N o r t h C a r o l i n a
Annual School Health Services Report
2 0 1 1 - 2 0 1 2
North Carolina Department
of Health and Human Services
Division of Public Health
Women’s and Children’s
Children and Youth Branch
School Health Unit
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Table of Contents
Executive Summary 1
Survey Population 5
Profile of Students Enrolled in N.C. Public Schools 5
Profile of Nurses Employed in N.C. Public Schools 6
Employment and Financing of School Health Services 10
School Health Services 13
Chronic Health Conditions 13
Diabetes – Compliance with State Law 15
Health Care Coordination and Case Management 16
Student Health Outcomes 17
Health Care Treatments and Procedures at School 18
Emergency Care 19
Medications at School 20
Health Counseling 24
Pregnancy 25
Tobacco Use by Students 27
Suicide/Homicide 27
Health Teaching 28
Health Screening, Referral, Follow-up and Securing Care 29
Health Policies 33
Community Involvement in School Health Services 35
School Health Advisory Councils 35
Cooperative Agreements with Local Health Departments 35
School – Located Influenza Clinics 35
School Based – School Linked Health Centers 36
Conclusion 37
Appendices 39
Appendix A: Chronic Health Conditions 39
Appendix B: Reported Injuries 41
Appendix C: School Nurse to Students Ratio by LEA 42
Appendix D: Map of School Nurse to Students Ratio 44
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Executive Summary
th largest
state public school system in the country.1
More than 1.4 million children were enrolled
in North Carolina public schools during the
2011-2012 school year, an increase of 8,473
students from the previous school year. North
of health-related barriers to learning is crucial
to the academic success of every student. By
the beginning of school year 2005-2006, North
health services in every school district. This
goal became a priority of the N.C. Public Health
Task Force. Subsequently, the state’s Division
of Public Health, the American Academy of
Pediatrics, the Centers for Disease Control
that every public school student in North
Carolina have access to a school nurse in a
Over the years, the state has made
comprehensive school health services a
priority through strategies such as the N.C.
Healthy Schools Coordinated School Health
Program, the School Health Advisory Councils
Assembly, and establishment of a School
Health Cabinet at the highest levels of state
government. Other strategies include the
funding directed toward school health services
provided through the Department of Public
including the state and regional school health
nurse consultants, among others.
During the 2011-2012 school year, the number
slightly from the year before from 1173.5 to
School nurses in North Carolina are employed
by a variety of agencies. Among the 115
three-quarters of the school health programs
are administered by the school districts
themselves. The remaining quarter of the
programs are administered by local health
of all three. Funding for school nurse
including local and state funds, federal
Title V block grant dollars, categorical funds,
management, supervision and
payment, regardless of funding
LEA 81 70%
Health Department 16 14%
Hospital 3 3%
Health Alliance 2 2%
13 11%
of school nurses this past year ensured that,
1:1201 in 2010-2011, to 1:1179 in 2011-2012.
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1998, about 556 school nurses delivered
carried caseloads of about 2,450 students
each. Over the past dozen years, the number
of students in the average nurse’s caseload
has been cut by more than half, enabling
more students to access health services
from a school nurse.
principles of professional nursing remain
consistent, the school nurse also must possess
skills related to:
to visitors to residents.
growth and development.
unique health issues of children and
adolescents.
may be related to a health problem.
Ability to problem-solve in order
and health needs into the challenges
of school.
Knowledge of, and ability to, implement
school nursing services in the federal and
state programs designed for students with
Ability to put epidemiological principles
clusters of symptoms that may indicate an
emerging health threat for students and
emerging issues, to educate the school
community and implement evidence-based
problems.
crisis.
health professional.
nurse’s role within the broader health care
system in support of families and children.
Ensures compliance with school
entry health requirements such as
Provides care and nursing case
management for students with chronic
health problems.
Assures the health and safety of the
Takes a lead role in managing disasters
and planning for emergencies.
programs.
Assures school compliance with state
and safety.
advocates for necessary resources.
in student care between the school and
the student’s medical home provider.
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standard by which school nurses are judged
to have the knowledge and skills necessary
to provide these health services. During 2011-
nurses, as a percentage of the total number
of school nurses in North Carolina, increased
slightly, by 1 percentage point to 53 percent.
North Carolina remains the state with the
nurses in the country.2
The skills and knowledge that the school nurse
dual goals of improving both a student’s health
and academic achievement. Data about these
improved outcomes are described further
under the heading “Student Health Outcomes,”
this report.
School nurses also provide general health
2011-2012 school year, the nurses reported
programs for students.
managing the care of students with chronic
During 2011-2012, the most common chronic
students in North Carolina, as reported
by the nurses who care for them, included
As part of care management, school nurses
develop individual health care plans and train
procedures delegated by the nurse to school
state’s school nurses developed 105,760
individual health plans for those students.
More than half of those plans, 54,965, were
for students with asthma. For each plan, the
individual student’s medical orders and
individual needs were assessed, goals for
members were trained and the student’s
health status following treatment was
evaluated.
and health maintenance were discussed.
During the 2011-2012 school year, school
nurses provided 248,443 health counseling
nurses facilitated health screenings conducted
in schools. Over a half-million school children
students were reported as seen by physicians
or eye care professionals as a result of the
referrals from school health professionals
to obtain comprehensive eye exams.
Nurses received 115,722 physician orders
ordered to be given regularly during each
use, as well as drugs ordered to be on hand
should the student need them. Drugs ordered
to be available included those for emergencies
headaches and other ailments. The school
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nurse reviews the orders prior to administer-of
the order by a Registered Nurse trained
to be given, can reduce the incidence of
to students, the incidence of errors and risks
reduced quickly.
School nurses work with their local School
Health Advisory Councils to develop and
implement local programs designed to prevent
illness and promote health. The SHACs are
mandated by the North Carolina State Board
disaster and emergency planning for their
to grow, so must the availability of school
is reached and, ideally, there is at least one
school nurse in every school in North Carolina.
Methodology
by school nurses based on their recording and
knowledge of health services provided in their
assigned schools. The survey instruments are
for use as surveillance or prevalence data. Data
specialists and school health nurse consultants
in the N.C. Division of Public Health’s Children
and Youth Branch developed the survey
electronically. These data address health
services in North Carolina public schools, not
schools. This report also does not include data
from federal schools, such as those on military
in private or parochial schools.
The data were collected and sorted by Children
in the School Health Unit and the Best
3
from other sources, including:
North Carolina Department of Public
Instruction;
North Carolina Department of Health and
Human Services, Division of Public Health,
Women’s and Children’s Health Section;
The National Society to Prevent Blindness
North Carolina Affiliate, Inc., and
North Carolina Child and Family Support
Teams Initiative.
by request.
Contact:
Ann Nichols, State School Health Nurse Consultant,
Ann.Nichols@dhhs.nc.gov
Carol Tyson, School Health Unit Manager,
Carol.Tyson@dhhs.nc.gov
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3 D ATA S O U R C E S
N.C. Annual School Health Nursing Survey: Summary Report of School Nursing Services 2009-2010
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North Carolina Annual School Health Services
Report. For each school year since 1996-1997,
the North Carolina Division of Public Health
collected school health data from each school
district. This report summarizes data for school
health services as reported by school nurses
during school year 2011-2012 and provides
The survey of the school health service
programs also asks for comments regarding
outcomes and successes during the past school
year and goals for future years. This report
of successful outcomes; they are labeled
student health issues.
S u r v e y P o p u l a t i o n
in North Carolina Public Schools
school children are as diverse as the state’s
4 They come from all socio-economic
backgrounds and represent
ethnic backgrounds from around the globe.
in our schools are: Black or African American,
26.3%; Asian, 2.6%; Hispanic, 13.5%; American
student’s ability to learn. Nearly 12 percent
of the state’s public school children have
degree that they are eligible to receive
from ages 3 through 21. During the 2011-2012
school year, approximately 19,928 preschool
students and 172,157 students ages 6-21
in grades kindergarten through 12th were
enrolled in EC programs.5 The incidence of EC
enrollment peaks at around age 10; among
students receiving EC services, one out of
every ten is 10 years old.6
assistance of school nurses, as many of them
primary disability that require health care
school nurses are assigned to work exclusively
in the EC program.
All students eligible for EC services must meet
criteria for one primary disability from among
13 eligible categories, and may meet criteria
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students.
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6
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L O C A L O U T C O M E
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among students in EC programs in North
Carolina, “other health impairment” was
the second most frequent primary disabil-brain
injured,” “visual impairment,” “hearing
impaired,” “orthopedically impaired” and “mul-in
planning and caring for the student with a
and overseeing nursing care provided by other
general supervision of other nurses in the
provided care to students who were medically
fragile and needed care on a one-on-one basis
under the supervision of a registered nurse as
required by the N.C. Board of Nursing. LPNs
may be hired by the school system or by an
agency to provide direct care to an individual
student who needs such a level of nursing care
provided by a teaching assistant.
The physical well-being of children when they
to success in school, according to the N.C.
government and the federal government
provide funding for students in pre-school
programs to promote future success in school.
In the public schools, those students enroll
in More at Four Pre-Kindergarten programs,
Preschool. The state’s school nurses serve
pre-K students to maximize their ability
to be “healthy and ready to learn” at
kindergarten entry, partnering with the
community to provide health screening and
health services to the children and their
families. During the 2011-2012 school year, the
school nurses reported serving 24,135 pre-K
students. Many of these preschoolers have
in preschool, 19,928 students, are enrolled
7 Although
enrolled due to speech impairments or
language delays and about 40 percent have
developmental delays. The remaining 12
student enrollment is not counted in this
survey for purposes of the formula that results
in N.C. Public Schools
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L O C A L O U T C O M E
experiences, skills and knowledge than that
of nurses working in acute care or even other
has a crucial role in the seamless provision of
comprehensive health services to children and
youth.8
of May 2008 states that increasing numbers
of students enter schools with chronic health
the school day. School nurses provide
outcomes. In North Carolina, the school nurse
as the coordinator, of the local School Health
Advisory Council. School nurses are involved
in each of the eight components of a
Coordinated School Health Program: health
counseling and psychological services, healthy
school environment, and family/community
involvement.
of School Nurses
School nurses are registered nurses, licensed
by the North Carolina Board of Nursing.
registered nursing is through one of three
routes: a bachelor’s degree from a four-year
college or university, an associate degree in
nursing from a community college or technical
college, or a diploma conferred by a hospital.
leaders in school health, and in part by
requirements of funding partners, the level
in North Carolina has increased steadily over
the years. It increased again this year, with 85
percent of school nurses holding bachelor’s
degrees or higher during the 2011-2012 school
year.
are new to the specialty of school nursing learn
Division of Public Health and its co-sponsors,
school district, health department or hospital
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8 American Academy of Pediatrics: Policy Statement “Role of the School Nurse in Providing School Health Services” May 2008.
Master’s
6%
B.S.N.—Bachelor of Science in Nursing
A.D.N.—Associate Degree in Nursing
Diploma
2% ADN
11%
Unknown
3%
BSN, BS, BA
78%
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L O C A L O U T C O M E
Carolina nurses working in public schools hold
As a rule, school nurses in North Carolina have
nurse in acute care and community health
specialty. During the 2011-2012 school year,
74 percent had more than three years’
needs; and 1:1 for some individual students
nursing services.9
would allow all students to have their health
10
working solely as administrators, without
caseloads of students, were not counted
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People 2010.
10
employers. The N.C. Board of Nursing requires
state’s registered nurses to renew licensure.
through the nine regional Area Health
of colleges of nursing, and through the Public
Health Nursing Professional Development
delivered through a network of state and
regional nurse consultants within the N.C.
Division of Public Health.
Since 1998, the N.C. Department of Public
date of employment. School nurses not
employed by LEAs are encouraged, and
in some cases required, through their funding
of achieving this increasingly recognized
exam that encompasses the full realm of
school nursing, both from clinical and student
that school nurses experience a full year in the
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L O C A L O U T C O M E there were 1201.81 FTE budgeted school nurse
year, 28.31 more than 2010-2011.
Each school district in North Carolina must
have at least one registered nurse available
to provide school health services, though only
only one. The number of schools assigned
to each school nurse varies from one-to-ten
with an average of two schools per nurse.
varies widely from LEA to LEA. At the end of
the 2011-2012 school year, the statewide
1:1,179. Most LEAs showed improvement,
to 1:3,650 in Davidson County Schools. For a
by LEA, see Appendix C.
School Year
2007-2008
School Year
2008-2009
School Year
2009-2010
School Year
2010-2011
School Year
2011-2012
Schools*
Agencies
2,354 2,399 2,422 2,425 2,512
Students** 1,404,957 1,410,497 1,402,269 1,409,895 1,417,458
School Nurse
FTEs
1,146.51 1,169.04 1,183.36 1173.50 1201.81
Average N.C.
School Nurse/
1:1,225 1:1,207 1:1,185 1:1,201 1:1,179
School Nurse
Personnel
1,266 1,231 1,233 1,231 1,244
* Public Schools of North Carolina, “Facts and Figures 2011-2012”, February 2012.
**
The following chart shows the yearly changes
in the number of North Carolina public school
small number of school nurses are employed
10
School Health Services
Employment
School nurses are primarily employed by their
responsibility for 69 percent of school health
service programs in North Carolina lies within
hires, supervises, and manages the school
those services, and in the remainder, there is
more than one agency providing oversight and
management of the school nurses.
districts (LEAs)*
70%
Health Department 14%
Hospital/ Health
Alliance
5%
agencies
11%
* rounded to the nearest percent
Funding
In any school health program, the funding
may come from a variety of sources and be
responsibility over the program. Rarely is the
through a sole source.
Funding sources include: local tax revenue,
through property taxes allocated to the
local school and local health department;
federal reimbursement, including approved
Medicaid expense reimbursements or
federal Title V grants and categorical funds;
nurses were funded through non-categorical
State categorical funds for school nurses
of the school nurses: Child and Family Support
health needs of school-age children and the
funds through the School Nurse Funding
the end of the 2011-2012 school year, the state
allocated through the SNFI program. These
funds are distributed by the N.C. Division
of Public Health to local health departments,
which may employ the nurses or may contract
to employ the school nurses.
In 2005, the Child and Family Support
been reauthorized in the 2007, 2009 and
2011 state budgets. It is the state’s only
inter-departmental, school-based family-centered
student support service system.
Leadership for the CFST comes from the North
Carolina Child and Family Leadership Council
and the Secretary of the Department of Health
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members include the Secretary of the
of school nurses and school social workers
assigned to schools in 21 selected districts
recurring funding for 79 of the teams, while
out-of-home placement due to physical, social,
to screen them for needed services; and then
to provide family centered services to plan
period of July 1, 2010 through March 31, 2012.
end-of-grade scores. It did show that students
services through the CFST program, and that
students in 3rd-8th grade who were referred
by the CFST team to tutoring services
experienced improved math and reading
scores in the school year in which they
received tutoring.
increase funding for school nurses, the number
between the 2003-2004 and 2010-2011
school years. The labor demand for all nurses,
the complexity of student health needs has
grown. School health program supervisors
retaining school nurses. In the 2011-2012
majority of the school year.
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School Health Services L O C A L O U T C O M E
School nurses provide basic and
including children with special health care
A number of these children – about one of
performance, and the students’ physical and
work closely with students, their families,
learning. Nurses serve as case managers,
environment. The number of unduplicated
individual students with chronic health
was 232,183 in 2011-2012, approximately 16.4
percent of students. The number of reported
students diagnosed with more than one
past decade. The number and percent change
illustrated in the following table. The chart
counted and also indicates the number of
care plans.
Asthma, a major chronic illness among
school children, is the leading cause of school
experts on lung disease. The number of North
Carolina students known to school nurses
to have asthma during 2011-2012 school year,
was 105,542.
Severe allergies, such as peanut allergies or
at school. During the 2011-2012 school year,
30,008 students were listed as having severe
allergies, 5,202 more than during school year
2010-2011.
There was a slight decline in the number of
students reported with diabetes, to 4,803.
School nurses provide care as well as train
who bring to school increasingly complex
needs and high technology. The school nurse
works with the student, family and physician
school personnel who are designated as
14
in 2003 to assure consistent care for students
with diabetes during the school day. Students
with diabetes are also encouraged to self-manage
their symptoms, which will most likely
Diabetes: Among the 4,803 students
reported with diabetes 2011-2012:
3,915 monitor blood glucose at school
at school;
1,698 manage insulin pumps; and
2,778 are known to self-carry their
Students in North Carolina public schools
in students with asthma, severe allergies and/
to increase in popularity. This past year, 3,454
more students with asthma, 1,338 more
students with severe allergies, and 1,077
more students with diabetes selected that
student to a registered nurse his or her ability
appropriately, and to understand when
to seek assistance. Students who are not
able to demonstrate that ability and
temporarily suspended and instead receive
students who are able to self-medicate for
seek the help of a school nurse to assist them.
Number 10-11 Number 11-12 compared
to all diagnosed
Asthma inhalers known
for self-carry
22,701 20,645 20%
for self-carry
3,681 2,778 77%
Epinephrine auto injectors
known for self-carry 4,910 3,909
17% of students with severe
allergies; 36% of students with
orders for injectors
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Number of Individual
11
And Percent Change Per Year
School Year
Number
and Percent
00-01 131,589
01-02
02-03
03-04
04-05
05-06
06-07
07-08
08-09
09-10
10-11
11-12 12
Diabetes – Compliance with
State Law
School Health Unit of DPH surveyed all public
schools in North Carolina, including charter
compliance with the act. All public schools
school year 2011-2012:
1. How many students with diabetes were
enrolled in your LEA/charter school this
generalized diabetes training to school
3. Did your LEA/charter school have at least
two persons who were intensively trained
on diabetes care, in any school in which
one or more students with diabetes were
4. How many students with diabetes had an
school nurse or other health care provider
Public, non-charter school districts
reported:
Number and percent
of school districts with
one or more students
with diabetes
Number of students
with diabetes
generalized training
about diabetes
system-wide, as
required by the statute
Students with
diabetes who had an
Individual Health Plan
or student over age 18
In each school where
one or more students
with diabetes were
enrolled, there were
two or more persons
intensively trained
on diabetes care
services report does not otherwise contain
summarizes data provided by charter schools
reported:
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L O C A L O U T C O M E
Charter schools reported:
Number and percent
of charter schools with
one or more students
with diabetes students with
Number of students
with diabetes
generalized training
about diabetes
wide, as required
by the statute
schools that had one
or more students with
Students with diabetes
who had an Individual
completed by a school
nurse or other health
or student over age
In each school where
one or more students
with diabetes were
enrolled, there were
two or more persons
intensively
schools with one or
more students with
Case Management
variety of strategies to communicate with all
those involved in the care of a student. Nurses
community agencies and families while
of students. Among the strategies school
nurses enlist to provide health care
making visits to the homes of students. More
than 11,187 home visits were conducted
during the 2011-2012 school year to assist
families with student health issues, to
health plans with parents and to visit
back to school.
Nursing case management has been found
to be an evidence-based model for
In 59 school districts, the process has been
formalized into a case management program
with core components of assessment, health
care management, community resources and
for a student with special health care needs
produced outcomes that indicate increased
in school, and students who receive case
management services from a school nurse
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L O C A L O U T C O M E
School nurse consultants made a concerted
management, even in schools without a
formalized case management program.
improvement in students’ skills in improving
their self-care, reducing their own exposures
to allergens in order to reduce the need for
and ability to manage their illnesses. Raw
numbers of students receiving school nurse
case management are tallied in the following
table. The tables below demonstrate the
provided case management of students:
Student Health Outcomes
Case Management:
Asthma Student Outcomes
students
measured
students who
demonstrated
improvement
students
measured who
demonstrated
improvement
1. Consistently verbalized an accurate
knowledge of the pathophysiology of
2,124 1,770 83%
2. Consistently demonstrated the correct
use of asthma inhaler and/or spacer
2,328 2,062 89%
3. Accurately listed his/her asthma triggers 2,142 1,827 85%
pulse oximeter parameters according to
care plan
506 395 78%
5. Improved amount and frequency of 1,169 956 82%
6. Improved grades 810 600 74%
7. Decreased number of absences 1,168 941 81%
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School Nurse
Case Management:
Diabetes Student Outcome
students
measured
students who
demonstrated
improvement
students
measured who
demonstrated
improvement
1. Consistently verbalized an accurate
knowledge of the pathophysiology of
904 737 82%
2. Consistently maintained normal blood 753 561 75%
3. Demonstrated improvement in the ability
to correctly count carbohydrates
649 544 84%
816 738 90%
285 226 79%
6. Calculated and delivered own dose of 614 520 85%
7. Improved grades 442 328 74%
8. Decreased number of absences 582 426 73%
School Nurse
Case Management:
Weight Counseling Student Outcome
students
measured
students who
demonstrated
improvement
students
measured who
demonstrated
improvement
1.Consistently verbalized accurate 288 214 74%
2. Kept a daily food diary for at least 30 days
and as needed
69 47 68%
school
177 151 85%
4. Consistently improved the ability to select
choices
279 206 74%
5. Improved overall grades 78 60 77%
6. Decreased number of absences 64 54 84%
Health Care Treatments
and Procedures at School
Some students with chronic illnesses, physical
care procedures to be performed during the
school day. The nurses reported processing
orders for at least 34,625 individual medical
treatments or procedures.
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The chart that follows lists the number of
medical orders for students for the listed
treatments or procedures. In some, a
emergency in a student with an underlying
a tube feeding, a nurse or a person to whom
the nurse has delegated the nursing care
performs a daily procedure. Among all the
listed procedures, only the epinephrine may
be used by the student without adult
assistance.
Health Care Procedure Total
Central venous line management 39
1,807
2,521
Nebulizer treatments 1,920
Shunt care 132
110
Tube feeding 607
13,575
For each of the listed procedures except
nebulizer treatments, the numbers increased
again from the previous year. For each of the
procedures or treatments, an individual health
plan, and in some cases also an emergency
physician.
Emergency Care
Injuries and illnesses are common occurrences
majority of school nurses cover more than
one school building, few schools have a school
nurse on duty every school day. Therefore,
school nurses must assure that school
in emergencies. Seventy-three percent
daily in each school building.
Currently, 109 LEAs reported having at least
on one or more school campuses. During
survived; three of the events were fatal.
Many minor incidents occur to students and
to assist with major injuries, of which there
were more than 20,554 this past year, a
decrease of 2,468. Serious injuries are
immediate medical care plus the loss of
one-half day or more of school.
Of the serious injuries reported, most occurred
22 percent occurred in the classroom. For a
complete breakdown of type and place
of injury, refer to Appendix B.
Three students died from their school-related
injuries this past school year. Those deaths
permanently disabled by their injuries, and
L O C A L O U T C O M E
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damage, right arm weakness, thyroid
of the injuries resulted from an incident in
The two students who died of football-related
injuries during the fall of 2008 provided
Concussion Awareness Act. It made North
Carolina the 21st state with a concussion law.
for high school and middle school sports.
classroom teachers, and teacher assistants
basis in the majority of school systems in North
perform this task with safety and accuracy,
of school policy and procedures, train and
serve as coordinator among parents, medical
providers, and the school. In nearly all of the
LEAs, school nurses provided formal training
programs for school employees who were
charts and records to assure compliance with
all physician and parent orders and to assess
During the 2011-2012 school year, nurses
daily to students while at school. Some
daily basis included psychotropic controlled
substances, including Ritalin®, Dexedrine®,
and Lithium®.
During the 2011-2012 school year, 87,213
is directed to be used “as needed” rather than
student does not need that drug at all during
any given school year. Students whose
treatments. For example, an order for an
Epi-pen® may not be needed if the student’s
requiring Diastat. A student with diabetes
whose blood sugar levels are frequently
monitored and treated before they get
dangerously low may not ever need a dose
necessary responsibility that school health
nurses manage.
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21
Number
2009-2010
Number
2010-2011
Number
2011-2012
Number of students on long term 20,322 19,954 22,213
Number of students on short term 9,207 8,060 6,296
Number of students on emergency, as 51,412 51,511 59,666
Number of students on non- 32,265 34,879 27,547
The number of orders for non-emergency
decreased slightly during the 2011-2012 school
year, from 34,879 to 27,574. School nurses
across the state, as well as physicians and
other health care providers who can prescribe
of the American Academy of Pediatrics to limit
absolutely necessary to maintain the student
13
Because a number of over-the-counter drugs
for the product. Determining whether the
interviewing the student, assessing the
nurse.
Without a nurse at every school, school nurses
in North Carolina must delegate the
personnel. The school nurse provides training
and oversight to these non-health care
professionals, also called “Unlicensed
commonly, those persons are teachers,
teaching assistants, coaches or school
secretaries. School administrators also
parameters, such as providing “one or two pain
relievers depending on pain level,” or providing
delivers a dose of epinephrine in order
to treat severe allergies. Although the student
herself, there is a statutory process requiring
physician orders and nurse assessment of the
student’s ability to do so. Medical orders for
Epi-Pens rose 21 percent during the 2011-2012
school year and have risen every year since
children to carry and self-administer this
drug. Between 2007 and 2012, orders for
epinephrine increased from 3,847 in 2007
to 13,575 by the end of the 2011-2012 school
students to self-carry and self-inject
_________________________________________________________________________________________________________________
13
22
epinephrine, only about 36 percent of the
students with an order to have epinephrine
available, and only 17 percent of all students
with severe allergies, also had orders allowing
to demonstrate this knowledge to school
and in many cases, parents want adult
management of their child’s emergency
severe allergies, it has been agreed that it is
experiencing a dangerously low blood
glucose level. Insulin, by contrast, is a drug
used to treat elevated blood glucose levels.
Of the two extremes, low blood glucose is the
most immediately life-threatening and needs
to be treated quickly to increase blood glucose
Diastat® is a drug with the generic name of
Valium®, and is given through the rectum
Versed is a form of anesthesia that some
physicians prescribe for children with
intractable seizures to be given through the
Health Unit advises school districts to seek
number of reasons, including the rare but
extremely serious risk of depressing a
student’s respiratory status quickly, leading
to respiratory arrest and death.
of midazolam, is given to children before
medical procedures or before anesthesia
for surgery to cause drowsiness, relieve
anxiety, and prevent memory of the event. It
breathing, their use is recommended to
physicians who are expert in the management
of airway and breathing.14 The NLM warns
parents that the drug should only be given
equipment that is needed to monitor heart and
lungs and provide life-saving medical treatment
and respond. No public school outside of
of emergency respiratory treatment.
who had administered Versed during school
year 2009-2010 led the state’s school health
nurse consultants to issue strong advisories
to school nurses regarding requests to
state’s school health nurse consultants led
Versed was administered in N.C. public schools
between those two years. The 2011-2012
surveys revealed zero instances of Versed
per year the following drugs were given in N.C.
public schools during the past two years.
_________________________________________________________________________________________________________________
14 .
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2011-2012
2010-2011 2011-2012
Diastat
Administered by licensed nurse 79 51
Administered by non nurse 121 94
Glucagon
Administered by licensed nurse 7 2
Administered by non nurse 12 3
Versed
Administered by licensed nurse 1 0
Administered by non nurse 0 0
school year.
The following table and graph provide a 10-year overview of the numbers and percentage of
Administered at School
School year # Students Emergencies
2002-2003 1,279,468 N/A
2003-2004 1,311,163 N/A
2004-2005 1,332,009 N/A
2005-2006 1,363,695 N/A
2006-2007 1,386,363 N/A
2007-2008 1,404,957
2008-2009 1,410,497
2009-2010 1,402,269
2010-2011 1,409,895
2011-2012 1,417,458
24
such encounters reported by school nurses
totaled 248,443—15,785 more than the
The single most frequent topic for school nurse
counseling was asthma. Second most frequent
was chronic illness and third was hygiene.
The school nurse is frequently engaged
other issues related to puberty. Students also
violence or bullying, and over possible neglect
or abuse within their family or their concerns
over a friend or neighbor. School nurses must
report suspicions of child abuse/neglect
whether observed or given credible suspicion
by another person. Students also sought the
advice of school nurses about substance abuse
and tobacco use. Individual discussions around
depression/suicide occurred in all grade levels.
Health Counseling
Students seek a school nurse for accurate,
normal growth and development to serious
expect a registered nurse to provide medically-related
to their health and concerns. The
chart that follows lists some of the health
as any encounter with a student where direct
maintenance were discussed. During the
2011-2012 school year, the numbers of
35,000
30,000
25,000
20,000
15,000
10,000
5,000
0
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
School Year
L O C A L O U T C O M E
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15
Health Counseling
Elementary
School
Middle
School
High School Total
ADD/ADHD 9,880 5,304 2,642 17,826
Asthma 29,624 10,701 7,054 47,379
Child abuse/neglect 2,477 1,061 658 4,196
16,198 10,701 8,133 35,032
1,313 1,989 3,022 6,324
Diabetes 10,653 10,004 7,678 28,335
Hygiene 21,873 8,281 4,453 34,607
Mental Health Issues 5,330 4,063 6,504 15,897
Pregnancy 60 1,313 7,790 9,163
3,774 4,332 7,600 15,706
Seizure disorders 2,581 1,556 1,752 5,889
Severe allergies 8,787 3,252 3,336 15,375
Sickle cell 343 296 266 905
Substance abuse including tobacco use, 471 1,555 2,710 4,736
82 334 413 829
Violence/bullying 2,301 2,558 1,385 6,244
Totals 115,747 67,300 65,396 248,443
Pregnancy
For the fourth year in a row, there was a
decrease in the number of pregnancies among
public school students across all grade levels,
as reported by the school nurses. Although
student’s pregnancy as part of nursing case
management or on physician orders, or
guidance of labor and delivery and infant
early pregnancies. The number of students
reported by school nurses to be known to have
been pregnant during 2011-2012 school year
_________________________________________________________________________________________________________________
15 Most but not all LEAs reported within these categories in the annual survey.
L O C A L O U T C O M E
26
Status of School Enrollment for Students Known to be Pregnant
Elementary Middle School High School Total
Known pregnancies
2008-2009: 7
2009-2010: 3
2010-2011: 2
2011-2012: 1
2008-2009: 300
2009-2010: 278
2010-2011: 226
2011-2012: 183
2008-2009: 4,353
2009-2010: 3,996
2010-2011: 3,659
2011-2012: 3,475
2008-2009: 4,660
2009-2010: 4,277
2010-2011: 3,887
2011-2012: 3,659
Students receiving homebound
2011-2012
1 48 983 1,032
Known Pregnancies by Year and Percent Change from Previous Year
School Year
Pregnancies reported % increase or decrease
2002-2003 2,697 - 7.6%
2003-2004 3,131
2004-2005 3,406
2005-2006 4,072
2006-2007 4,422
2007-2008 4,904
2008-2009 4,660 - 5%
2009-2010 4,277 - 8%
2010-2011 3,887 - 9%
2011-2012 3,659 -6%
is 3,659. That number is 228 fewer than the
previous year. This represents more than 1,245
fewer student pregnancies from the recent
high of 4,904 during school year 2007-08.
decrease since 2008. This trend is also
With assistance from school nurses, the
majority of students managed their
pregnancies well enough to remain enrolled
the prenatal or postpartum period, or both,
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L O C A L O U T C O M E
Tobacco Use by Students
Since Aug. 1, 2008, all schools must adopt,
implement, and enforce tobacco-free16 school
and school policy, schools communicate
tobacco-free messages to young people
and provide mentoring to youth groups
In a May 2012 press release the North Carolina
Department of Health and Human Services
rate in North Carolina reached an historic low
rates have fallen steadily, according to results
from the 2011 N.C. Youth Tobacco Survey. The
rate dropped to 4.2 percent from 4.3 percent
in 2009, and high school smoking lowered
to 15.5 percent from 16.7 percent in 200917.
media campaigns and school and community
www.tru.nc.gov
Carolina.
Suicide and Homicide
suicide or homicide, is a public health
emergency. Although the number is small
loss of a student through homicide or suicide
According to reports from the LEAs, suicide was
students, and 19 of those suicides resulted
in death. Suicide cases decreased slightly,
from 23 the previous year to 19 in 2011-2012.
Twelve students died through homicide. One
suicide death occurred at school. None of
the deaths from homicide were reported as
occurring at school.
_________________________________________________________________________________________________________________
16
17 .
28
nurses also conducted health fairs and made
boards, and civic and community groups.
School nurses reported providing a total of
the 2011-2012 school year.
programs for students.
problem. In some cases, the nurse is the only
health care provider the student sees for minor
illnesses and injuries. During the 2011-2012
school year, school nurses assessed and man-aged
166,103 students for illness or injury that
originated at home. Issues such as the stu-dent’s
health insurance status, access to care,
to the number of illnesses and injuries treated
medical and dental resources and referring stu-dents
to providers for the diagnosis and treat-ment
of a wide variety of health problems.
Health Teaching
School nurses were involved in a variety
to groups and in classrooms. Classroom
other asthma management programs, AIDS
management, including general training on
diabetes, and intensive training for the care
of individual students with diabetes. The
Death by Suicide/Homicide: School Year 2011-2012
Elementary Middle School High School Total
29 99 264 392
Deaths from suicide 1 3 15 19
Suicides occurring at school 0 0 1 1
Death from homicide 1 3 8 12
Homicides occurring at school 0 0 0 0
L O C A L O U T C O M E
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Screening Screened
%
Secured Care
%
Secured Care
Body Mass Index 57,273 3,659 6% 116 3%
Hearing 145,763 3,079 2% 2,048 67%%
Vision 513,884 39,999 8% 28,897 72%
L O C A L O U T C O M E Follow-up, and Securing Care
Voluntary mass screenings by grade or school
of trained volunteers or other health
professionals.
Vision screenings are conducted by school
volunteers. School nurses follow up on those
cases are the persons who locate sources
of low-cost or free care for those unable
screening process did not or were not able
to secure that care from a health professional.
follow-up and care management services
for students may reduce this gap in the
providers may also reduce the gap.
The following table lists the results of some
of the mass screening projects that were
conducted during the 2011-2012 school year.
L O C A L O U T C O M E
30
between mass screening of all students or
occasional screening of students referred
between referral for overweight or
underweight. Some students with results
in either height or weight may have been
percentage of public school students screened
for BMI in North Carolina by the school health
screening for BMI is not universally accepted
2011-2012, 57,273 students were screened
for BMI. About 6 percent of those students
who were measured received referrals for
either overweight or underweight. The referral
rate of six percent is much lower than the
expected 33 percent if the screening had
but the sample of students screened was not
due to the limited presence of formal
screening programs for BMI in North Carolina
schools. Three percent of those students
the screening process.
Vision Screening
There is no mandate in North Carolina for
screenings required for students needing
other health care providers who examine
children prior to entry into kindergarten are
required to screen for vision as part of that
state-created Kindergarten Health Assessment
if indicated. One indicator of the success of a
school health screening program is the percent
students who did not pass a screening, were
evaluated by another health care provider who
could diagnose and determine the appropriate
during the 2011-2012 school year, screening
for vision achieved a 72 percent rate of
screening process.
Screening for Obesity
North Carolina’s children and youth are among
state ranking 11th
obesity18. In North Carolina, nearly one-third
of children aged 10 – 17 are overweight or
to what is called an epidemic of obesity
Force on Childhood Obesity. This task force
to screen at least some students for
overweight/obesity by measuring height
and weight and obtaining the Body-Mass Index
Some school districts measure growth in height
to a BMI. These screenings are conducted
height and weight data. In some cases, the
other health partners. Data from 2011-2012
_________________________________________________________________________________________________________________
18
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Many schools, however, follow state
periodically through elementary age and once
more in middle or high school. Screening for
vision is the most frequent school screening
program in North Carolina. More than half a
had their vision checked for possible eye
by the Prevent Blindness North Carolina Vision
working under contract with the N.C.
the Children and Youth Branch to deliver vision
of Public Health’s primary means of assuring
criteria across all schools in North
school vision screening program is an example
providers.
screening conducted in schools and report
their results both to Prevent Blindness and
to the Division of Public Health.
Hearing Screening
As with vision screening, there is no mandate
screen for hearing, although the same rules
academic support. Physicians and other health
care providers who examine children prior
to entry into kindergarten are required
to screen for hearing as part of that exam
Not all school nurses are trained in and
authorized to conduct hearing screenings.
School nurses assist in hearing screenings,
especially related to referrals and follow-up.
32
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H e a l t h P o l i c i e s
health programs. All local health departments
in the state develop an agreement, the
are locally developed and provide an avenue
and procedures.
provide parents a consistent method of
to health and safety. The School Health Unit
of the Division of Public Health provides
guidelines regarding policy development
at the local level, and recommends, at
minimum, that school boards study and
on the chart below.
The percentage column in the table that
follows indicates the percent of LEAs that have
policy addresses maintenance of electronic
health records in school. The trend in the
health care industry is greater reliance
document at least some of the nursing care
they provide onto computer systems.
School Health Policy
board-approved policy
100%
Provision of emergency care 100%
Screening, referral and follow-up 83%
59%
81%
Maintenance of student health records 25%
care needs
70%
90%
45%
27%
34
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C o m m u n i t y
I n v o l v e m e n t
i n S c h o o l
H e a l t h S e r v i c e s
Community involvement contributes to the
programs and services. School nurses
encourage and promote community
involvement through:
Establishment of school health advisory
councils;
Development of inter-agency planning
Recruitment of local physician advisors;
and,
Development of parent-teacher
community involvement include:
Departments;
and,
School-Based School-Linked Health Centers
School Health Advisory Council
(SHAC)
School Health Advisory Councils. These
all of the SHACs have a school nurse among the
have a physician serving on the council.
According to the policy, each SHAC must
behavioral health, safe school environment,
parents/community members, the local health
SHACs advise LEA leadership, superintendents,
health and academics, and can disseminate
Local Health Departments
In every county in the state, a Memorandum
of Agreement between the local health
department and the school district is required
in order for the health department to receive
state funds. These annually reviewed
to support the health of children in public
of each regarding epidemics and other
experts, 70 LEAs are able to consult with a
physician regarding the school health program.
physicians or pediatricians.
During school year 2011-2012, 26 percent of
the school districts hosted school-located
in 2011-2012 experienced a more normal out-
36
during the previous year, there was a large
source of federal funding that supported a
to implement SLIC. School nurses and
local health departments, hospitals and others,
made it possible for more than 10,923 doses
Parental permission was required to administer
doses to students.
School-based, School-linked
Health Centers
established school health centers in the
schools using grants, local funding and
some state funding assistance. During
school year 2011-2012, there were at least 50
school-based or school-linked health centers
20 The clinics
primarily serve students in middle and high
adolescents for access to medical care,
including care for mental health or behavioral
health issues. Centers provide primary care
the school nurse’s ability to refer a student
or his family for medical care, especially
in areas of low resources. The school-based
or school-linked centers provide clinical health
services and may bill for the services to the
parent’s insurance, other insurance providers
and Medicaid. Parental permission is required
for receipt of school health center services, in-diagnosis
and treatment for medical
Nurses employed by school-based health
these registered nurses working in the school
health centers are not counted among the
School Health Centers depend on a
resources to support the health services that
funded by the N.C. Division of Public Health.
resources at the local level. Partners in these
centers include N.C. Department of Public
centers may be obtained from the NCSCHA
website, www.ncscha.org.
_________________________________________________________________________________________________________________
20
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C o n c l u s i o n
School health services are just one component
of a Coordinated School Health Program. By
Division of Public Health, North Carolina
Division of Medical Assistance, North Carolina
Carolina Pediatric Society, North Carolina
Academy of Family Physicians, North
Carolina Dental Society, Prevent Blindness
North Carolina, North Carolina School and
Community Health Alliance and more, school
nurses are working to help students achieve
at levels they might not otherwise reach. An
increase in the number of school nurses
outcomes.
38
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Appendi x A :
Elementary Middle High Total
Total with Total with
a related
504 plan
ADD/ADHD 35511 18501 13519 67531 3844 6009
18117 5965 5926 30008 18865 380
Asthma 57718 25724 22100 105542 54965 823
including Asperger’s
Syndrome, PDD
6124 2290 2250 10664 1079 546
Blood disorders not
chronic anemia,
624 316 442 1382 424 60
Cancer, including
leukemia
428 189 263 880 335 141
2557 1277 1715 5549 1753 140
Cerebral Palsy 1287 545 702 2534 782 123
Chromosomal
otherwise listed
including Down's
Syndrome, Fragile X,
Trisomy 18
1397 518 610 2525 587 96
Chronic encopresis 501 111 72 684 226 17
diseases: including
Toxoplasmosis,
Cytomegalovirus,
C, HIV, Syphilis,
Tuberculosis
82 37 68 187 35 6
166 68 89 323 180 66
Diabetes Type I 1132 1060 1567 3759 5230 914
Diabetes Type II 218 350 618 1186 655 74
81 92 172 345 60 12
and/or psychiatric
disorder not otherwise
listed
5030 3438 3866 12334 778 817
Fetal Alcohol Syndrome 226 199 83 508 191 11
celiac disease, IBS,
2426 1418 1617 5461 1229 155
Hearing loss 2269 1015 1026 4310 561 344
Hemophilia 234 108 105 447 226 25
40
Elementary Middle High Total
Total with Total with
a related
504 plan
Hydrocephalus 395 126 146 667 321 40
Hypertension 375 413 811 1599 399 17
Hypo/Hyperthyroidism 319 251 416 986 115 20
endocrine disorders not
otherwise listed
446 237 311 994 257 52
Migraine headaches 3038 3324 4570 10932 2349 146
186 128 124 438 229 26
Muscular Dystrophy 99 56 72 227 77 20
6145 1871 1881 9897 112 22
Orthopedic disability 1216 719 851 2786 521 144
Other neurological
listed
647 238 392 1277 383 142
Other neuromuscular
listed
444 204 293 941 285 84
Renal / Adrenal /
including Addison's
1192 635 747 2574 722 89
Rheumatological 311 227 361 899 374 82
Seizure Disorder/
Epilepsy
4674 2058 2351 9083 5352 401
Sickle Cell Anemia 814 376 385 1575 1334 85
892 378 395 1665 200 16
258 85 137 480 208 42
215 130 186 531 173 66
Visually impaired 1107 446 649 2202 333 249
Total Number: 148994 70584 66384 285962 96768 11388
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Appendi x B : Reported Injuries in North Carolina Public Schools
Requiring EMS Response or Immediate Care by Physician/
School Year 2011-12
Abdominal/Internal
Injuries
4 7 52 67 53 1 1 10 22 217 1%
Anaphylaxis 5 7 87 32 10 0 1 37 27 206 1%
Back or Neck Injuries 17 23 57 180 135 1 10 5 43 471 2%
Dental Injury 13 30 116 321 177 2 14 31 49 753 4%
Drug Overdose 16 15 98 5 5 2 8 7 37 193 1%
Eye Injuries 14 42 268 209 170 29 1 15 82 830 4%
Fracture 13 91 135 1240 718 12 17 24 447 2697 13%
Head Injuries 48 172 357 933 718 8 80 50 315 2681 13%
Heat Related Emer-gency
0 4 37 90 68 3 3 6 24 235 1%
47 132 520 712 379 99 49 51 362 2351 11%
Other 34 119 531 393 298 9 32 63 376 1855 9%
Psychiatric Emergency 7 41 527 17 15 0 10 9 142 768 4%
Respiratory
Emergency
9 27 583 214 202 1 10 18 332 1396 7%
Seizure 48 72 870 76 59 1 14 33 104 1277 6%
Sprain or Strain 76 270 316 1385 2025 18 35 68 431 4624 22%
351 1052 4554 5874 5032 186 285 427 2793 20554 100%
Total % 2% 5% 22% 29% 24% 1% 1% 2% 14% 100%
42
Appendi x C :
County/LEA Name
(Nurse:Student)
County/LEA Name
(Nurse:Student)
Alamance-Burlington Schools 902 Forsyth County Schools 1,815
Alexander County Schools 986 Franklin County Schools 1,105
724 1,471
469 601
Ashe County Schools 1,048 496
1,095 1,709
Beaufort County Schools 1,381 435
683 2,249
Bladen County Schools 916 478
Brunswick County Schools 1,197 724
Buncombe County Schools 1,425 512
Asheville City Schools 1,134 1,847
Burke County Schools 1,208 Haywood County Schools 1,181
Cabarrus County Schools 921 Henderson County Schools 1,464
688 619
Caldwell County Schools 1,141 Hoke County Schools 1,002
635 575
Carteret County Schools 1,204 Iredell-Statesville Schools 1,428
720 Mooresville City Schools 1,084
Catawba County Schools 1,139 Jackson County Schools 1,007
Hickory City Schools 848 Johnston County Schools 2,104
722 569
Chatham County Schools 1,336 Lee County Schools 1,131
Cherokee County Schools 740 Lenoir County Schools 1,304
572 Lincoln County Schools 1,459
664 Macon County Schools 854
Cleveland County Schools 1,123 1,275
Columbus County Schools 916 624
566 753
710 1,159
Cumberland County Schools 2,054 1,028
651 Montgomery County Schools 821
482 Moore County Schools 1,768
Davidson County Schools 3,118 Nash-Rocky Mount Schools 869
Lexington City Schools 592 New Hanover County Schools 745
803 582
Davie County Schools 927 Onslow County Schools 1,113
639 629
Durham Public Schools 1,292 649
Edgecombe County Schools 1,013 316
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Appendi x C :
County/LEA Name
(Nurse:Student)
County/LEA Name
(Nurse:Student)
Pasquotank County Schools 981 Surry County Schools 1,055
Pender County Schools 843 Elkin City Schools 769
860 Mount Airy City Schools 536
985 333
1,276 Transylvania County Schools 1,170
1,166 565
Randolph County Schools 2,041 Union County Schools 1,190
Asheboro City Schools 913 687
Richmond County Schools 755 Wake County Schools 2,517
Robeson County Schools 1,013 615
Rockingham County Schools 1,691 583
Rowan-Salisbury Schools 1,677 Watauga County Schools 1,074
Rutherford County Schools 1,461 Wayne County Schools 1,111
Sampson County Schools 1,085 Wilkes County Schools 1,044
601 Wilson County Schools 2,006
473 Yadkin County Schools 968
Stanly County Schools 1,494 501
Stokes County Schools 1,369 North Carolina 1,179
44
Department of Health and Human Services | Aldona Z. Wos, M.D., Secretary
Children and Youth Branch | School Health Unit
www.ncdhhs.gov
N.C. DHHS is an equal opportunity employer and provider.
10/13