Emergency care for students not enrolled in the school-based health center

In September 2001, Sharon Hobson from the Baltimore City Health Department school-based health centers sought advice from the field on how other centers helped students in emergency situations when those students were not enrolled in the center. What follows are sample responses to this query:

Pat Papa, NP, from Prince Georges’ County school-based health centers reported that:

The school nurse and the clinic staff respond to all emergencies together. We provide emergency care to all students (and staff), without even checking enrollment. To treat asthmatics with a nebulizer – they need to be acutely wheezing and having a moderate amount of difficulty breathing. This was also our policy when I was at Sandtown Winchester in Baltimore. I do not think you have much of an option when a situation is an emergency – or potentially could become a severe respiratory event (like in asthma). At least that is what the lawyers at Dimensions Healthcare stated. I also think that there is an ethical issue
too.

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Donna Amidon from the Minneapolis Health Department weighed in with this comment:

In the Minneapolis SBCs we find this to be a bit of a problem at times. Generally, the school nurse takes care of emergencies. However, if she is not there we are sometimes asked to do it. If it is a true emergency we will do whatever needs to be done initially and contact the parents with the help of school personnel. Our schools have emergency response teams though and they are supposed to deal with emergencies for the most part. It is therefore quite rare that we would be asked to respond. Usually we get involved in after school accidents when students are still in the building for sports or meetings and the rest of the school staff, including the school nurse has gone home. Again, the coaches are ultimately responsible but sometimes they ask for help. With regards to asthma, we have”emergency’ inhalers (albuterol) on hand and have given them to students whom the school nurse has brought in and can verify the student has asthma. She is responsible for contacting the parent initially because we like to have their consent to give the medication at least verbally. We can enroll the student afterwards. Many of these students have a clinic consent from parent on file even if we have not seen them in clinic previously. All students are supposed to turn them in at the beginning of the year or when they enroll. We do not have a nebulizer but the school nurse does. She can only use it with a student who has brought in neb medication and has a consent from parent and MD to give the neb treatment though. Needless to say, she sometimes has to resort to calling 911, especially if we cannot reach parents. The issue of liability is tricky and it is definitely a
gray area. Our attorney says City (code) which governs us would probably cover us for any students in the building where we are, regardless of whether or not the student was a registered patient or not….but it would depend on the circumstances to some degree. One principal told me that if he were a parent and his child had an emergency and the school-based health center was asked to help and refused, he would be more likely to sue us in that case than if we responded the best we could and didn’t have their consent or made a mistake.
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Anne Gribble, PA-C, from the Catawba Adolescent Health Partnership in North Carolina adds this:

In North Carolina, we are developing a credentialing process for our
centers. Many of our centers administer medications, “treat” under emergency situations (acting as first responders), or perform pre-participation physical exams for non-center enrolled students. The credentialing document simply states that we must have a policy in place to address the treatment of non-center students. The following excerpts from the documents are examples:

See also:
North Carolina School-linked Health Centers Credentialing Standards and Evidence of Performance December 10, 1999:

“1.8 SLHC has a written policy concerning treatment of clients who are not
enrolled in the SLHC.

a. When SLHC has been identified as the first responder in a school
emergency situation and client is not enrolled in the SLHC *

b. When SLHC is administering medication and client is not enrolled in the SLHC. When sports physicals are done for clients who are not enrolled in the SLHC (either from the school where the SLHC is housed or from another school)

* Note, a policy statement must address at least a. above. ”

Our center’s Policy and Procedure Manual:

“Students not enrolled in the SBHC Program will not be denied emergency
care. On any day health clinic personnel are not available, other TTHC-CVHS team members or school personnel will contact emergency medical services and/or the student’s parent (based on the severity of the condition) . On the day the health clinic is open, the clinic serves as first responder in emergency situations for all students and staff.”

We operate a SLHC and SBHC. Since our enrollment procedure allows some lateral movement I have not shared some of the other intricacies of our policy.

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Jennifer Pinard, RN, C-FNP from West Virginia writes:

Our center developed a written policy and procedure for Emergency Response. It discusses both our responsibility and the schools’ responsibility in a true medical emergency. It was presented to and approved by our Advisory Board. We emphasize that caring for a child in an emergency (especially a child without a consent) is a JOINT responsibility with the school since we only respond at their request. We do not specify which illness and injury constitutes an emergency so as to leave room for judgment on a case by case basis.

We respond to any true medical emergency regardless of a child’s consent status (unless our response to the school involves abandoning a more critical pt already in our clinic). We offer triage and basic treatment to stabilize a point while the school personnel immediately contact the parents and arrange for them to pick up the child. If the injury is severe or if the parents are unreachable, then we advise the schools to call an ambulance. We limit our treatment to what is truly necessary for stabilization unless a parent gives us witnessed verbal consent to go ahead and do more.

Many parents are very appreciative and give us verbal consent over the phone while they’re en route. Many parents chose to complete a consent form after they interact with us (we send a form home in every situation where a child without consent sought treatment). We’ve only had one occasion where a parent was really upset, but the school personnel backed us on our involvement because they had called us to respond.

A statement that we will respond to an emergency regardless of consent status is included on our consent form, the parent information that we send out to announce our program, and our Emergency Response Policy.

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Eileen Navarro, Family Nurse Practitioner for Teen Xpress in Orlando, Florida, comments:

Our program has consulted with risk management through our hospital regarding these questions. With or without consent for treatment, any asthmatic in distress is treated, while parents are being contacted. I have had cases when family contact information was not accurate and the school assisted in helping through police contact to help with family contact. I have even had a child transported through EMS to the hospital before family contact was made. As healthcare providers at the school, even though our program is not there every day, we are looked at as the expert person on school grounds to help with any and all health needs. Of course, we have to document everything specifically. I usually enlist the help of the school resource officer, who is a police officer for any emergencies that would involve large numbers. Our program has also obtained the school emergency policies for each school individually and submitted those into our emergency policy and procedures. I hope this answers some of your questions.

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Melva D. Visher, program director for the Kaleida Health School Health Program in Buffalo, New York, adds:

In NY State, we are required to provide “first aid” to school students not
enrolled in the SBHC. The first aid will include assessment of minor
injuries, consultation with parents and referral to PCP. First aid for our
program also includes initial assessment of asthma exacerbation (to use your example). Of course, we will provide treatment if the situation is deemed “urgent” or “emergent,” and will consult with the child’s PCP.

At the high school location, we treat “emergencies” on a daily basis, which
will include treatment for sports injuries, fights and altercations
(gang-related, usually), and medical emergencies, such as seizures. All
students receive an assessment, and wound care and dressings (if indicated) whether or not they are enrolled. This is included in our “first aid” treatment. Treatment and continued monitoring, including follow-up care is done for those enrolled. For non-enrolled, the students is referred to their PCP and/or emergency room (the last resort), depending upon the severity of the injury. Most first aid treatments however are for minor injuries, falls, scrapes, minor trauma, etc. We do not charge for these first aid services. All students are entitled to them. We treat every child presenting for any type of emergent or first aid need.
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Carol Veloso of the Urban Health Plan in the Bronx, NY reports:

We send consent forms to be signed home with them as well as having our outreach worker follow-up by phone. We will do this up to three times before we send a letter stating we will not see the child unless a consent is signed. The reality is we would see the child … but this usually works to get a consent signed.
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Liz Feldman, physician with Ravenswood Hospital Family Practice Residency in Chicago adds

In our two school-based health centers in Chicago, we treat anyone for “first aid” – we would do a neb if a kid was acutely short of breath, then we’d send them home with a blank consent form to have their parents sign – or we’d call their parents at the time to discuss follow-up. If they lost their inhaler we’d again give a neb or an inhaler treatment without consent, then work to get consent as soon as possible.