Procedural Guidelines

In this section

• Process for the Identificuation of Students with Life-threatening Food Allergies and Glycogen Storage Disease
• Process for Annual Development of IHCP and Action Plans
• Administration of Medications
• Communication Plans
• Provisions for Initial and Ongoing Education and Training for School Communities
• Prevention Measures
• Food Service and Food safety Considerations
• Monotoring Effectiveness of District Plan and Procedures

 

The following procedural guidelines address considerations that have district-wide implications and may be adopted into district procedures. When these considerations are not addressed in district management plans or district procedures for food allergy and GSD, they will need to be considered by school teams when developing IHCPs and action plans for students with life-threatening food allergies and GSD.

Process for the Identification of Students with Life-threatening Food Allergies and GSD

School district should develop and implement strategies for the early identification of students with life-threatening food allergies and GSD. Strategies may include using the school district’s Web site, school newsletters, kindergarten registration, school nurse communications with families (such as, new student health history form) and communication with community preschool programs. These strategies for identification of students with life-threatening food allergies and GSD facilitate proper planning prior to the beginning of the school year.

 

Process for Annual Development of IHCPs and Action Plans

Districts procedures should include a formalized process for the development of IHCPs and action plans for students with life-threatening food allergies and GSD. This process should include:

• a standardized template for the development of IHCPs and action plans;
• recommendations of team members who should be involved in the development of IHCPs and action plans;
• a process to obtain medical information and proper authorizations to administer medication from the student’s health care provider and parents; and
• a process to develop other accommodations within IHCPs and action plans (such as, allergen-free zones in the cafeteria for students with allergies or provision of food or dietary supplements to students with GSD, when needed, in the classroom).

 

Administration of Medications

Medication administration for students with life-threatening food allergies and GSD must follow school district’s policy and procedures regarding medication administration. Medication administration at schools and at school activities must be in compliance with Section 10-212a of the C.G.S. and Sections 10-212a -1 through 10-212a -10 of the Regulations of the Connecticut State Agencies.

Who May Administer Medications During the School Day?

“Qualified personnel” for schools means:
a) a full-time employee who meets the local or regional board of education requirements as a principal, teacher, occupational therapist or physical therapist and has been trained in the administration of medication in accordance with Section 10-212a-3 of these regulations;
b) a coach and licensed athletic trainer who has been trained in the administration of medication pursuant to Section 10-212a-8 of these regulations; or
(c) a paraprofessional who has been trained in the administration of medication pursuant to Section 10-212a- 9 of these regulations. For school readiness programs and before- and after-school programs, directors or director’s designee, lead teachers and school administrators who have been trained in the administration of medication may administer medications pursuant to Section 10-212a-10 of these regulations (Section 10-212a-1 Definitions,2010).

In the absence of a licensed nurse, only qualified personnel for schools who have been properly trained may administer medications to students as delegated by the school nurse, specifically:

• qualified personnel for schools may administer oral, topical, intranasal or inhalant medications;
• medications with a cartridge injector may be administered by qualified personnel for schools only to a student with a medically diagnosed allergic condition which may require prompt treatment to protect the student against serious harm or death;
• coaches and licensed athletic trainers during intramural and interscholastic events may administer medications pursuant to Section 10-212a-8 of the Regulations of the Connecticut State Agencies; and
• paraprofessionals, if approved by the local or regional board of education, may administer medications, including medication administered with a cartridge injector to a specific student with a medically diagnosed allergic condition that may require prompt treatment in order to protect the student against serious harm or death pursuant to Section 10-212a-9 of the Regulations of Connecticut State Agencies.

When developing IHCPs and action plans for students with GSD, those plans must include, but not be limited to, “the provision of food or dietary supplements by the school nurse, or any school employee approved by the school nurse, to a student with glycogen storage disease provided such plan shall not prohibit a parent or guardian, or a person designated by such parent or guardian, to provide food or dietary supplements to a student with glycogen storage disease on school grounds during the school day” (Public Act 12-198, 2012).

Training for Medication Administration

The school nurse provides the training on administration of medication, at least annually, to all qualified personnel to whom they delegate the administration of medications. This training must include, but not be limited to:

• the general principles of safe administration of medication;
• the procedural aspects of the administration of medication, including the safe handling and storage of medications and documentation; and
• specific information related to each student’s medication and each student’s medication plan including the name and generic name of the medication, indications for medication, dosage, routes, time and frequency of administration, therapeutic effects of the medication, potential side effects, overdose or missed dose of the medication and when to implement emergency interventions (Section 10-212a-3 Training of school personnel, 2010).

Boards of education must maintain documentation of administration of medication trainings as follows:

• dates of general and student-specific trainings;
• content of the training;
• individuals who have successfully completed general and student-specific administration of medication training for the current school year; and
• name and credentials of the nurse or school medical advisor trainer or trainers (Section 10-212a-3 Training of school personnel, 2010).

Supervision

The school nurse is responsible for general supervision of administration of medications in the schools to which that nurse is assigned. This must include, but not be limited to:

• availability on a regularly scheduled basis to:
  • review orders and changes in orders and communicate these to the personnel designated to give medication;
  • set up a plan and schedule to ensure medications are administered properly;
  • provide training to qualified personnel for schools and other licensed nursing personnel in the administration of medications and assess that the qualified personnel for schools are competent to administer medication;
  • support and assist other licensed nursing personnel and qualified personnel for schools to prepare for and implement their responsibilities related to the administration of specific medications during school hours;
  • provide appropriate follow-up to ensure the administration of medication plan results in desired student outcomes; and
  • provide consultation by telephone or other means of telecommunication. In the absence of the school nurse, an authorized prescriber or other nurse may provide this consultation.
• implementation of policies and procedures regarding all phases of administration of medications;
• periodic review of all documentation pertaining to the administration of medications for students;
• observe competency to administer medications by qualified personnel for schools; and
• periodic review, as needed, with licensed nursing personnel and all qualified personnel for schools regarding the needs of any student receiving medication (Sec. 10-212a-7 Supervision,2010).

(See Appendix E for state statutes and regulations.)

Standing Orders

School procedures should include a standing order from the school medical advisor for school nurses to administer epinephrine to students who are not known to have a life-threatening food allergy, do not have their own medication order and have their first anaphylactic reaction in school. This standing order should also include an order to administer a second dose of epinephrine if the symptoms of an anaphylactic reaction have not subsided within a specified number of minutes with the first dose of epinephrine. These orders need to be reviewed and signed by the school medical advisor on an annual basis.

 

Communication Plans

Communication is essential for the implementation of an effective district plan. Defining expectations for communication and privacy issues between relevant school staff (such as school nurses, teachers and administrators), families and the student’s health care providers includes:

• obtaining documentation by the student’s health care provider of the life-threatening allergies and GSD, which includes the proper authorizations for medications and emergency response protocols;
• developing a communication process with the student’s health care providers and parents regarding individual student’s prevention and management plans;
• establishing communication systems within the school (such as, walkie-talkies) and during off-site activities (such as, cell phones or radios on school transportation and field trips);
• determining communication processes between school and all parents, including standard parental notification letters regarding allergen classrooms; and
• establishing procedures that ensure the appropriate people (such as teachers, paraprofessionals, custodian, bus driver and substitute staff) are familiar with IHCPs and action plans.

 

Provisions for Initial and Ongoing Education and Training for School Communities

Each school district will need to answer questions based upon their local needs for education and training regarding life-threatening food allergies and GSD. Questions may include:

• why are we doing this education and who will conduct it?
• will this education be offered on a school or district-wide basis?
• who will attend these educational opportunities?
• what are the key messages that need to be delivered? and
• how often will this education occur?

Education and training regarding life-threatening food allergies and GSD should include:

School Nurses

School nurses may need to update clinical knowledge and skills related to severe food allergy and GSD in school settings. This would include information pertaining to:

• allergies;
• types of GSD and associated management strategies;
• IHCPs;
• action plans for emergencies;
• transportation plans and issues;
• accommodations within regular education;
• requirements of Section 504 and appropriate school district policies and procedures;
• collaborating with families; and
• implications of normal development in drafting care plans and action plans.

School Personnel

School nurses in collaboration with students, parents of students with life-threatening food allergies and GSD and school medical advisors should provide education to relevant school personnel such as classroom teachers, substitutes, school administrators, school food service staff, custodians, bus drivers, coaches and other on-site persons in charge of conducting before- and after-school activities. This education may include:

• overview of life-threatening food allergies;
• overview of GSD;
• prevention strategies;
• IHCPs;
• action plans for emergencies;
• medication training (if appropriate);
• food safety;
• sanitation; and
• specific accommodations.

Parents

School nurses in collaboration with school administration may provide education to parents of students with life-threatening food allergies and GSD. This education may include:

• general information (such as, anaphylaxis, hypoglycemia);
• school medication policies and procedures; and
• school policies and procedures related to the development of school plans to manage life-threatening food allergies and GSD.

School and community partners

School nurses in collaboration with school administration, school medical advisors and parents of students with life-threatening food allergies and GSD may provide education to the school and community partners (including parents of children without life-threatening food allergies and GSD, health care providers and parent volunteers). This education may include:

• overview of life-threatening food allergies;
• overview of GSD;
• general terms (such as anaphylaxis, hypoglycemia, epinephrine, glycogen);
• prevention strategies; and
• school policies and procedures.

Students

School nurses in collaboration with school administration and disease specific educators may provide education to students with life-threatening food allergies and GSD and their peers. This education may include:

• overview of life-threatening food allergies;
• overview of GSD;
• general terms (such as anaphylaxis, hypoglycemia, epinephrine, glycogen);
• school policies on prevention strategies, such as prohibiting food swapping and allergen free zones; and
• school policies on bullying and teasing.

Strategies to promote self-advocacy and competence in self-care are often incorporated into IHCPs and action plans for students with life-threatening food allergies and may include:

• collaborating to help families and school staff define appropriate responsibilities for children at each developmental stage. These may include making food choices in the school cafeteria and educating peers about life-threatening food allergies and hypoglycemia; and
• determining appropriate steps for safety in the context of children’s need to assume responsibilities in order to learn and develop self-care.

 

Prevention Measures

Each school district should consider district-wide preventive measures. If these issues are not addressed district-wide, consideration of these measures may be incorporated into IHCP and action plans, when appropriate. These measures include:

• establishing effective sanitation and cleaning measures, such as cleaning of lunch table and classroom surfaces with disposable paper towels and cleaning products known to effectively remove food proteins;
• promoting hand-washing practices following eating to prevent cross-contact using recommended procedures of soap and water or hand wipes when soap and water are not available. Hand sanitizers are not effective for removing food allergens or dirt;
• enforcing safe practices among students, such as prohibiting meal/snack swapping, utensil swapping among students and prohibiting eating on school transportation;
• options for allergen-free zones such as the classroom, lunch tables or cafeteria zone to decrease exposure to allergen;
• options for food-free common areas (such as libraries, music and art rooms);
• developing common practices for alerting and assigning substitute staff for school nurses and teachers;
• providing supervision in the cafeteria and on school grounds by school staff trained in recognizing adverse symptoms of food allergies and GSD (such as anaphylaxis and hypoglycemia) and action plans;
• planning for school celebrations (such as, birthdays, school parties and holiday events) which may include alternatives to food for celebrations and provisions for allergy-free foods for celebrations;
• planning for school emergencies (such as, fire drills and lockdowns) which should include considerations for access to medications, access to food or dietary supplements for students with GSD or allergy-free foods for students with food allergies; and
• adhering to Occupational Safety and Health Administration (OSHA) and Universal Precautions Guidelines for disposal of epinephrine auto-injectors after use and tubes for tube-feedings after use.

 

Food Service and Food Safety Considerations

Meal substitutions for medical or other dietary needs

“Regulations for United States Department of Agriculture (USDA) school nutrition programs require that all meals served to students must meet the USDA’s specific menu planning and nutrition requirements. However, food substitutions and other modifications to the meal patterns may be necessary to meet the dietary requirements of:

• children who qualify for a disability under Section 504 of the Rehabilitation Act of 1973 (Section 504);
• children who are eligible for special education under the IDEA; and
• children with other special dietary needs.

Examples of possible modifications include food restrictions, texture changes (such as, pureed, ground, chopped or thickened liquids), increased or decreased calories, tube feedings and carbohydrate counts” (CSDE, Accommodating Special Dietary Needs in School Nutrition Programs, 2011).

“The USDA nondiscrimination regulations (7 CFR 15b) and regulations governing the school nutrition programs require substitutions or modifications in meals for children who are considered disabled under Section 504 or the IDEA and whose disability restricts their diet, when the need is certified by a licensed physician. Substitutions are also required when a physician determines that a child’s severe medical condition requires specific dietary modifications, even if the child is not considered disabled under Section 504 or the IDEA” (CSDE, Accommodating Special Dietary Needs in School Nutrition Programs, 2011).

Generally, the school nurse has the lead in obtaining appropriate documentation such as medical statements. It is essential that this information is communicated to the district’s school food service director. Collaboration with food service staff is essential to assist students with life-threatening food allergies and GSD participate in the school meal program. With documentation from the student’s health care provider, meal substitutions can be made to ensure that students are provided with food choices that avoid certain foods. To the extent possible, school food service staff should provide parents with food labels so that they can identify and approve which foods that their child may select for meals in school.

“It is important for families to understand that the school food service program cannot provide food substitutions or modifications without an adequate diet order or diet prescription signed by the appropriate medical personnel. In some cases, it may be appropriate and helpful for the physician to provide a written referral to a registered dietitian or other qualified professional for diet substitutions” (CSDE, Accommodating Special Dietary Needs in School Nutrition Programs, 2011).

“USDA regulations permit substitutions or modifications in meals for children without disabilities who are unable to consume the regular meals because of medical or other special dietary needs. School food service programs may choose to make these accommodations on a case-by-case basis but the USDA does not require these substitutions” (CSDE, Accommodating Special Dietary Needs in School Nutrition Programs, 2011).

The CSDE’sAccommodating Special Dietary Needs in School Nutrition Programs contains detailed information on providing meals for children with special dietary needs, based on federal laws, USDA regulations and Connecticut laws and regulations. It is available on the CSDE’s Web site.

Food Safety

The DPH Food Protection Programs governs the state food safety regulations. The Food Protection Program’s overall mission is to reduce the risk of food-borne disease by ensuring reasonable protection from contaminated food and improving the sanitary condition of food establishments. This is accomplished by enforcement of regulations, training and education, technical consultation, special investigations, and food safety promotion. For information regarding food safety and the DPH Food Protection Program, visit DPH’s Web site.

 

Monitoring Effectiveness of School District Plan and Procedures

Ensure periodic assessments of the effectiveness of the school district plan and procedure. Assessments should occur:

• at least annually with the school district team;
• after each emergency event involving the administration of medication to determine the effectiveness of the process, why the incident occurred, what worked and did not work in the district plan and procedures; and
• include medically-accurate, research-based practices in the annual review of the plan and procedures.