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Inhalers in schools could save lives

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In 2011/2012, 25,073 children were admitted to hospital because of asthma.1 This equates to approximately 70 admissions per day. Ninety per cent of these admissions could have been prevented had the children had quicker access to an inhaler. Yet school nurses are not allowed to administer asthma medication to children suffering from severe asthma symptoms.

It is illegal to include inhalers in school first aid kits because they are prescription-only medicines (POMs). But this could change in the next couple of weeks. The charity Asthma UK has been campaigning to allow schools to have emergency reliever inhalers in school first aid kits. A petition, signed by 4000 people was submitted to health minister Dan Poulter at the end of April 2014. The petition called for including inhalers in school first aid boxes.

A spokesperson from the Medicines and Healthcare Products Regulatory Agency (MHRA) said: 'Advice from the Commission on Human Medicines (CHM) following an evaluation of risks and benefits, recommended that the regulations be changed to allow schools to keep a spare asthma inhaler containing salbutamol for use in emergencies.'

The Department of Health (DH) last year launched a consultation on asthma inhalers being kept in schools, the results of which will be announced 'shortly' it says.

In 2012, Asthma UK made enquiries as to whether the rules could be changed to allow schools to keep a spare reliever inhaler for use in emergency. The DH consulted with the Department of Education and interviewed teachers and parents to ascertain their feelings on the subject. Staff and parents were almost unanimously in favour of schools being allowed to hold an inhaler for emergency use. Some schools had already implemented effective protocols for holding and using inhalers in an emergency, but because this was not permitted by the legislation some have since stopped.

Since schools are not allowed to receive or supply POMs to their pupils, legislation will need to be amended to allow schools to hold a salbutamol inhaler.

Debbie Waddell, the clinical lead at Asthma UK, with a background in school nursing, said that the introduction of emergency inhalers would need to be accompanied by strict guidance for school nurses and that the inhaler would only be used in emergency situations, when there were no other options for the child.

Asthma statistics in children
  • 5.4 million people in the UK are currently receiving treatment for asthma: 1.1 million children (one in 11) and 4.3 million adults (one in 12).
  • There were 1,167 deaths from asthma in the UK in 2011 (18 of these were children aged 14 and under).
  • An estimated 75 per cent of hospital admissions for asthma are avoidable and 90 per cent of deaths from asthma are preventable.
  • One in 11 children has asthma and it is the most common long-term medical condition in children.
  • On average, two children in every UK classroom have asthma.
  • The UK has among the highest prevalence rates of asthma symptoms in children worldwide.
  • 25,073 children were admitted to hospital with asthma in the UK during 2011/2012: 69 per day, or one every 21 minutes.
  • Asthma prevalence is thought to have plateaued since the late 1990s, although the UK still has some of the highest rates in Europe. On average three people a day die from asthma.

Source: Asthma UK

Campaign concerns

However, some concerns have been raised about whether this campaign really gets to the root cause of the problem. Rosalind Godson, professional officer for school nursing at Unite, said that Asthma UK found that 86 per cent of children say that they have been without their own inhaler at school because they have been forgotten, lost, run out or broken it. 'If emergency inhalers are introduced into schools, these children will still have these problems and it would not be right for parents and children to rely on emergency inhalers at school.'

Ms Waddell says that the introduction of emergency inhalers into schools aims to standardise the level of care provided across schools for asthmatic students, not for them to be used as replacements for a child's own inhaler. 'Schools have to understand that these inhalers should only be used as a last resort. Having to use them would mean that there was a failure to uphold the governance and to manage a child's asthma. Parents are still responsible for ensuring that their children's inhalers are in good condition. Some schools are very good at managing this, but others are not, so hopefully this will help all schools focus on managing asthma.'

Viv Marsh, clinical lead for asthma and allergy at Education for Health and a children's nurse specialising in asthma, backs the campaign to introduce emergency inhalers in schools. 'Emergency inhalers will be voluntary for schools and will be offered with supporting guidance.'

Ms Godson believes there should be a multi-pronged approach to reduce hospital admissions. 'This would include creating healthcare plans within schools, systems to monitor a child's medication and educating parents and children about asthma. I understand where the campaign is coming from, but it needs more.'

School nurses are key in working with parents, students, other healthcare professionals, and school staff to make sure that asthma is continuously monitored over the course of a child's school life.

Healthcare plans

'Asthma UK has conducted research and found that those with action plans are four times less likely to need to go to hospital,' says Ms Waddell. 'School nurses can actively get involved in creating these plans and ensuring that all school staff are aware of them.'

Ms Godson says that it could be useful for school nurses to work with the GPs and practice nurses, to draw up healthcare plans in order to monitor the children that have asthma, in the way that children with severe allergies or insulin dependent diabetes are monitored.

'As asthma is a condition that changes over the course of someone's life, it is important to continuously monitor it, and ensure that the patient is correctly informed on how to deal with it at any given time.'

Healthcare plans would also ensure that all school staff are able to correctly identify the children with asthma and act appropriately during emergencies if a school nurse cannot be reached.

Good practice

In Shropshire, the school nurse team provides guidance for schools and they already train school staff every two years in asthma care for children. All of the schools currently have spacers, which can be used with the child's inhaler, that they have provided, in case of emergency.

All of the children with asthma have individual care plans, which are filled out by the parents including information on the child's asthma triggers and treatments. Ms Ellmore, says that currently these plans are not formed in conjunction with GPs and practice nurses, but they are hoping to copy them into them in the future, so that the information is not repeated.

Ms Ellmore supported the consultation to introduce emergency inhalers in schools. 'I think it will work in harmony with the guidance that we already have in place in Shropshire. However it needs to come with robust guidance for teaching staff and we need to make sure that only children that are identified as asthmatic are given them, rather than any child who appears to have asthmatic symptoms.

School staff

In 2009, a survey of 1600 teachers in England by Asthma UK found only 24 per cent said they would know what to do with a pupil having an asthma attack.2

'If a child has an asthma attack, and there are no healthcare professionals around, the teacher will be required to identify the problem, and administer the medication,' says Ms Godson. 'They need to have the proper support from school nurses so that they feel comfortable enough to do that.'

This highlights a need for school nurses to have the tools to be able to support other school staff when emergencies arise.

However, the provision of asthma training for school staff is not equal across the country. Many schools have no or limited access to a school nurse and in many areas school nurses have no capacity to provide asthma training. It is likely that there are not enough school nurses to be able to effectively monitor children with asthma and that non healthcare professional school staff will not be able to access the relevant training.

Ms Waddell said: 'In an ideal world, it would be great for schools nurses to be involved in the training. But this does raise a capacity issue.'

'As children spend a large proportion of their time at school where they are exposed to a wide range of asthma triggers, it is essential for schools to recognise signs of acute asthma and enable intervention as soon as possible. This does not mean that school staff take on the role of healthcare professionals but that they offer care for individual children. Parents rightly expect their children to be safe at school,' agrees Ms Marsh.

Ann McMurray, a school asthma nurse specialist from Scotland, agrees that to be able to implement the guidance correctly there would need to be education for school nurses and teachers. 'There needs to be a commitment to educate school staff to identify asthma symptoms. In Scotland, in Lothian where I work, we provide annual updates for the school nurses and then they teach the school staff, so they have continuing professional development so they are aware of asthma and allergies and the school nurses develop these sessions. However I am aware that this doesn't happen often.'

'To implement this training [for teachers] the school nurses would need training themselves. Things change whenever the guidelines are updated, so it is important for school nurses to have regular access to CPD around asthma.'

Training and support

Ms Godson recommends enhancing school nurses knowledge so that they can work with parents and children to manage a child's asthma effectively.

This would include ongoing education for children on correct inhaler technique. This is something many children forget and they can pick up bad habits.

'School nurses can work closely with practice nurses, to ensure that children receive regular assessment to ensure that their inhalers are in good condition and that they are using them correctly,' she said.

Different approaches will need to be taken with different age groups Ms Godson says. 'Younger children will need the support of parents or carers and their teachers to ensure that they are using their inhalers correctly and also to ensure that they have their inhalers with them.

'Teenagers on the other hand, need different support. They are old enough to take responsibility for themselves but may not want to use their inhalers or carry them around for fear of appearing different. In this case, school nurses should ensure teenagers understand the importance of using their inhalers when they need them.'

Three quarters of hospital admissions due to asthma are believed to be avoidable through better management at school and at home.

The DH is working closely with Asthma UK to ensure that the introduction of emergency inhalers in schools is accompanied by clear guidance to ensure that they are used correctly by all school staff. At the time of going to press, the results of the consultation and guidance had still not been released but it is believed it will be released shortly.

It is hoped that the introduction of emergency inhalers will be accompanied with clear guidelines to support school nurses. Kirsten Ellmore, a specialist community public health nurse and a school nurse at Shropshire Community NHS Trust, says: 'Without support and training, emergency devices might not be used effectively.

'They should be cautiously used alongside a robust package of training.

'In an ideal world the school nursing service would provide the training for teachers, but this is down to individual areas. If [emergency inhalers were] introduced it would need to be looked at how this will be supported and who will provide that support.'

However, this campaign is widely supported in the hope that it will raise awareness of the fatal consequences that can occur when children with asthma are not monitored and supported correctly.

'I do believe that the campaign is a good thing,' says Ms Godson, 'as it will help to raise awareness for the importance of ensuring children are aware of the implications of their asthma.'

References

1. Asthma UK http://www.asthma.org.uk/asthma-facts-and-statistics accessed April 2014.

2. Missing Out. Asthma UK http://www.asthma.org.uk/scotland-publications. Accessed April 2014.

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