
    PARENT OR GUARDIAN AND THERE IS A PHYSICIAN'S
    STANDING MEDICAL ORDER.
(II) THIS SECTION IS NOT INTENDED TO AFFECT THE
     AUTHORITY OF A PROFESSIONAL NURSE TO DELEGATE
     NURSING TASKS.
https://www.cde.state.co.us/healthandwellness/sb033otc-
medication2017pdf

• 7.1 – RN can delegate administration of Prescription
  and non-prescription medication after appropriate
  training
• 7.2 - RN can delegate dose specific emergency
  medications to delegatee after appropriate training
  completed (pre-packaged unit dose removed)
• 7.3 – RN shall not delegate administration of any
  medication that requires assessment, judgment or
  evaluation before, during or immediately after
  administration

• FDA statement regarding risks of using expired medications
• The Colorado Med Admin Training requires meds not to be
  expired
• Continue calling different pharmacy locations
• Other brands of auto-injectors are still available
   • AuviQ
   • Generic
• Parents should work with care providers to develop a plan
• Communicate school’s needs with local first responders
  while maintaining strict confidentiality
The shortage is projected to be resolved in December 2018

Focus on a comprehensive approach
• Prevention
• Preparedness
• Response
Continue to train and verify & document staff competency!
• Colorado Staff Online Training

Potential Risk to Children and Adults:
• Represents an environmental trigger
• Not evidence-based or regulated by FDA
• Should be kept out of reach of children
Guiding Frameworks:
• Childcare Rules – Not allowed
• BOH Rules – Do not mention
Standards of Practice School Nursing - Standard 17.
Environmental Health:
• Reduces environmental health risks to self, colleagues and
  students

Colorado Kids with Diabetes     Rocky Mountain Poison Control
Colorado Talking Book Library   CSU Integrated Pest Management
Attendance Works                Rocky Mountain Hospital for
CDE Brain Injury                Children Pediatric Mobile
                                Simulation
CDE School Medicaid
                                Children’s Hospital Colorado Bug
CDPHE Immunization Resources    Watch
CDPHE Office of Health Equity   CDC Flu Info for Schools
Stop the Bleed Colorado         CDC Handwashing Posters
Emerging RN Leader              Allergy Safe Kids
Safe to Tell Colorado           Colorado Epilepsy Foundation

Thank you for making children the
    center of all that you do!